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Trust Board Papers

Isle of Wight NHS Trust

Board Meeting in Public (Part 1)

to be held on

Wednesday 4th October 2017

at

9.00am - Conference Room, School of Health

Sciences (South Hospital)

St. Mary’s Hospital, Parkhurst Road,

NEWPORT, Isle of Wight, PO30 5TG

Staff and members of the public are welcome

to attend the meeting.

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Block Numbers

01 AMBULANCE STATION02 SOCIAL CLUB03 HELI PAD04 AMBULANCE HQ, RESEARCH DEPT.

05 MAIN BOILERHOUSE06 MAIN SOUTH HOSPITAL BUILDING07 WHEELCHAIR SERVICES08 LAIDLAW DAY UNIT09 ALMONDGATE/CHERRYGATE10 PODIATRY/ORTHOTICS/SPEECH THERAPY11 ALLERGY RESEARCH CENTRE12 HOLLY HOUSE13 DIABETIC CENTRE14 BREAST SCREENING UNIT15 BREAST CARE UNIT16 SCHOOL OF NURSING17 THE COTTAGE18 VECTASEARCH UNIT19 SOUTH PUBLIC WC's/GENERATOR20 MAIN HOSPITAL21 HV ELECTRICAL INTAKE22 MOTTISTONE BLOCK23 B BLOCK24 PHYSIO/MANAGEMENT BLOCK25 A BLOCK26 MFU/ORTHODONTICS27 DAY PROCEDURES UNIT28 MATERNITY29 LINEN SERVICES/MORTUARY30 SEXUAL HEALTH SERVICE

31 MED. RECS./TEL. EXCH./PRINTROOM32 NEWCROFT BLOCK33 FINANCE AND INFORMATION34 MARGHAM HOUSE35 EDUCATION CENTRE36 WESTERN HOUSE37 NORTH BLOCK GENERATOR38 ESTATES BLOCK39 SEVENACRES40 PORTACABIN41 PRE-OPP ASSESSMENT42 LINK CORRIDORS NORTH43 ENT/AUDIOLOGY BLOCK44 NORTH X-RAY45 NORTH BLOCK OUTBUILDINGS46 STORES GENERATOR47 C BLOCK48 YMCA DAY NURSERY 49 RENAL DIALYSIS UNIT50 SOLENT51 MEDINA52 EBME DEPARTMENT53 H.S.D.U.

And Buildings List

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ByItemDateRev

Revisions

Project Title

Drawing Title

Scale Date Drawn

Level.Site No. Block. Project No.

ESTATES MANAGEMENT DEPARTMENTSt Mary's Hospital NHS TrustNewport, Isle of Wight,PO30 5TGTel: (01983) 534256Fax:(01983)525157

ALL201

06/10/2014Not to Scale @A1

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Isle of WightSt Mary's Hospital

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Conference Room in the School of Health Science Building - Building No 16

Excellent patient care

Our vision and goals guide us; our values underpin everything we do

Quality care for everyone, every time

Our Values

Work with others to keep improving our

services

Skilled and capable staff

Cost effective, sustainable services

Go

als

P

rio

riti

es

A positive experience for

patients, service users and staff

Enab

lers

QI1 – Patient safety: Safe and secure handling of medicines

QI2 – Patient Experience: Reduce the number of inpatient bed moves that are not related to clinical need

QI3 – Clinical Effectiveness: Improve the management of nutrition and hydration needs of patients Qu

alit

y

P1 - To effectively deploy resources and direct patients to the most appropriate level of service for their needs.

P2 – To develop and improve Mental Health services which meet the needs of clients and carers

P3 - To develop an infrastructure with partners that delivers more care, that is safe and closer to home.

P4 - To develop an infrastructure to support the treating of patients safely through the unscheduled care and elective pathways

E1 - Establish and implement systems and processes for more effective financial decision making and control

E2 – To improve workforce recruitment, retention and organisational development to support our services

E3 - To improve informatics to inform efficient and effective decision making

E4 - To ensure the Trust has a fit for purpose Estates and Facilities

E5 - To develop a Trust that is well led with a clear vision and objectives

E6 – To improve communications and engagement with staff, service users and carers and our stakeholders

Effective from September 2017

PRINCIPAL RISKS & ISSUES Risk 671, Human Resources: If the Trust is unable to attract, recruit and retain sufficient staff of the right quality and skillset then it will be unable to meet demand

Risk 676, ICT Strategy: If the Trust is unable to deliver against the ICT Strategy, then there will be a negative impact on quality, Income, Performance, Information Governance Compliance and Staff morale

Risk 673, Strategy and Planning: If our Trust Strategy is not robust and embedded then staff will be unable to create effective service plans.

Risk 677, Local Health and Social Care Economy Resilience: If there is insufficient resilience in the local health and social care economy then we will be unable to deliver safe effective and financially viable care.

Risk 674, Quality Governance: If the Trusts quality governance processes are not robust and embedded then the Trust may not be able to maintain adequate patient safety, patient experience and clinical effectiveness.

Risk 705, Board Capacity and Capability: If there is not sufficient capacity and capability within the Executive and Non Executive Team, then the Trust will not be able to achieve its strategic ambitions.

Risk 675, Culture: If the Trusts culture does not reflect our core values then we will be unable to deliver our vision, goals and priorities.

Risk 712, Financial Resources: If the Trust is unable to manage within the revenue and capital financial resources it receives then it may become financially unsustainable in 16/17 and in future years.

Issue 1085, CQC Section 31 Warning Notice: The CQC have served the Trust with an warning notice of decision to impose conditions on our registration as a service provider in respect of a regulated activity in relation to the Mental Health and Learning Disabilities CBU, under Section 31 of the Health and Social Care Act 2008. They have also issues the Trust with a regulation 17.

IW NHS Trust Board (Public) 4th October 17 - Page | 1

Agenda

AGENDA

No. Item Lead Purpose Enc/Verbal STAFF AWARDS 1 Employee Recognition of Achievement Awards ICEO Receive Presentation

PROCEDURAL 2 Apologies Chair Receive Verbal

3 Confirmation that meeting is Quorate Chair Receive Verbal

4 Declarations of Interest Chair Receive Verbal 5 Minutes of previous meeting Chair Approve A 6 Matters Arising and Schedule of Actions Chair Receive B

7 Chair's Update Chair Receive Verbal 8 Interim Chief Executive's Update ICEO Receive C

STRATEGY 9 Board Committee Structure and Board Governance DCEO Approve D 10 Financial Recovery Plan ITCFO Approve E 11 Emergency Planning & Business Continuity Plan COO Approve F 12 Integrated Improvement Framework Report DCEO Assurance G 13 Progress of Partnership with Earl Mountbatten Hospice to Improve

End of Life Care IDNQ Assurance Presentation

PERFORMANCE 14 Single Oversight Framework COO Assurance H 15 Operational COO Assurance I

16 Quality IDNQ & IMD

Assurance J

17 Workforce DHR&OD Assurance K 18 Financial ITCFO Assurance L COMMITTEE ASSURANCE 19 Quality Governance Committee - 26th September 2017 Chair of

QGC Assurance M

20 Finance, Investment, Information & Workforce Committee - 26th September 2017

Chair of FIIWC

Assurance N

21 Mental Health Act Scrutiny Committee - 18th July 2017 Chair of MHASC

Assurance O

22 Audit & Corporate Risk Committee - 9th August 2017 Chair of ACRC

Assurance P

Isle of Wight NHS Trust Board Meeting in Public Date: 4th October 2017 Time: 9.00am – 1.00pm Venue: Conference Room – School of Health Science Building, South Hospital, St. Mary’s Hospital, Newport, Isle of Wight PO30 5TG

IW NHS Trust Board (Public) 4th October 17 - Page | 2

CLOSING MATTERS 23 Issues to be covered in Private

The items which will be discussed and considered for approval in private due to their confidential nature are:

• Trust Contracts • Pathology Hub & Spoke Update • Employee Relations • Clinical Claims • Neo Natal Services • Ultra Sound Discrepancies Update • Interim Solution for Improvement of Shackleton & Older

Peoples Services

Chair Receive Verbal

24 Questions from the Public Chair Receive Verbal

25 The next meeting in Public of the Isle of Wight NHS Trust Board will be on: Date: Wednesday 8th November 2017 Venue: Conference Room - School of Health Science Building, St Mary's Hospital, Newport, Isle of Wight, PO30 5TG

Chair Receive Verbal

Public and Staff Attendance Staff and members of the public are welcome to attend the meeting. Questions for the Board Staff and members of the public are asked to send their questions in advance to [email protected] to ensure that as comprehensive a reply as possible can be given. Issues to be Covered in Private 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. Recording of Meeting This meeting will be recorded for the purposes of assisting in transcribing the minutes and actions from the meeting. Confirmation of Quoracy No business shall be transacted at a meeting of the Board of Directors unless one-third of the whole number is present including: The Chairman; one Executive Director; and two Non-Executive Directors. Apologies Received from

• Chris Palmer, Executive Director of Financial & Human Resources • Alan Thorne, Improvement Director

mailto:[email protected]

IOW NHS Trust Board Meeting Pt 1 6th September 2017 1

Minutes of the meeting in Public of the Isle of Wight NHS Trust Board held at 9.00am on Wednesday 6th September 2017 in the Conference

Room, School of Health Science, St Mary’s Hospital, Newport, IW PO30 5TG

PRESENT: Eve Richardson Chair Jessamy Baird Non-Executive Director David King Non-Executive Director Charles Rogers Non-Executive Director Vaughan Thomas Non-Executive Director Maggie Oldham Interim Chief Executive Sarah Johnston Deputy Director of Nursing (deputising for Interim Director of

Nursing & Quality) Julie Pennycook Director of Human Resources & Organisational

Development Mark Pugh Executive Medical Director Shaun Stacey Chief Operating Officer In Attendance: Dr Charles Godden Associate Non-Executive Director Kevin Bond Interim Director of Mental Health Darren Cattell Interim Turnaround Chief Financial Officer Suzanne Rostron Board Advisor – Clinical Governance David Haycox Board Advisor – Corporate Governance Dr Paul Evans Board Advisor – Medical Leadership Judy Dyos Head of Nursing & Quality, Clinical Support, Cancer &

Diagnostic CBU Andy Hollebon Head of Communication & Engagement Observers: Ben Rusholme Trainee GP/FY2 Doctor (Shadowing ICEO) Mike Carr Patient Council Representative Philippa Slinger Improvement Director Alan Thorne Improvement Director Minuted by: Lynn Cave Board Governance Officer

Members of Staff and Public in attendance:

There were five staff members and sponsors attending for the Employee Awards. There were seven members of the public present. Representatives from the IW County Press and IW Radio also attended

Minute No. 17/T/116 APOLOGIES FOR ABSENCE, DECLARATIONS OF INTEREST AND

CONFIRMATION THAT THE MEETING IS QUORATE Apologies for absence were received from Chris Palmer, Executive Director of

Financial & Human Resources; Jon Burwell, Executive Director of Strategy & Planning; Barbara Stuttle CBE, Interim Director of Nursing & Quality and Frank Sims, Deputy Chief Executive, Chris Orchin, Chair of Healthwatch The Chair announced that the meeting was quorate. Declarations of Interest were received from Charles Rogers, Non-Executive Director as a Director of Wightlife Partnership. The Chair welcomed Dr Charles Godden who is joining the Board as an Associate Non-Executive Director. She also welcomed Suzanne Rostron, Board Advisor –Clinical Governance; David Haycox, Board Advisor – Corporate Governance and Dr Paul Evans, Board Advisor – Medical Leadership, and confirmed that they would be advising the Board over the coming months. The Chair welcomed Alan Thorne who has been appointed by NHS Improvement as Improvement Director and will be taking over from Philippa Slinger who has come to the end of her tenure with the Trust. She also welcomed Ben Rusholme who is a Trainee GP/FY2 Doctor who is shadowing the Interim Chief Executive.

Enc A


Staff Awards 17/T/117 EMPLOYEE RECOGNITION OF ACHIEVEMENT AWARDS The Interim Chief Executive presented the Employee Recognition of Achievement

Awards. Category 1 – Quality Care & Innovation:

• Kathy Clifford, Preceptorship Midwife Queens Nurse Award: The Board congratulated Lynn Salmon, Advanced Care Practitioner who has been awarded the title of Queens Nurse and will receive her award at a ceremony in London in October. She will be joining the other Queens Nurses in the Trust.

The Interim Chief Executive congratulated them both on their achievements.

17/T/118 MINUTES OF PREVIOUS MEETING Minutes of the meetings of the Isle of Wight NHS Trust Board held on 5th July 2017

were reviewed and approved with the following amendments: a) Page 3 – 17/T/11 c): It was confirmed that the revised Infection Prevention &

Control Annual Report 2016/17 would be presented to QGC in September and be taken to Board in October.

b) Page 6 – Additional SIRI Action: Jessamy Baird, Non-Executive Director requested that an action be added. Action: The Interim Director of Nursing & Quality to arrange for a SIRI report to be created, alongside a more detailed SIRI report for QGC, to ensure effective assurance for Trust Board that serious incidents are identified, acted upon and lessons learned.

Action by: ICN The Isle of Wight NHS Trust Board approved the minutes of the 5th July 2017 and noted the amendments.

17/T/119 REVIEW OF SCHEDULE OF ACTIONS a) TB/231 & TB 266 – Revision of Performance Report: Jessamy Baird, Non-

Executive Director requested that effective KPIs are clearly shown in future reports which she felt were still not clearly shown and that assurance is provided. It was noted that work is included within the IIF and the format of the performance report would be included within the governance review.

b) TB/245 – Revised Assurance Reporting on Safer Staffing: It was confirmed that a revised report would be seen by the Assurance Committees in September.

17/T/120 CHAIR’S UPDATE The Chair presented her update.

a) Chief Inspector of Hospitals: She advised that a very positive meeting with the

new Chief Inspector of Hospitals, Professor Ted Baker who came to the Trust with Anne Davis. She advised that it was a very positive session in which they understood the full range of challenges the Trust faced as a small Trust. During the visit Professor Baker and Anne Davis had the opportunity to speak to members of staff in the workplace and they reported that they could see that staff were engaged with the changes and that the Trust was working hard to improve.

b) Bob Seely, MP: The Chair advised that together with the Interim Chief Executive

she had a very positive meeting with the new MP Bob Seely and confirmed that he will be shadowing the Interim Chief Executive in October. She advised that he is leading an all-party parliamentary group on Islands and Coastal areas where there are financial issues and at the meeting it was suggested that health and


social care needed to be included. She advised that the Trust was looking forward to building a good relationship with him.

c) Consultant Paediatricians: The Chair advised that she had sat on the

appointment panel for this post and confirmed that a number of strong candidates had been seen.

d) National Organ Donors Week: The Chair advised that the Island had good

results in previous campaigns for people to sign up as organ donors and confirmed that the team would be in Sainsbury’s on Saturday 8th September signing people up and she encouraged people to come along.

The Isle of Wight NHS Trust Board received the Chair’s Update

17/T/121 INTERIM CHIEF EXECUTIVE’S UPDATE The Interim Chief Executive presented the report and highlighted the following:

a) 7 Day Services: She advised that there had been media reports on the 7

Day Service initiative and advised that all Trusts are being encouraged to move towards this model. She outlined the work the Deputy Medical Director has been undertaking to enable the Trust to move towards achieving this goal. She stressed that it would not be an immediate solution and that the Quality Governance Committee was monitoring progress

b) International Nurses and Junior Doctors: She confirmed that a cohort of

international nurses had now arrived and she thanked them for choosing the Island and wished them well in their exams. She also welcomed the new Junior Doctors who had joined the Trust in August.

c) Improvement Director: A personal thanks was given to Philippa Slinger

who has come to the end of her tenure with the Trust. She also welcomed Alan Thorne, who is taking over as Improvement Director.

d) Performance Report: There have been a number of challenges during July

as well as a number of successes in August and these will be highlighted within the report later in the meeting. She thanked all the staff involved with the Emergency Department and Patient Pathways.

The Isle of Wight NHS Trust Board received the Interim Chief Executive’s Update

Principal Risk 674 - Quality & Principal Issue – Section 31 CQC Letter 17/T/122 SAFER STAFFING MONTHLY REPORT The Deputy Director of Nursing presented the report and advised that the staffing

picture is improving and although there are red indictors where consistent issues are evidenced, there has been action taken and these are addressed or improving. She confirmed that the number of areas that are indicating below 90% of registered nurses in the day is static this month. Osborne (MH), Rehab, Colwell and Appley (medical) are areas that have more than one red indicator and require support to rectify this position. She advised that the Matrons and Heads of Nursing & Quality were aware of this; however, during this period there have been difficulties in obtaining temporary staff including agency staff due to holidays. She confirmed that the staffing review has incorporated issues needing action in relation to these areas. For Health Care Assistants she advised the position shows this is below at 90% against achieving our planned hours in the day for 6 areas. However, there are no significant concerns raised from this position as the broader picture for these areas is good.


The Deputy Director of Nursing highlighted that sickness remains red rated in 15 out of 20 areas. She advised that bank and agency have been difficult to source in some instances and the request to fill rate for agency registered nurses has dropped which is unusual. This is likely to be due to the holiday period and will extend through the holiday period. She confirmed that mandatory training is much improved with 15 areas now rated green. She advised that shortfalls in staffing related to short term sickness, high acuity and dependency and skill mix for ITU1 and NICU2 have been identified and she provided an update on how these were being mitigated and managed to ensure that the areas remain safe. The Deputy Director of Nursing advised that the introduction of the Safe Cover system was being trialled in 4 pilot areas and a detail roll out plan was being developed. The Head of Nursing & Quality (CSCD3) gave an update on the review of staffing levels within the ITU and the measures taken within the NICU unit including periods when it was necessary to close the unit to new patients. It was stressed that patients within the unit at these times were safe and that emergency cases would still be admitted, but that additional support was used at these times through partnership arrangements with Southampton and Portsmouth hospitals provided support and the national network. The Board discussed the issues raised within the report and received assurance that support for neo natal cases was always available and that areas were all safe. The Isle of Wight NHS Trust Board received the Safer Staffing Monthly Report

17/T/123 SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRI) REPORT The Deputy Director of Nursing presented the report and advised that covered activity

during July 2017. She confirmed that there were 5 SIRI’s reported to the Isle of Wight Clinical Commissioning Group (CCG) during July. At the time of writing this report there were 40 open investigations and gave an overview of these. In addition the IW CCG had closed 4 SIRI case during the period. She confirmed that there were twice weekly incident review meetings were all incidents are discussed and assessed as to whether they are escalated to SIRI status. In addition safety monitoring meetings take place with the ward managers to share lessons learnt, to share knowledge and skills and to ensure that these are embedded within the organisation. The Board discussed the report. Vaughan Thomas, Non-Executive Director asked that the QGC meeting review the current cases to assess if there were any significant incidents which the Board needed to be made aware of. He also highlighted that cases of unexpected death should be reviewed by QGC to assess if trends were evident. Jessamy Baird, Non-Executive Director advised that the report was being reviewed (see Min 17/T/118 b)) and that a more detailed report was due to be presented to QGC. She also advised that mortality data was reviewed by QGC and that she would request that this is linked with the SIRI reporting in the revised report. The Deputy Director of Nursing confirmed that this was included within the quality governance review and would be reflected in the revised reports. The Isle of Wight NHS Trust Board received the Serious Incidents Requiring Investigation (SIRI) Report.

1 Intensive Treatment Unit 2 Neonatal Intensive Care Unit 3 Clinical Support, Cancer & Diagnostics CBU


17/T/124 LEARNING FROM DEATHS: A FRAMEWORK FOR IDENTIFYING, REPORTING,

INVESTIGATING & LEARNING FROM DEATHS IN CARE The Executive Medical Director outlined the framework and advised that future

reporting would reflect these requirements. He advised that a detailed report would be provided for assurance to the Quality Governance Committee (QGC) and a high level report would come to the Board meetings. Charles Rogers, Non-Executive Director asked that the QGC report be circulated to the Non-Executive for information and that any feedback is sent to the Chair of QGC to be raised at the meeting. Action: The Executive Medical Director to arrange for the revised Mortality Report to be sent to future QGC meetings and circulated to all Non-Executives in advance of the meeting.

Action: EMD The Isle of Wight NHS Trust Board received the Learning from Deaths: A framework for identifying, reporting, investigating & learning from deaths in care update

17/T/125 CQC INSPECTION UPDATE The Interim Chief Executive presented the report and advised that it had been seen

at QGC in July and by the IIF Programme Board in relation to Section 31 & Regulation 17. In addition she confirmed that updates have been reviewed by the QIPOG4 meetings which are the external monitoring forum. She confirmed that the report was in the process of being revised and that the Patient Council and Healthwatch would be consulted to ensure that the format was clear to the lay person. The Chief Operating Officer gave an overview of the current progress and stressed that these actions were being reviewed both within the IIF and by QGC. David King, Non-Executive Director stated that as the report had been late arriving with members, could the key points be highlighted. The Chief Operating Officer gave an overview of the key points with support from the Interim Director of Mental Health who updated on the mental health elements. The Interim Director of Mental Health also advised that a seminar session was planned for the Board on looking at risks within mental health in a dynamic way. The Interim Chief Executive confirmed that the report was discussed in detail at the Trusts committee meetings which ensured that measures taken were appropriate and long lasting to ensure that problems did not reoccur. The Chair also advised that measures taken will reflect the new models of care and would be discussed with the CQC. She stressed that the Trust was doing everything possible to come out of special measures and she was encouraged by the feedback she had from Anne Davis. The Isle of Wight NHS Trust Board received the CQC Inspection Update

17/T/126 SHACKLETON WARD & OLDER PEOPLES HEALTH IMPROVEMENTS UPDATE The Interim Director of Mental Health gave an overview of the issues facing

Shackleton Ward and how the Trust would provide older people’s health services including dementia services in the future. He advised that current services provision was safe and outlined that discussions were taking place with the CCG to provide a long term solution to services for older people’s illness including dementia care and confusion. He confirmed that a business case is being prepared for a short term solution which will cover the next 2 years but that a long term solution would need to be agreed with the CCG as part of wider commission solutions.

4 Quality Improvement Plan Oversight Group


Charles Rogers, Non-Executive Director stated that he was encouraged to hear that a short term solution had been identified but requested that when the finances are reviewed that a clear indication is made between the difference the short term and long term permanent solutions. The Interim Director of Mental Health advised that this would become clearer once the decision had been made by the CCG. The Chair advised that whilst the CCG decision was important, that new models of care and partnership working are also explored and that this includes housing options. Jessamy Baird, Non-Executive Director reflected that the proposed solution is only transitional and could the CCG decision be expedited. The Interim Director of Mental Health advised that the proposed solution was of a higher quality than the current provision but that it was not a permanent solution and this had been made clear to the CCG. He advised that a bespoke environment was needed and this would be included within the permanent solution to be agreed with the CCG. The Interim Turnaround Chief Financial Officer acknowledged that a decision on the short term proposal needed to be made as soon as possible and confirmed that he would be reviewing the financial implications for both this and outside solutions. The Interim Chief Executive also advised that she would be taking this issue to the Local Care Board as it related to the whole island and not just the Trust. The Isle of Wight NHS Trust Board received the Shackleton Ward & Older Peoples Health Improvements Update

Principal Risk 673 - Strategy 17/T/127 INTEGRATED IMPROVEMENT FRAMEWORK (IIF) PROGRAMME BOARD

REPORT Vaughan Thomas as Chair of the Integrated Improvement Framework Programme

Board presented the report and highlighted that the work was being undertaken across the organisation by hundreds of staff who are providing evidence that work is being completed; this is then rigorously tested to ensure that it is embedded within day to day working practices. He highlighted that there were overlaps between the work of the IIF and projects being delivered by outside organisations. He advised that some slippage was due to awaiting responses from consultations with outside the organisation and that this was being followed up with these organisations. He stressed that the Trust should not hold itself back from implementing actions which it feels are appropriate whilst waiting for partners to agree to them. He advised that if at a later date and consultation further improvements to services based on input from partner organisations then this was alright but it was not right to not take action whilst we wait for other organisations to come up with their perspective of how things can be finessed. Vaughan Thomas, Non-Executive Director acknowledged that there had been some slippages due to sickness and annual leave and that this had impacted on actions as the named individual was not available. He stressed that the IIF work was part of the day job and that in a number of cases pressure of work had been cited. He advised that following discussions it was felt that perhaps staff nearer the front line did not see the programme in the same way as management. This has been identified as an issue and the Executive team are taking this forward. Another reason for slippage is the interdependency between areas and corporate support services such as IT, HR and Estates, and he highlighted that delays in these areas are starting to impact on the lead work streams. As a result of the slippage matters the IIFPB took the decision to change two work streams to red assurance status and that this was to highlight that these needed to be brought back on track. These were Community Services and Mental Health, he also advised that a discussion about whether Ambulance should be included and the Acting Director of Nursing & Quality had argued at the meeting that the issues were related to leadership and that she would take responsibility. She did not want to make staff feel that their efforts were not valued.


From the last meeting two pieces of work were requested – one was a Critical Path. He advised that whilst it was acknowledged that the whole of IIF needs to be completed, there were specific items which needed to be done on time otherwise they have a significant effect on the rest of the programmes. These have now been identified so that they can be managed and the IIFPB was assured by the report and that it would be management by the Programme Office to ensure that none of the vital items are allowed to slip. The second piece of work was undertaken by the Executive Medical Director to review the entire work plan to assess if quality impact assessments are required in areas to ensure that before any work is done that the impact on patients is assessed. 24 work areas have been identified to be reviewed and quality impact assessments have been scheduled. The IIFPB accepted that whilst it was not happy with the slippages it acknowledged that they do not impact on the overall delivery of the programme. The Interim Director of Mental Health provided an update on mental health areas highlighted within the report. Jessamy Baird, Non-Executive Director expressed concern that the infrastructure is not clear and how systems link across areas. The Chief Operating Officer provided an update on the CAD system and the measures being taken to move the project forward. The Executive Medical Director provided an update on the community programme and advised that the team has requested that this be changed to highlight their concerns that whilst the original scope of work is all on track they have identified some additional work which they want to include. The team is therefore refining their plans and these would be incorporated within the IIF. The Interim Chief Executive advised that the executive directors are all taking the work of the IIF very seriously and were aware how disappointed staff will be that areas are turning red. She commended the staff for all their hard work and confirmed that the executive team would be reviewing how to connect the programme with front line staff to make it real for them. The Isle of Wight NHS Trust Board received the Integrated Improvement Framework Programme Board Report and agreed with the identified assurance status levels

17/T/128 QUALITY IMPROVEMENT PLAN (QIP) HIGHLIGHT REPORT The Deputy Director of Nursing presented the report and outlined how the QIP is a

subset of the IIF which has its own themes and goals which are being used by the team to assess progress and which report to QGC who monitor progress. She outlined how the Committee would be assessing progress and the report would be developing to ensure that a cohesive dashboard is produced which will measure success and progress and provide the assurance required. Jessamy Baird advised that the QGC had discussed this at their last meeting in July at which a number of concerns were raised (see min no. 17/T/133 a)). David King, Non-Executive Director also stated that it was important that the QGC is used appropriately and is given the time required to adequately assess the reports submitted. He highlighted that the agendas and papers for this meeting are long and detailed and this needed to be reviewed as a priority. The Interim Chief Executive advised that this would be reviewed as part of the quality governance review and acknowledged that meetings should be allowed time to be effective and that duplication of work with be removed. She also stressed that this would apply to the other assurance committees also who have input into the IIF work streams. The Isle of Wight NHS Trust Board received the Quality Improvement Plan Highlight Report


17/T/129 REPORT ON PROGRESS OF NHSI UNDERTAKINGS The Interim Chief Executive presented the report and advised that in order to deliver

the IIF and QIP the Trust also had to deliver on the NHSI undertakings. She confirmed that a revised report was being prepared which would show how it links to the IIF and QIP and that this would be presented from the November Board meeting. The Isle of Wight NHS Trust Board received the report on the Progress of NHSI Undertakings

Principal Risk 712 – Finance & Principal Risk 671 – Workforce 17/T/130 PERFORMANCE REPORT The Chief Operating Officer presented the report and highlighted the following:

Positive status positions:

• Pressure Ulcers: We have continued to sustain a reduction in grade 4 and ungraded pressure ulcers with 0 grade 4 ulcers reported in the period.

• MRSA5: 0 new cases of MRSA • Referral to Treatment has continued to perform above our trajectory ending

the month of July at 92% validated against a trajectory of 89%. • Diagnostic services : We continue to achieve our waiting times for

Diagnostic services in the month • Surgical Cancellations: We continue to have a low level of surgical

cancellations on the day of admission since April 2017 5 patients. • 111 performance: This has achieved 88% year to date with a 90%

achievement in month which continues to show improvement and recovery of this service against a target of 95% and in the upper quartile nationally for performance. Training and recruitment issues continue but the team are working effortlessly to attain the high standard this service has been known for.

• Re-admissions: In Medicine we continue to see a fall in 30 day re-admission rates

• Stroke: Patients again have shown an improvement in the length of their stay on the Stroke Ward up to July with 86% of patients being on the Stroke Ward against an 80% target

• Emergency Department 12 Hours target: 0 patients have waited over 12 hours in A&E from decision to admit to admission in since April.

• Emergency Care 4 hour standard: This trajectory was not achieved in July however we began to see the improvements with an increase in performance of 7.2% taking us to 84% against a trajectory of 86%. I am pleased to report we have continued to see the performance in our emergency department rise to achieve 94% un validated for the month of August against a national position of 87%

• Compliments: We received 195 compliments during July • Frailty: Our community services team have mapped and developed a frailty

pathway for those older residents of our island. This work has been completed in conjunction with our colleagues in Primary care and a task and finish group are now established to roll out and deliver this program of work

• Mental Health: • Early Intervention Psychosis (EIP): Mental Health all patients

have been placed on an Early Intervention Psychosis (EIP) pathway within 2 weeks of referral which sustains this service above the national standard at 80% against a national target of 50%.

• IAPT6: Patients that have completed their IAPT treatment and moved to recovery at 54% against a trajectory of 50%

• Community Mental Health: There has been a further increase in those patients who are known to community mental health services that have had a risk assessment completed in the last 12 months which has had an increase from 19% to 81% year to date.

5 Methicillin-resistant Staphylococcus Aureus (bacterium) 6 Improving Access to Psychological Therapies (IAPT) programme


Areas of concern and challenge:

• Clostridium Difficile (C.diff): 1 new case of Healthcare Acquired Clostridium Difficile identified in the Trust during July. This has increased the year to date figure to 8 against an agreed total of 7. Actions to drive C.diff reduction continue, this now includes discussion with the CCG where the diagnosis of C.diff has been made in the community.

• Ambulance: The Trust continues to under-performed against these 3 national ambulance targets and the system-wide agreed trajectories; Red 1 slightly under-performed at 64.3% against trajectory of 67.4% (and 75% national target) but against a National picture of 70%. Red 2 also slightly under-performed at 71.4% against trajectory of 74.7% (and 75% national target) again against a national picture of 63%. 19 mins under performed at 91.8% against target of 95% and trajectory of 95.2% with the National figure being at 90%

• Cancer treatment <31 day and <62 day targets – For July the Trust achieved all Cancer waiting time standards with the exception of the 62 day. The current 62 day standard was not achieved with a position of 70% of patients treated in time against a target of 85%. The team continue to work closely with services at the tertiary centre and review all cases.

• Theatre utilisation; It is disappointing to report a slight decrease in the utilisation of these resources during July although important to note that main theatre utilisation has increased on previous months use.

• Mixed sex accommodation: There were 3 breeches reported in July linked to the day surgical unit and 2 reported within the Intensive Care unit relating to patients whose acute treatment had ended and a suitable bed on a main ward was not available within 4hrs.

• Complaints and concerns: The Trust received 36 formal complaints in July against 26 in June and the previous months and 65 concerns against 66 in the previous month. The complaints were related to communication (21), appointments (14), and clinical treatment (14) with these being related to the Emergency Department, Outpatients scheduling team, and Surgical Wards.

• Community Nurse Locality Teams: Continue to struggle with the increasing demands on their service. We have placed some additional leadership into the team to ensure measures reflected in the integrated improvement framework are being completed and these actions are improving the position in this valuable service.

Workforce:

• Workforce report is in revised format, open to feedback and work in progress • Contracted staff in post under budgeted establishment by c300 fte and active

recruitment correlates to vacancies in full • Additional staffing in month covering vacancies in full • Agency usage exceeded NHSI ceiling – actions are in place to address:

recruitment drive, focus on effective e-rostering, authorisation controls and weekly reporting

• Sickness absence 4.17% in month and 4.5% rolling 12 month period – individual case management now in place

• Mandatory Training compliance has improved to 80%. Subject compliance and service areas of concern are being supported to increase compliance rates. Bank staff, and Medical/Dental are target staff groups.

• Appraisal rates have declined due to 12 month rolling record and actions are in place to improve to 2016 rates

• Improving health and wellbeing CQUIN are on target to be achieved with the actions

Finance: The Interim Turnaround Chief Financial Officer presented the finance section of the report and advised that despite the Board only recently agreeing the annual financial plan with a deficit of £18.8m, the position at Month 4 showed that the Trust was not on plan. He advised that the deficit was larger than expected by around half a million pounds at this stage of the year. He outlined the reasons for this and stressed the need for action to be taken now to correct this. The main reasons for this are:


• The Trust is currently seeing and treating more Patients than we expected to in our plan which is reducing the length of time our Patients are waiting for treatment which is a really good thing; however we are not being paid to treat those extra Patients by our Commissioners. The Trust will be working with our Commissioners to try to rectify this.

• In order to see and treat our Patients the Trust is using more Agency staff than it planned and this is not in our budget. The Trust is now producing short, medium and longer term plans to reduce this reliance on Agency staff and would welcome any thoughts and ideas from staff on how this might be done this safely in their areas.

• The Board has also made a commitment to invest in improving the quality of some of our services we are providing as a response to the CQC findings. This investment totals a maximum of almost £2.5m in this year and the Trust will expect to see significant benefits in the quality of the services to Patients. The finance team is working with Clinical Business Unit leaders to firm up the plans for this investment and again if you have any thoughts and ideas on what and how to do this please let us know.

• The in-year Cost Improvement Plan with a target of £8.6m was behind schedule and urgent work was required to identify at least a further £4m worth of saving schemes in this year. This work has just started and the finance team would like to hear from staff on how to reduce waste in their areas. For example, if every member of staff saved £1,500 between now and the end of the year the target would be reached

The Interim Turnaround Chief Financial Officer confirmed that the Board had also agreed the £8m Capital Investment programme for this financial year with work having started to deliver these plans. He advised that the Trust had secured over £400k from the Department of Health to upgrade our Emergency Department and plans are being finalised to do this as soon as possible.

The Board discussed the report and clarity was given on a number of points raised by the Non-Executive Directors. The Isle of Wight NHS Trust Board received the Performance Report

17/T/131 CHIEF OPERATING OFFICER’S REPORT The Chief Operating Officer presented his report which provides an overview of

current service issues and challenges, mitigating actions and good news, affecting the five clinical business units for the period 24th June to 11th August 2017. The Isle of Wight NHS Trust Board received the Chief Operating Officer’s Report.

17/T/132 FINANCIAL PLAN 2017/18 The Interim Turnaround Chief Financial Officer advised that this paper was presented

to Board for formal approval. He confirmed that it had previously been discussed at the Board Committees and at Board on 7th June 2017 when if was agreed that it would come for formal approval following the Independent Financial Review. It was also confirmed that the Trust had been operating in accordance with the plan for the past 5 months. The Isle of Wight NHS Trust Board approved the Financial Plan 2017/18

17/T/133 TOP KEY ISSUES & RISKS ARISING FROM SUB COMMITTEES The Chair presented the Top Key Issues and Risks arising from Sub-Committees.

1) Quality Governance Committee: Jessamy Baird as Acting Chair of the

committee reported on the key points raised at the last meeting held on 25th July & 18 August 2017.


a) 17/Q/093 - Clinical Prioritisation of IT Projects: The Committee was

concerned that clinical prioritisation is given to key IT Projects to ensure that they align with clinical need. The Committee recommended that the ICT Assurance Committee and IIF Programme Board ensure that these are aligned and appropriately scheduled. The Committee requested that an Executive Director member of QGC take accountability for ICT related items that impact on clinical care provision.

b) 19/Q/095 - Recruitment to key Clinical Roles: The Committee is concerned that a number of critical posts are struggling with recruitment. These have been assessed as being clinically important and need a full recruitment plan for QGC review beyond statement that role is out for recruitment. The roles include: anaesthetist, physicians for ICU, Emergency Care, Paediatric Nurses, Woodlands staffing, and safeguarding. It is essential an enhanced recruitment strategy for these roles is brought to QGC and/or Board as a matter of urgency.

c) 17/Q/095 - Relocation of Key Teams due to unsuitable accommodation: The Committee is concerned about the delay in finding suitable alternative accommodation to facilitate the relocation of the Ophthalmology environment, the Speech & Language Therapy and District Nursing teams. It recommends that a full review is undertaken and appropriate plans are implemented at the earliest time.

d) 17/Q/096 - Quality Improvement Plan: The Committee highlighted the following areas for further discussion: End of Life Care, E-Rostering and Safe Staffing, Bed flow and Patient Discharge, Ambulance targets and Cancer target for patients waiting up to 62 days for treatment. The Committee recommends that these areas are reviewed as a priority under the IIF.

e) 17/Q/097&105 - Woodlands & new Model of Care for Mental Health: The Committee had reviewed and considered the proposals and recommends that the Board approve the plans.

f) 17/Q/098 - QGC approval of Section 31 Rating: The Committee agreed that sufficient evidence was provided to enable it to be formally agreed that Sections A and H are advanced to ‘Substantial Assurance’

g) 17/Q/107 & 112 - Discharge & Patient Flow: The Committee was concerned about the continued delay in discharge summaries being issued. It was also concerned that Patient Flow continued to be impacted upon by delayed discharge and requested that this is reviewed by the CBUs and the Chief Operating Officer. The Committee decided that at present they had received Negative Assurance.

h) 17/Q/112 - Consultant Job Planning & Workload: The Committee was concerned about the delay in completing the job planning and workload review for consultants and requested that this be reviewed by the CBUs and the Executive Medical Director. The Committee decided that at present they had received Negative Assurance. In addition to the above, Jessamy Baird, Non-Executive Director highlighted that the Committee had discussed the general awareness of infection control throughout the Trust and that this did not just apply to clostridium difficile. She confirmed that the Acting Director of Nursing & Quality would be taking this forward. She advised that the Committee was aware that lots of work is being undertaken to improve discharges and patient flow and that the Committee would be continuing to monitor progress. In relation to 7 Day Services, she advised that the Committee had received reports on the progress to date but it remained concerned over Job planning and that this


would also continue to be monitored.

2) Finance, Investment, Information & Workforce Committee: Charles Rogers,

as Chair of the committee reported on the key points raised at the last meeting held on 25th July 2017:

a) 17/F/145 - Commissioning Intentions – QIPP7 Savings: The main contract

with the CCG includes a need to deliver QIPP savings of £6.4m in year. The CCG has formally informed the Trust that it does not yet have in place identified programmes that will result in these quality improvement initiations. However, the revenues have already been withdrawn from the Contract. The Committee was clear that the implied £533k per month revenue reduction could not be accepted by the Trust until agreed programmes were in place.

b) 17/F/154 - Overseas Patients: The Committee received an update on the Trusts compliance with the Overseas Visitors Charging Regulations and the associated challenges.

c) 17/F/149 - Annual Estates Return Information Collection (ERIC) 2016/17: The Committee agreed the annual ERIC return for 2016/17.

3) ICT Assurance Committee: Jessamy Baird as Vice Chair of the committee

reported on the key points raised at the last meeting held on 21st July 2017.

a) 17/I/022 - Civica Paris Risk Mitigation: A Paris Improvement Programme is

in place and being work through alongside the clinical teams; however the Board should note the need to ensure mitigation remains in place for the full time whilst the programme is delivered. The risk mitigation should be monitored through Quality Governance Committee as part of QIP reporting.

b) 17/I/018 - ICT Capital requirements and impact: The Board should note the significant reliance on capital funding to support improvement which must be aligned with the system priorities. There is a risk that with no clinical strategy agreed and ICT being a key enabler, that projects could be delayed if earl requirements are not identified with the Informatics Strategy becoming fast out of date.

c) 17/I/023 - Information Governance Tool Kit 2017/18: The Board should note the year end position on the IG Toolkit as report through Finance, Investment, Information and Workforce Committee. There is a risk that without a clear plan for 2017/18 aligned with the recent release of the toolkit the Trust may not achieve Level 2 compliance which will have a detrimental impact on reputation and have regulation/contractual impact.

The Isle of Wight NHS Trust Board received the Top Key Issues & Risks Arising From Sub Committees

17/T/134 ANY OTHER BUSINESS None

7 Quality, Innovation, Productivity and Prevention (QIPP) Commissioning


17/T/135 QUESTIONS FROM THE PUBLIC None

DATE OF NEXT MEETINGS The Chair confirmed that the next meeting of the Isle of Wight NHS Trust Board to be

held in public is on Wednesday 4th October 2017 to be held in the Conference Room, School of Health Science Building, St Mary’s Hospital, Newport, IW PO30 5TG

The meeting closed at 12:15pm Signed………………………………….Chair Date:…………………………………….

Enc B

28/09/20171 of 2

ISLE OF WIGHT TRUST BOARD Pt 1 (Public) from April 17 - March 18ROLLING SCHEDULE OF ACTIONS TAKEN FROM THE MINUTES

Date of Meeting

Minute No. Action No.

Item Action Exec Lead Update Report Author

Further Action by Other

Committee

Due Date Forecast Date

Progress RAG

Date Closed

05-Oct-16 16/T/192 TB/226 Annual report of compliance against the Code of Accountability (Code of Conduct)

An annual report of compliance against theCode of Accountability (Code of Conduct)would be presented at the end of the financialyear.

DCEO 17/05/17 - This report will be presented to the next meeting of the Audit &Corporate Risk Committee on 8th August 201708/08/17 - Report has been deferred to November meeting due to changeswithin the Board28/09/17 - To be included as part of 2017/18 review and in support ofAnnual Governance Statement for 2017/18. Action Closed

ACRC 30-Apr-17 01-Apr-18 Closed 28-Sep-17

08-Mar-17 17/T/030 TB/237 Patient Story Action Plan The Deputy Director of Nursing to provide theaction plan on the Patient Story to QGC

DDN 29/03/17 – The Out Patient team own the action plan for this patient story and will present to QGC in April05/04/17 - This will now be presented at the next QGC as April meeting has been cancelled and May meeting is due to be a planning workshop.22/06/17 - QGC continue to monitor this and a review will be provided to the July meeting25/06/17 - Update on progress planned for QGC on 27th June with summary update at the September meeting28/09/17 - Update provided to the QGC meeting. Action is now closed

QGC 05-Apr-17 26-Sep-17 Closed 28-Sep-17

08-Mar-17 17/T/042 TB/243 Local Area Co-ordinator Pilot Scheme

The Chief Operating Officer to bring a reportto the Board on the outcome of the LocalArea Co-ordinator Pilot Scheme.

COO 31/05/17 - The Trust continues to wait for the decision to be made on thefuture of the ownership and direction of travel for this pilot. Currently theJoint Commissioning Board is looking to make a decision on the future ofthis in June. The Trust will be in a position at the end of June to report onthe future of these services26/06/17 - The development has been discussed with the health and socialcare economy on 27th June. Further discussion on progress will be takenforward through the Joint Commissioning Board at the next meeting 19/09/17 - Update was presented to Board at Seminar. A full evaluation ofthe pilot is due to be completed by the end of September.

07-Jun-17 08-Nov-17 Progressing

05-Apr-17 17/T/057 TB/246 Revised Board Committee Structure

The Company Secretary to prepare theTerms of Reference for the new Committeestogether with a timeline for theimplementation of the new Board CommitteeStructure.

CS 17/05/17 - Chair emailed NEDs to confirm implementation of Board Sub Committee structure postponed until Associate NEDs are recruited.07/06/17 - The Company Secretary confirmed that terms of reference for the committees was being covered within the Corporate Governance Framework report later in the meeting. 05/07/17 - It was confirmed that this would be discussed at the Remuneration & Nominations Committee later in the day.29/08/17 - Structure to be agreed following outcome of Extermal Governance Review

07-Jun-17 06-Dec-17 Progressing

05-Jul-17 17/T/101 TB/262 Pressure Uicers The Deputy Director of Nursing to provide anupdate on the pressure ulcer situation atSeminar in July.

DDN 18/07/17 - Seminar Programme amended. This item was deferred to later Seminar.

18-Jul-17 17-Oct-17 Progressing

05-Jul-17 17/T/104 TB/263 Woodlands Estate The Deputy Director of Finance to review theprovision for dilapidation costs in relation toleasehold buildings and in particularWoodlands.

DDF 01/09/17 - Finance team provided an update to Vaughan Thomas concerning the provision for dilapidation costs on leasehold buildings. This action is now closed.

04-Oct-17 04-Oct-17 Closed 01-Sep-17

Non Executive Directors: Eve Richardson (ER) Charles Rogers (CR) David King (DK) Jessamy Baird (JB) Vaughan Thomas (VT)

Key to LEAD: Interim Chief Executive (ICE) Deputy Chief Executive Officer (DCEO) Interim Turnaround Chief Financial Officer (ITCFO) Executive Director of Strategy & Planning (EDSP)

Director of HR &OD (DHROD) Board Governance Officer (BGO) Head of Communications (HC) Head of Corporate Governance (HoCG)

Chief Operating Officer (COO) Deputy Director for Allied Health Professionals (DDAHP)

Executive Medical Director (EMD) Acting Director of Nursing & Quality (ADNQ) Deputy Director of Nursing (DDN) Director of Mental Health (DMH)

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28/09/20172 of 2

Date of Meeting

Minute No. Action No.

Item Action Exec Lead Update Report Author

Further Action by Other

Committee

Due Date Forecast Date

Progress RAG

Date Closed

05-Jul-17 17/T/106 TB/264 QIPP Agreements for 2017 The Deputy Director of Nursing to reviewwhen the QIPP agreements had been madefor this financial year.

DDN 28/09/17 - Update to be provided to QGC QGC 04-Oct-17 31-Oct-17 Progressing

05-Jul-17 17/T/106 TB/265 E-Rostering Reporting The Board Advisor – HR & OD to arrange forfuture e-rostering reporting to be split intocorporate and clinical care areas.

IDHR&OD 28/09/17 - Revised HR Performance Report submitted for October Board. This action is now closed

04-Oct-17 04-Oct-17 Closed 28-Sep-17

05-Jul-17 17/T/107 TB/266 Performance Report additional data

The Executive Director of Strategy &Planning to discuss including data onunexpected deaths/birth defects, reviewingthe focus on community services within thereport and introducing trend lines into thereports for the next Performance Report andthat any future amendments to the report willbe flagged in the coversheet for reference asthey are introduced.

EDSP 06/09/17 - Jessamy Baird, Non-Executive Director requested that effective KPIs are clearly shown in future reports which she felt were still not clearly shown and that assurance is provided. It was noted that work is included within the IIF and the format of the performance report would be included within the governance review. 28/09/17 - Will form part of updated performance reporting structure

04/10/2017 08-Nov-17 Progressing

05-Jul-17 17/T/112 TB/267 Fire Risk Assessment Report The Executive Medical Director to provide areport on the outcome of the audit and riskassessment for all Trust properties issubmitted to the Board.

DCEO 28/09/17 - Update to be provided to FIIWC as part of the Estate report FIIWC 04-Oct-17 31-Oct-17 Progressing

06-Sep-17 17/T/118b) TB/268 Revised SIRI Report The Interim Director of Nursing & Quality to arrange for a SIRI report to be created, alongside a more detailed SIRI report for QGC, to ensure effective assurance for Trust Board that serious incidents are identified, acted upon and lessons learned.

IDNQ 28/09/17 - SIRI report is being developed. A revised version has been seen by QGC but further developments are planned

QGC 04-Oct-17 31-Oct-17 Progressing

06-Sep-17 17/T/124 TB/269 Revised Mortality Report The Executive Medical Director to arrange for the revised Mortality Report to be sent to future QGC meetings and circulated to all Non-Executives in advance of the meeting.

EMD 28/09/17 - Revised Mortality report included within the Quality Performance Report and was also seen at last QGC meeting. This action is now closed

QGC 04-Oct-17 04-Oct-17 Closed 28/09/2017

Trust Board (Part 1 – Public) Page | 1

REPORT TO THE TRUST BOARD (Part 1 - Public)

ON 4th OCTOBER 2017 Title Chief Executive Officer’s Report

Sponsoring Executive Director

Maggie Oldham, Interim Chief Executive Officer

Author(s) Andy Hollebon, Head of Communications and Engagement

Purpose For information

Action required by the Board:

Assurance X Approve

Previously considered by (state date):

Sub-Committee Dates Discussed

Key Issues, Concerns and Recommendations from Sub Committee

Trust Leadership Committee

Audit & Corporate Risk Committee

Charitable Funds Committee Finance, Investment, Information & Workforce Committee

Mental Health Act Scrutiny Committee Remuneration & Nominations Committee

Quality Governance Committee Information & Communications Technology Assurance Committee

Integrated Improvement Framework Programme Board

Please add any other committees below as needed Board Seminar Other (please state) Integrated Improvement Framework: IIF Workstream Section/Clause Section/Clause

Section/Clause

Staff, stakeholder, patient and public engagement: This report has been prepared by the Head of Communications & Engagement on my behalf. The report covers the period 31st August to 28th September 2017. The report is intended to provide information on activities and events and cover issues of national, regional and local importance that would not normally be covered by the other reports and agenda items. Detailed information about the five Clinical Business Units appears in the performance reports. Executive Summary & Analysis:

This report provides a summary of key successes and issues which have come to the attention of the Chief Executive. The report covers the following issues: National • Meeting of Chairs and Chief Executive Officers/Accountable Officers of the NHS Trusts and

CCGs

Enc C


Local • Board Membership • Car Parking and Security at St. Mary’s Hospital • Island Mental Health Services shine • Funding awarded to Trust to improve emergency and urgent care services for patients • Flu Vaccination and Winter Planning • Fundraising, Charitable Funds and community support for the NHS • Governance - Trust Leadership Committee

Recommendation to the Board:

The Board is recommended to note the contents and receive the report.

Attached Appendices & Background papers For following sections – please indicate as appropriate:

Trust Goals & Priorities All Principal Risks (BAF) None

Legal implications, regulatory and consultation requirements

None

Date: 28th September 2017 Completed by: Andy Hollebon, Head of Communications and Engagement


Chief Executive’s Report covering the period 31st August to 28th September 2017

My report this month covers a range of issues between 31st August to 28th September including items of national and regional importance, and local issues. More detailed information relating to the five Clinical Business Units appears in the performance reports.

National

Meeting of Chairs and Chief Executive Officers/Accountable Officers of the NHS Trusts and CCGs

Non-Executive Director Vaughan Thomas and I attended a national meeting on 15th September of Chairs and Chief Executive Officers/Accountable Officers of the NHS Trusts and CCGs which experienced the greatest challenges last winter . We heard from Jeremy Hunt (Secretary of State for Health), Simon Stevens (Chief Executive of the NHS), David Behan (Chief Executive of the Care Quality Commission) and Jim Mackey (Chief Executive of NHS Improvement, our regulator).

It was a challenging meeting as you would expect and yet it was also motivational as we got to hear some of the stories of success that were described from Trusts like ours that had got into difficulty in the past with patient flow but had managed to sort their problems out. We came away with a very strong sense of how we need to be brave in challenging our practices and behaviours to genuinely ensure that our sickest and/or most injured patients arriving in our Emergency Department receive the excellent care that our Island community deserves this winter.

All NHS acute trusts have been categorised this year from 1 to 4, with 1 being the exemplars and 4 being those who require significant help or perhaps even changes in their leadership teams. During the discussions it was plain that in many organisations emergency patients are spending too much time in the Emergency Department or queuing in ambulances.

The Isle of Wight NHS Trust has been categorised as a category 3 trust. This means that we have made progress but that there is not the assurance that we can maintain our improvement. I have asked all staff to take that challenge quite personally, to look at our practice and behaviours and ask ourselves whether that is a true reflection of where we are.

It was made very clear to me, along with all of the other CEOs, that our emergency patients must come first. There is so much evidence now around sepsis, fractured neck of femur, frailty, patients requiring emergency surgery and many other presentations that early intervention by senior decision making clinicians directly affects outcomes. In other words, how seriously each of us takes our commitment to emergency care will be directly reflected in the outcomes for our patients.

My vision for this Trust is that we will learn how to do these things as routine ‘business as usual’, not just to help out occasionally and we will shape our services accordingly so we can proudly say that we offer our Island and its visitors the best emergency care in the NHS.

Local

Board Membership

I wrote last month about changes to the membership of the Board including the appointment of Barbara Stuttle, Charles Godden, Darren Cattell and Kevin Bond. There have now been further changes as follows:

(i) Following external advertisement we have appointed, with the support of NHS Improvement, Julie Pennycook as Director of Human Resources and Organisational Development. Julie has been working with the Trust since January 2017 and has extensive experience in the NHS with Solent NHS Trust and in the private healthcare sector.

(ii) After nine years as the Trust’s Medical Director and having helped steer the Trust through the publication of the CQC report Mark Pugh has decided to stand down and focus on his work as a Consultant Rheumatologist and research and development. Mr Steve Parker,


Consultant General, Breast & Paediatric Surgeon and Clinical Director for Surgery, Women’s and Children’s Health will be Interim Medical Director. Arrangements to recruit a permanent Medical Director will be made once a new Chair and permanent Chief Executive Officer are in post.

(iii) Non-Executive Director Jessamy Baird’s appointment came to an end on 30th September 2017.

The Trust Board currently comprises:

Name Board role

Eve Richardson OBE Non-Executive Chair

Dr Charles Godden Associate Non-Executive Director

Charles Rogers Non-Executive Director

David King Non-Executive Director

Vaughan Thomas Non-Executive Director

Maggie Oldham Interim Chief Executive Officer

Frank Sims Deputy Chief Executive

Dr Barbara Stuttle CBE Interim Director of Nursing and Quality

Darren Cattell Interim Turnaround Chief Finance Officer

Jon Burwell Director of Strategy and Planning

Julie Pennycook Director of Human Resources and Organisational Development

Kevin Bond Interim Director of Mental Health

Shaun Stacey Chief Operating Officer

Mr Steve Parker Interim Medical Director

Notes:

• Interviews for the new Chair were held on 22nd September 2017. The appointment is made by NHS Improvement and is subject to confirmation by the Cabinet Office. An announcement is expected shortly.

• Chris Palmer, Executive Director of Financial and Human Resources, retires from the NHS in December 2017. Chris is currently undertaking specific projects for me and handing over the Executive responsibilities for financial and human resources to new Directors.

• Jon Burwell has been on secondment to a mainland NHS Trust and returns on 2nd October. • Dr Paul Evans is currently supporting the Board on engagement with clinical staff. • Alan Thorne has taken over from Philippa Slinger as Improvement Director for the Trust. This

is an appointment made by NHS Improvement.


Car Parking and Security at St. Mary’s Hospital

I wrote last month about the improvements we’re making to car parking and safety on the St. Mary’s Hospital site. Working with our partners APCOA Parking UK we have now arranged for a barrier to be installed across the road outside the South Block (old Workhouse) to curtail the use of the site as a short cut between Medina Way and Dodnor Lane. Automatic Number Plate Recognition (ANPR) is also being introduced into two car parks to enable the introduction of ‘pay on exit’, something patients and visitors have been asking for. We are still refining the arrangements but current details are available on the Trust’s website and we will update the details as more information becomes available.

Island Mental Health Services shine

The Trust’s work with Hampshire Constabulary on the Serenity Integrated Mentoring (SIM) network was highlighted at a national mental health and policing conference on 5th September organised by the National Police Chiefs’ Council (NPCC) and the College of Policing.

Sgt Paul Jennings from Hampshire Constabulary and Vicki Haworth, the Trust’s Innovation Lead for Mental Health services spoke about improving care, recovering lives and managing demand for services. You can find out more more about the project online at https://www.highintensitynetwork.org/. As well as running a workshop for the conference participants Paul and Vicki spoke with HRH Prince William about the importance of addressing mental health issues.

Funding awarded to Trust to improve emergency and urgent care services for patients

The Department of Health has announced on 10th September that the our Trust is among 19 hospitals across England who have been awarded a share of £13.34m The £714,000 awarded to the Trust is to help support NHS England’s wider plans to improve A&E performance in England by 2018. In particular, it will improve the flow of patients in the hospital and help the Trust hit the target of admitting, transferring or discharging 95% of patients within 4 hours.

The money will be used to improve the current emergency department (A&E). We will look to build a dedicated area to receive patients referred to the hospital by their GP to see the medical team. This will mean they will not have to wait in the emergency department. In addition we will be looking to improve the service for patients who attend the Emergency Department with minor illnesses and/or injuries. These will be streamed away into a new care area so that the emergency care doctors remain free to deal with the major emergencies that arrive by ambulance.”

More information about NHS England's plans for A&E can be found here: https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/urgent-and-emergency-care/

Flu Vaccination and Winter Planning

At the national meeting of Chairs and Chief Executives/Chief Officers mentioned above all the speakers mentioned the importance of ensuring that organisations renewed their efforts to encourage front line staff to take up the offer of the flu vaccination. We heard from all the speakers how much of a strain flu had placed on health care systems in Australia and New Zealand during their recent winter period, and how we should take this as a serious warning of what is potentially heading our way.

Our flu vaccine uptake for frontline staff last year reached 47%, which was an improvement on the previous year, however our Trust is still one of the lowest nationally for flu vaccine uptake, hence why we need a different approach this year.

It is important that we embed a cultural shift towards it being considered standard to receive the flu vaccination. There are many myths and misconceptions about the vaccine which we need to put straight and we will be making sure that we address this in our communications when we launch the campaign in October. I really believe the flu vaccine can help save the lives of the most vulnerable

https://www.highintensitynetwork.org/

https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/urgent-and-emergency-care/

https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/urgent-and-emergency-care/


members of our communities so I feel compelled to take every opportunity I have to encourage people to receive the vaccination.

Fundraising, Charitable Funds and community support for the NHS

A cake sale on 22nd September in the Main Entrance at St. Mary’s Hospital raised funds to support the work of Mercy Ships. Mercy Ships provide the world’s largest charitable floating hospital. They bring free medical care to some of the world’s poorest people and are almost entirely staffed by volunteers. Staff Nurse Patience Wells on Children’s Ward will be volunteering with them for three months later this year on a ship visiting Cameroon. Colleagues Nursery Nurse Karli Toogood, Staff Nurse Sam Matthias and Play Specialist Dionne Davies from the Children’s Ward raised £400 in two hours – enough to fund Patience’s stay on the ship for one month. More information about Mercy Ships can be found at www.mercyships.org.uk. Thanks to all our staff who are involved and to those who bought a cake.

Governance - Trust Leadership Committee

The Trust Leadership Committee (TLC) comprises Executive Directors and Clinical Business Unit representatives and meets monthly. The following key points were approved/discussed:

20th July 2017

• Option Appraisals Paper for Approval for Integrated Dermatology Beyond 2017 - Approved • Business Case for Hampshire & IW Sustainability & Transformation Partnership Clinical

Director - Approved • Business Case to Increase Practitioner Capacity Across The Community Mental Health (CMH)

Service – Approved • SBAR* ADHD – Approved • SBAR* for Retrospective Agency Spend MH & LD CBU – Approved

*SBAR stands for Situation, Background, Assessment, Recommendation Maggie Oldham Interim Chief Executive Officer 28th September 2017

http://www.mercyships.org.uk/



ON 4 OCTOBER 2017 Title Board Committee Structure and Board Governance


Frank Sims, Deputy Chief Executive

Author(s) David Haycox, Governance Advisor

Purpose To approve the proposed Board Committee Governance Structure


Assurance Approve X










Please add any other committees below as needed Board Seminar 19/10/2017 Initial proposals presented and views of

Board members taken in to account Integrated Improvement Framework: IIF Workstream

Leadership and Governance

Section/Clause Board governance

Staff, stakeholder, patient and public engagement: Since the Board seminar, considered through meetings with individual Non Executive Directors. Executive Summary & Analysis:

The Board has previously accepted the urgent need for Board governance to improve. This view has been supported through independent reviews reported to the Board. There are a number of components and steps to making improvements to the governance of the Board. These include consideration and amendment where necessary of:

• Board Committee structure • The frequency and timing of meetings – to support the alignment of availability of Board

members, especially Non Executive Directors • The terms of reference of each Committee – to ensure clarity of purpose and delegated

authority

Enc D


• The membership of each Committee – balancing the need for appropriately quorate meetings whilst not over-burdening Board members with unnecessary membership of Committees

• Annual work plans for each Committee – to deliver the purpose and authority of the Committee and to be clear about reporting expectations

• The inter-relationship between Committees and reporting to Board – recognizing the benefit of cross referral between Committees

• Sub-committees, Executive led, reporting directly or indirectly to each Committee • A Calendar of Business for the Board, all Committees and Board Seminars – to support all

members of the Board being absolutely clear about required formal commitments • The content and timing of reports to each Committee and to the Board – to support efficiently

run Committees, maximizing available time Initial proposals for the Board Committee Structure (including key changes to roles of each Committee) were presented to the Board Seminar in September 2017 and since then the views of members of the Board have been taken into account in developing updated proposals summarised within this report for the Board to approve. Following approval of the Board Committee Structure then the next stages of improvement for Board Governance are proposed as:

Ref. Objective Timescale 1 Develop and update full terms of reference, including authority, purpose,

responsibilities and membership proposals for all Committees and present to each respective Committee for support

October / November

2 Annual work plans for and reporting arrangements to each Committee and a Calendar of Business for the Board and Committees to be prepared and considered by respective Committees for support

October / November

3 Discuss and agree with Executive Directors core protocols for the production of reports to Committees and to the Board in terms of content, length, ownership and production

October / November

4 Present to the Board for approval the final terms of reference, (including authority, purpose, responsibilities and membership), work plans, reporting arrangements for each Committee and protocol and Calendar of Business for January 2018 to March 2019

December


Approve the proposed Board Committee Structure and agree to the timescales as described for the next stages of improvement for Board Governance.

Attached Appendices & Background papers Attached is the proposed Board Committee Structure. For following sections – please indicate as appropriate:

Trust Goals & Priorities Cost effective, sustainable services – an enabler Principal Risks (BAF) 604 / 705


None directly but effective Board governance arrangement will support the Trust in being compliant with regulatory and legislative requirements.

Date: 27 September 2017 Completed by: David Haycox, Governance Advisor

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

Board Committee Structure

Proposals

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


IW NHS Trust Board

Remuneration & Nominations Committee

Quality Governance Committee

Information Communication

Technology Assurance Committee

Finance, Investment, Information & Workforce

Committee

Mental Health Act Scrutiny Committee Audit & Corporate Risk

Committee

(Senior Board Assurance Committee)

Charitable Funds Committee

(Board is Corporate Trustee)


Current Board Committee Structure


Proposal received from Quality Governance Solutions:

“Separate Quality from Assurance”

Quality Committee

• Quality Strategy • Quality Accounts • Patient Experience (including complaints, PALS,

surveys, focus groups) • Patient Safety (including serious incidents/never

events, incident analysis, claims reports, inquests, regulation 28 reports)

• Clinical Effectiveness (including clinical audit, NICE compliance, mortality and morbidity data and alerts, clinical outcome benchmarking, research)

• Monthly meetings • To include CEO in membership • Subcommittee structure to remove SEE and have a

Patient Safety Forum, Patient Experience Forum and Clinical Effectiveness Forum reporting directly to the Quality Committee.

Assurance, Risk & Compliance

• Risk Management Strategy • Information Governance Strategy • Data Quality Strategy • Board Assurance Framework • Corporate Risk Register • External Agencies • CQC (horizon scanning & compliance) • IG Toolkit • Annual reports including Health and Safety,

Emergency Preparedness

• Quarterly meetings • Subcommittee structure to include an operational

risk committee, health and safety committee, information governance committee


Proposed Board Committee Structure

Trust Board (monthly)

Quality Committee (monthly)

Assurance Risk and

Compliance Committee (quarterly)

Audit Committee (quarterly)

Finance and Performance Committee (monthly)

Mental Health Act

Scrutiny Committee (quarterly)

Nominations and

Remuneration Committee (biannually)

Integrated Improvement

Framework Board

(monthly) (short life

Committee)

Charitable Funds

Committee (quarterly) (Board is

Corporate Trustee)

Trust Leadership Committee (monthly) (Executive Committee of Board)

Other Key Proposals: Audit Committee: To consider risk assurance (not risk monitoring) Finance and Performance Committee: In addition to financial, contract and workforce performance, to also consider operational performance In addition to the key enabler of estates matters, to also consider the key enabler of ICT matters Quality Committee: In addition to all matters of quality improvement and performance, to consider cultural and organisational development matters




ON 4 OCTOBER 2017 Title Financial Recovery Plan Update


Darren Cattell – Interim Turnaround Chief Financial Officer

Author(s) Gary Edgson – Deputy Director of Finance

Purpose To provide an update on the development of the Financial Recovery Plan for the Trust


Assurance X Approve




Trust Leadership Committee 14 Sept 2017 In year financial performance is currently off track and long term financial sustainability is not secured



26 Sept 2017 In year financial performance is currently off track and long term financial sustainability is not secured




19 Sept 2017 In year financial performance is currently off track and long term financial sustainability is not secured

Please add any other committees below as needed Board Seminar Other (please state) Integrated Improvement Framework: IIF Work stream Finance

Section/Clause 5.5 - To ensure final 17/18 budgets and the financial plan is delivered thus

providing value for money and sustainable services Section/Clause

Section/Clause

Staff, stakeholder, patient and public engagement:

Enc E


Executive Summary & Analysis:

The Trust has a control total of a £366k deficit for 2017/18. The Board has agreed a 2017/18 deficit plan of £18.8m which is a significant move away from the control total. The deficit figure is after delivery of a CIP target of £8.6m in year. The deficit figure has been validated by a recent KPMG independent review commissioned by the Trust. A forecast has been produced at M5 which outlines a worst case deficit of £26.3m for 2017/18. This is line with the worst case deficit as identified by KPMG in their review. The detail of this position is outlined in the Finance report to this Board. Contract arrangements with the IOW CCG are not satisfactory from a Trusts perspective IOW CCG has indicated the growth funding available to increase any contract sum to the Trust is negligible in 2018-19 and beyond and the CCG (as well as NHSE from a Specialist Commissioning perspective and Adult Social Care from a Local Authority perspective) face considerable cost pressures themselves. The Trust is one of three key partners in the Local Care Plan (LCP) where Island strategic/tactical clinical and financial decisions will be made. The Trust is one of the numerous partners in the Hampshire and Isle of Wight Sustainability and Transformation Plan (STP) where longer term strategic clinical and financial sustainability decisions will be made. The Trust is already in Quality Special Measures and faces the prospect of being placed in Financial Special Measures by NHSI, our regulator, if there is; 1). No demonstrable improvement in financial performance in the immediate term 2). No credible longer term financial sustainability plan as part of the LCP or STP The Board is asked to note that the way we will address this multi-faceted challenge is to develop, agree and then implement a three year Financial Recovery Plan (FRP). This will be a Trust plan which will need to be fully integrated into the FRP for the Local Authority and the IOW CCG. The attached presentation update paper describes the framework and the process for preparing the FRP.


Approve the requirement for a FRP and the development timeline as proposed by the Executive.

Attached Appendices & Background papers

Finance Report, as at 31st August 2017 For following sections – please indicate as appropriate:

Trust Goals & Priorities Cost effective, sustainable services Principal Risks (BAF) Risk 712 Financial Resources


Achievement of Statutory Financial Duties

Date: 28 September 2017 Completed by: Gary Edgson – Deputy Director of Finance

Board presentation 4th October 2017

Financial Recovery Plan

Financial Recovery Plan - Why do we need one and how do we do it?

1.1

01 The current financial position of the Trust requires immediate intervention to stabalise the position and recover to a breakeven

position. Current forecast is £26.3m deficit.

02 The Trust needs to control processes around spend, running parallel to the financial stabilisation will be a programme “getting a grip” to do

this.

03 Model Hospital and the STP are key elements of the routes to financial stability being promoted by NHSI, NHSE and DoH. Model Hospital data is in its infancy but is developing quickly, we have the opportunity to be ahead of

the curve by embracing the NHS benchmark targets.

04 Using Model Hospital we can focus limited resources on the key areas for quick wins and maximum benefit. In coming months the Trust will

be measured against performance against Model Hospital.

05 Working collaboratively with the STP, CCG and LA we can achieve early quick wins and plan for the gap that will exist between income

and expenditure even after implementing Model Hospital recommendations.

Financial Recovery Plan - The stages of development and high level timescales

1 17/18 & 18/19 Efficiencies &

Income correction

6 to 18 months

Top 10 services in Model Hospital & Support Services/Corporate back office

12 to 24 months

3 Remainder of Model Hospital &

Local Care Planning &

STP Transformation plans

24 to 36 months

2

1.3

System wide FRP development Actions in next 2-3 weeks… Actions in next two-three months…

2017/18 In year cost out plans

Longer Term Financial Sustainability – develop and commence the implementation of FRP

Process for Development of the FRP • Size of the 3 year challenge – system deficit • Timescale for Implementation • Key Components of the solution

Baseline –Trust, LA and CCG financial projections

KPMG Desktop Long Term Financial Plan

Provider CIP incl. Model Hospital for Trust

Commissioner QIPP savings

Local Care Plan savings across all 8 programmes incl. any Transitional costs

IOW system back office and non clinical support savings

STP solutions

Structural Deficit

System Financial Sustainability by 2020-21

Key - Colour code is progress status not comfort zone!

Organisation Action and £

Trust X

CCG X

LA X

System Impact X

• CCG allocation • Tariff top up

Cost out

decisions - what do we

stop?

Financial Recovery Plan - The Trust actions 1.2

Immediate Focus - In the next two months, the plan focuses on improved understanding of the extent of our financial position, increased awareness and compliance with our financial control frameworks, closing any in year planning gaps and developing our longer term FRP

1. Trust wide communication of financial position, fully integrate into IIF

2. Wider stakeholder engagement, including understanding of Trust financial position and potential longer term impact on services

3. Quality, impact of required Quality investments and any negative risk impact of improvement in run rate/QIA process under CIP and other financial change

4. Immediate actions under first phase of FRP, building on FIP in IIF including getting a grip, cash management, establishment review and Agency spending, procurement, budget accountability

5. Closure of CIP gap

6. Securing appropriate Commissioner funding support

7. Informatics & analytics for decision making including robust financial forecasting. Assess, quantify and report impact

8. Translate KPMG independent review actions, Identify and secure appropriate support to develop longer term FRP. Start to develop joint FRP with Commissioners

9. Develop a long list of medium term actions to improve efficiencies e.g. Carter

10. Join up Acute Services Review for longer term aspect of FRP

11. Introduce a “Getting a Grip” process to effect financial control.

11. Governance and standards including streamlined processes e.g. Scheme of Delegation, Business Cases and assurance. Training and development for key staff

12. Ensure financial Performance Management Framework exists and is integrated into wider Trust “business as usual” and change Performance Management Frameworks

Our immediate financial priorities

Planned deficit and risks

(2 Weeks)

Mitigating Risks (4 weeks)

Further Planning (6 weeks)

Framework and accountability

(8 weeks)

Financial Recovery Work stream

Progress Outstanding Outcome Expected completion date

1. Communication First phase complete Continue Informed and engaged Trust staff Ongoing, messages change

2. Stakeholder Engagement First phase complete Continue – System LTFP Ongoing, link to LTFP and collective actions

3. QIA Started Continue Aligned QIA process to CIPs On going

4. Getting a Grip Initiated Actions underway - to be included in FRP

Financial Control 2-10-17

5. CIP plan refresh Initiated Quick wins, refreshed process, link to Carter

Financial Efficiency 2-10-17

6. Mitigations Plan developed Alignment with IIF, agreements with CCG

Agreed investment in Quality initiatives, appropriate funding

30-9-17 31-10-17

7. Information for decision making Initiated Tiered hierachy of reporting

Better informed decision making 31-10-17

8. Develop FRP Initiated Plan for the plan to be developed by 30-9-17

Plan for long term Financial Sustainability

30-9-17

9. Carter Efficiencies Initiated Plan for the plan to be developed by 30-9-17

Most efficient and effective Trust services prior to transformation

2-10-17

10. ASR Initiated Refreshed Financial Modelling

Strategic of Transformational change programme

31-10-17

11. Financial Governance Initiated Link to wider Governance Review

Financial decisions made through correct governance routes

31-10-17

12. Financial PMF Initiated Link to wider Governance Review

Accountability for financial responsibilty

31-10-17

Financial Recovery Plan – Progress with Trust actions

FRP next steps and key dates Action Action Comment Date FRP process Presentation to and sign off of process by FIIWC 26-9-17

System FRP Joint Health System FRP session – planning direction and outputs

27-9-17

Local Care Board Finance Deep dive – in year and longer term planning 28-9-17

KPMG support Long Term System Financial Plan development – size of challenge

Starts 28-9-17

Trust CIP workshop CBU and Corporate Depts. 2-10-17

Trust Board Adopt approach 4-10-17

Formalise CIP outputs Development of phase 1 FRP – in year financial recovery

9-10-17

Board Workshop Deep Dive into Finances and FRP 17-10-17

Board to Board Trust and CCG Board meeting – part of agenda is Finances, including in year risk share and contracting

17-10-17

Trust meeting with NHSI Critical Check point on FRP development Mid-late October

Sharing system LTFP and outline FRP with STP Socialise 31-10-17

Trust Board Receive update on FRP progress 8-11-17

FIIWC/Trust Board Receive updates and final FRP Nov and Dec 17



ON 4 October 2017 Title Emergency Planning and Business Continuity Plan:

1) Major Incident Plans (Ambulance and Hospital) 2) Emergency Preparedness Resilience and Response Core

Standards Sponsoring Executive Director

Shaun Stacey Chief Operating Officer

Author(s) Justin Burke-Jones, Head of Emergency Planning and Business Continuity

Purpose Under the Civil Contingencies Act 2004, and NHS Commissioning Board Core Standards for Emergency Preparedness, Resilience and Response (EPRR), each ambulance service provider and acute healthcare provider has a statutory duty to have a Major Incident Plan in place. These plans set out how we plan for, respond to and recover from major incidents and emergencies and has to be approved by the Trust Board. This report highlights the key changes made to the Plan in response to the national standards for EPRR. To inform and advise the board of the Trust compliance against the EPRR Core Standards


Assurance Approve X








Quality Governance Committee 26 Sept 2017 The Committee approved the plans subject to any comments provided by Committee members by 29 September 2017.

Information & Communications Technology Assurance Committee


Please add any other committees below as needed Emergency Planning and Business Continuity Group

15 Feb 2017 04 April 2017

Other (please state) Integrated Improvement Framework: IIF Workstream (Ambulance) 1.7.1 and 1.7.3

Enc. F


Section/Clause (Ambulance) 1.7.1

Section/Clause (Ambulance) 1.7.3

Section/Clause Staff, stakeholder, patient and public engagement: Appropriate Ambulance service stakeholders. Departmental Heads where consulted and asked to review the action cards for their respective areas. Executive Summary & Analysis:

The Board are asked to consider and approve the Emergency Planning and Business Continuity Plan, which has been reviewed by the Quality Governance Committee. This is a substantial and detailed set of documents that have been developed with the CBUs. Board members can access an electronic version of both Major Incident Plans and the Core Standards at the link provided. Some aspects of both the Major Incident Plans and the Core Standards documentation are read most easily through the electronic versions; however, to support Board members, hard copies of both Major Incident Plans and the Core Standards are being provided to Board members in advance of the Board meeting. The Board will receive a presentation that describes the key changes to the plans from previous versions, the highlights, key risks and steps planned to mitigate against those risks. Specifically, the presentation will identify the issues and risks relating to compliance with the Core Standards (see summary below) and planned actions to become compliant. The following provides the brief background and summary for the Major Incident Plans and Emergency Preparedness Resilience and Response Core Standards. Major Incident Plans The current plan for the Ambulance Service was written in October 2012 and updated in May 2014 and due for review in May 2015. It is a requirement under both the CCA2004 and NHS Core Standards to have an in date plan that is reviewed on a regular basis. The current plan for the Hospital was written in February 2014 and due for review in February 2016. It is a requirement under both the CCA 2004 and NHS Core Standards to have an in date plan that is reviewed on a regular basis. Emergency Preparedness Resilience and Response Core Standards Self-assessment along with discussions with the CCG has shown the Trust is not compliant with 34 (30%) of the 112 applicable standards, the remaining 78 standards (70%) are compliant and the non-compliant standards are detailed within the EPRR work plan. This is a significant risk to the Trust and in order to achieve full compliance the organisation / emergency preparedness function must deliver / identify; 1. All incident response plans to be review and meet best practice / national guidance. 2. An ISO 22301 aligned business continuity programme. 3. Identification of an emergency preparedness budget, to ensure maintenance of CBRN equipment as a minimum. 4. Undertake Training Needs Analysis and develop / implement a robust training and exercising schedule. 5. Appoint a NED to hold the EPRR portfolio by 31 October 2017. 6. Produce a comprehensive EPRR work plan to deliver against the standards.


Significant progress will be made against these actions by January 2018 and the plan for doing so will be led by Chief Operating Officer, a summary included within the presentation to Board and progress reported to and monitored by Quality Governance Committee.


The Board is recommended to approve the Major Incident Plans and the compliance rating and key priority areas to ensure the level of compliance is further improved by the end of March 2018.


For following sections – please indicate as appropriate:

Trust Goals & Priorities Excellent Patient Care – Improve Mortality – Prevent Harm Principal Risks (BAF) Risk 674 - If the Trusts quality governance processes are not

robust and embedded then the Trust may not be able to maintain adequate patient safety, patient experience and clinical effectiveness.


Civil Contingencies Act 2004 NHS Core Standards Human Rights Act Article 2

Date: 28 September 2017 Completed by: Justin Burke-Jones Head of Emergency Planning and Business Continuity



ON 4th OCTOBER 2017 Title Integrated Improvement Framework – progress update


Frank Sims, Deputy Chief Executive

Author(s) Frank Sims, Deputy Chief Executive

Purpose Agree the proposed approach


Assurance X Approve







26/9/17 Introduced in discussion, which received support

Mental Health Act Scrutiny Committee Remuneration & Nominations Committee Quality Governance Committee 26/9/17 Introduced in discussion, which received

support Information & Communications Technology Assurance Committee


20/9/17 Introduced in discussion, which received support

Please add any other committees below as needed Board Seminar 19/9/17 Agreement to approach Other (please state) Discussed with executives and broad approach introduced

and supported at NHSI Oversight meeting and QIPOG (with CQC) both on 20/9/17. IIF and priorities workshop held on 25/9/17 including Board and CBUs.

Integrated Improvement Framework: IIF Workstream Relates to the entire IIF approach Staff, stakeholder, patient and public engagement: Not applicable as this is normal business. However, appropriate to discuss and agree at board in public. Executive Summary & Analysis:

The Integrated Improvement Framework (IIF) has been in place for several months and was drafted to ensure there was a comprehensive methodology and a single plan to ensure the Trust focused on responding to the inadequacies highlighted by the Care Quality Commission (CQC) and the legal undertakings issued by NHS Improvement (NHSI). The IIF is recognised as the single place where improvement actions are located and managed and as such it remains important to use the IIF as the Trust key delivery methodology. Since establishing the IIF a new leadership team has been recruited and has taken ownership of the management of the IIF and the various work streams. Progress has been made and the leadership team now wants to move to the next stage in the improvement journey. Discussion has taken place with NHSI, CQC and Clinical Commissioning Group (CCG) colleagues as well as with the Clinical

Enc G


Business Units (CBUs) and the NHSI Improvement Director as to the best and most coherent way of managing and reporting on the progress and improvements at the Trust. The Board and Committees of Board along with Commissioners and external Regulators have all required information to gain detailed understanding of progress as well as assurance against delivery and sustainability of actions taken. This has meant that different reports have been produced for different audiences including; the IIF report, the QIP plan, progress against NHSI undertakings, the CQC ‘’must dos and should dos’’. In addition, as ownership of the work streams becomes more embedded at operational level, staff and CBU leaders have expressed a desire to re-shape the delivery plans in a way that is meaningful for more staff. The themes and timelines are unchanged. Concurrent with this thinking, the Trust has had an external leadership review and is going through a governance review and these are already moving the Trust to work in a better and more dynamic way. In addition, the Deputy CEO has been charged with redesigning an accountability framework that links together the governance changes and the need to hold Directors and CBUs to account in a clear way, which does not duplicate effort in reporting. This is due to be considered by the Board by December 2017. The IIF brings together actions agreed and progress on them but the need for continuous improvement is essential in any well-led organisation. To support this; Board held a priority setting workshop on 25/9/17 that included Clinical Business Units (CBUs) and the NHSI Improvement Director. This has set out the critical actions that need to be undertaken in 4, 6, 12 and 24 months. These will now be mapped clearly within the IIF so that the whole organisation is focused on milestones and the longer term delivery. Attached is a summary of the prioritised road map for the next 4 and 12 months that will ensure the Trust can exit special measures and meet the strategic changes necessary to deliver long term clinical and financial sustainability. The Trust works closely with Island partners as well as other NHS Providers and these priorities are being mapped, in detail, with the local care plan 8 initiatives. This will ensure that all actions are focused on critical action and use the same metrics to evaluate and check progress. Therefore, this has led to the following recommendation:

1. That the IIF continues to be the single place for overall Trust delivery of improvement. 2. That the internal performance management aspects of the IIF need to be mapped to any

changes proposed in the accountability framework to ensure proportionality and avoid duplication.

3. That the IIF is refined to ensure CBU ownership and language and scope that is understood and delivers the priorities in the appropriate timeline.

4. That the IIF is used to produce performance metrics that show progress on the improvements. 5. That the IIF is used as the single source of reporting for internal and external scrutiny. Actual

reports may need to look different and reflect different detail, depending on use.

It is expected that actions 3-5 above will take two months to work through and ensure clear audit trail from our existing reports to any new reports. In future, it is expected that Board will see a comprehensive report under the IIF that address the following issues, with agreed content. This report therefore includes existing and separate papers for each of the following:

1. IIF Programme Board report (Appendix 1)

The key concerns and delays that the Integrated Improvement Framework Programme Board on 20 September 2017 considered are:

• Mental Health Programme has been returned to AMBER following discussions identifying clear progress and impact.

• Community Programme has remained RED and a deep dive into Community Nursing is taking place to understand the specific issues, impact and plans to address. To be completed by


05/10/17 • Delays within PIDS and Information Systems are stalling delivery within the Clinical Business

Units. Actions have been taken at Programme Board to address all areas detailed above and are for Trust Board awareness at this point.

2. CQC Section 31 and Regulation 17 update (Appendix 2) This report sets out the steps the Trust has taken to address the conditions that have been imposed:-

• The specific conditions imposed within the Section 31 letter; • Actions already taken to address the condition, their current status, evidence, and the level of

assurance reached; • How risks are being mitigated in the interim, until all actions have been undertaken and there

is sufficient assurance that the actions have had the desired outcome; • Further actions planned to resolve the above.

The report summarises and details that for most of the conditions for both Section 31 and Regulation 17 there is either substantial or reasonable assurance regarding progress in meeting requirements. However, for Section 31 Care Planning and Documentation, CMHS Strategy and Ligature risks there is limited assurance at the timing of the report of August 2017. Additionally there are some areas detailed within the report that indicate limited assurance in respect of requirements for compliance with Regulation 17.

3. Quality Improvement Plan update (Appendix 3)

The Quality Governance Committee received the Quality Improvement Plan (QIP) report describing the output measures to understand the impact as part of its assurance role. These quality metrics are summarised as:

• Patient safety • Patient/User experience • Staff engagement and Leadership • Operational performance • Clinical and corporate governance

The report identifies each of the five key themes within the QIP and by exception highlights the key areas that were considered by QGC.

4. Progress on NHSI undertakings Following the NHSI investigation into the Leadership and Governance of the Trust in November 2016 and the NHSI letter informing the Trust that it was being placed in Special Measures, NHSI issued a set of Undertakings the Trust must comply with. The following summary provides the detail of those Undertakings and highlights actions taken toward their achievement. In future, delivery of undertakings will be clearly mapped into the IIF to avoid duplication and to improve consolidation of reporting at Board.

For the undertaking of Governance and Leadership, the Trust is progressing towards a comprehensive clinical and corporate governance structure that ensures the flow of timely information from all services to Board delivered within an effective Board Assurance Framework. A separate report to the Board proposes a revised Board Committee structure with the aim for full terms of reference to be considered by each Committee in October and November and the final terms of reference being approved by Board in December.


For the undertaking of operational performance, there are a number of objectives and these are captured by the Chief Operating Officer’s Operational Performance report to Board. For the undertaking of Sustainability, the Trust is in the process of developing its future strategy as part of the wider STP and MLaFL plans aligned with the output of the financial review to ensure clinically and financially sustainable services on the Island. The aim is for this strategy to be approved by Board by April 2018.


Board is asked to receive the report for assurance regarding progress of the IIF and to agree the future reporting approach and timeline.

Attached Appendices & Background papers Appendix 1 – IIF Programme Board Report Appendix 2 – CQC Section 31 & Regulation 17 Update Appendix 3 – Quality Improvement Plan Update For following sections – please indicate as appropriate:

Trust Goals & Priorities Excellent patient care Principal Risks (BAF) 673, 674, 675, 712, 1085


Only in relation to S31 and R17 undertakings

Date: 27/9/17 Completed by: Frank Sims, Deputy Chief Executive


NOW

CQC Jan 2018

Exit Special MeasuresDec 2018

Good by 2020

IIFQuality Governance SolutionsBehavioural InsightsNHS electFreshwater communications

TargetSAFE – RIRESPONSIVE - RI

Target SAFE – GOODWELL LED - GOOD

StrategyMy Life…, LCB, Hampshire Solent, STP External assumptions Public viewpoint

Isle of Wight NHS Trust – Prioritised Road Map

Vision and values

4 month priorities

EnablersComms strategyVisibility of execsSharing and learning strategyPerformance frameworkGovernance processKey system upgrade – PARISQuality Governance arrangementsBoard StrategyAmbulance CADCost benefit analysisMH records

ServiceNational KPI reportingComm MH Re – design (caseload)SI investigation policyWoodlands phase 1MH physically safe environmentSection 31, Regulation 17Ligature risksKPI’s dashboardCancerEmergency DeptRecruitment & retention planStat Man trainingAppraisals

6-12 month priorities

Deteriorating patient – EWS, documentationAudit for evidence- Environment, RecordsRisk managementCheck MUST DO’s

EnablersComms team developmentAudit to Quality CommitteeCapital plan deliveryInformation governanceSoft FM – improving PLACEBacklog maintenanceCompliance with health records

ServiceAcute MH care pathwayAdult community CQC issuesCommunity Nurse caseloadNursing standardsDSU re designWoodlands phase 2MH 7 day followTW 7 day servicesAdult community services specAdult Community IT systemsJob planningNOC/DOD embeddedRTTUrgent care centre capitalTheatre projectDigital strategyCIPSCFE

IIF Programme Board

Integrated Improvement Framework Highlight Report

Date: August 2017

To Note: Report is based on Master IIF Version 36

Enc G – Appendix 1

Key Messages Current Status

• A&E performance figure for August (invalidated) was 94.88% so well above the KPI of 90% by Oct 17 and narrowly missing the

95% constitutional standard. Performance last week was 13th best in the country. • ED has received £714k of funding for improvements following a bid nationally. The proposal used to secure the money is

centred on redesigning the current Emergency Department (ED) footprint to allow a self-contained area which will be used as the medical assessment area.

• Treat at least 92% of patients within 18 weeks of RTT by Sept 17 – has been achieved for August and we have achieved over 92% consistently for the last 31days. On 14/09/17, we achieved 93.3% which is a fantastic achievement to all involved.

• There has been a positive outcome of Quality Measures regarding level of compliance for Blood sciences. They have achieved their 90% on their non-conformances cleared from ISO inspection, evidencing good quality services.

• IM&T Programme status changed from Amber to Red in part due to capacity issues at all levels and changes at senior level,

impacting decision making and milestone progress; and in part due to slippage on critical workstreams such as Paris MH & Community system development / upgrade

• Key Performance Indicators have been developed for Programme Board there are still a number of definitions to be identified

– explained throughout report

• Programme Risk Log has been updated and reviewed inline with Critical Path.

Status Criteria: Red: Significant Issues to delivering agreed outcomes Amber: Progressing to Plan Green: Completed / Signed Off N/S: Not due to start

A

Integrated Improvement Framework Report

Delivery of Programmes is detailed within the following slides. Key milestones have been highlighted in red for information of the Board. There will be specific requirements of this Board, programme by programme that will need to be discussed and addressed. For each Programme some of the highlights and areas of concern will be brought to the attention of the Programme Board.

31st August 2017

1. Ambulance Programme To provide an clinically led 111 service that dispatches the right level of resource and directs potential patients to the most appropriate level of service for their needs. When an ambulance needs to be despatched it will arrive with the patient within target response times as often as is possible

Overall Rating A

Work Streams

1.1 To make the hospital handover process as timely and safe as possible so that ambulances can get back onto the road and respond to further life threatening calls A

1.2 To increase the coverage of the volunteer community first responder provision across the island using well trained staff who have access to the right equipment ensuring a safe and sustainable service

A

1.3 The deployment of our workforce to meet the known demands of the service through the implementation of new rota's

A 1.4 To ensure known vacancies are filled with well trained staff

achieving full staffing with no vacancies and improved staff retention, so there are sufficient numbers of suitably qualified and competent staff and managers, to provide a safe, effective and responsive ambulance service

A

1.5 Embed the national directives of Nature of Call & Dispatch on Disposition to assess situations correctly and despatch the right level of resource to our patients

A 1.6 To assess the accuracy of data provided during the last

two years to ensure Trust has correctly reported its ambulance performance

A 1.7 The Trust is compliant in the requirements of EPPR, CBRN

and MTFA capability in the Ambulance Service as agreed by the Board A

1.8 To have visibility of the service's response to patient needs and demonstrate improvements in it's performance A

1.9 To ensure equipment is available to for use by our ambulance crews to respond quickly to all patient needs A

1.10 Ambulance Services - CQC Specific actions which require resolution A

1.11 CCG Responsibilities A

1.5 - PIDs are analysing the test data for accuracy currently and as soon as cleared will begin reporting. 1.6 - CAD Solution had been agreed but supplier now can’t support works – further options being sought

(Added to Risk Log) 1.7 - Work begun on reviewing and updating major incident and business continuity plans. Major incident

Plans for Hospital and Ambulance service for submission to the October Board 1.8 - High level audit completed, results not conclusive, another audit requested based on weekly heatmap

from PIDS to be completed by CSO CSD, 31.08.17. 1.10 - KPIs developed with PIDs and produced for CCG. Existing KPIs go to Ambulance service but CCG

asked for enhanced set of KPIs which is being finalised with them. Potential cost implication if software alterations required.

Changing codes. Service now looking at swipe card system that gives authorised access as required by job role. So Ambulance driver swipe card will access Ambulance station and medicines cupboard on ambulance

Areas of Concern on plans that should be delivered by 31st August

1.1 – ED Escalation policy being written to respond when service comes under pressure to support work already taken place.

1.2 - All CFR equipment reviewed and now stored at Unit 18. Shortfalls for new CFRs identified and a Business case for any new equipment to be prepared.

1.4 - Senior Management Group have met and agreed structure; with finalised paper to go to CBU Exec meeting for agreement of funding of posts required. New permanent operational Manager in appointed

1.7 - Head of Emergency Planning role appointed 1.9 - Equipment is available to for use by our ambulance crews to respond quickly to all patient needs –

Process to measure ambulance turnround in ambulance station now being put in place to measure the success

Areas achieved on plans that were delivered by 31st August

Programme Board should acknowledge this

Future Areas of Concern

South East Coast Ambulance now not able to support CAD solution.

Programme Board should explore this

Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s

1. Ambulance Services (1)

4

P AMB 1 Description Aggregate Position

% R

ed 1

Cal

ls

Res

pond

ed W

ithin

8

Min

utes % Red 1 Calls Responded

Within 8 MinutesMonitor Trajectory

towards target


% R

ed 2

Cal

ls

Res

pond

ed W

ithin

8

Min

utes % Red 2 Calls Responded

Within 8 MinutesMonitor Trajectory

towards target


% R

ed 1

&2

Cal

ls

Res

pond

ed W

ithin

19

Min

utes % Red 1&2 Calls

Responded Within 19 Minutes

Monitor Trajectory towards target

Variation

-

Variation

-

-

Variation

0.010.020.030.040.050.060.070.080.090.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% W

ithin

Tar

get

Baseline Trajectory Target

0.010.020.030.040.050.060.070.080.090.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% W

ithin

Tar

get


84.0

86.0

88.0

90.0

92.0

94.0

96.0

98.0A

pr-1

6M

ay-1

6Ju

n-16

Jul-1

6A

ug-1

6S

ep-1

6O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb-

18M

ar-1

8

% W

ithin

Tar

get


Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s

1. Ambulance Services (2)

5


NH

S 11

1 - %

Cal

ls

Clo

sed

With

Clin

cal

Adv

ice

Onl

y

% of (TRIAGED) calls transferred to OR

answered by a clinical advisor

Target 50%

Variation

-

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Apr-1

6M

ay-1

6Ju

n-16

Jul-1

6Au

g-16

Sep-

16O

ct-1

6No

v-16

Dec-

16Ja

n-17

Feb-

17M

ar-1

7Ap

r-17

May

-17

Jun-

17Ju

l-17

Aug-

17Se

p-17

Oct

-17

Nov-

17De

c-17

Jan-

18Fe

b-18

Mar

-18

% C

alls

Clo

sed


Board Discipline Category Ref Measure of Success Due Date Status Update RAG

Y 1. Ambulance 1 Milestone 5. Standardised access to urgent care centres through NHS 111 CCG discussion ongoing for definition of standard NHS 111 A

Progress - KPI Development

2. Mental Health Programme Overall Rating R

Work Streams

2.1 To take the necessary focused action and ensure the service is compliant against CQC Section 31 and Regulation 17.

A 2.2 To develop and implement a clinical business unit

infrastructure with sufficient capacity and capability that enables the safe and effective delivery of MH&LD services.

A 2.3 Ensure the patient environment is physically safe

and protects the privacy and dignity of patients across the CBU at all times

A 2.4 Ensure Patient and Carer Stakeholder Feedback

is captured and acted upon as part of the daily business across the CBU

A 2.5 Ensure that robust and embedded Quality

governance arrangements are in place across the CBU which include clear escalation routes to the wider Trust

A 2.6 Ensure that robust and appropriate KPI's are in

place for all CBU services and that there is a direct line of sight in relation to these from front line through to the board

R

2.7 Ensure that appropriate documentation is in place, and that across the CBU there is robust document control. This will provide staff with sufficient instruction and guidance to operate safely and effectively, taking into account the redesign work streams and therefore the needs to update documents as changes in process are made. In addition robust document control will support efficiency and effectiveness across the CBU.

A

2.8 Ensure that the MH&LD CBU has in place an appropriate Electronic Paper Record that is fit for purpose and support the Trust to capture, submit and analyse relevant data as required in order to meet local and national requirements and support service improvement

A

2.1 – Whilst the Care Plan Audit been completed the triumvirate do not feel assured that the risk assessments and care plans are of a good standard. An SBAR has been completed and submitted for approval for a Nurse Consultant who will coach and support the staff through the development of evidence based care plans.

2.2 – IIF shared and appraisals to be completed. Expectations being set these will be completed by January 2018. SBAR competed for Community Matrons and submitted for approval to TLC on 24/08/17. All SBAR’s removed from the agenda for TLC. At the Senior Managers away day on 13/09/17 agreement will be made if posts should be substantive moving forward. A further meeting will then take place with CD, HoO, COO and ITCFO to discuss and approve SBAR’s.

2.5 – Risk Management Training – additional sessions to be run through September to capture remaining staff.

CQUIN Quality Advisor recruited and work plan to be agreed by 21/08/17 2.6 - Delays in developing the mechanisms to enable data capture for the identified KPIs due to capacity

within PIDS. Escalated to Exec Lead 2.8 - TOR not agreed for Clinical Reference Group– Chair to approve ASAP



2.1 – Phase 1 of the Nurse Led clinic is coming to completion. On receipt of feedback from the service users they have expressed their opinion that they did not like attending appointments in Sevenacres. A decision has therefore been made that phase 2 will move to a Community based clinic setting.

2.2 - OOH recruitment for SPA complete 2.4 - A “You Said, We Did” poster has been produced and cascaded to all public Mental Health and Learning

Disability areas. 2.5 - Quarterly report outlining trend analysis and lessons learnt from complaints, incidents and SIRI’s is

reported in the CBU leadership Group 2.6 - Complaints included in Performance Report



2. Mental Health Programme [2] Overall Rating R

Work Streams

2.9 Shackleton - To ensure that Shackleton can provide an appropriate Dementia Care Pathway that is fit for purpose and meets the needs of the ageing population of the Isle of Wight, whilst ensuring compliance with the CQC specific items relating to this Ward

A

2.10 Woodlands - To work in partnership with the CCG to deliver a new non medical model re-ablement strategy and provision for the Isle of Wight whilst ensuring compliance with the CQC specific items relating to this Estate

A

2.11 Reconfigure Acute care pathways through Single Point of Access and into the Community to deliver a safe and effective service for patients A

2.12 Redesign the Community Mental Health Services to ensure they are safe, effective in line with best practice, financially viable and outcome focused as well as ensuring compliance with the CQC specific items relating to this Service

A

2.13 Learning Disabilities - 1.Undertake a comprehensive review of the Community Learning Disability Service to plan, re-design and implement integrated NICE compliant treatment pathways for those with learning disabilities and/or autistic spectrum disorders and co-morbidities such as Attention Deficit and Hyperactivity Disorder (ADHD), significant mental disorders and behaviours that challenge for the adult population. 2. Ensure compliance with the CQC specific items relating to this service

A

2.14 CAMHS - Undertake a comprehensive review of Child and Adolescent Mental Health Services and ensure compliance with the CQC specific items relating to this service

A 2.15 IRIS - Undertake a comprehensive review of Island

Recovery Integrated Service to ensure it is deliverable within the financial envelope and ensure compliance with the CQC specific items relating to this service

A

2.16 To review and deliver clear protocols for inpatient and community staff to better manage CPA and achieve 7-day follow up ensuring this meets national best practice.

A

2.9 – All staff have now undertaken the breakaway training. 70% staff compliance Physical Intervention training with the remaining 3 staff due to complete the training by the end of October 2017.

2.10 - Meeting booked with CBU Management team on the 18th September to discuss and agree on the future organisational chart, roles and responsibilities, required staffing for delivery of projects.

2.11 - Rapid Tranquilistation competency training – only 3 members of staff remaining to attend and will be completed by 22/09/17.

2.12 - Meeting arranged with Human Resources 31/08/17 to batch adverts and incentivise vacancies.

2.13 – MCA & DOLS , more training sessions are planned to ensure that the team embed the training.

2.14 - CPD (continuing professional development) for adult psychiatrists to discuss learning points and questions raised from out of hours cases.

2.15 - CBU environmental risk assessment top be drafted 31/08/17



2.9 - Contract of agreement in place for fully functioning step down facility at Northbrooke House 2.10 – Extension on Woodlands lease has been agreed 2.11 - Increase awareness of safeguarding issues and how to report them Introduction of new seclusion paperwork 2.12 - Robust process is in place to record and monitor fridge temperatures-complete 2.14 - Review of incidents has been added as a standing item on team meeting agenda for lessons

learnt feedback and discussion




Recruitment of MH Specific posts (added to risk log) PARIS System and capacity within ICT to support / make changes PIDS Capacity to support KPIS and performance reviews

Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s

2. Mental Health Services (1)

8

P MeH 1 Description Aggregate Position

Patie

nts

with

a fu

ll as

sess

men

t/car

e pl

an

and

CPA

leve

l al

loca

ted Number of patients known

to the service with a Risk Assessment Completed

Target of 100%


Cas

eloa

d m

anag

emen

t su

perv

isio

n

Caseload management supervision

If monthly is the standard then at 90% target

P WKF 16a Description Aggregate Position

App

rais

als Proportion of staff with

current appraisal completed in 12 month

rolling period

95% in rolling 12 month period

Variation

Target may need to be reviewed unlikely to be 100% due to timing.

Improvement trajectory needs to be agreed

Variation

-

Currently only includes Community MH team

Variation

0.0

20.0

40.0

60.0

80.0

100.0

120.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% P

atie

nts


0.0

20.0

40.0

60.0

80.0

100.0

120.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% S

uper

visi

on


0.010.020.030.040.050.060.070.080.090.0

100.0A

pr-1

6M

ay-1

6Ju

n-16

Jul-1

6A

ug-1

6S

ep-1

6O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb-

18M

ar-1

8

% A

ppra

isal

s Co

mpl

eted


Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s


9

P WKF 13a Description Aggregate Position

Clin

ical

Sup

ervi

sion

Proportion of relevant staff receiving clinical supervision in line with

policy

-

P QUA 22a Description Aggregate Position

Ris

k M

anag

emen

t Tr

aini

ng Compliance with risk management training

requirements-


Patie

nts

bein

g fo

llow

ed u

p w

ithin

7

days

of d

isch

arge The proportion of people

under adult mental illness specialties on CPA who were followed up within 7 days of discharge from

psychiatric in-patient care during the period

Target of 95%

Variation

Working with HR to collect data for this KPI in Employee Online. Functionality has been tested

currently awaiting roll out.

Variation

-

Note, training needs analysis being undertaken and approach will

change significantly. Unable to currently say % untrained risk staff

in CBU

Variation

0.010.020.030.040.050.060.070.080.090.0

100.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% S

uper

vise

d


0.010.020.030.040.050.060.070.080.090.0

100.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% S

uper

vise

d


82.084.086.088.090.092.094.096.098.0

100.0102.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% C

ompl

eted


Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s


10


Com

plai

nts,

SIR

I's a

nd

inci

dent

s co

mpl

eted

w

ithin

the

Trus

t re

quire

d tim

esca

les

Complaints, SIRI's and incidents are completed within the Trust required timescales by 31/03/17

1% Quarterly Increase Working to identify appropriate data source for this KPI

Variation

0.00.10.20.30.40.50.60.70.80.91.0

Apr-1

6M

ay-1

6Ju

n-16

Jul-1

6Au

g-16

Sep-

16O

ct-1

6No

v-16

Dec-

16Ja

n-17

Feb-

17M

ar-1

7Ap

r-17

May

-17

Jun-

17Ju

l-17

Aug-

17Se

p-17

Oct

-17

Nov-

17De

c-17

Jan-

18Fe

b-18

Mar

-18

-


3. Community Programme Overall Rating A To Develop an Infrastructure alongside partner colleagues that delivers more care, that is safe, closer to home for the people of the Isle of Wight

Work Streams

3.1 Adult Services - To have caseloads that are consistent across all staff and ensure patients are managed safely

A

3.2 All Services - Developing a workforce that is resourced to provide safer care A

3.3 Adult Services - Ensure the right patients are accessing services with well written specifications

A

3.4 Adult Services - Improved record keeping for patients and staff have skills and competencies to use IT systems available to them.

A

3.5 Adult Services - To improve access to service provision and care for patients with frailty needs

A

3.6 Adult Services - More rehab patients cared for in a community setting closer to their own homes A

3.7 Adult - Other CQC Specific A 3.8 Community Services - CQC Specific:

Children, Young People and Families A 3.9 Plus MLaFL [Care Home TEC, Integrated

Locality Teams] and single change plan N/A

Due to concerns arising from the Community Nursing Deep dive programme was turned RED. Jenni Edgington has a session booked on 27th Sept to align the issues to the current plan. Improvement plan will be reviewed at October’s Programme Group and changes requested of October’s Programme Board. Work to rectify the issues will continue to happen. 3.5 - SOPS- behind schedule with mapping of individual SOPS. Will be reviewed and modified

following week 3 of going live with AFS in order to ensure most suitable. Aim To be completed Dec 2017.


3.1 - Current CHC arrangements – Shaun Stacey is currently leading on this. Work completed to identify current backlog and need outstrips current capacity of community nursing team to effectively support. New model of patient pathway navigation teams involvement being trialled.

3.2 - Clinical Supervision in Community Nursing/Physio/OT and 0-19 is established. Mental Capacity Act 2005/ Deprivation of Liberty training has been delivered bespoke in

Localities. 3.3 - Wheelchairs Specification has now changed, and the service has transferred to a new provider

(Millbrook) 3.4 - All community nurses had initial documentation training. 3.5 - Frailty Strategy is in development in alignment with input from New Models of Care and NHS Elect

Acute Frailty Network. Initial Meeting 12/10/17 3.6 - Rehab ward decommissioning in line with CCG intentions has commenced and reduced inpatient

rehab beds from 22 to 13 over past month. 3.8 - Service level KPI’s generated monthly with quarterly returns, this information is fed back to quality

meetings. ‘I Want Great Care’ in use across 0-19 services and monthly report saved with feedback.




Community Nursing – review being undertaken

Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s

3. Community Services (1)

12

P Com 7 Description Aggregate Position

Vaca

ncy

Fill

rate

s

% establishment currently not filled by permanent

staff.Monitor Trends

P Com 10 Description Aggregate Position

Reh

ab p

atie

nts

care

d fo

r in

a co

mm

unity

se

tting

100% rehab patients cared for in a community

setting and not on the hospital ward

-

P WKF 9c Description Aggregate Position

Vaca

ncy

rate

s

Vacancy ratesKey vacancy levels

reduced by 50% from Apr 17 baseline

Variation

-

Variation

-

Working to identify appropriate data source for this KPI

Variation

0.02.04.06.08.0

10.012.014.016.018.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

Vaca

ncy

Rate


0.0

20.0

40.0

60.0

80.0

100.0

120.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% P

atie

nts


0.02.04.06.08.0

10.012.014.016.018.020.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

Vaca

ncy

Rate


Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s

3. Community Services (2)

13

P WKF 1b Description Aggregate Position

Man

dato

ry tr

aini

ng

Training compliance including DoLS, MHCA, Safeguarding, Duty of

Candour etc

Monitor Trend

P WKF 13b Description Aggregate Position

Clin

ical

Sup

ervi

sion

Proportion of relevant staff receiving clinical supervision in line with

policy

-

Variation

Does this need to include all mandatory training or specific

training only, currently includes all mandatory training?

Duty of Candour is not mandatory, should it be?

Working with HR to collect data for this KPI in Employee Online. Functionality has been tested

currently awaiting roll out.

Variation

76.0

78.0

80.0

82.0

84.0

86.0

88.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% C

ompl

eted


0.010.020.030.040.050.060.070.080.090.0

100.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% S

uper

vise

d



Y 3. Community Milestone 8. Quality and performance metrics in place at service level and evidence of them being used at team meetings

KPI's under review with services A

Y 3. Community Milestone 9. Updated assessment of demand and capacity by end of Q3D&C plan being developed.CCG and Internal review of service specifications underway

A


3

4. Acute Programme

To Develop an organisational infrastructure and approach that supports the treating of patients safely through the Unscheduled Care and Elective Care Pathways

Overall Rating A

Work Streams

4.1 Unscheduled Care - To have the ability to make decisions and manage at least 90% of patients through the ED within 4hrs by Oct 17 and 95% by 31st Mar 18

A

4.2 Unscheduled Care - To Have a focused approach to managing specific medical patients using an ambulatory care philosophy to reduce the proportion of medical admissions

A

4.3 Unscheduled Care - To drive a philosophy of care in MAU/SAU/PAU that assesses and discharges a greater number of patients within 24hrs and 72 hrs from the current baseline

A

4.4 Unscheduled Care - To focus on flow and a way of working on each ward that supports safe care and discharges that balance admissions 7 days per week.

A

4.5 Unscheduled Care - To show respect to patients, families and carers and be an advocate for their wishes throughout the end of life phase

A

4.6 Unscheduled Care - Other CQC Specific: Stroke and Rehab A

4.1 – ED Staffing paper going to TLC 28/09/17 CBU and PIDS working together to provide minor breach information 06/09/17 4.2 - A Briefing Paper presented to unscheduled care programme group 14th Sept gone back

to review and agree the next steps. Update paper regarding MAAU/SAU direction to be written and subsequent IIF plans revised by Performance Reviews (Due: 10/10/17)

4.4 –Interprofessional standards being redrafted and taken to Physicians meeting on 27/09/17


Programme Board should explore these

4.1 –A&E performance figure for August (invalidated) was 94.88% so well above the KPI of 90% by Oct 17 and narrowly missing the 95% constitutional standard. Performance last week was 13th best in the country.

4.2 - Review of current service and baseline has been completed by Dr Feathers 4.3 - 10% patients daily who could be discharged identified before 10am. 4.4 –Safe Care & Discharges: The Trust achieved 2.9% against a September 17 target of 3.4%. 100K funding for Medworxx now allocated, work starting this month with a completion

date of 30/11/17. D2A commissioning needs identified by gaps analysis undertaken by the hospital at

home, system wide partnership, task and finish group. Dementia is being picked up as part of frailty.

4.5 - Through collaborative working between the End of Life Care Facilitator and the Hospital Palliative Care Team we were able to rapidly transfer a lady who was deemed to be in her last day(s) of life across to EMH in order that she could be closer to her husband, who was also a patient within the inpatient unit at EMH receiving end of life care. The family were visibly shocked and distressed with the situation of having their parents both dying at the same time but in different care settings. Despite both services having high demand we were able to collaborate to enable the lady to be transferred within 2 hours of assessment.

4.6 – Lockable notes trollies been delivered and regular IG audits undertaken.




Capacity of Information Systems to deliver at required changes aligned with Acute IIF Programme

4. Acute Programme [2] To Develop an organisational infrastructure and approach that supports the treating of patients safely through the Unscheduled Care and Elective Care Pathways

Overall Rating A

Work Streams

4.7 Elective Care - To manage , as a minimum, 92% of patients safely from referral to treatment within an 18 week period. A

4.8 Elective Care - To make the correct decisions at MDT's that results in our cancer patients being treated safely within 62 days of referral

A

4.9 Elective Care - Develop the internal diagnostics provision so that it supports safe and efficient patient care and decision making 7 days per week

A

4.10 Elective Care - Manage outpatients in an efficient way to further improve access to a specialist opinion for our patients and GPs

A

4.11 Elective Care - To improve the process of pre-assessment so that hospital resources are maximised and patients are fit and healthy and better prepared for their elective procedure

A

4.12 Elective Care - Increased Day Surgery, Theatre & OPD Procedures efficiency to improve access for our patients

A

4.13 Elective Care - 7 Day Services - Delivery of NHS 7 Day Services Clinical Standards Self-Assessment Readiness Tool

A

4.14 Primary Care - GP out of hours and walk in service A

4.7 - Updated framework to be presented to joint DNT/OMG 26/09/17 (as OMG ceased) Demand & Capacity Plans - quarterly monitoring not yet received, escalated to COO by 29/09/17 4.8 - Oncology provision across the Alliance to be agreed and implemented to address Acute Oncology

issues. . Funding to be established. Cancer Alliance Board provisionally booked for 22/09/17. Review of mainland (tertiary) and local diagnostic capacity to ensure all investigations to be

undertaken within 7 days of receipt of referral. Plan: Need to be OLM meeting discussion with CCG, CCG own the contract, so Trust has limited influence.

Clinical Nurse Specialist provision business case written. With Finance for approval. 4.9 - funding for 62 day cancer funding MR's Radiographers including running Sundays. This will address

the backlog for 3 months. A Business Case is being preparing for going forward for resilience. 1st draft complete by 15/09/17. Soton to manage GI bleeds as per NEPOD guide. Review on Endoscopy to plan for future being drafting by 30/09/17 (including temp outsourcing).

4.11 – Creation of Pre-assessment capacity & Booking dashboard. Committed to complete by 30/09/17



4.7 - Treat at least 92% of patients within 18 weeks of RTT by Sept 17 – This has been achieved for August and has also been consecutively achieved for the past 2 months.

4.8 - Review of all local diagnostic testing for Cancer to ensure all diagnostics to be performed within 7 days of receipt of referral has been completed. Route cause analysis active on every breach. Discussed at Access Group

Specialty Doctor, in conjunction with tertiary centres has been recruited and is now in post as from 04/09/17

4.9 - Business Case for development/improvement of the Sunquest ICE system to enable full GP Order Comms implementation has been approved and order from the software company. GP Order Comms plan is being drafted for the provisional delivery date of 02/18.

4.11 - ICP is moving forward new draft has been received from the print room a meeting has been booked with Clinical Lead for PAAU w/c 18/09/17. 1 hour every Wednesday has been set aside to go through this until it is completed.

4.12 - DSU/Theatre Opportunities. A review of environmental needs for the top 15 HRG procedures has been completed. A large proportion of locations are considered appropriate, however there are pockets of activity that will be reviewed with the clinician to clarify the appropriate location

4.13 - 100% Completion of audit against 7 Day working Standards



Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s

4. Acute Services (1)

16

P Acu 1 Description Aggregate Position

DTO

C's

Reduction in DTOC numbers Trajectory by Sept 17


Med

icin

e Pa

tient

s Lo

S

Reduction in overall LoS for medicine patients

10% reduction Oct 17 and 20% by April 18 from Apr

17 baseline


Emer

genc

y C

are

4 H

our S

tand

ard

Emergency Care 4 Hour Standard

Monitor Trajectory to achieve target by Mar'18

Variation

-

Variation

-

-

Variation

0.0

5,000.0

10,000.0

15,000.0

20,000.0

25,000.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

DTO

C D

ays


0.0

2.0

4.0

6.0

8.0

10.0

12.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

LoS

Day

s


70.0

75.0

80.0

85.0

90.0

95.0

100.0A

pr-1

6M

ay-1

6Ju

n-16

Jul-1

6A

ug-1

6S

ep-1

6O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb-

18M

ar-1

8

% P

atie

nts <

4 H

rs


Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s


17


Thea

tre

Util

isat

ion

of

at le

ast 8

5% fo

r all

spec

ialti

es

Theatre utilisation 85% for all specialties


RTT

Tot

al In

com

plet

e

% of admitted and non-admitted patients waiting less than 18 weeks for

treatment at time of report

Monitor agreed recovery trajectory


Can

cer 2

wk

GP

refe

rral

to 1

st O

P

Cancer 2 wk GP referral to 1st OP Monitor Trend

Variation

-

Variation

-

-

Variation

0.010.020.030.040.050.060.070.080.090.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% U

tilis

atio

n


78.0

80.0

82.0

84.0

86.0

88.0

90.0

92.0

94.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% w

ithin

targ

et


90.091.092.093.094.095.096.097.098.099.0

100.0A

pr-1

6M

ay-1

6Ju

n-16

Jul-1

6A

ug-1

6S

ep-1

6O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb-

18M

ar-1

8

% w

ithin

targ

et


Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s


18


Bre

ast S

ympt

oms

2 w

k G

P re

ferr

al to

1st

OP

Breast Symptoms 2 wk GP referral to 1st OP Monitor Trend


31 d

ay s

econ

d or

su

bseq

uent

(sur

gery

)

31 day second or subsequent (surgery) Monitor Trend


31 d

ay s

econ

d or

su

bseq

uent

(dru

g)

31 day second or subsequent (drug) Monitor Trend

Variation

-

Variation

-

-

Variation

86.0

88.0

90.0

92.0

94.0

96.0

98.0

100.0

102.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% w

ithin

targ

et


84.086.088.090.092.094.096.098.0

100.0102.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% w

ithin

targ

et


96.5

97.0

97.5

98.0

98.5

99.0

99.5

100.0

100.5A

pr-1

6M

ay-1

6Ju

n-16

Jul-1

6A

ug-1

6S

ep-1

6O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb-

18M

ar-1

8

% w

ithin

targ

et


Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s


19


31 d

ay d

iagn

osis

to

trea

tmen

t for

all

canc

ers

31 day diagnosis to treatment for all cancers Monitor Trend


62 d

ay re

ferr

al to

tr

eatm

ent f

rom

sc

reen

ing

62 day referral to treatment from screening Monitor Trend


62 d

ays

urge

nt re

ferr

al

to tr

eatm

ent o

f all

canc

ers

62 days urgent referral to treatment of all cancers

Monitor agreed recovery trajectory

Variation

-

Variation

-

-

Variation

93.0

94.0

95.0

96.0

97.0

98.0

99.0

100.0

101.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% w

ithin

targ

et


0.0

20.0

40.0

60.0

80.0

100.0

120.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% w

ithin

targ

et


0.010.020.030.040.050.060.070.080.090.0

100.0A

pr-1

6M

ay-1

6Ju

n-16

Jul-1

6A

ug-1

6S

ep-1

6O

ct-1

6N

ov-1

6D

ec-1

6Ja

n-17

Feb-

17M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb-

18M

ar-1

8

% w

ithin

targ

et


Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s


20


Dia

gnos

tic W

aitin

g Ti

mes 99% of diagnostics seen

within 6 weeks of referral 99% Seen within 6 Weeks

P WKF 1c Description Aggregate Position

Man

dato

ry tr

aini

ng


Candour etc

Monitor Trend

Variation

-

Does this need to include all mandatory training or specific

training only, currently includes all mandatory training?

Duty of Candour is not mandatory, should it be?

Variation

98.498.698.899.099.299.499.699.8

100.0100.2

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% w

ithin

targ

et


77.0

78.0

79.0

80.0

81.0

82.0

83.0

84.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17Fe

b-17

Mar

-17

Apr

-17

May

-17

Jun-

17Ju

l-17

Aug

-17

Sep

-17

Oct

-17

Nov

-17

Dec

-17

Jan-

18Fe

b-18

Mar

-18

% C

ompl

eted


5. Financial Programme Overall Rating R

To establish and effectively implement systems and/or processes for effective financial decision making, management, governance and control to achieve Financial Recovery and Financial Sustainability whilst improving Quality

Work Streams

5.1 To develop a cost improvement programme for 17/18 that is supported by operational plans

R

5.2 To develop a Capital Investment Programme for 17/18 and 18/19 that reflects the organisations strategic and operational priorities and meets the Capital Resource Limit

R

5.3 To develop and refine a Long Term Financial Plan that reflects a sustainable portfolio of services and service quality on the Island

A

5.4 To develop a finance training programme that supports operational managers to be better equipped for taking on the responsibility of financial management decisions within their CBU/Directorate

A

5.5 To ensure final 17/18 budgets and the financial plan is delivered thus providing value for money services

R

5.6 To ensure good systems and controls are in place and assure our stakeholders that financial governance is being adhered to A

5.7 To be prepared for future years and align the 18/19 cost improvement programme with the business planning cycle N/S

5.1 - Awaiting development of Local Delivery Service Plan. CIPs to be aligned once finalised. CIP full year shortfall of £3.992m

5.2 – 18/19 priorities not identified 5.5 – £5.2m commitment of additional resources to support the Quality Improvement



5.2 - Board approved £8.32m capital plans 15th August 2017 5.3 - Current LTFP - 2nd & final draft cascaded 26th July 2017 5.4 - Bi-weekly meetings held internally; training requirements identified and evidence being

captured 5.5 – All Budgets signed off




Identification of remaining CIP Additional spend for resources to support QIP. Support in delivering the capital plan by 31st March 2018 Recognition that IIF plans are required to prioritise to ensure focus is maintained on the ‘right risks’ and existing issues

Inte

grat

ed Im

prov

emen

t Fra

mew

ork

KPI’s

5. Finance (1)

22

P FIN 1 Description Aggregate Position17

/18

CIP

Ach

ieve

d

£8.613M CIP achieved 100% Monitor Trend

P FIN 2 Description Aggregate Position

Cap

ital R

esou

rce

Lim

it fo

r 17/

18

achi

eved

at 3

1 M

arch

20

18 Capital Resource Limit achieved Monitor Trend

P FIN 3 Description Aggregate Position

Fina

ncia

l pla

n ac

hiev

ed a

t 31

Mar

ch

2018

100% achievement of 17/18 budgets and

agreed financial planMonitor Trend

Variation

Year to date, CIP savings of £0.697m have been achieved,

which is ahead of plan by £0.180m. However the full year

savings forecast is £5.481m, which is £3.132m less than the total of

£8.613m required.

Variation

Currently ahead of plan at M2 but with risks, opportunities and

mitigating actions the likely year end forecast scenarios are:

Best Case - £18.8mLikely Case - £21.2mWorst Case - £28.5m

Any risks to the revised forecast need to be mitigated by identification of further

opportunities.

As at 31 May £0.189m of capital allocation has been spent and

there are only £2.6m pf projects that are underway. There remains

£3.7m of the £8.3m allocation uncommitted against specific schemes. The Trust Board is holding a Capital Seminar to

decide priorities by the end of July.

Variation

0.01,000.02,000.03,000.04,000.05,000.06,000.07,000.08,000.09,000.0

10,000.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

eted


0.01,000.02,000.03,000.04,000.05,000.06,000.07,000.08,000.09,000.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% A

bsen

ce


0.02,000.04,000.06,000.08,000.0

10,000.012,000.014,000.016,000.018,000.020,000.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

£


Inte

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KPI’s

5. Finance Additional Milestones

23


Y 5. Finance Milestone 3. LTFP prepared and understoodPlan signed-off subject to triangulation with financial recovery plan

A

Y 5. Finance Milestone 4. CIP operational plans for 18/19 developed by Dec 17Current forecast shows non acheivement of £8.6m. Current gap £4m.

R5


6. Workforce & OD Programme Overall Rating A

Deliver the HR & OD Strategic plans underpinning organisation vision & values

Work Streams

6.1 HR & OD Strategy 2017-20 - create the 2017-20 HR & OD Strategy to underpin delivery of organisational vision and strategic objectives

A 6.2

Recruitment, Retention & Resourcing - develop the Trust Recruitment & Retention plan to position the Trust in a better place to be able to attract, recruit and retain people with the right skills and attitude

A

6.3 Employee Engagement & Cultural Development - Develop and deliver an Employee Engagement Strategy & delivery plan to ‘win hearts & minds and create a great place to work’

A

6.4 Develop and launch an integrated leadership competency & behavioural framework for IOW NHS Trust leaders with corresponding self -assessment audit and modular programme of training/coaching & mentoring interventions

A

6.5 Education & Development - Develop and implement Education & Training Plan 2017-18 A

6.6 Development and promotion of mechanisms to enable employee voice and make it easy for staff to raise concerns in confidence that the Trust will act

A

6.7

Health & Wellbeing - Health & Wellbeing - Maintain a focus on Health & Wellbeing to achieve a sustainable reduction in absence to <4% by March 2018

A

6.8 HR & OD Department Development - Develop and implement an OD & HR Department continuous development plan A

6.3 - New post in place to support Employee Engagement Delivery Plan sign off by 29/09/17 6.4 -Incomplete competency documents/profiles identified 04/09/17. Outstanding

competencies received from stakeholders 18/09/17. Individual competencies mapped to appropriate training modules 22/09/17. Clear definition/plan of who will assess individuals and where documents will be saved/how they will be accessed 30/10/17.



6.1 – OD Strategy presented to OMG on 15/08/17. JP signed off 31/08/17 6.2 - Linkedin success during August; 1 consultant Paediatrician has had an interview. One

contact for Consultant Anaesthetist being progressed with Recruiting Manager 99% of junior doctors have moved onto the new contract. The remaining 6 will move

when they rotate in September and October. 6.3 - First draft of Employee Engagement and Delivery plan sent to JP for comment.

Equalities Lead now in post. Workplace Race Equality Scheme data submitted to NHS England within required timescales

6.4 - Appraisal behavioural competencies included and align with appraisal paperwork. Plan to advertise coaching availability by the 31/08/17 6.5 - Clinical Competency Assessment process in place Content of Mandatory training reviewed. 6.6 - Training sessions for the 3 Freedom to Speak Up Advocates commenced in August and

will run through until October. Plans in place to hold a launch session to include the Anti Bullying Advisors in mid-November during National Anti-Bullying week.

6.7 - Trust committed to Sugar Smart Island project led by Public Health All staff absent due to any form of stress have been sent a letter outlining all avenues

of support available and advice regarding remaining in contact with their manager and potential referral to OH. The stress management e-learning module has been updated ready for re-launch and promotion. There is a monthly long term sickness meeting with OH, HR and BCAT to monitor all cases over 100 days.

6.8 - Initial review of structure undertaken, SBAR raised and resources agreed.



Inte

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KPI’s

6. HR & OD

25

P WKF 1 Description Aggregate Position

Man

dato

ry tr

aini

ng


Candour etc

Monitor Trend

P WKF 15 Description Aggregate Position

Staf

f rec

omm

endi

ng

the

Trus

t as

a pl

ace

to

wor

k or

rece

ive

treat

men

t > National sector average score - Acute

3.77, Ambulance 3.46 & Mental Health 3.63

> national average

Variation

Figures reported shows the total compliance against all mandatory

training.

Total for all Trust still futher breakdown by sector is being

developed

Variation

75.0

76.0

77.0

78.0

79.0

80.0

81.0

82.0

83.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

eted


0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

ianc

e


7. IM&T Programme Overall Rating R The Trust will have an Informatics service that supports the clinical services to deliver safe and effective patient care, working in a paper light environment using information to drive decision making.

Work Streams

7.1 The Trust will have an approved informatics strategy that will achieve paperless at the point of care (P@POC) with a robust implementation plan

R 7.2 The Trust will have in place robust IT Infrastructure and

Hardware to enable staff to provide high quality and effective patient care and clinical services A

7.3 The Trust will have a professional and responsive service desk which supports the organisation A

7.4 The IOW Care System is working towards an integrated Care Record being developed to support the future strategy of integrated health and social care alongside self-care

R

7.5 The Mental Health and Community services that use Paris will have a system fit for purpose supporting effective management of patient care, paperless working and reporting

R

7.6 The Trust has an effective process of monitoring the quality of services through key performance indicators and benchmarking, undertaking deep dives to understand actions to be taken in outlying areas. The Trust is able to effectively and proactively operationally manage the organisation and make decisions through the use of business intelligence and management information. The organisation will have an evidence based performance management data set to ensure that it can monitor the performance of its services against national benchmarks

R

7.7 Develop the internal diagnostics provision so that it supports safe and efficient patient care and decision making 7 days per week.

R 7.8 The Trust will be compliant with Information Governance

(IG) requirements including information sharing. The Trust will maintain a level 2 IG toolkit rating and seek to improve upon this.

A 7.9 The Trust will have fit for purpose standard operating

procedures and focused KPIs in place to monitor, improve and maintain an excellent level of data quality across all users and reports.

A

7.10 Information Security - working towards a ISO27001 ISMS A

7.1 - Strategy finalisation impacted by senior capacity. Review of informatics contracts impacted by capacity of senior managers – not yet started Plan: Exec lead to

identify lead for this milestone by 14 Sept 2017. IT Service Desk and IT Dept reviews completed, further work impacted by senior/team capacity , proposal for

milestone end date to be rebased to 31 Dec 2017 7.2 - Report to be reviewed at ICT Programme Planning meeting in Sept and agreed by Programme Group 3 Oct 2017. Disaster Recovery Plan (DRP) in draft outlining framework and principles, governance route - To be submitted to

Corporate Risk in Sept for agreement to proceed with proposed framework. Formal approval route to be confirmed by 3 Oct 2017.

ICT Staffing review outcome - overall staffing review and approval of associated business cases 31 Dec 2017, organisational change process following this date if required.

Local Authority change of direction in relation to SSIDs due to updates in technology, Trust dept working in partnership to facilitate this - to be escalated to senior level with aim for approach to be confirmed by end of Sept 2017

7.3 - Service Desk workshop date set for 22 Aug 2017, delayed due to limited venue options – dates to be rebased to 01/09/17

7.4 - LCB now established with 10 priorities identified, expect to receive understanding of system integration ask by Sept 2017

7.5 – Paris upgrade subject to delay and currently planned for mid-Oct 2017. Noted this impacts on delivery of outcomes and benefits for a number of services and poses some organisational risk particularly in relation to CHIS contract. Plan: agreed to pursue developing key modules in version 5.1 in order to deliver before upgrade. Dates and details of 5.1 module development and 6.1 upgrade to be confirmed 13/9/17 and 6/10/17 respectively, IM&T plan to be reviewed / confirmed.

7.6 - Dashboards, reports and data sets have been discussed with relevant departments and service. Wider engagement with staff, patients and public stakeholders has not yet begun and has been impacted by changes at senior level. Clarity is required about approach and methodology. Plan: Discuss with Exec lead w/c 11 Sept to determine scope for initial plans and how to build into ongoing development.

Agreement that incremental changes will take place, proposal for MH indicators to be sent to TLC in Sept 2017. 7.8 - Contracts review resource not yet identified and delayed by changes at senior level. Plan: CFO to nominate a lead

for the contracts-related indicators within the IG toolkit by 8 Sept 2017 7.9 - Finalised list of KPIs has now been agreed for all of programmes - baselines to be established by 30/09/17


7.1 - Review of staffing: IT Service Desk and IT Dept reviews complete 7.3 - Service Desk workshop held 22 Aug 2017, good level of feedback gathered and being collated by theme to inform

improvement plan. On track for approval of plan at Programme Group on 3 Oct 2017. Password reset software operational and communications underway



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KPI’s

7. IM&T

27

` Description Aggregate Position

100%

of s

taff

have

ac

cess

to T

rust

WiF

i fo

r Tru

st d

evic

es b

y 31

/12/

17 Staff have access to Trust WiFi 100% Compliance

P IMT 2 Description Aggregate Position

50%

of P

aris

use

rs

retra

ined

by

31/1

2/17

, 10

0% re

train

ed b

y 31

/03/

18 Paris users identified as requiring retraining have

been retrainedMonitor Trend

Variation


Currently 63 staff have been identified from each of the services

for retraining.

Variation

0.0

20.0

40.0

60.0

80.0

100.0

120.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% S

taff


0.0

0.2

0.4

0.6

0.8

1.0

1.2

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

eted



Y 7. IM&T Milestone Trust Informatics Strategy signed off by Board on 07/6/17 Not Yet Due – not yet ready for sign off R

Y 7. IM&T Milestone Trust devices will be on Trust WiFi by 31/12/2017 Not Yet Due A

Y 7. IM&T Milestone MH Paris system issues resolved by 30/9/17 Not Yet Due A

Y 7. IM&T Milestone Community Paris system issues resolved by 31/12/17 Not Yet Due A


7

8. Estates & Facilities Programme Overall Rating A

To ensure the Trust has a fit for purpose Estates and Facilities function with a clear Strategy and programme of work supporting the improvement in Estate for high quality and safe clinical service provision.

Work Streams

8.1 The Trust will have a clear Estates Strategy and associated plan to develop and improve the Estate supporting effective and high quality clinical services. The Trust will have robust Estates governance arrangements in line the Assurance Framework

A

8.2 Wherever possible, Ligature risks within Sevenacres will be removed/made safe and wider Estates issues within Sevenacres will be resolved

A 8.3 The Trust has addressed / mitigated immediate

ligature risks with the current Shackleton. The Trust will have fit for purpose estate solution for patients currently residing in Shackleton

A

8.4 The Trust will have fit for purpose estate for patients currently residing in Woodlands A

8.5 The Soft FM department provides an safe, timely and high quality service with robust monitoring in place to provide assurance of this delivery

A 8.6 The Trust has in place effective oversight and

management processes for environmental risks and wider legislation/alerts relating to Estates and Facilities

A

8.7 The Trust enters into the Carbon Energy Fund Contract in order to un-lock the associated benefits; carbon reduction, financial savings and cost avoidance, investment and reduced risk

R

8.8 The Trust pro-actively manages Backlog Maintenance and Statutory Compliance through a planned and prioritised process, ensuring alignment with the Estate Strategy. The Trust understands the Quality and Functional Suitability of the estate.

A

8.9 The Trust is engaged in the HIOW STP Estates and Facilities work-streams to ensure alignment of strategies and to identify opportunities.

A 8.10 The Trust as a 'key stakeholder' is engaged in the IOW

One Public Estate (OPE) Programme in order to work with public sector partners to un-lock and enable opportunities.

R

8.1 - Strategy development and approval dates to be aligned with wider development of Estates & Facilities strategy. Development to be completed by 4 April 2018, detailed schedule / workplan and governance timetable to be confirmed by 5 Oct 2017.

Review of governance for Estates & Facilities portfolio has yet to be agreed, TOP for Oversight Group not yet developed

8.3 - Options paper/business case requires further development and costings with approval through appropriate governance routes prior to Board meeting - Consideration for approval by Trust Board on 1 Nov 2018 (provisional – earliest possible date).

8.4 - Implementation of physical improvement works are no longer required, subject to evidence of formal approval from CQC via MHIG.

8.5 - Trust Lead working with SOEPS to ensure partner is appointed by 18/08/2017 8.6 - Procedure being developed to enable CBU’s to work with Estates to routinely review environments to

establish risks – confirm review of process with CBUs by 29/09/17 8.7 - No response from CEF team as of 25 August 2017, planned approval of contract by Trust Board on 6

Sept 2017 no longer achievable. 8.8 - 6 facet surveys to start in September 8.10 - Work with OPE team to identify resource. Planned completion date of 31/08/2017 will not be met

due to lack of resource One Blue Light Project being led by Fire Service, to be noted that planned completion date of

31/08/2017 will not be met, no further information and no programme agreed to date


Programme Board to explore

8.1 - ERIC information ratified at FIIWC (25/07/2017) and final version submitted 8.2 - Trust Board approved business case for estate related solution, workstream timetable adjusted

accordingly 8.4 – Minor works to be carried out by Estates team to resolve 13 remaining ligature points. To be

completed by end of Sept 2017. 8.6 - MiCAD report sent to all relevant areas on a monthly basis 8.7 - DoH approval to ‘lease land’ has been achieved 8.9 - Submission of estates related STP Capital Bids for Newport and Sandown ILS, outcome awaited.



Support Decision re: detailed design of doors/curtains for Jack and Jill bathrooms due following meeting on 18 Sept 2017. To be escalated if not confirmed by 5 Oct 2018 in order to maintain planned completion date.


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8. Estates & Facilities Additional Milestones

29


Y 8. Estates and Facilities Milestone Sign off of Estates Strategy by 7/6/17 Not Yet Due A

Y 8. Estates and Facilities Milestone Revised governance in place by 01/06/17 Awaiting confirmation of Governance structure R

Y 8. Estates and Facilities Milestone Confirmation by MH Team that all immediate l igature risks have been resolved by 16/5/17

16/05/2017 Minor works at Woodlands to be completed R

Y 8. Estates and Facilities Milestone Confirmation by MH Team that all planned ligature works have been completed by 13/10/17

13/10/2017 Not Yet Due A

Y 8. Estates and Facilities Milestone Catering service tendered out by 01/12/17 Procurement of specialist partner to be completed by 18/08/17 R

Y 8. Estates and Facilities Milestone Effective monitoring Estates and Facil ities legilation and alerts with effective oversight of recommended actions in place by 01/06/17

Developing procedures with CBUs R

8


9. Leadership, Governance & QI Programme Overall Rating A

To develop a Trust that is well led with clear visibility of key operational, quality and financial performance at all levels of the organisation within an accountability framework

Work Streams

9.1 To develop a Trust that is well led A 9.2 The Leadership of the organisation is robust and "fit

for purpose" A 9.3 The organisation will have a comprehensive clinical

and corporate governance structure that ensures the flow of timely information from all services to Board to ensure that there is an effective Assurance Framework

A

9.4 To develop a Trust wide culture of improvement by skilling up key staff in recognised techniques and methodology

A

9.5 To increase the use of patient safety measures to drive improvement A

9.6 To improve compliance with NICE Guidance A

9.7 To improve the Learning from National and Local Never Events and Serious Incidents

A 9.8 To embed and improve the Trust's awareness and

safer deliver of medicines management A 9.9 To improve the content of key patient records

across the Trust R 9.10 To ensure our systems, processes and training of

our people is sufficiently in place to better safeguard both children and adults of the IoW

A

9.11 To provide our patients with a much better patient experience when they come into contact with our people and our services

A

9.2 – Meeting with Kings Fund 02/10/17 to discuss Leadership Development Centres 9.3 – Expert resource in place to support redesigning the Corporate and Clinical Governance

Structures 9.9 – Improve content of Key Patient Records has not started. Capacity been requested to

specifically support this piece of work via TLC but not agreed. Approach to this work has been reviewed and a delivery plan in place by 30/09/17


9.4 – Report received from NHS Elec and delivery plan to be produced by 30/09/17 9.8 – Drugs advisory Group TOR updated and agreed. 9.10 – Executive Lead for Safeguard attends both Adult and Children’s Safeguarding Boards




A number of workstreams will be amended to align with expert advice being given to the Organisation . This will ensure there is a clear what are we trying to achieve statement.

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KPI’s

9. Leadership, Governance & Quality (1)

31

P QUA 22 Description Aggregate Position

Trai

ning

in R

isk

Man

agem

ent

How many have been trained so far and what

groups?-


At l

east

50

staf

f tra

ined

in

impr

ovem

ent

met

hodo

logy

by

- -


100%

com

plia

nce

with

m

edic

ines

lock

ed

door

s an

d m

onito

ring

of te

mpe

ratu

re

- -

Variation

Note, training needs analysis being undertaken and approach will

change significantly. Unable to currently say % untrained risk staff

in CBU

Variation


Awaiting update on the improvement methodology and those that have been trained.

Variation

0.010.020.030.040.050.060.070.080.090.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

ete


0.00.10.20.30.40.50.60.70.80.91.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

ete


0.00.10.20.30.40.50.60.70.80.91.0

Apr

-16

May

-16

Jun-

16Ju

l-16

Aug

-16

Sep

-16

Oct

-16

Nov

-16

Dec

-16

Jan-

17F

eb-1

7M

ar-1

7A

pr-1

7M

ay-1

7Ju

n-17

Jul-1

7A

ug-1

7S

ep-1

7O

ct-1

7N

ov-1

7D

ec-1

7Ja

n-18

Feb

-18

Mar

-18

% C

ompl

ete


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KPI’s

9. Leadership, Governance & Quality Additional Milestones

32


Y9. Leadership,

Governance and Quality

Milestone 1. A Board approved, costed strategy by 01/04/2018

Y9. Leadership,


Milestone 2. Board development programme agreed by 01/08/2017

Y9. Leadership,


Milestone 3. Corporate services embedded into CBU structure by 01/12/2017

Y9. Leadership,


Milestone 4. Development plan for each senior manager agreed by 02/01/2017

Y9. Leadership,


Milestone 5. Performance management framework approved and launched by 01/10/2017

Y9. Leadership,


Milestone 7. 100% of Board and sub-committees use appropriate dashboards to inform and monitor reviewed by 31/09/17

Y9. Leadership,


Milestone 9. Whole Trust using safety thermometer by 01/10/2017

Y9. Leadership,


Milestone 10. Audits reported to Quality Governance Committee in December 17 and April 18

Y9. Leadership,


Milestone 11. Where appropriate, all learning from historic local Never Events and national Never Events have been reviewed and implemented by 01/10/17

Y9. Leadership,


Milestone 12. Process for SI investigation updated and implemented by 01/08/17

Y9. Leadership,


Milestone 14. Action plan in place for improving compliance with the health records policy by 31/10/17


9

10. Communications & Engagement Programme Overall Rating A

Work Streams

10.1 To enhance the capability and capacity of the Trust's communication team and ensure the key messages and engagement with staff, patients and the public around the improvement programme are maximised

A

10.2 To promote more Community Engagement and promote a culture whereby the public are more involved with the Trust and feel more connected

A

10.3 To maximise social media and other key communication channels as part of the focused approach to ongoing recruitment of key staff

A

10.4 Visibility of the Executive Team A

10.5 To develop one message and clarity of message internally and externally about the IIF and QI

A

10.6 To promote a sharing and learning organisation A

10.2 - Review & make Recommendations on the Trust’s Membership Scheme, Patient Council & Patient’s with a Disability Working Group are now due 15/09/17

10.3 - Align with HR & Agree Key Channels of Focused Communication are due 15/11/17 10.5 - Paper looking at the Benefits/Outcomes of ‘Social Media’ & a Radio Campaign. Share with

Programme Group & TLC is due 31/08/17.



10.1 - The Staff Engagement Programme ‘Getting to Good’ has been launched. The video is live with over 150 views. Feedback has been received and is being logged.

10.2 - Events continue to be publicised and supported. Support was provided for the Trust stand at Fairweather Festival. Hundreds of people were engaged with by the Trust’s Equalities Lead and Sexual Health Service. AGM/Medicine for Members was well attended and in partnership with Sunshine Radio and the Friends of St. Mary the Trust was present at the Chale Show. New Trust Members were recruited at both Chale show and Fairweather Festival.

Staff Engagement Advisory Group is being established – initial membership identified, first meeting set up

10.4 – Meet Maggie sessions going well. Move of the Exec Team into the main hospital and the Executive Director (e.g. CEO) appointments once completed will help.

10.5 - Partners are progressively being briefed on the IIF and QIP.



Update Assurance Report Care Quality Commission (CQC) Section 31 Received on 9th December 2016 Update September 2017


Contents Page Introduction 3

Assurance Progress Summary 4&5

Section 31 Requirements

A - Escalation Protocol 6

B - Patients Placed in Business Continuity 7

C - Care Planning and Documentation 8&9

D – Community Mental Health Services Redesign 10

G - Ligature Risks 11&12

H – Policies and Procedures 13

Regulation 17 Requirements

Person Centred Care: Community mental health care plans were not person centred or holistic - Training for staff

14

Dignity & Respect: The seating area at the end of the corridor on Afton ward not complying with privacy and dignity standards. Mixed sex accommodation and occurrences

15

Safe Care & Treatment: 1) Care and treatment in Osbourne ward not safe. 2) Improved core assessment, care plans & risk assessment required in CMHS. 3) Jack & Jill bathrooms inappropriate. 4)temperamental locks on Shackleton & Afton wards. 5) No maximum and minimum temperature monitoring of medicine fridge on Seagrove. 6) Woodlands garden environment was not safe for use.

16

Premises & Equipment: 1) Osbourne Ward not to exceed 19 patients. 2) Staff alarm system to be fixed on Seagrove & Osbourne Wards

17

Patient transfers [including EoLC} for non clinical reasons 19

24/7 RSCN cover to ED. Also ED nurses to be trained in PILS and safeguarding up to level 3

20

2

Contents Page Regulation 17

Overcrowding in ED and excessive waiting times 20

There were 3 medicine cupboards at Medina House School which were unlocked or keys kept very close

21

The Medicine Fridge storing vaccinations at the school nurse base was reporting high temperatures.

21

Adrenaline was stored in an unlocked staff fridge with no monitoring of the temperatures by the District Nurse (DN) team.

22

Treatment Rooms on the general rehabilitation ward and stroke unit were unlocked and contained unlocked pharmacy return boxes containing medicines

22

There were no facilities for medicines storage in the discharge lounge 23

The Ambulance Station was not secure and there was no garage door 23

Inadequate segregation of clean and dirty equipment in the equipment cleaning area. There was a risk of contamination

24

The Emergency Department did not meet the minimum registered nursing levels for safe care

24

There is insufficient Consultant Medical Cover in the ED to cover 16 hours a day

25

There is not the appropriate levels of nursing staff in acute medicine- Coronary Care Unit (CCU)

25

Nurses on CCU were not appropriately trained and did not have competencies for some patient’s needs

26

ITU Staff were not appropriately trained to care for medical outliers 26

There was inadequate supervision of independent non-medical prescribers in community and adult services

27

Introduction This report sets out the steps the Trust has taken to address the conditions that have been imposed:- • The specific conditions imposed within the Section 31 letter; • Actions already taken to address the condition, their current status, evidence, and the level of assurance reached; • How risks are being mitigated in the interim, until all actions have been undertaken and there is sufficient assurance that the

actions have had the desired outcome; • Further actions planned to resolve the above. For the Trust to gain assurance that actions have been undertaken, the evidence is being reviewed internally by the relevant Clinical Business Unit (CBU). The Trust will use its governance framework to assure evidence on the actions being taken to address the CQC concerns contained within the section 31 letter. Given the serious nature of the Section 31, assurance and actions for Mental Health has been led and reviewed by the Trust Mental Health Improvement Group. This is a task and finish group with the responsibility of ensuring the progress of actions and mitigations around the mental health services provided by the Trust. This group is chaired by the Chief Operating Officer, meets fortnightly and directly reports into the integrated improvement framework [IIF] Programme Group for Mental Health, chaired by the Chief Operating Officer. To provide assurance that actions are consistently delivering the outcomes, planned audits have been and will continue to be undertaken. The key assurance committee is the Trust Quality Governance Committee, a sub-committee of the Board. Using the defined assurance definitions [Table 1 below] the Quality Governance Committee make recommendations to the Trust Board for sign off.

Table 1 – Assurance Definitions

3

Substantial Assurance

Based upon our findings there is a robust series of suitably designed internal controls in place upon which the organisation relies to manage the risk of failure of the continuous and effective achievement of the objectives of the process, which at the time of our review were being consistently applied. This level of assurance is only reached when the Trust Quality Governance Committee has signed off the evidence and action.

Reasonable Assurance

Based upon our findings there is a series of controls in place, however there are potential risks that they may not be sufficient to ensure that the individual objectives of the process are achieved in a continuous and effective manner. Improvements are required to enhance the adequacy and effectiveness of the controls to mitigate these risks. Reasonable assurance for the Trust Board will always be the position until such time as the Quality Governance Committee have reviewed the actions and the evidence and confirmed that they are content for the position to move to substantial assurance.

Limited Assurance

Based upon our findings the controls in place are not sufficient to ensure that the organisation can rely upon them to manage the risks to the continuous and effective achievement of the objectives of the process. Significant improvements are required to improve the adequacy and effectiveness of the controls.

No Assurance Based upon our findings there is a fundamental breakdown or absence of core internal controls such that the organisation cannot rely upon them to manage the risks to the continuous and effective achievement the objectives of the process. Immediate action is required to improve the adequacy and effectiveness of controls.

4

Assurance Progress – Summary of Section 31

Section 31 Definition Apr 17

May 17

Jun 17

Jul 17

Aug 17

A Escalation Policy

Addresses the condition

Organisation assured that risks associated with the condition have been mitigated

B BCP &

Risk Assessment



C Care Planning & Documentation



D CMHS Strategy



G Ligature Risks



H Policies &

Procedures



Substantial Assurance Reasonable Assurance Limited Assurance No Assurance

Assurance Key

5

Assurance Progress – Summary of Regulation 17 Substantial Assurance Reasonable Assurance Limited Assurance No Assurance

Assurance Key

Regulation 17 Definition Apr 17

May 17

Jun 17

Jul 17

Aug 17

Person Centred Care: Community mental health care plans were not person centred or holistic



Dignity & Respect: The seating area at the end of the corridor on Afton ward not complying with privacy and dignity standards. Mixed sex accommodation and occurrences.



Safe Care & Treatment: 1) Care and treatment in Osbourne ward not safe. 2) Improved core assessment, care plans & risk assessment required in CMHS. 3) Jack & Jill bathrooms inappropriate. 4)temperamental locks on Shackleton & Afton wards. 5) No maximum and minimum temperature monitoring of medicine fridge on Seagrove. 6) Woodlands garden environment was not safe for use.



Premises & Equipment: 1) Osbourne Ward not to exceed 19 patients. 2) Staff alarm system to be fixed on Seagrove & Osbourne Wards



Patient transfers [including EoLC} for non clinical reasons



24/7 RSCN cover to ED. Also ED nurses to be trained in PILS and safeguarding up to level 3.



Overcrowding in ED and excessive waiting times



There were 3 medicine cupboards at Medina House School which were unlocked or keys kept very close



The Medicine Fridge storing vaccinations at the school nurse base was reporting high temperatures.



6


Assurance Key


May 17

Jun 17

Jul 17

Aug 17

Adrenaline was stored in an unlocked staff fridge with no monitoring of the temperatures by the District Nurse (DN) team



Treatment Rooms on the general rehabilitation ward and stroke unit were unlocked and contained unlocked pharmacy return boxes containing medicines



There were no facilities for medicines storage in the discharge lounge



The Ambulance Station was not secure and there was no garage door



Inadequate segregation of clean and dirty equipment in the equipment cleaning area. There was a risk of contamination



The Emergency Department did not meet the minimum registered nursing levels for safe care



There is insufficient Consultant Medical Cover in the ED to cover 16 hours a day



There is not the appropriate levels of nursing staff in acute medicine- Coronary Care Unit (CCU)



Nurses on CCU were not appropriately trained and did not have competencies for some patient’s needs

7


Assurance Key


May 17

Jun 17

Jul 17

Aug 17

ITU Staff were not appropriately trained to care for medical outliers - Marcia



There was inadequate supervision of independent non-medical prescribers in community and adult services



The Registered Provider must operate an effective escalation protocol in community mental health services. This escalation protocol will need to ensure patients are prioritised appropriately in response to service demands and pressures. There should be appropriate governance and leadership arrangements, and appropriate resources and support to the service and staff. The use of the escalation protocol should be on the corporate risk register and there should be clear mitigation and monitoring arrangements. The trust should ensure the escalation procedures are adhered to.

Section 31 - Specific Undertakings

A Level of Assurance Addresses the condition Substantial Assurance Organisation assured that risks associated with the condition have been mitigated Substantial Assurance

8

Evidence to Date: • The following evidence was reviewed by the Clinical Business Unit

and the Quality Governance Committee; • Community Mental Health Services Standard Operating Procedure; • Early intervention psychosis Standard Operating Procedure; • CMHS Business continuity plan; • CBU Quality meeting minutes of 25th January 2017 approving the 2

SOP’s and Business Continuity Plan. • Sign off sheets indicating staff have read and understood the above

documents • DATIX incident logs relating to when caseloads exceed the expected

levels

Caseload Tolerances = 40 maximum (CMHS)

Actions Taken in the Last 4 weeks Evidence and covering paper submitted to the Trust Quality Governance Committee on the 25th July 2017 where it was signed off as completed.

In month Update The number of staff who have a caseload exceeding the anticipated maximum reduced to 3 in May. However the acuity of these 3 practitioner caseloads have been reviewed and it has been determined that they are manageable due to the acuity of the patients.

Actions Taken to Mitigate Caseload management monitoring has become part of the Mental Health CBU performance Key Performance Indicators’ (KPI) and is reviewed currently via bi-monthly executive lead monitoring. Caseload data confirms that there are still 4 practitioners whose caseload exceeds the expected parameters as outlined in the standard operating procedures. As indicated previously a DATIX incident form has been submitted in relation to each of these. However, it has not been deemed necessary to adjust their caseloads as there are mitigating circumstances as to why the caseloads are manageable.

The Registered Provider must ensure that every patient who has received a letter, as part of the current action taken under the business continuity plan, is risk assessed and appropriately managed. Each patient must have a documented risk assessment and a clear date for review. B

Level of Assurance Addresses the condition Substantial Assurance Organisation assured that risks associated with the condition have been mitigated Substantial Assurance

9


Evidence to Date: • A Database of all 159 patients including; confirmation of risk

assessment and care plans are in the right place on PARIS and confirmation that this has been quality assured by a named senior clinician;

• Evidence that all 159 have been assessed and either discharged or held on caseload for active management;

• Community Mental Health Services Standard Operating Procedure;

• Early intervention psychosis Standard Operating Procedure; • CMHS Business continuity plan; • One new Matrons in post • Caseload Management and Clinical Supervision now taking

place and levels are monitored via the CBU Improvement Group

• All patients were sent a letter of apology from the Trust

Any other Significant New Actions Taken in the Last 4 weeks • No further actions taken

Patients Reviewed = 159

In month Update No further update required as condition addressed.

Actions Taken to Mitigate No further update required as condition addressed.

The Registered Provider must complete the review of the current caseload of each clinician. Each patient must be identified, have a full assessment of their needs and patients should be allocated for CPA according to the set criteria and guidelines. C

Level of Assurance Addresses the condition Reasonable Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

10


Evidence to Date: • Initial consultant caseload review undertaken by lead

consultant psychiatrist • CPA audit of all patients with a risk assessment/care

plan facilitated by Quality lead and additional patients identified for CPA.

• CPA audit tool in place and representative sample audit undertaken monthly.

• Consultant and practitioner caseloads including % with a risk/core assessment reviewed at the mental health improvement group fortnightly, and CBU improvement group weekly.

• Nurse led clinics operational to support reviews being undertaken.

Any actions taken to recover the position on the key indicators • An additional nurse has been appointed to increase

capacity in the nurse led clinics • Business Case approved at Trust Leadership Committee

to increase practitioner capacity across the CMHS by 4 wte in order to ensure that all patients have a named lead clinician who oversees their care. Recruitment has commenced.

• Assertive outreach approach being utilised with patients who fail to attend for their appointment.

Key Indicators in the Month

Please Note: Data is refreshed on varying times across the month

June 17 July 17 August 17

% of patients with a risk assessment and care plan on PARIS

As of w/e 18/06/17 73.31% (21.46% increase in the last 12 months) 404 outstanding

As at 02/08/17 81.5% 293 outstanding

As at 27/08/17 84.43% 246 outstanding

Total patients open to CMHS without core assessment and risk assessment

404 (as of 25-6-17) 293 as of 02/08/17

246

Proportion of patients on CPA As of w/e 11-6-17 20.98%. Increased by 13.47% from w/e 12/06/2016 compared to w/e 11/06/2017

As of 30/07/17 22.0% 13.77% increase from 31/17/16

As at 27/08/17 22.28% 12.62% increase from 28/08/16

Revised Core and risk assessment tool installed on PARIS

Due 17-11-17 Due 17-11-17 Due 17-11-17

Clinical risk assessment training compliance

CMHS 79% (as of the 2-6-17 Non CMHS 68% (as of the 2-6-17)

CMHS 77% Non CMHS 66% As at 27/07/17

CMHS 96% Non CMHS 70% As at 31/08/17

Refocussing CPA training compliance 80% (as of the 2-6-17)

83% As at 27/07/17 87% As at 31/08/17

The Registered Provider must complete the review of the current caseload of each clinician. Each patient must be identified, have a full assessment of their needs and patients should be allocated for CPA according to the set criteria and guidelines. C

Level of Assurance Addresses the condition Reasonable Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

11


Any actions taken to recover the position on the key indicators: Phase 1 of the Nurse Led clinic is coming to completion. On receipt of feedback from the service users they have expressed their opinion that they did not like attending appointments in Sevenacres. A decision has therefore been made that phase 2 will move to a Community based clinic setting.


In month Update A/ Number with core assessment already on electronic system = 185 B/ Number discharged not needing further service = 46 C/ Number declining further assessment (letter to be sent to GP and Consultant Psychiatrist) = 10 D/ Number moved away or out of catchment = 2 E/ Number deceased = 1 (I understand not MH related) F/ Number sent to IAPT as they were on the waiting list = 28 G/ Further allocations to care coordinators = 3 J/ Seen by Consultant Psychiatrist but no letter on Paris or plan (to be placed on system, or if discharge advised discharged) = 53 K/ Complex cases (under psychology) = 16 L/ Transfer to CAHMS = 1 M/ Opted to be seen by their Consultant Psychiatrist rather than nurse assessors = 6 N/ Outstanding appointments = 53 Breakdown of outstanding appointments as of 11/09/17 Patients to be seen this week = 20 Patients to be seen after this week = 16 Patients declined = 12 (mitigation as described in C above) Patients discharged = 1 Patients RIP = 1 Patients with core/risk already done = 3

The Registered Provider should agree a comprehensive community mental health services improvement plan. There should be the necessary external advice and agreement for this improvement plan. The plan should ensure demands on the service are appropriately escalated, assessed and managed. There should be structures that ensure national guidance and best practice is followed; that promote effective leadership, and review capacity and capability of staff; there should be sufficient resources and support to the service. Staff must be effectively supervised and supported to review their caseloads. The improvement plan should be adhered to and the necessary changes must be implemented at the appropriate pace and urgency.

D Level of Assurance Addresses the Condition Limited Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

12


Evidence to Date: • Community MH service

improvement plan; • Minutes from MH

Improvement group where the plan was discussed on 27th March 2017;

• Emails to and from Clinical Director for Solent Community and Mental Health Trust;

• Appointment of a number of Senior Clinical Staff;

• Appointment of Director of MH to add further Board capability;

• MH plans part of the Trust’s overall integrated improvement framework focusing on operational and more strategic issues.

In month Update Further to the appointment of the Executive Lead for Mental Health and the Associate Medical Director for Mental Health changes are being discussed and proposed for this section. A meeting was held on the 22nd August where it was agreed that the milestones for the implementation of the Community Mental health Services Redesign were to be re focused and amalgamated with the acute services pathway. Objectives The following are the key objectives for the redesign: • Delivering a whole system pathway for adults and older people with serious mental illness that is person-centred,

strengths based, focussed on recovery, delivers care according to need not age, accessible, and can be easily navigated by people who use services, and their families and carers

• Creation of evidence based clinical pathways for psychosis, mood and anxiety disorders, dementia and emotionally unstable personality disorder, that are delivered by a workforce that is aligned to the pathways

• Improving the experience of people who use services, and their families and carers • Improving the experience of staff working in services • Improving the quality of care delivered by services • Creation of a learning culture in services, with a focus on continuous improvement

Governance A steering group will be established to oversee the redesign. It will be chaired by the Associate Medical Director for Mental Health, and membership will include senior operational and clinical staff from adult and older people’s services, service users, CCG and local authority. The group will report to the MH&LD CBU leadership meeting, the IIF meeting and to the Reconfiguration Board (jointly chaired by CCG and Trust).

The registered provider must carry out an urgent assessment of the physical environment on the inpatient mental health wards at St Mary’s Hospital. The trust must ensure there is a comprehensive ligature assessment and an action plan to mitigate the risks. The action plan must include a stated time for completion. The assessment must cover all inpatient mental health wards and environments. There should be effective leadership, and the necessary resources and support to ensure changes have appropriate governance, are appropriately supported and are implemented with the necessary pace and urgency.

G Level of Assurance Addresses the Condition Reasonable Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

13


Evidence to Date: • Comprehensive risks and ligature action plan; • Broader environmental risk action plan; • Board Seminar Agenda from 8th March and the 5th April; • Fortnightly ligature risk review meeting minutes; • Ligature Policy Approved at Corporate Governance and Risk Sub-

Committee held 10th January 2017; • Specialist Director level estate support engaged to test and mature

current plans; • Berkshire Healthcare NHS FT received and reviewed. Recommendations

are being progressed by the CBU Ligature champions.

693

465

259

328

837

Risks by Ward:

AftonOsborneSeagroveShackletonWoodlands

Risk Managed Status Afton Osborne Seagrove Shackleton Woodlands Total

Risks by Ward Assessed as not requiring further action shows the number of ligatures risks which have been identified and are being managed locally by the ward managers. These are being managed by staff procedures, restriction of environment or policy. 200 142 115 70 770 1297 Already fully mitigated 194 169 89 258 54 764 Risks temporarily mitigated show the number of ligatures identified where the risk is being locally mitigated through staff procedures, restricted access to the environment or policy until the permanent solution has been delivered by the estates improvement plan due 05/01/2018. 299 154 55 0 13 521 Total 693 465 259 328 837 2582

G Level of Assurance

Addresses the Condition Reasonable Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

14


Risks by Ward Assessed as not requiring further action shows the number of ligatures

risks which have been identified and are being managed locally by the ward managers. These

will be managed by staff procedures, restriction of environment or policy.

Risks already fully mitigated show the number of ligature risks which have

been completed through intervention by estates in the physical environment.

Risks temporarily mitigated show the number of ligatures identified where the risk is being locally

mitigated through staff procedures, restricted access to the environment or policy until the

permanent solution has been delivered by the estates improvement plan due 05/01/2018.

200

142

115

70

770

Risks by Ward Assessed as not requiring further action:

Afton

Osborne

Seagrove

Shackleton

Woodlands

194

169

89

258

54

Risks by Ward Already fully mitigated:

Afton

Osborne

Seagrove

Shackleton

Woodlands

299 154

55

13

Risks by Ward temporarily mitigated:

Afton

Osborne

Seagrove

Woodlands

Outliers in Woodlands : 1) Two blinds the conservatory that have been ordered and are awaiting delivery and installation. 2) Eleven door closers to be replaced post inspection by clinical director on the 8th August 2017

The registered provider must immediately review its policy and procedures and governance arrangements to ensure there is appropriate assurance to identify, assess, manage, mitigate and monitor all environmental risks to patients’ care and safety across all inpatient mental health services. This includes where patient privacy and dignity may be compromised. The governance arrangements need to identify where additional resources and support are required and how staff will be supported to understand what actions need to occur to effectively manage all environmental risks.

H Level of Assurance Addresses the Condition Substantial Assurance Organisation assured that risks associated with the condition have been mitigated Substantial Assurance

15


Evidence to Date: • Revised Risk Management Strategy and Policy ratified and

approved by the Trust Board on the 8-2-17 • Ligature risk assessment policy ratified and approved at

the Corporate Governance and Risk Subcommittee on the 10-1-17

• Email re policy draft for comment to senior leaders in the CBU

• CBU meeting minutes including feedback from CQC • Fortnightly CBU Ligature Risk meeting minutes 24

November 2016 & 7 February 2017 • Attendance list for CBU dedicated risk management

training session. • Risk Management Training slide pack • Evidence of regular CBU risk meetings recorded in new

notes field for each risk/issue. • Terms of Reference for the 3 senior CBU meeting relating

to management of risks and issues.

Any other Significant New Actions Taken in the Last 4 weeks Evidence and covering paper submitted to the Trust Quality Governance Committee on the 25th July 2017 where it was signed off as completed.

External estates confirm and challenge External review carried out and final report received on the 14th July 2017. Proposal to address the Jack and Jill bathrooms presented at the Trust Board Seminar on the 18/07/17 and subsequently approved via voting buttons, with an anticipated completion date for the works of February 2018.

16

Regulation 17 - Specific Requirements Person Centred Care - Community mental health care plans were not person centred or holistic and lacked any detail to enable staff to understand individual needs and monitor progress. 1.1


Level of Assurance

Evidence to Date: • Monthly representative sample quality assurance

audits are being undertaken in relation to risk assessments and care plans.

• Audit outcomes are being presented to the CBU Quality Meeting to determine actions required.

• Audit outcomes also presented to the Mental Health Improvement Group by exception for further assurance.

• Clinical Risk Assessment in-patient competencies x 4 introduced.

• CPA audit undertaken, and higher proportion of patients now allocated to CPA

• Regular ward based audits undertaken by the Head of Nursing and Quality / Inpatient Matron to assess the quality of risk assessments and care plans


Any other Significant results and actions from audits and/or quarterly unannounced visit by CBU triumvirate A Situation, Background, Assessment and recommendation (SBAR) report has been submitted and approved for recruitment to a Nurse Consultant post. The purpose of this a post is to provide daily mentoring and coaching for clinical staff in relation to care planning and risk assessment.

June 17 July 17 August 17

Clinical risk assessment training compliance (CMHS)

CMHS 79% (as of the 2-6-17

CMHS 77% As at 27/07/17

CMHS 96% As at 31/08/17

Clinical risk assessment training compliance (non CMHS)

Non CMHS 68% (as of the 2-6-17)

Non CMHS 66% As at 27/07/17

Non CMHS 70% As at 31/08/17

Care planning for Mental Health CMHS (commenced 31-5-17)

52% as of the 2-6-17

72% As at 27/07/17

89% As at 31/08/17

Care planning for Mental Health (non CMHS) (commenced 31-5-17)

8% as of the 2-6-17

64% As at 27/07/17

70% As at 31/08/17

17

Regulation 17 - Specific Requirements Dignity & Respect: The seating area at the end of the corridor on Afton ward not complying with privacy and dignity standards. Mixed sex accommodation and occurrences. 2.1


Level of Assurance

Seating area Afton Ward Evidence to Date: • Due to patient wishes it was agreed that frosting would be

installed to left hand fire escape door only so as not to obscure the view, however, Anti ligature curtains have also been installed in May 2017, and can be drawn at the request of patients to prevent dignity breaches. Signs in bathrooms regarding use of bathrooms

Mixed Sex Evidence to Date: • All contingency areas were closed at the beginning of

February 2017 and have remained closed • A revised contingency bed escalation protocol is in place

which reduces the risk of utilising areas where a mixed sex breach was a risk

• The Trust practice around single sex compliance has been externally reviewed leading us to improve our policy and procedures to include the use of mixed sex accommodation. Staff have received training to include a comprehensive focus in reducing the risk of “Mixed Sex Occurrence”.

Any other Significant New Actions Taken in the Last 4 weeks Proposal to address the Jack and Jill bathrooms presented at the Trust Board Seminar on the 18/07/17 and subsequently approved via voting buttons, with an anticipated completion date for the works of February 2018.


Number of DATIX identified for single sex

1 reported from the 01/08/17 to 31/08/17 Appropriate action to mitigate Privacy & Dignity issues were undertaken by the Ward Manager.

18

Regulation 17 - Specific Requirements Safe Care and Treatment: 1) Care and treatment in Osbourne ward not safe. 2) Improved core assessment, care plans & risk assessment required in CMHS. 3) Jack & Jill bathrooms inappropriate. 4)temperamental locks on Shackleton & Afton wards. 5) No maximum and minimum temperature monitoring of medicine fridge on Seagrove. 6) Woodlands garden environment was not safe for use.

3. 1/.4/.5/.6

/.9/.13


Level of Assurance

Evidence to Date: • 2 Band 6 nurses and 2 Band 3 Healthcare

assistants have been substantively appointed to complete the required complement of staff to cover 24 hours in Crisis Resolution Home Treatment

• Ward environmental checks are carried out daily. • Medicines fridge temperatures are being

recorded daily in line with the SOP and reported monthly to the CBU. This forms part of a Trust wide monitoring database.

• A Health and Safety inspection of the Woodlands garden was undertaken on the 20th December 2016, and actions were undertaken to address the identified risks. These actions have all now been completed.

• The smoking shelter within the Woodlands gardens has been removed.

• Repairs have been made to the greenhouse. Broken furniture etc. has been removed.

• The garden is checked daily as part of the environmental checks.


Tender for estates work out to the market Green

Preferred supplier agreed Green

Works being completed according to plan n/s

Manchester Audit Tool Training [ Total Staff Identified] 29

Total staff completed training to date

27

Any other Significant New Actions Taken in the Last 4 weeks Proposal to address the Jack and Jill bathrooms presented at the Trust Board Seminar on the 18/07/17 and subsequently approved via voting buttons, with an anticipated completion date for the works of February 2018. Ligature Training – Session held on the 09/08/17 and further session being held on the 11/09/17.

19

Regulation 17 - Specific Requirements Premises & Equipment: 1) Osbourne Ward not to exceed 19 patients. 2) Staff alarm system to be fixed on Seagrove & Osbourne Wards 4.3/.4

Addresses the Condition Substantial Assurance Organisation assured that risks associated with the condition have been mitigated Reasonable Assurance

Level of Assurance

Evidence to Date: • Osborne has not exceeded the bed capacity of 19 since the initial report

was received from the CQC. • Revised alarm has now been installed (7-6-17) and testing has taken place.

Draft Standard Operating Procedure produced and awaiting sign off at the CBU Quality meeting. During this intervening period staff have continued to carry an Ascom alarm. Personal alarms have been issued to staff and the Security nurse on the ward carries an additional radio which immediately communicates to the following areas:

• All Mental Health Wards • Security


June July

Osbourne admissions greater than 19 None None

Alarm test compliance Yes Yes

Number of Datix submitted for alarm failure None None

Key Actions Taken to Improve Key Indicators • Standard operating procedure (PIT Alarms) completed and is on the Agenda

for the Quality and Risk meeting for approval on the 19/07/17. This was not discussed at this meeting and has now gone out on voting buttons for approval. Expected replies by the end of September.

• Clinical Commissioning Group have agreed to develop outcome measures

Patient transfers [including EoLC} for non clinical reasons

2.2

Addresses the Condition Substantial Assurance



Level of Assurance

Evidence to Date: • The Non clinical transfer SOP has been approved at Executive

Led Operational Management Group Meeting (OMG) December 2016. This has subsequently been added to the Trust Patient Transfer Policy.

• A non-clinical transfer code has been added to the Trust DATIX system. Daily reports on non-clinical transfers, has been requested but yet to be fully developed, currently weekly reports are being provided.

• Reports from Datix on non-clinical transfer are reviewed by Clinical Capacity and Patient Pathway manager.


June July Aug

EoLC non clinical moves reported during the period

Zero

Zero Zero

Root Cause and Action Taken Patient transfer form has now gone live w.e.f 17 July 2017. Communication plan and training of relevant staff now completed. PIDS on a monthly basis will provide reports on non-clinical transfers for monitoring to the Clinical Capacity and Pathway Manager.

20

Regulation 17 - Specific Requirements 24/7 RSCN cover to ED. Also ED nurses to be trained in PILS and safeguarding up to level 3 3.2

Addresses the Condition Limited Assurance Organisation assured that risks associated with the condition have been mitigated Limited Assurance

Level of Assurance

Evidence to Date: • Open advert for dual trained nursing staff with incentives. • Business case being developed and presented in June for the

development of a PAU. • Increased PILS training. • Increased safeguarding training,


Key Actions Taken to Improve Key Indicators • Agency and substantive posts out to recruitment struggling to fill via

agency • Band 5 ED Nurse (paediatric trained) appointed and due to commence

beginning of August • Agency paediatric staff and staff from the paediatric service are being

used to ensure cover within the ED • ED/Paediatric team from UHS visited at the end of June &

recommendations are currently being reviewed around training nurses differently to meet the demands. Final full report awaited from UHS.

Overcrowding in ED and excessive waiting times 3.3

Level of Assurance Addresses the Condition Substantial Assurance Organisation assured that risks associated with the condition have been mitigated Reasonable Assurance

Evidence to Date: • A draft Standard Operating Procedure has been written to

support the escalation. • Review of breaches to identify specialty review and late

discharges as the key challenges • Two new locum Consultants appointed. Another 2 out to advert.


Key Actions Taken to Improve Key Indicators • ED full capacity SOP out to consultation within CBU. To be

ratified at July CBU Governance Meeting. • Ambulance draft escalation / handover protocol in

development. • Draft RAT’ing procedure developed by clinical lead. To be

agreed at July Consultants Meeting. • Identification of designated Ambulance handover bay. • Key performance data requested to analyse internal and

external departmental timeliness and efficiencies. • Interim Emergency Care Improvement Lead in Dept since June

to support improvement of ECS and patient flow in dept

25.5.17 – 24.617

25.06.17 - 16.07.17

Staff in ED who are PILS trained 21 of 27 21 of 27

Level 1 safeguarding training in ED 89% 89%



% of Shift/Fill availability of paediatric nurses in period

n/a % data to be provided in next

report

25.5.17 – 24.617

25.06.17 - 16.07.17

Number of hours ED has more than 33 patients

219 90

Number of days full capacity triggered 28 Awaiting data review

outcome

Number of days Opel 4 triggered 3 0

Regulation 17 - Specific Requirements There were 3 medicine cupboards at Medina House School which were unlocked or keys kept very close 3.7 The Medicine Fridge storing vaccinations at the school

nurse base was reporting high temperatures. 3.8




Level of Assurance Addresses the Condition Substantial

Assurance Organisation assured that risks associated with the condition have been mitigated


Level of Assurance

Evidence to Date: • The Trust is helping the school to implement ‘Supporting Pupils at

School with Medical Conditions’ statutory guidance for state funded schools

• All cupboards now locked. • Audit results being reviewed by School Nurses with Teachers. • School has adopted Trust guidance. • To date 2 unannounced checks have taken place with full

compliance observed. • Part of medicines management routine annual audit.

Evidence to Date: • Daily Checks in place in line with the SOP for recording medicines

fridge temperatures, with a sign in temp sheet / log. • Instructions for resetting the maximum and minimum readings

have been provided. • The Head of Service is checking the logs on a daily basis these are

scanned and sent to the CBU Quality meeting monthly.


June July Aug

Audit undertaken this month

Yes Yes Yes

Compliance Results 100% 100% 100%

Key Actions from Audit As at 23.6.17 All recent audits have demonstrated 100% compliance. Independent external review undertaken 20.7.17 and results to be reviewed. Action will be closed after evidence of assurance presented to the QGC due to be presented at 26.9.17 meeting


June July Aug

Daily Log max or min temperatures compliance

100% 100% 100%

Audit undertaken this month Yes Yes Yes


Key Actions from Audit As at 23.6.17 All recent audits have demonstrated 100% compliance. Independent external review undertaken 20.7.17 and results to be reviewed Action will be closed after evidence of assurance presented to the QGC due to be presented at 26.9.17 meeting

21

22

Regulation 17 - Specific Requirements Adrenaline was stored in an unlocked staff fridge with no monitoring of the temperatures by the District Nurse (DN) team

3.10 Treatment Rooms on the general rehabilitation ward and stroke unit were unlocked and contained unlocked pharmacy return boxes containing medicines

3.11







Level of Assurance

Evidence to Date: • The DN’s have been educated about the correct storage of

adrenaline. • service has now been provided with a locked medicines cabinet. • Audit by Pharmacy Locality Leads monthly and is also now part of

medicines management ongoing annual audit.


June July Aug

Daily medication check list compliance

90% for months of

May & June

90% 90%

Audit undertaken this month by pharmacy

Yes Yes Yes


Key Actions from Audit Medication locked cabinets in bases now attached to walls. Awaiting confirmation from pharmacy re interval timescale between audits and feedback from latest audit.

Evidence to Date: • functioning locks and are monitored daily for compliance with the

SOP. • Concerns with compliance are reported on DATIX • All medicines deliveries are in sealed tamper evident containers • A works request has been made to improve the locking systems

on the treatment room doors.


June July Aug

Locking systems on treatment doors fixed

Yes Yes Yes


Checks undertaken this month Yes Yes Yes


Key Actions from Audit Awaiting confirmed quote from Estates team for swipe card locks for both treatment room doors which will improve ease of entry for staff when carrying equipment this does not impact on meeting the above condition Evidence to be provided to the Quality Governance Committee for 26 September meeting.

23

Regulation 17 - Specific Requirements There were no facilities for medicines storage in the discharge lounge 3.12 The Ambulance Station was not secure and there was no

garage door 4.1







Level of Assurance

Evidence to Date: • Mobile POD locker unit and stock storage units ready for

immediate access for contingency beds • Audit results have been presented to the CBU Quality Group at

the Monthly Meeting commencing January 2017 and is dependent on whether contingency beds are opened.


June July Aug

Contingency beds in discharge lounge used

No No No

Medicines Trolley with individual locked drawers available

Yes Yes Yes

Key Actions No further action required and will be presented for closure to the QGC at the Sept meeting as evidence is currently being collated

Evidence to Date: • A new garage door was ordered on 23rd December 2017 and

delivered to the island during week commencing 27th February 2017.

• The New door was installed during the last week of February 2017 and is now in place and fully operational.

• Any future issues identified will be immediately raised to the duty officer or on-call officer out of hours.

• An issue log will be maintained and any problems that arise in the future will be reviewed in the CBU Quality Meeting from April 2017.

Key Actions No further action as door now installed and fully operational will be closed after evidence presented to the QGC at September meeting as evidence is being collated currently and is to be presented to the CBU

24

Regulation 17 - Specific Requirements Inadequate segregation of clean and dirty equipment in the equipment cleaning area. There was a risk of contamination 4.2 The Emergency Department did not meet the minimum

registered nursing levels for safe care 5.1







Level of Assurance

Evidence to Date: • Consultant Nurse for IPC has contacted department and reviewed

and inspected the premises on Thursday 22nd December 2016. • The department has purchased plastic curtains to assist in

segregation of clean and dirty equipment; these have been in place since 20th February 2017.

• IP&C Consultant Nurse continues to monitor the risk with surveillance reports presented at The Infection Prevention and Control Group and reported through to the Trust Quality Governance Committee monthly.

• service is owned and managed by the Local Authority, who also own the building.

• Curtained structure in place. • Hazard tape in situ on floor marking designated area of curtained

space. • Signage in place identifying purpose of area. • Local Authority have taken over management of store. Request

submitted to CQC liaison officer to close this action for the Trust.

Service no longer run by the Trust and will be closed after evidence presented to the QGC

Evidence to Date: • A trajectory showing the new staff arriving. • ED staffing monitored by Matron and ED Sister daily. • 145% registered nursing shifts covered from 1st May (143% in

April). An additional nurse has been placed on night shift which is above the current agreed establishment.

• 66% Unregistered nursing shifts covered from 1st May (68% in April)


June July Aug

Workforce plan agreed No No

Agency Request and fill rates 100% 100%

Substantive Posts Commenced Against Workforce Plan

1 wte B6 1 wte B5

1 wte B6 1 wte B5

Key Actions • ED Reception vacant posts recruited (91.5 hrs) Due to

commence post within 4 weeks – end of July 17 • Identification of Band 4 post to assist with ED and

Ambulance handovers. Advert will be placed with two weeks of agreement to recruit.

Regulation 17 - Specific Requirements There is insufficient Consultant Medical Cover in the ED to cover 16 hours a day 5.2 There is not the appropriate levels of nursing staff in acute

medicine- Coronary Care Unit (CCU) 5.3







Level of Assurance

Evidence to Date: • 2 Additional Locum Consultants commenced 11th May and 1st

June 2017. • consultant staff providing cover for the period 8am – 8pm [12hrs]

Monday to Friday and 8am – 4pm at weekends [8hrs]. • A further 2 Locums out to advert to accommodate 16 hours ED

cover. • 100% of agency requests fill rates reviewed by CBU. • Daily Staffing monitored/reviewed by CBU. • Electronic job plan portal. • Incident reporting mapped to Consultant presence using DATIX

for review by CBU.


June July Aug

Compliance of 12 hour weekday and 8 hours weekend Consultant cover with 6 Consultants

100% 100% 100%

Locum Interest Received No No No

Interview Dates Agreed No No No

Appointment(s) Made and Start Dates Agreed

No No No

Key Actions Draft rota being developed to evidence how 16hrs would be covered.

Evidence to Date: • The Trust has recognised that ‘Safer Staffing’ levels cannot currently

be achieved on CCU without the use of agency and bank staff. 1.64wte have now been recruited and have commenced in post in February and March 2017.

• 100% of agency requests fill rates reviewed by CBU • Daily Staffing monitored reviewed by CBU • Evidence of report. Skill mix and staff deployment reviewed when

short staffed. • Twice daily staffing covering all in-patient beds has commenced. • Additional recruitment of 1.0 WTE substantive appointment. Start

date May 2017.


June July Aug

Safer Staffing Level Compliance Average fill rates for RN’s 87.5%

Average fill rates for RN’s 84.7 %

Average Fill rates for RN’s 86.4%

Key Actions • Tight management of all sickness utilising Bradford scores in conjunction

with HR - further long term sickness and maternity impacting on staffing levels

• Twice daily ICU/CCU staffing reviewed to assess how the units can assist with shift cover for short term sickness as required

• All bank shifts escalated to HR three weeks in advance • Average fill rates for RN’s 84.7 % • Further recruitment over establishment now agreed & completed 25

Regulation 17 - Specific Requirements Nurses on CCU were not appropriately trained and did not have competencies for some patient’s needs 5.4




Level of Assurance

Evidence to Date:. • BIPAP training has taken place and competence assessment for all

staff has been completed as at 31st March 2017 • Training records uploaded to the DATIX system • CBU leading a collaborative on the recording of competence on

medical devices to reduce the risk • Mandatory Training reviewed at CBU Quality and Patient Safety

Group • All staff have completed competency assessment for BiPAP records

available for review • CCU identified as a pilot project area for Medical Devices QC May till

October 2017


ITU Staff were not appropriately trained to care for medical outliers 5.5




Evidence to Date: • ITU staff were not trained to use the Electronic Patient Prescribing

and Medicines Administration system (EPMA). • When supporting contingency beds they were unable to

administer medicines unaided and patients may have sustained delays in receiving medication.

• Training records uploaded to the DATIX system including a copy of competence.

• All Mandatory Training reviewed at Clinical Business Unit Quality and Patient Safety Group.


June July Aug

Compliance of EPMA Training for ICU Staff

100% 100% 100%

Hardware for ICU utilisation of JAC sourced

Yes Yes Yes

JAC system implemented No No No

Key Actions • Substantial assurance will be achieved once ICU fully

transfers to the JAC system which will be implemented following a trust wide JAC upgrade date to be confirmed. Retraining will occur annually in the period that the staff are not using the system regularly if upgrade is delayed

July Aug

Staff signed for as competent in BiPAP NIV therapy

100% 100%

Reviewed at Quality and Patient Safety Group Yes Yes

Competencies developed for all medical devices in CCU

100% 100%

Key Actions • Staff sign off for all medical devices aiming for 50 % compliance end

of August , 75% by end of September and 100% by end of October • A renewed focus to get mandatory training to 100% has been

launched within the CBU 26

Regulation 17 - Specific Requirements There was inadequate supervision of independent non-medical prescribers in community and adult services 5.5




Level of Assurance

Evidence to Date: • There has been a robust clinical supervision process

implemented in Community Nursing. • work is underway to review the work of advanced practitioners

in the Community through the Consultant in MAU. • Advanced Nurse Practitioners in Community are being

supervised by MAU Consultant and supported in their prescribing.

• Community Matrons are sourcing supervision from Locality GP’s in practice.

• One GP practice has expressed an interest in supporting the Supervisor/Prescribing Mentor role.


June July Aug

Non-Medical Prescribers in Community & Adult Services on a single list

Yes – Community Nursing



Staff receiving supervision

Community Matrons – peer supervision & %



Key Actions Email received from GP at Esplanade Surgery to offer to undertake supervision to NMP. GP unavailable at present to plan dates as on annual leave. This will be chased up on return to clarify dates

27

August Position 2017

1


QIP Highlight Report


Introduction

2

It is important that the Quality Improvement Plan [QIP] is driven by the Trust through the infrastructure and governance that has been developed as part of the overall Integrated Improvement Framework [IIF]. It is important that the Quality Governance Committee [QGC] adds real value to the overall process and does not duplicate the role and function of the IIF Programme Board. Going forward the QGC should have the following role with respect to driving forward the changes required to deliver the Trust’s QIP:

1. Understanding progress and impact against the 9 QIP goals that have been set and agreed; 2. Discuss, challenge and debate the impact the milestones are having on the relevant key theme(s); 3. Deep dives as per the IIF Programme Board against the relevant key theme(s); 4. Assurance of evidence against the relevant key theme(s)

The priority measures have been assessed by the Quality Governance Team and the 250 metrics have been prioritised down to 82. Fifty two of the eighty four have been identified as output measures and these are the measures that the QGC will focus on to understand impact as part of its assurance role within the overall governance of delivering a sustainable organisation that aspires to get itself out of special measures within 12 months. Quality Metrics for the QGC to Focus on

• Patient safety – 24 [8 process and 16 outputs]; • Patient/User experience – 11 [5 process and 6 outputs] ; • Staff engagement and Leadership – 19 [11 process and 8 outputs]; • Operational performance – 22 [4 process and 18 outputs]; • Clinical and corporate governance – 6 [2 process and 4 outputs].

The following report identifies each of the five key themes within the QIP and by exception will highlight the key areas for discussion required of the QGC.

OVERALL GOALS

HIGH LEVEL GOALS

KEY THEMES

Avoidable Harm

Demand & Capacity

Staff Engagement 3.41 – 3.80

Improvement Methodology

Bulling & Harassment

survey results

Reduced vacancy and agency rates

Mandatory Training

85% Compliance

Operational Access Times

Increased Patient

Satisfaction from 16/17

Patient Safety

User Experience

Staff Engagement

Ops Performance

Clinical & Corporate Governance

REMEMBER THIS IS THE MINIMUM WE MUST DO TO GET IMPROVE FROM INADEQUATE TO NEEDS IMPROVEMENT BY APRIL 2018 3

Summary - Impact Overview

1. A reduction in avoidable harm to patients through improved clinical risk identification, mitigation and management. 2. Clear demand and capacity management of all services to improve patient experience and safety evidenced by improved

access to all services and access target achievement and short wait times for assessment in all services. 3. Improved Employee Engagement score to greater than national average median score for sector: acute 3.80, ambulance

3.41 & mental health 3.80. 4. The development of a continuous improvement culture through Board and leadership development and specific training in

improvement methodology. 5. Improve % of staff/colleagues reporting most recent experience of harassment, bullying or abuse > national sector score:

acute 45%, ambulance 48% and mental health 60%. 6. Reduce variance from budgeted establishment verses staff in post by 10%. 7. 85% compliance with all Mandatory training 8. All operational national performance targets being met 9. An increase in patient satisfaction.

High Level Goals/Impact: 1. A reduction in avoidable harm to patients through improved clinical risk identification, mitigation and management. 3. Improved Employee Engagement score to greater than national average median score for sector: acute 3.80,

ambulance 3.41 & mental health 3.80. 6. Reduce variance from budgeted establishment verses staff in post by 10%.

7. 85% compliance with all Mandatory training 8. All operational national performance targets being met 9. An increase in patient satisfaction

Patient Safety

Output Measures of Success

PS1 - Achievement of ambulance performance targets against trajectory - Red 1 – Mar 18, Red 2 Jun 17 and 19 min response by May 17

PS 2 - Revised job plans that address the availability of current Consultants in ED - 30/06/2017

PS3 - Paediatric nursing skills available to the ED on 100% of shifts – 15/05/2017

PS4 - Increased 2wte Acute Physicians in establishment from Apr 17 baseline - 30/09/2017

PS5 - National guidance targets for medical staffing in EoLC achieved 100% by Q3

PS6 - Key vacancy levels in the Community reduced by 50% from Apr 17 baseline by 31st Dec 2017.

PS9 - New Lessons Learnt Framework launched for SI’s – 30/09/2017

PS10 - Improved overall position of Carter Metrics in medicines management by Q4, compared to the Peer group benchmarked using Apr 17 baseline

PS11 - 10% reduction on prescribing errors from Apr 17 baseline - 31/11/2017

PS12 - At least 85% NMP have had supervision within the previous 4 months - 30/10/2017

Key Analysis of Impact This Month

Key Patient Safety Risks Mitigation NMP’s in the community delivering a generic model of care which means their range of prescribing will be extensive.

Develop the model of care and roll out around competencies and availability. GP supervision.

Substantive paediatric nurses to cover ED are proving difficult to appoint. Shifts currently covered by agency staff and 100% shift fill rate reported this month.

Ambulance response times not being effected positively Recruitment drive on paramedics

PS1 PS4 PS6

General Update

4

Red 1 response times for still struggling to get above 50% achievement. The pilot results relating to new Quality Indicators would suggest they are more meaningful for patients but more challenging to meet within current resources. A successful workshop involving the wider team took place w/c 28th August to map these through. Numbers remain relatively small and performance against the two other targets are still below the revised trajectory.

A rolling advert is out with incentives but it is unlikely a further 2 WTE acute physician will be employed over the next few months. Interviews in June did not appoint as candidates not suitable. The QGC to request a detailed, specific recruitment plan for these posts that describe the approach to ensuring they can be filled sustainably.

Key vacancy reductions in the Community Workforce are identified as being on plan to meet December 31st deadline. However, the workforce plans and improvements against plans are so important that QGC should explore progress and seek assurance and more detail of managing the risks.

• Metrics that the QGC need to focus on have not been fully developed and impact lacks visibility. • Job plans in ED have been significantly revised to support different working patterns and extend

coverage in the department to 8am-8pm weekdays and 8am-4pm weekends and bank holidays. • Performance during the August Bank Holiday was much improved compared to the same period

last year and could be viewed as a proxy of successful impact of revised job plans.

High Level Goals/Impact: 1. A reduction in avoidable harm to patients through improved clinical risk identification, mitigation and management. 3. Improved Employee Engagement score to greater than national average median score for sector: acute 3.80,

ambulance 3.41 & mental health 3.80. 6. Reduce variance from budgeted establishment verses staff in post by 10%. 7. 85% compliance with all Mandatory training 8. All operational national performance targets being met 9. An increase in patient satisfaction

Patient Safety


PS13 - Reduced ambulance handover delays by 50% from Apr 17 baseline - 31/07/2017

PS14 - 30% increase in end of life care plans from April 17 baseline - 30/09/2017

PS16 - 50% reduction in reported incidents relating to lone Working in the Community- 30/09/2017

PS18 - In MH 100% of patients have a risk assessment and care plan in place within PARIS and % of patients on CPA - 30/06/2017

PS19 - All identified ligature risks in MH mitigated - 30/09/2017

PS20 - Mandatory training compliance at a minimum of 85% - 31/01/2018

Key Patient Safety Risks Mitigation Ambulance handover baseline figures yet to be agreed New ED [more real time] dashboard to go live in July to

include handover information which will create more focus

Lone working in the Community not seen as a priority. Part of the IIF and therefore escalation options for staff.

Consultant caseloads in MH still have not been thoroughly risk assessed and CPA status allocated.

Extra focus on these patients and the plan is to complete this action by end of August.

PS13 PS19 PS20

General Update

5


Action plan to address ED handover complete. Bay 4 ring fenced for ambulance handover. Capital monies received to develop ambulatory care area which will have an impact. ED live dashboard includes ambulance handover delays. Baseline handover figures and progress of improvement should be presented to the October QGC for discussion.

• The September QGC needs to discuss the impact of having no visibility of current performance relating to the agreed measures of success. • As a result of the revised plan for dealing with the ligature risks long term, the dates for completion will likely be sometime in Q3 and the revised plan

needs to inform and update the IIF and QIP.

Original timeline to mange the risks was not met. However, the external review by Berkshire Healthcare FT NHS Trust carried out in July demonstrated that all outstanding risks are being managed and mitigations are in place. A new plan has been signed off by the Trust Board and supported by NHSI through the oversight meeting and the CQC through QIP OG.

Mandatory training rates for the Trust are slightly below 83% Mandatory Training Policy out for consultation 11/08/17. Statutory and mandatory training plan in place and along with the workforce plans the content of these should be explored by the QGC to assure themselves they are fit for purpose.

Patient/Service User Experience


PE3 - Achieve “about the same” rating for waiting lists and admissions “better” rating for at least 10% of the other questions in the CQC questionnaire - 28/02/2018

PE4 - Reduction in complaints for all services – 30/09/2017

PE6 - Children’s facilities in ED all meet Standards for Children and Young People in Emergency Care Settings - by the Royal College of Paediatrics. Where this is not possible evidence of mitigation to improve the situation from Apr 17 Baseline - 30/08/2017

PE7 - Reduced single sex accommodation breaches by 75% from Apr 17 baseline - 15/10/2017

PE8 - As a minimum 85% of all staff in the priority areas dealing with dementia identified and trained - 15/03/2018

PE9 - 50% increase in end of life patients dying in their preferred place of care from Apr 17 baseline - 15/09/2017

Key Patient/Service User Experience Risks Mitigation

Reliance on agency staff to fill the paediatric shifts in ED Advert out for substantive staff and the use of longer term agency staff means they are more familiar.

Patient flow challenges out of ICU mean mixed sex breaches are a possibility

Definition of the acceptable standard and visibility of adherence to it. More prioritisation of ICU patients into general beds

PE4 PE7 PE9

General Update • Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Oct]. • EoLC joint venture with the Hospice is being progressed and will improve this overall patient

experience. The first step is a joint planning board.

High Level Goals/Impact: 2. Clear demand and capacity management of all services to improve patient experience and safety evidenced by improved access to all services and access target achievement and short wait times for assessment in all services. 3. Improved Employee Engagement score to greater than national average median score for sector: acute 3.80,

ambulance 3.41 & mental health 3.80. 8. All operational national performance targets being met.

9. An increase in patient satisfaction.

6


The trend in complaints numbers is not on the decrease. More detailed analysis needs to be undertaken at the October QGC to understand reasons and impact. It is important that services understand exactly why their patients, carers and service users have not be fully satisfied with their service offer. QGC needs to see and explore the top 5 complaints and actions for each key service.

DSU refurbishment is now rolling forward into 18/19. Much operational planning through the current unit continues to minimise mixed sex breaches. Agreements on the ICU definition of when there is a mixed sex breach needs to be agreed. QGC should request that it receives the baseline data and August/Sept performance at its October meeting.

QGC should agree as an action at its September meeting when it will undertake a deep dive review of EoLC provision and when the outputs will be presented to Trust Board. Regular month on month figures are still not fully visible as a matter of routine and as part of business as usual. QGC should consider the benefits of including these in the monthly CBU performance review meetings.

Staff Engagement and Leadership


SE1 - The Trust will aim for, in the 2017-18 annual staff survey, to increase its EE score: acute 3.80, ambulance 3.41 & mental health 3.80 - 31/03/2018

SE2 - Improved score of staff recommending the Trust as a place to work or receive treatment: Acute 3.77; ambulance 3.46 & mental health 3.63 - 30/06/2017

SE13 - 60% of staff trained have completed at least 2 improvement projects - 31/03/2018

SE14 - Impact survey shows that at least 25% of the staff within each service (Ambulance, Mental Health, Acute, Community, Support Services) can articulate the top 3 quality improvements for patients and or staff that are being worked on in their area. By week 15 of the project increasing to 40% by week 20, 60% by week 25 and 85% by week 30

SE15 - Recruitment campaign schedule approved and delivered to achieve a reduction in variance from budgeted establishment verses staff in post by 10%. - 31/12/2017

SE16 - Increase Apprenticeships from 50 to 70 by Q4 - 31/03/2018

SE17 - Facilitate implementation of Healthroster Optima, including Safe Care to maximise effective use of available resources and achieve 100% compliance with rostering targets - 31/12/2017

Key Staff Engagement and Leadership Risks Mitigation Inadequate resource to deliver IIP ED/Rostering posts agreed, moving to recruitment.

Business case completed.

Recruitment into key posts not successful .A multi pronged approach to recruitment and stronger marketing material and advertising channels

The ability to train and supervise the level of Apprentices identified

Phased approach covering a number of CBU’s and support areas

SE1 SE13 SE15

General Update • Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Oct]. • Improvement movement has just started to mobilise through NHS Elect. • Multi channel approach to recruitment.

High Level Goals/Impact: 2. Clear demand and capacity management of all services to improve patient experience and safety evidenced by improved access to all services and access target achievement and short wait times for assessment in all services. 3. Improved Employee Engagement score to greater than national average median score for sector: acute 3.80,

ambulance 3.41 & mental health 3.80.. 4. The development of a continuous improvement culture through Board and leadership development and specific

training in improvement methodology. 5. Improve % of staff/colleagues reporting most recent experience of harassment, bullying or abuse > national sector

score: acute 45%, ambulance 48% and mental health 60%. 6. Reduce variance from budgeted establishment verses staff in post by 10%. 8. All operational national performance targets being met.

7


First draft of Employee Engagement and Delivery plan sent to Director of Workforce and OD for comment and should be signed off by end of Sept.

Work progressing ahead of schedule for the implementation of the Employee Staff Record.

NHS Elect have mobilised their resources and are gathering intelligence on the current position of the Trust. They will link closely with the communications work being developed by Freshwater Consultancy. An update paper should be requested by QGC at the October meeting.

Recruitment advertisements on IW ferries gone live. Overseas recruitment – 5 further nurses will arrived on 25/08/17. LinkedIn has been used to advertise hard to fill posts within Gastro, Anaesthetics, Urology and Paediatrics and Psychiatry. This is such a significant area, QGC should be presented with more detail and evidence at the October meeting


OP1 - Achievement of 4 hr national target trajectory of 90% by Oct 17 and 95% - 31/03/2018

OP2 - Achievement of RTT target trajectory by – 31/03/2018

OP3 - Achievement of ambulance service target trajectory: Red 1 by Mar 18; Red 2 by June 17; 19 mins – 30/05/2017

OP4 -Achievement of Cancer Service target trajectory [Cancer 62 days] – 31/11/2017

OP5 - Reduction in DTOC numbers against agreed trajectory – 30/09/2017

OP6 - 10% reduction in overall LoS for medicine patients Oct 17 and 20% by April 18 from Apr 17 baseline – 31/03/2017

OP7 - 99% of diagnostics seen within 6 weeks of referral – 30/06/2017

OP8 - Theatre utilisation of at least 85% for all specialties – 28/02/2018

OP9 - Ambulance handover times achieving 15 mins 95% compliance – 30/10/2017

Key Operational performance Risks Mitigation Achievement of cancer 62 day standard Daily focus on all patients waiting over 62 days.

ED 4hr performance and overall patient flow Significant change programme in the IIF and experienced senior leadership recruited

Reduction in DTOC days reduces the focus on internal waits Visibility required for all waits against internal professional standards

OP1 OP4 OP8

General Update • Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Oct]. • Good overall position on ED, RTT and DTOC performance.

High Level Goals/Impact: 2. Clear demand and capacity management of all services to improve patient experience and safety evidenced by improved access to all services and access target achievement and short wait times for assessment in all services.

4. The development of a continuous improvement culture through Board and leadership development and specific training in improvement methodology.

8. All operational national performance targets being met. 9. An increase in patient satisfaction.

Operational Performance

8


Theatre utilisation nearing 85% for many specialties however, much work still to be done. Decision made not receive support from the centre through four eyes/Deloitte as the cost benefits to the Trust were considered low. QGC should consider a deep dive into theatre performance to assure itself of progress and help unblock the challenges.

The backlog position for 62 day treatment is showing a static trend. A critical friend review tool place by NHSI on 7th September. Feedback will be reported at October meeting. The Cancer PTL, using Somerset as the source data, continues to be validated and used by the operational teams.

Significant progress made in August compared to the July position for the 4hr performance target. Sept position is forecast to continue with further performance improvement. The ED and the Operations Centre new live dashboard shows the current level of attendance and performance. The new Mental Health Assessment Room in ED has been signed off as complete.


OP10 - Zero breaches in non admitted stream – 30/06/2017

OP11 - As a minimum 15% increase in numbers with a LoS less than 24hrs from Apr 17 baseline – 31/01/2018

OP12 - As a minimum 15% increase in numbers with a LoS greater than 24hrs and less than 72 hrs from Apr 17 baseline – 31/03/2018

OP13 - Reduced breaches for specialty review by 50% from Apr 17 baseline – 30/06/2017

OP14 - As a minimum 30% increase in ambulatory care activity as a proportion of the medical take from Apr 17 baseline - 31/03/2018

OP15 - 10% of overall MAU daily discharges before 10am - 31/07/2017

OP20 - 25% increase in numbers of CPA’s from Apr baseline in MH - 31/01/2018

OP21 - 95% of service users on a CPA and followed up by MH within 7 days - 31/01/2018

OP22 - DTOC numbers in MH less than 7.5% for at least 3 months in 17/18 - 31/03/2018

Key Operational Performance Risks Mitigation The ability of the organisation to protect ambulatory care when flow is challenged.

Revised Trust escalation policy that protects ambulatory care. Consider making it a never event if used for inpatients. Capital investment for a protected area alongside ED.

The ability if the organisation to develop the assessment units as a chance to assess patients and not admit them.

Promotion and education by the Clinical Lead. Visibility of performance against short stay LoS.

Internal professional Standards [IPS] not being adopted by all CBUs.

Agreements by all CBU CDs. Individual conversations by the Medical Director with individual Consultants to understand barriers

OP11 OP13 OP14

General Update • Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Oct]. • Whilst LoS is an indicator time of day for the available resource is as important and multiple

measures of success should be used to understand the story.

High Level Goals/Impact: 2. Clear demand and capacity management of all services to improve patient experience and safety evidenced by improved access to all services and access target achievement and short wait times for assessment in all services.

4. The development of a continuous improvement culture through Board and leadership development and specific training in improvement methodology.

8. All operational national performance targets being met. 9. An increase in patient satisfaction.

Operational Performance

9


Whilst performance in this area has shown improvement the trend analysis from the baseline position have still not been developed. The development of these metrics and agreeing the overall process for recording and having visibility is a key priority.

Overall performance in Aug has improved from the July position. The Sept unvalidated position also looks to be in the right upward direction. However, QGC should assure itself there is evidence that correlates to changes in practice and assure themselves of the sustainable position.

Pathway developed that links with frailty service/ access to Comprehensive Geriatric Assessment if clinically appropriate has been achieved. Review of current service and baseline has been completed by Dr Feathers. The report received and circulated 14/08/2017 .


G1 - The Trust will develop a Board Assurance Framework - 01/08/2017

G4 - 80% staff in leadership roles to be trained in Risk Management - 01/02/2018

G5 - 85% staff trained in the Risk Management Policy and how to report risks, issues and raise concerns - 01/04/2018

G6 - A Board approved Audit plan to inform the BAF - 01/09/2018

Key Clinical and Corporate Governance Risks Mitigation The key external and specialised support does not leave a legacy with the organisation. Key output from the individual specifications and key responsibility for the Executive sponsor.

Ownership by the Quality Governance Team Identification of resource within this team by the new Chief Nurse and a detailed handover

G1 G4 G6

General Update • Metrics that the QGC need to focus on to be finalised and proposed at the next meeting [Oct]. • Longer term measures of success under this theme but its important that the QGC tests the impact as they penetrate the organisation.

Clinical and Corporate Governance

High Level Goals/Impact: 1. A reduction in avoidable harm to patients through improved clinical risk identification, mitigation and management.

10


Quality Governance Solutions commenced in August and an interim update presented to the CEO. Assurance on when the revised BAF will be developed should be sought by QGC on behalf of Trust Board.

Quality Governance Solutions partner procured and are due to complete work in September. Internal audit programme commenced. Those that relate to work steams in the QIP need to be owned and sponsored by the Quality Governance Team.

Risk management approach to date has been limited and not systematic. Specialist external resource appointed to support this work. Position on the risk management training numbers needs to be made clearer to QGC at Oct meeting.

Isle of Wight NHS Trust Board Single Oversight Framework Performance Report 2017/18August 17

TitleSponsoring Executive DirectorAuthor(s)PurposeAction required by the Board: Approve

Legal implications, regulatory and consultation requirements NHSI Regulations

Date: 28th September 2017 Completed by: Iain Hendey, Deputy Director of Information


Trust Goals & Priorities ALL

Principal Risks (BAF) ALL

Excellent Patient Care, A positive experience for patients, service users and staff, Skilled and capable staff and Cost effective, sustainable services.


The Board is recommended to receive the report

Attached Appendices & Background papersIsle of Wight NHS Trust Board Single Oversight Framework Performance Report 2017/18

Other (please state)

Integrated Improvement Framework:

Board Seminar


Please add any other committees below as needed

Finance, Investment, Information & Workforce Committee






This paper sets out the key performance indicators by which the Trust and the Trusts regulators are measuring performance in 2017/18.

Mental Health Act Scrutiny Committee



Charitable Funds Committee

Single Oversight Framework

Shaun Stacey, Chief Operating Officer

Iain Hendey - Deputy Director of Information

To inform the Board of the progress against the Single Oversight Framework

Assurance X




Page 1

Enc H

Isle of Wight NHS Trust Board Single Oversight Framework Performance Report 2017/18

Index

3Balanced Scorecard - Aligned to 'Key Line of Enquiry (KLOEs)………………………………………………………………………………………………………………………………………………………………………………………………………………….4

56-15

6789

1011

Ambulance, Urgent Care and Community…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………12Chief Operating Officers Report - Ambulance, Urgent Care and Community…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………13Mental Health and Learning Disabilities…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………14Chief Operating Officers Report - Mental Health and Learning Disabilities ……………………………………………………………………………………………………………………………………………………………………………………………… 15

August 17

Executive Summary…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Performance Summary Pages…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Surgery, Women's and Children's Health…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Single Oversight Framework…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Chief Operating Officers Report - Surgery, Women's and Children's Health…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Chief Operating Officers Report - Medicine……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Chief Operating Officers Report - Clinical Support, Cancer and Diagnostics……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Medicine……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Clinical Support, Cancer and Diagnostics……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Page 2


Ref Indicator Timeframe (If different to current data)

Threshold Jun-17 Jul-17 Aug-17YTD/Annual

Figure

1 3% 3.90% 4.17% 4.40% 4.14%

2 5% 0.62% 0.61% 0.59% 0.59%

3 - 0.00% 0.00% 0.00% 0.00%

4 2016 - - 44%

5 Q4 2016/17 - 639.31

6 - 26 36 19 123

7 Q1 2017/18 - 0.00%8 0 0 0 0 09 - 3 3 1 -

10 0 9 5 9 44

11 - 13.54% 25.80% 24.6% 25.48%

12 90% 87.59% 94.38% 87.41% 87.79%13 <15% >15% 13% 16% 12% 13%14 90% 100.00% 100.00% 100.00% 100.00%

15 95% 99.46% 99.39% 99.29% 99.28%

16 - 2 1 -1 -

17 7 3 1 0 8

18 0 0 0 0 0

19 Jan-17 - - 89.6 (low)

20 Jan-17 - - 99.6 (as exp)

21 Published June 2017 1 - 1.047

22 - 5.6% 6.0% 5.4% 6.05%

23 Published 15th November 2016 - - 28.0%

24 90% 88.05% 89.16% 86.02% 90.61%

25 90% 97.78% 98.53% 94.55% 95.74%

26 - 0 0 0 0

27 95% 97.62% 88.20% 96.88% 95.53%

28 - 33% 33% 34% -

29 - 9% 9% 9% -

30 90% 0%* 0%* 0% 0.00%

31 - 50% 86% 56% -

32 - 2 2 2 3

33 Submitted in August 2017, figures from April 2017 - 1 0 1 -

*0 responses in April, 1 response in May, 0 responses in June, 1 response in July

**Pending further validation, snapshot as at end of month Please note that the Mixed Sex Accomodation figure for May has now changed due to further validation

August

Current Data

Org

anis

atio

nal H

ealth

Indi

cato

rs Staff Sickness

Staff Turnover

Executive Team Turnover (Staff within Trust Board)

NHS Staff Survey - Response Rate

Proportion of temporary staff -

Written complaints - Rate

Staff Friends and Family Test % recommended - Care -Occurance of any Never EventNHS England/NHS Improvement Patient Safety Alerts Outstanding

MRSA Bacteraemias

Acu

te P

rovi

ders

Mixed Sex Accomodation breaches

Inpatient Scores from Friends and Family Test - % Positive (Response rate)

A&E Scores from Friends and Family Test - % Positive (% Recommended)Emergency C-Section rate

Hospital Standardised Mortality Ratio (DFI)

Hospital Standardised Mortality Ratio - Weekend (DFI)

Maternity scores from Friends and Family Test - % Positive

VTE Risk Assessment

Clostridium Difficile - Variance from plan

Clostridium Difficile - Infection rate

Summary Hospital Mortality Indicator

Emergency Re-Admissions within 30 days following an elective or emergency spell at the provider

Men

tal H

ealth

Pro

vide

rs Mental Health scores from Friends and Family Test - % positive (Recommended)

Admissions to adult facilities of patients who are under 16 years old

Care Programme Approach (CPA) follow up - proportion of discharges from hospital followed up within 7 days - MHMDS

% Clients in settled accommodation**

% Clients in employment**

Community ProvidersCQC Inpatient/Mental Health and Community Survey - Response Rate

Community scores from Friends and Family Test - % positive

Am

bula

nce

Pro

vide

rs

Ambulance see and treat from Friends and Family Test - % positive

Return of Spontaneous Circulation (ROSC) in Utstein group

Stroke 60 minutes (Thrombolysis delivery within 60 minutes)

ST Segmented elevation myocardial infarction (STeMI) 150 minutes (As at month of submission)

Page 3

4


Balanced Scorecard - Aligned to Our Goals

Excellent Patient Care AreaAnnual Target

YTD Month TrendA positive experience for patients, service users and staff

AreaAnnual Target

YTD Month TrendCost effective, sustainable services

AreaIn month

planAnnual Target

YTDMonth Trend

Patients that develop a grade 4 pressure ulcer TW3 (80%

reduction on 15/16)

0 Aug-17 0 � Emergency Care 4 hour Standards AUC 95% 95% Aug-17 86% � RTT % of incomplete pathways within 18 weeks - IoW CCG TW 89.6% 92% Aug-17 �

Patients that develop an ungraded pressure ulcer TW 1 Aug-17 5 �Number of patients who have waited over 12 hours in A&E from decision to admit to admission

AUC 0 0 Aug-17 0 �� RTT % of incomplete pathways within 18 weeks - NHS England TW 92% 94% Aug-17 �

VTE (Assessment for risk of) TW >95% 99.3% Aug-17 99.3% � Ambulance Category A Calls % < 8 minutes AUC 75% 69% Aug-17 70.7% � Zero tolerance RTT waits over 52 weeks (Incomplete Return) TW 0 0 Aug-17 0 6 ��

MRSA (confirmed MRSA bacteraemia) TW 0 0 Aug-17 0 �� Ambulance Category A Calls % < 19 minutes AUC 95% 91% Aug-17 92% � No. Patients waiting > 6 weeks for diagnostics TW <8 27 Aug-17 <100 45 �

C.Diff(confirmed Clostridium Difficile infection - stretched target)

TW 7 0 Aug-17 8 � Number of Ambulance Handover Delays over 1 hours AUC N/A 7 Aug-17 104 � % Patients waiting > 6 weeks for diagnostics TW <1% 2.3% Aug-17 <1% 0.8% �

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

TW 6 0 Aug-17 8 � % of CPA patients receiving FU contact within 7 days of discharge MH 95% 96.9% Aug-17 95.5% � Theatre utilisation SWC / CCD 83% 80% Aug-17 83% 80% �

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

TW 1 Aug-17 3 � % of CPA patients having formal review within last 12 months MH 95% 99.1% Aug-17 98.2% � Total pay costs (inc flexible working) (£000) TW £10,729 £11,122 Aug-17 £52,711 £53,595

Falls - resulting in significant injury TW 5 0 Aug-17 1 ��% of MH admissions that had access to Crisis Resolution / Home Treatment Teams (HTTs)

MH 95% 100.0% Aug-17 97.3% �� Staff in Post (£000) TW £10,718 £9,579 Aug-17 £52,473 £47,416

Symptomatic Breast Referrals Seen <2 weeks* CCD 93% 98.0% Aug-17 98.0% � All Cancelled Operations on/after day of admission SWC / CCD

23 Aug-17 84 � Variable Hours (£000) TW £12 £1,543 Aug-17 £237 £6,179

Cancer patients seen <14 days after urgent GP referral* CCD 93% 97.9% Aug-17 97.8% �

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

SWC / CCD

0 5 Aug-17 11 � Staff absences - Acute Acute 3.5% 3.88% Aug-17

Cancer Patients receiving subsequent Chemo/Drug <31 days* CCD 98% 100.0% Aug-17 100.0% �� Patient Satisfaction (Friends & Family test - Total response rate) TW 31% Aug-17 29% � Staff absences - Ambulance Ambulance 5.5% 9.07% Aug-17

Cancer Patients receiving subsequent surgery <31 days* CCD 94% 100.0% Aug-17 100.0% �� Patient Satisfaction (Friends & Family test - A&E response rate) TW 4% Aug-17 4% � Staff absences - MHLD MHLD 4.5% 5.68% Aug-17

Cancer diagnosis to treatment <31 days* CCD 96% 100.0% Aug-17 98.6% � Mixed Sex Accommodation Breaches TW 0 9 Aug-17 44 � Staff Turnover TW 5% 0.59% Aug-17 5% 0.59%

Cancer Patients treated after screening referral <62 days* CCD 90% 100.0% Aug-17 100.0% �� Formal Complaints TW 19 Aug-17 123 � Mandatory Training* TW 80% 81.0% Aug-17 81.0%

Cancer Patients treated after consultant upgrade <62 days* CCDNo measured

operational standard

50% Aug-17 50% �� Compliments received TW N/A 264 Aug-17 1,022 � Appraisal Monitoring TW 100% 47.0% Aug-17 47.0%

Cancer urgent referral to treatment <62 days* CCD 85% 95.7% Aug-17 79.9% � Achievement of adjusted financial performance TW (£2.514) Aug-17 (£18.8m) (£10,740)

Summary Hospital-level Mortality Indicator (SHMI)July-15 - June-16

TW 1 1.047Published Jun 2017 N/A � Variance against adjusted financial performance TW (£0.91) Aug-17 £0 (£1.39)

Never events TW 0 0 Aug-17 0 �� Liquidity ratio days metric TW Aug-17 4.0 4.0

Stroke patients (90% of stay on Stroke Unit) M 80% 85% Aug-17 86% � Capital Servicing Capacity (times) TW Aug-17 4.0 4.0

High risk TIA fully investigated & treated within 24 hours (National 60%) M 60% 100% Aug-17 100% �� Agency spend variance against plan (£000's) TW £0 (£636) Aug-17 £0 (£1.867)

*Cancer figures for September are provisional. Capital Expenditure as a % of YTD plan TW 42% Aug-17 =>75% 17%

Working with others to keep improving our services

AreaAnnual Target

YTD Month Trend Skilled and capable staff AreaIn month

planYear to

date planYTD I&E Margin Rating TW Aug-17 4.0 4.0

I&E Margin Variance from Plan TW Aug-17 1.0 4.0

Delayed Transfer of Care (lost bed days) - (MH) TW N/A 0 Aug-17 30 �� Total Workforce (inc flexible working) (FTE's) TW 2,964.06 2,875.0 Aug-17 N/A N/A Single Oversight Framework - Use of Resources TW Aug-17 2.8 4.0

Delayed Transfer of Care (lost bed days) - (Acute) TW N/A 95 Aug-17 508 � Total workforce SIP (FTEs) TW 2,750.76 2,660.0 Aug-17 N/A N/A Debtors over 90 days as a % of total debtor balance TW Aug-17 =<5% 37.0%

Delayed Transfer of Care (lost bed days) - (Community) TW N/A 236 Aug-17 970 � Variable Hours (FTE) TW 213.3 215.0 Aug-17 853.2 1066.0 Creditors over 90 days as a % of total creditor balance TW Aug-17 =<5% 2.0%

Notes Agency Spend above Ceiling TW Aug-17 1.0 4.0

Delivering or exceeding Target � Key to Area Code Total CIP savings achieved TW 100% 52% Aug-17 100% 94%

Underachieving Target �� TW = Trust Wide Recurring CIP savings achieved TW 100% 59% Aug-17 100% 93%

Failing Target � SWC = Surgery, Women's and Children's Health Contract Penalties TW £4,482 Aug-17 £0.0 £11,982

M = Medicine Employee Relations Cases TW 0 24 Aug-17 113

CCD = Clinical Suppprt, Cancer and Diagnostics * Rolling year

AUC = Ambulance, Urgent Care and Community

MH = Mental Health and Learning Disabilities

Actual Performance

Actual Performance

Improvement on previous month

Sparkline graphs wil be included in M1

Report to present the trends over time for

Key Performance Indicators

Actual Performance

Deterioration on previous month

Actual Performance

Actual Performance

No change to previous month

Page 4


Executive SummaryAugust 17

Excellent Patient Care:Pressure ulcers: There are a number of ungradable pressure ulcers that are still under review, the numbers will continue to change following investigation and validation of all lesions as attribution is more accurately assessed and learning shared with the appropriate teams. A recent trial with hand held Tissue Scanners has demonstrated early detection of tissue damage up to 10 days prior to development of a visual lesion. This has indicated that the majority of ulcers developed within 10 days of admission have already passed the preventable stage prior to arrival on the wards and has proved a more reliable indicator than the current system scoring of risk. C.diff: There has been no new case of Healthcare Acquired Clostridium Difficile identified in the Trust during August. The objective for 2017/18 remains at no more than 7 cases across the year and this has now been exceeded.

There have been no new cases of MRSA within the Trust during August.

Cancer urgent referral to treatment <62 days target was achieved in August.

A positive experience for patients, service users and staff:

The Ambulance service targets were not achieved in August, however, all have shown improvement upon the previous month, with both Red 1 and Red 2 performance increasing the most significantly. Recent recruitment has been successful with 5wte new paramedics employed and in the interim, senior paramedic managers are now rostered to achieve more coverage. 2 EVO staff will commence training in September for CertHe paramedic course. All will have a positive impact on the workforce going forward.A workforce workshop held in August reviewed the future requirements in order to meet the new Ambulance Response Programme (ARP) standards which are being introduced nationally from 1st September. The service in the meantime has started a deep dive (August) in order to make internal improvements of the 'green up' time by improving the visibility of the Performance Support Officers (PSO) in ED to make sure ambulance staff are completing their ‘green up’ in a timely manner.

Emergency Care 4 Hour Standard -The Trust significantly improved its performance against the ECS in August by over performing against the 89.2% trajectory by achieving 94.9%; this is just 0.1% under the national target of 95%. This is a tremendous achievement for the Trust given recent pressures and difficulties and is due to a number of changes and improvements including implementation of an ED dashboard.

Mixed Sex Accommodation - There were 7 mixed sex accommodation breaches during August that involved sleeping/personal care accommodation. However, there were 2 additional incidents of ACP endings over 4 hours where the patient was unable to be returned to ordinary level care and personal care facilities were not of the standard required. All 9 of the MSA breaches during August involved lack of available stepdown beds at the end of Acute Care Pathways and were on either ITU or CCU. We have received 19 formal complaints during August (36 in July).We have received 264 compliments during August (195 in July).

% of Care Programme Approach patients having formal review within last 12 months is achieving month & YTD and % of Care Programme Approach patients receiving Follow Up contact within 7 days of discharge is also achieving month & YTD.

0 patients have waited over 12 hours in A&E from decision to admit to admission in August.

Skilled and capable staff:

• Sickness absence has increased in July 17 within Acute, MHLD and Ambulance. Trustwide 4.17% • Anxiety, stress and other psychiatric illnesses remains the highest cause of absence although there has been a decrease of 2.48 % in July 2017. • Agency usage has exceeded the national ceiling, with Medics providing cover for vacancies and additional activity cover.• During July, agency nurses were used to cover vacancies within MH and to staff additional beds/capacity in Acute areas. • The Trust appraisal position has increased to 50.03% in month from 48.49%, and now represents the full rolling year figure since the appraisal “reset”. Information is being provided to identify those outstanding so that this position can be improved upon.• Turnover is stable at 0.61% in month 4• Mandatory training is at 80% Trustwide• Update to Occupational Health and Wellbeing CQUIN

Cost effective, sustainable services:

Referral to treatment times - In July the Trust over-performed against the system-wide trajectory of 88.8% by achieving 92.2%; this is also slightly over-performing against the national target of 92% which the Trust had forecast it would not be achieving until March 2018. This over-performance against the trajectory is a continued improvement upon the performance achieved in June of 91.2%.

Overall theatre utilisation has decreased very slightly over the last month from 79.7% to 79.4%. The percentage utilisation of Main Theatre facilities has increased from the previous month from 78.8% to 80.1% against the local target of 83%. Day Surgery Unit utilisation has decreased slightly from 81.0%, to 78.6% A daily review of individual list utilisation is in place with processes being further developed and monitored to embed consistency in clinician sign off of lists and agreed utilisation levels; this is alongside regular monitoring of reasons for late starts and early finishes as well as on the day cancellations and the identification of appropriate actions to reduce, such as reviewing the informed booking data and reviewing the Access Policy around patient choice .

The Trust has a cumulative deficit of £8.226m as at 31 July 2017. This is an adverse variance of £0.485m behind the Board approved deficit plan.The adverse variance to date against the Board approved plan is due to the increased additional expenditure on both agency and the Quality Improvement Plan.The control total for 2017/18 is a deficit of £0.366m.The current cumulative deficit is £6.6915m behind this control total.The most likely forecast outturn is £18.8m. This assumes a further £2.4m of additional quality improvement plan costs over the plan deficit, as approved by the Trust Board in May 2017. However, this will be offset by uncommitted centrally held investment funding.Any best case scenario will be in the region of £11m, assuming full delivery of CCG QIPP plans.Under a Worst Case scenario the Trust will deliver a £30.4m deficit. This includes a shortfall in CIP achievement of £3.5m and further QIPP assigned from the CCG, without equivalent cost reduction, of £4.3m.Year to date, CIP savings of £1.780m have been achieved, which is ahead of plan by £0.201m. As at 31 July £0.406m of capital allocation has been spent. The Trust board is meeting on 15th August to prioritise schemes for 2017/18 to the value of the approved Capital Resource Limit of £8.3m.The cash position for the Trust remains a key risk, with monthly approvals of uncommitted loan funding required.The Trust’s Use of Resources Rating is a score of 4 (1 being best and 4 being worst). This is based on the control total of £0.366m deficit, which the Trust is monitored against with NHSI.

Page 5


Performance Summary - Surgery, Women's and Children's Health

Target Actual Target Actual Target Actual Target Actual

MRSA (confirmed MRSA bacteraemia) Aug-17 0 0 0 0 Mixed Sex Accommodation Breaches Aug-17 0 0 0 0

C.Diff (confirmed Clostridium Difficile infection) Aug-17 0 3 No. of Complaints Aug-17 4 35

Clinical Incidents (Major) resulting in harm

(all reported, actual & potential, includes falls & PU G4)Aug-17 1 0 3 2 No. of Concerns Aug-17 16 73

Clinical Incidents (Catastrophic) resulting in harm

(actual only - as confirmed by investigation)Aug-17 0 1 No. of Compliments Aug-17 149 435

Falls - resulting in significant injury Aug-17 0 0

Cancelled operations on/after day of admission

(not rebooked within 28 days) - including those not rebooked at

the time of reporting

Aug-17 0 5 0 11

Emergency 30 day Readmissions Aug-17 4.3% 3.7% All Cancelled Operations on/after day of admission Aug-17 23 84

Never Events Aug-17 0 0 0 0 No. of Reported SIRIs * Aug-17 1 4

Pressure Ulcers - Grade 1 Aug-17 1 9 Physical Assaults against staff Aug-17 2 13

Pressure Ulcers - Grade 2 Aug-17 4 11 Verbal abuse/threats against staff Aug-17 3 9

Pressure Ulcers - Grade 3 Aug-17 0 0


Pressure Ulcers - Ungradable Aug-17 0 1


Appraisals Aug-17 58.7%

Plan Actual Plan Actual Target Actual Target Actual

Total SLA Value Jul-17 3,475,151£ 3,464,775£ 13,478,553£ 13,484,820£ RTT % of incomplete pathways within 18 weeks (IoW CCG + NHS

England)Aug-17 92% 91.7%

Zero tolerance RTT waits over 52 weeks (Incomplete Return) Aug-17 0 0 0 6

% Sickness Absenteeism Aug-17 3.5% 3.27% 3.89%

*12 hour breaches are now included in Siri figures

**The Acute Service Level Agreement performance reports a month behind, therefore figures are from June 2017.

August 17

Balanced Scorecard - Surgery, Women's and Children's Health

Excellent Patient CareLatest

data

In Month YTD A positive experience for patients, service users and staff

Latest

data

In Month YTD


Latest

data

In Month YTD Skilled and capable staff Latest

data

In Month

YTD

YTD


Latest

data

In MonthIncome**

Latest

data

In Month YTD

Key Headlines:

• As at mid-September, the SWC services are now achieving the RTT incomplete target overall. A number of individual services are not and remain behind trajectory. These are being reviewed through the Access meetings.

• Recruitment continues to fill nursing and consultant/middle grade posts to reduce levels of agency staffing currently being used; this presents one of the most significant challenges to the CBU

• The CBU achieved its target sickness rate for the first time this year and are working with HR to focus on 'hot spots'

• Appraisal information is now being received weekly and being used to target areas which are significantly behind, in particular ward areas.

Page 6


Chief Operating Officers Report - Surgery, Women’s and Children’s Health

Good News and General Update:

2. Improvements have been seen around the Cancer 38 day referral figures

3. All Serious Incidents Requiring Investigation are within the timeframe and are being actioned

Sep-17

1. RTT performance is currently at 93.1%

Date:

Issue Mitigation Action Owner Completion Date

Ongoing issues with medicines i.e. left out or lockers not closed. Majority of wards have improved compliance, however issues continue to persist

Relevant ward Matron and Ward Sister are conducting focused audits alongside the Pharmacy team to improve the situation

Head of Nursing & Quality

30th September 2017

Ongoing issues with recruiting nurses to Whippingham ward and recruiting a locum consultant for Urology

Both medical and nursing recruitment remains a challenge across the CBU. Agency staff are being used to cover clinically required posts and staff acting down when required for safety.

Head of Nursing & Quality and the Clinical Director for medical vacancy

Linked to Trust recruitment strategy for hard to fill posts

Increase in 52 week breaches No current waits above 52 weeks across the whole CBU

Mitigation in place around offering patient choice much earlier in the pathway to avoid delays pushing into 52 week breaches

Head of Nursing & Quality

Linked to the (RTT) recovery trajectory

Page 7


Performance Summary - Medicine








Falls - resulting in significant injury Aug-17 0 0 No. of Reported SIRIs * Aug-17 1 4

Emergency 30 day Readmissions Aug-17 8.3% 9.3% Physical Assaults against staff Aug-17 1 12

Stroke patients (90% of stay on Stroke Unit) Aug-17 80% 84.6% 80% 85.8% Verbal abuse/threats against staff Aug-17 1 11

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

60%)Aug-17 60% 100.0% 60% 100.0%

Never Events Aug-17 0 0 0 0















August 17

Balanced Scorecard - Medicine


data


Latest

data

In Month YTD


Latest

data


data

In Month

YTD

YTD


Latest

data

In MonthIncome**

Latest

data

In Month YTD

Key Headlines:

• Sickness absenteeism continues to be monitored and discussed at the monthly leadership meetings. Medicine CBU met the 3.5% target in May, June and July but have failed in August 2017

• Medicine CBU are working with HR to remove staff that no longer work in the Trust from the appraisal data. Once completed this will show an improvement in the % of completed appraisals.

• Physical assaults against staff has been placed on risk register with an appropriate action plan

Page 8


Chief Operating Officers Report - Medicine

Good News and General Update:

1. The Linking of the Partnering Health Limited (PHL) and Adastra systems

2. Achievement of RTT 92%

3. Achievement of the IIF target to reduce delays in transfer of care

Sep-17

Date:


Urgent Care Service (UCS) staffing and financial challenges

Sufficient cover is now in place from 18.30 – midnight for the GP UCS rota Monday –Friday and from 08.00 – Midnight on Saturday and Sunday. Following a stakeholder workshop, a proposal paper has been developed jointly between the CCG and Trust. This proposal explores the option of UCS moving under the leadership of the Emergency Department. In terms of financials, the finance teams from the Trust and the CCG are working to finalise the costs the service as incurred.

Medicine CBU/Trust Finance team

Complete The costing has been completed and shared with the CCG. The Trust is in communication with the CCG to finalise

Achieving 100% compliance with implementation of SAFER Bundle on all wards

There has been good progress with the implementation of SAFER:

- Reviews of all stranded patients have been completed daily.

- A plan to roll out all the elements of the SAFER bundle has been written and full ward roll out will commence in September and run until December 2017

Matron and Head of Nursing & Quality

As per IIF timetable

Underachieving Referral To Treatment (RTT) targets in Gastroenterology and Hepatology

Dr Slapak, NHS Locum Consultant joined the Trust on 14/09/17 in a job shared role with Dr Grellier. It is anticipated that both specialties will meet the 92% target by the end of September 2017

Head of Operations

Ongoing

Page 9


Performance Summary - Clinical Support, Cancer and Diagnostics








Falls - resulting in significant injury Aug-17 0 0

Cancelled operations on/after day of admission

(not rebooked within 28 days) - including those not rebooked at the time of

reporting

Aug-17 0 5 0 11

Emergency 30 day Readmissions Aug-17 0.0% 0.0% All Cancelled Operations on/after day of admission Aug-17 23 84

Symptomatic Breast Referrals Seen <2 weeks* Aug-17 93% 98.0% 93% 98.0% Theatre utilisation Aug-17 83% 79.9% 83% 79.9%

Cancer patients seen <14 days after urgent GP referral* Aug-17 93% 97.9% 93% 97.8% No. of Reported SIRIs *** Aug-17 2 2

Cancer Patients receiving subsequent Chemo/Drug <31 days* Aug-17 98% 100.0% 98% 100.0% Physical Assaults against staff Aug-17 1 3

Cancer Patients receiving subsequent surgery <31 days* Aug-17 94% 100.0% 94% 100.0% Verbal abuse/threats against staff Aug-17 3 11

Cancer diagnosis to treatment <31 days* Aug-17 96% 100.0% 96% 98.6%

Cancer Patients treated after screening referral <62 days* Aug-17 90% 100.0% 90% 100.0%

Cancer urgent referral to treatment <62 days* Aug-17 85% 95.7% 85% 79.9%

Never Events Aug-17 0 0 0 0









Total SLA Value Jul-17 1,207,526£ 1,227,825£ 4,748,928£ 4,737,465£ RTT % of incomplete pathways within 18 weeks (IoW CCG + NHS England) Aug-17 92% 96.9%


No. Patients waiting > 6 weeks for diagnostics Aug-17 <8 27 <100 45

% Patients waiting > 6 weeks for diagnostics Aug-17 <1% 2.3% <1% 0.8%


*Cancer figures for April are provisional. These are subject to further validation and may change.


***12 hour breaches are now included in Siri figures

August 17

Balanced Scorecard - Clinical Support, Cancer and Diagnostics


data


Latest

data

In Month YTD


Latest

data


data

In Month

YTD

YTD


Latest

data

In MonthIncome**

Latest

data

In Month YTD

Key Headlines:• Cancer Performance – The Trust is provisionally achieving all measurable cancer standards for August as at 18/09/17. 62 Day standard – 50 treatments have been identified to date with 2 local breaches (1 x Haematology – Complex Diagnostic Pathway, 1 x Lung – Required cardiology review. Refused surgery and elected immunotherapy).

Breach reports have been prepared and shared appropriately. Weekly PTL and Patient Access meetings continue to focus on reducing the number of patients passed the 62 day target.

• NHSI/IST visit 7th September to review service pressure areas and offer assistance.

• Short term funding secured to address backlog and improve timely access to MRI.

• Theatre Utilisation - Performance has increased slightly from 79.7% to 79.9% against a local target of 83%. Close monitoring of underutilisation plus daily meeting with the other CBU's expedite actions and challenge to improve these figures lists .

• Actions to improve overall utilisation includes review of reasons for late starts to theatre lists, early finishes and reasons for one day cancellations. Qlikview dashboard has been developed by PIDS to ensure we are reporting one % figure and this is still work in progress . This information will then be displayed and shared with staff.

• Diagnostic breaches are due to Nurse Endoscopist vacancy and Consultant Surgeon locum vacancy, cancer and urgent patients are being prioritised. Despite this there is still not enough capacity to manage fast tracks and patients continue to breach.

• Mixed Sex Breaches - Options paper drafted to refurbish DSU and address mixed sex accommodation going forward. Work will not commence until 2018. Risk being mitigated in interim.

• Sickness Absence Monitoring Analysis - Increase in sickness absence in August. Management is addressing long term absences and supporting their return to work.

Page 10


Chief Operating Officers Report - Clinical Support, Cancer & Diagnostic Services

1. National Health Service Improvement (NHSI) Cancer Critical Friend Visit took place on 7th September. The Trust is awaiting feedback regarding this visit Sep-17

Good News and General Update: Date:


62 day Cancer waiting times are not currently being achieved due to complex pathways and access to diagnostics

£46,000 worth of funding from NHS England has enabled more support into Magnetic Resonance imaging (MRI), which it is predicted will halve the length of the waiting list by the end of September 2017. £32,000 funding has also identified been for Cancer Pathways to allow more admin support in order to free up more time for the Cancer Nurse Specialists.

Head of Operations

March 18

The Pathology Telepath system currently has no assured backup for the hardware

The business case for disaster recovery was presented and approved at the August Capital Investment Group and is now in the process of being implemented. Pathology Network is being proposed which will require a new Laboratory Information Management System (LIMS) system across all sites.

Head of Operations

March 18

Page 11

`


Performance Summary - Ambulance, Urgent Care and Community



C.Diff (confirmed Clostridium Difficile infection - stretched target) Aug-17 0 0 No. of Complaints Aug-17 3 37

Clinical Incidents (Major) resulting in harm (all reported, actual & potential,

includes falls & PU G4)Aug-17 1 0 3 2 No. of Concerns Aug-17 15 73

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

investigation)Aug-17 0 0 No. of Compliments Aug-17 0 79

Falls - resulting in significant injury Aug-17 0 1 Emergency Care 4 hour Standards Aug-17 95% 94.9% 95% 86.1%

Never Events Aug-17 0 0 0 0Number of patients who have waited over 12 hours in A&E from decision to admit

to admissionAug-17 0 0 0 0

Pressure Ulcers - Grade 1 Aug-17 3 6 Category A 8 Minute Response Time (Red 1) Aug-17 75% 66.1% 75% 65.5%

Pressure Ulcers - Grade 2 Aug-17 1 4 Category A 8 Minute Response Time (Red 2) Aug-17 75% 69.8% 75% 71.0%

Pressure Ulcers - Grade 3 Aug-17 0 0 Category A 19 Minute Response Time Aug-17 95% 91.4% 95% 92.3%

Pressure Ulcers - Grade 4 Aug-17 0 0 Number of Ambulance Handover Delays over 1 hours Aug-17 7 104

Pressure Ulcers - Ungradable Aug-17 0 0 No. of Reported SIRIs * Aug-17 3 15

Physical Assaults against staff Aug-17 4 12

Verbal abuse/threats against staff Aug-17 5 20




Total SLA Value Jul-17 2,477,524£ 2,556,191£ 9,515,396£ 9,717,562£ % Sickness Absenteeism Aug-17 5.5% 5.02% 4.80%

Ambulance re-contact rate following discharge from care by telephone Aug-17 3% 4.5% 3% 11.4%

Ambulance re-contact rate following discharge from care at scene Aug-17 2% 5.6% 2% 6.3%

Ambulance time to answer call (in seconds) - median Aug-17 1 1 N/A N/A

Ambulance time to answer call (in seconds) - 95th percentile Aug-17 5 1 N/A N/A

Ambulance time to answer call (in seconds) - 99th percentile Aug-17 14 28 N/A N/A

NHS 111 Call abandoned rate Aug-17 5% 3.6% 5% 4.7%

NHS 111 All calls to be answered within 60 seconds of the end of the introductory

message Aug-17 95% 91.4% 95% 89.0%

NHS 111 Where disposition indicates need to pass call to Clinical Advisor this should

be achieved by ‘Warm Transfer’ Aug-17 95% 95.1% 95% 94.7%

NHS 111 Where the above is not achieved callers should be called back within 10

mins Aug-17 100% 34.9% 100% 35.4%



August 17

Balanced Scorecard - Ambulance, Urgent Care and Community


data


Latest

data

In Month YTD


Latest

data


data

In Month

YTD

YTD

Cost effective, sustainable services Latest

data

In MonthIncome**

Latest

data

In Month YTD

Key Headlines:• Successful recruitment of paramedics and ongoing recruitment across the CBU to fill vacant posts

• Appraisal information is now being received weekly and being used to target areas which are significantly behind, in particular ward areas.

• Emergency Care Standard - The 95% National target was not achieved in August by a narrow margin but showed further improvement. Work continues to further improve and embed processes within the ED and the service is working closely with a newly appointed urgent care service improvement lead who is facilitating and guiding the change process

• Ambulance - The Ambulance service targets were not achieved in August although have shown a minor improvement. The service has implemented a number of changes in order to improve performance including daily review of missed one calls and change in staff . The service has recently employed a new operational manager who commenced on the 11/9

• Improvement has been seen within the 111 service post successful recruitment to call handlers

• The ambulance service held a workshop in August and recommendations from this will be presented to the CBU

• Community - There is continued pressure within the community nursing service and AUCC HONQ has been released to concentrate entirely on community nursing. a secondment has been advertised for backfill HONQ position to urgent care and ambulance service

• Frailty service at the front door commenced 11/9

• System One training has commenced for community services

Page 12


Chief Operating Officers Report - Ambulance Urgent Care and Community

1. Continued sustained performance of the 4 hour emergency care standard throughout August

2. Improvement in NHS 111 performance throughout August

3. Improvement in the Ambulance Red 1 response performance throughout August

4. Commenced Frailty Project at the front door

Sep-17

Good News and General Update Date:


Ambulance

Failure to meet the current performance standards

The service has completed a deep dive into the current performance and the contributing factors and are putting in place measures to address and improve performance; this is being supported by the Head of Operations (HOO) for the CBU

Head of Operations

30th September 17

Implementation of the new Ambulance Response Programme (ARP) standards recently issued by the Department of Health (DoH)

Implementation of staffing workshop recommendations where appropriate The service will further be supporting this with a paper outlining gaps in service and recommendations to address the gaps The Trust will be asking the DoH for a deferment to implement the reporting of the new standards to the 1st April 17

Operations Manager Head of Operations COO/Deputy Chief Executive

30th September 17 30th September 17 30th September 17

Urgent Care

Sustainability of the 4 hour emergency care standards (within the Emergency Department (ED)

Improvement in sustainability of the achieving the 4 hour emergency care standard has been seen throughout August 2017.

Operations Manager ED

On going

Community

Quality concerns within the community nursing team and the significant backlog of Continuing Healthcare Care (CHC) reviews

Head of Nursing & Quality (HONQ) has been redirected to focus on community nursing only for next 6 months A 6 month secondment post for a HONQ to support ED, MAU and Ambulance is currently out to advert. Interim arrangements involve using HOO and Urgent Care Improvement Lead

Head of Nursing & Quality Urgent Care Improvement Lead & Head of Operations

30th October

Significant volume of transformation schemes within the community services requiring immediate action and delivery with limited resource within the CBU E.g.

• Frailty • Rehab redesign • Discharge to assess • MPPT • ILS • Co-ordinated access • Performance

improvements

Senior staff within the CBU are managing time and prioritising their workload as much as possible. Any risks identified have been shared with executive colleagues Additional resource (1 whole time equivalent (wte) band 5 for 6 months to 31st March) has been bought in to assist with Rehab redesign/discharge to assess Assistant Operations Manager returns to post within CBU on 1st September 17

Head of Operations & Clinical Director

Asap

Page 13


Performance Summary - Mental Health and Learning Disabilities


MRSA (confirmed MRSA bacteraemia) Aug-17 0 0 0 0 FFT - % Response Rate Aug-17 1.6% 1.7%

C.Diff (confirmed Clostridium Difficile infection) Aug-17 0 0 FFT - % Recommending Aug-17 90% 95% 90% 96%


(all reported, actual & potential, includes falls & PU G4)Aug-17 1 0 3 1 No. of Complaints Aug-17 4 12


(actual only - as confirmed by investigation)Aug-17 0 0 No. of Concerns Aug-17 2 25

Falls - resulting in significant injury Aug-17 0 0 No. of Compliments Aug-17 21 32

Never Events Aug-17 0 0 0 0 No. of Reported SIRIs * Aug-17 2 4

% of EIP pathways completed within two weeks Aug-17 50% 100.0% 50% 80.0% Physical Assaults against staff Aug-17 11 68

IAPT – Proportion of people who have completed treatment and

moving to recoveryAug-17 50% 69.3% 50% 56.9% Verbal abuse/threats against staff Aug-17 13 76

% of Users known to CMHS with a risk assessment completed

within the last 12 monthsJul-17 100% 81.0% 81.0% % of CPA patients receiving FU contact within 7 days of discharge Aug-17 95% 96.9% 95% 95.5%

% of CPA patients having formal review within last 12 months Aug-17 95% 99.1% 95% 98.2%

% of MH admissions that had access to Crisis Resolution / Home

Treatment Teams (HTTs)Aug-17 95% 100.0% 95% 97.30%


Delayed Transfer of Care (lost bed days) - (MH) Aug-17 0 30 Appraisals Aug-17 22.3%




4 19685000 Zero tolerance RTT waits over 52 weeks (Incomplete Return) Aug-17 0 0 0 0


Caseload management supervision Aug-17 90% 100% 85%

Bed occupancy Aug-17 81.9% 82.4%



August 17

Balanced Scorecard - Mental Health and Learning Disabilities


data


Latest

data

In Month YTD


Latest

data

In Month YTD Skilled and capable staffLatest

data

In Month

YTD

YTD


Latest

data

In MonthIncome**

Latest

data

In Month YTD

Key Headlines:• Sickness levels continue to be high and is being monitored and actioned by the Head of Operations through the Operational Management Performance Meetings.

• The CBU has been working to address the issues in relation to RTT 18 week waits and is currently undertaking validation of all patients on the waiting list for MH, LD and ADHD services.

• The YTD and Monthly Caseload management figure continues to be improved.

• The CBU Management Structure is currently under review. Once complete the responsibility for completion of 7-day follow-up will transfer to CRHT and be managed by the matron responsible for that service.

Page 14


Chief Operating Officers Report - Mental Health & Learning Disabilities (MH&LD)

1. 3 nurses are undertaking the Advance Nurse Practitioner course

2. Robust plans are in place to address ligature risks identified by the CQC

3. Crisis Café opened in Quay House in September 2017

Sep-17

Good News and General Update Date:


Capacity and Capability to deliver the transformation required whilst also addressing the urgent quality issues and risks.

Clinical Commissioning Group (CCG) have indicated they will fund a further 2 post (Band 8a and Band 4) to support the transformation work required, however, nothing further has progressed. Training continues to be prioritised based on risk. A revised operating structure is being developed, and associated business cases are being produced to address key immediate capacity gaps, however longer term workforce strategy will be completed in line with wider transformation work-streams. Transformation working groups being mobilised which will include vertical slice of MH&LD CBU staff and patients. These will design and ultimately mobilise new operating models.

Associate Medical Director & CCG Mental Health and Learning Disabilities Director. Clinical Director MH&LD

31st October 2017 1st November 2017 All groups to be in place by the 1st

October 2017

Staff and service user engagement inadequate

Revised project plan to be approved at the next Integrated Improvement Framework (IIF) meeting in (October) with a view to increasing engagement and involvement of people who use our services and staff in determining the next steps.

Head of Operations

11th October 2017

Funding Significant funding issues for the CBU have been identified which need to be worked through. These are being addressed incrementally.

Director for MH&LD

1st April 2018

Training and development and therefore there are significant skills deficits as identified by the Care Quality Commission (CQC)

Training is being prioritised based on risk which links to the CQC report. Revised Training Needs Analysis is being undertaken alongside the Education Training and Development Department throughout October and November 2017.

Head of Nursing & Quality Head of Nursing and Quality

18th December 2017 1st December 2017

Page 15

Isle of Wight NHS Trust Board Operational Performance Report 2017/18

TitleSponsoring Executive DirectorAuthor(s)

Purpose

Action required by the Board: Approve

Date: 28th September 2017 Completed by: Iain Hendey, Deputy Director of Information

Principal Risks (BAF) ALL


Issue 1085, CQC Section 31 Warning Notice:The CQC have served the Trust with a warning notice of decision to impose conditions on our registration as a service provider in respect of a regulated activity in relation to the Mental Health and Learning Disabilities CBU, under Section 31 of the Health and Social Care Act 2008. They have also issued the Trust with a regulation 17.

This paper sets out the key performance indicators by which the Trust is measuring its performance in 2017/18 and provides details and action plans by exception for underperforming measures.


The Board is recommended to receive the report





Mental Health Act Scrutiny Committee



Finance, Investment, Information & Workforce Committee


Audit & Corporate Risk CommitteeCharitable Funds Committee

Sub-Committee Dates DiscussedKey Issues, Concerns and Recommendations from Sub Committee


Assurance XPreviously considered by (state date):

Operational Performance Shaun Stacey, Chief Operating Officer Iain Hendey - Deputy Director of InformationTo update the Trust Board regarding progress against key performance measures and highlight risks and the management of these risks.


Please add any other committees below as needed

IIF Workstream

Board Seminar

August 17

Trust Goals & Priorities ALL


Other (please state)

Enc I


Index

3-634

Theatre Utilisation……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..5Diagnostics …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….6

7-10789

101112

August 17

Exception Reports…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Glossary of Terms…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

A&E Performance - Emergency Care 4 hours Standard……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Benchmarking of Key National Performance Indicators……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Summary Report……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..IW Performance Compared To Other 'Small Acute Trusts'…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..IW Performance Compared To Other Trusts in the 'Wessex Area'…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Ambulance Performance……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Data Quality……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Ambulance………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Page 2


Ambulance Performance

Commentary: Analysis:

Analysis:

August 17

Action Plan: Person Responsible: Date:

The Ambulance service targets were not achieved in August, however, all have shown improvement upon the previous month, with both Red 1 and Red 2 performance increasing the most significantly; in particular, Red 1 performance for August achieved 66.1% against the trajectory of 68.9%. Recent recruitment has been successful with 5wte new paramedics employed and in the interim, senior paramedic managers are now rostered to achieve more coverage. 2 EVO staff will commence training in September for CertHe paramedic course. All will have a positive impact on the workforce going forward.

A workforce workshop held in August reviewed the future requirements in order to meet the new Ambulance Response Programme (ARP) standards which are being introduced nationally from 1st September; some immediate changes have been made, alongside the identification of good medium and longer term changes, which will be developed into a business case for Trust consideration. The CAD requirements continue to be prioritised for agreeing a way forward, including collaborative working with another service to potentially share systems.

The service in the meantime has started a deep dive (August) in order to make internal improvements of the 'green up' time by improving the visibility of the Performance Support Officers (PSO) in ED to make sure ambulance staff are completing their ‘green up’ in a timely manner; looking at ways of being more efficient in replenishing stock on the vehicles; ensuring all dispatchers are prompting frontline staff when timeliness looks to be a concern and escalating to PSOs as appropriate to provide support.

Recruitment to call handlers has been successful with a number of staff now completing their training and the 111 service has seen a continued improvement in performance as a direct result of this. Further recruitment is ongoing to additional call handler posts. The service is working towards compliance against actions in the IIF.

Develop ARP requirements into business case for Trust considerationHead of Operations for Ambulance, Urgent Care

& Community Clinical Business UnitOct-17 In progress

Status:

0.0%

25.0%

50.0%

75.0%

100.0%

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Ma

r-1

7

Ap

r-1

7

Ma

y-1

7

Jun

-17

Jul-

17

Au

g-1

7

Cat A 8 minutes response time (Red 1)

Target achieved Target not achieved

Target Trajectory 0.0%

50.0%

100.0%

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Ma

r-1

7

Ap

r-1

7

Ma

y-1

7

Jun

-17

Jul-

17

Au

g-1

7

Cat A 19 minutes response time

Target achieved Target not achieved

Target Trajectory

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Ma

r-1

7

Ap

r-1

7

Ma

y-1

7

Jun

-17

Jul-

17

Au

g-1

7

Cat A 8 minutes response time (Red 2)

Target achieved Target not achieved Target Trajectory

Page 3


Emergency Care 4 hours Standard (ECS)


Analysis:

Ambulatory Care Service

Winter resilience planning for delivering emergency careHead of Operations for Ambulance, Urgent Care & Community Clinical

Business UnitSep-17 Commenced

August 17

Action Plan: Person Responsible:

Emergency Care 4 hours Standard

Date: Status:

The Trust significantly improved its performance against the ECS in August by over performing against the 89.2% trajectory by achieving 94.9%; this is just 0.1% under the national target of 95%. This is a tremendous achievement for the Trust given recent pressures and difficulties and is due to a number of changes and improvements including implementation of an ED dashboard, reestablishment of clinical pathways and ring fenced trauma beds to improve flow. Equally, the implementation of Red2Green methodology on the wards and daily 7day length of stay reviews in priority areas of the Trust has reduced the overall length of stay, alongside the sustained reopening of the surgical assessment unit. Most importantly, staff knowledge and understanding of flow throughout the hospital has increased and taking responsibility for the actions in place to achieve the improved performance seen during the month.

This achievement has improved the Trust's national position to being one of the best performing in the country and, as a result, some ward teams have been invited to speak nationally on the changes being made on the Island.

The ability to sustain such good performance is key and the Trust is reviewing the impact of the improvements and how to sustain the performance with internal and external pressures impacting on delivery, alongside preparations for delivering emergency care as the Trust enters the winter period.

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Se

p 1

6

Oct

16

No

v 1

6

De

c 1

6

Jan

17

Fe

b 1

7

Ma

r 1

7

Ap

r 1

7

Ma

y 1

7

Jun

17

Jul

17

Au

g 1

7

Target not achieved Target achieved Target Trajectory

Point of delivery Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

2016/17

Total Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

2017/18

Total

Admissions to AEC Ward 24 47 45 29 42 187 9 9 10 20 10 1 58

Follow Up Outpatient Visit 1 1 1 2 1 6 0 0 0 0 0 0 0

AEC Admissions by demand stream (Admission source)

Data as at 08/09/2017

Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

2016/17

Total Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17

2017/18

Total

NO DATA! 2 1 3 1 1

OTHER NHS HOSPITAL - GENERAL PATIENTS WARD 1 2 3 2 8 1 1

USUAL PLACE OF RESIDENCE 21 44 42 29 40 176 8 9 10 19 10 1 56

Grand Total 24 47 45 29 42 187 9 9 10 20 9 58

Page 4


Theatre Utilisation

Analysis:

Review of all non elective activity undertaken in theatres to be recorded and shown within the utilisation % going forward to give a true reflection of the activity and utilisation

Operational Manager (Theatres, Day Surgery & PAAU)

Oct-17 Commenced

August 17

Commentary

Overall theatre utilisation has improved slightly over the last month from 79.4% to 79.9%. The percentage utilisation of Main Theatre facilities has continued to increase by 4% over the last two months and is now at 82.8%, just below the local target of 83%. Day Surgery Unit utilisation has decreased slightly from 78.6% to 75.8%. A daily review of individual list utilisation is in place with processes being further developed and monitored to embed consistency in clinician sign off of lists and agreed utilisation levels; this is alongside regular monitoring of reasons for late starts and early finishes as well as on the day cancellations and the identification of appropriate actions to reduce, such as reviewing the informed booking data and reviewing the Access Policy around patient choice.

Action plan Person Responsible: Date: Status:

Theatre utilisation data to be shared with theatre staff and clinicians, and discussed at the Theatre Users Group to agree recovery action plan

Operational Manager (Theatres, Day Surgery & PAAU)

Sep-17 Commenced

0.0%

50.0%

100.0%

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

Jul 1

7

Aug

17

Main Theatres

Target failed Target met Target

0.0%

50.0%

100.0%

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

Jul 1

7

Aug

17

DSU


0.0%

50.0%

100.0%

Sep

16

Oct

16

Nov

16

Dec

16

Jan

17

Feb

17

Mar

17

Apr

17

May

17

Jun

17

Jul 1

7

Aug

17

Main & DSU


Page 5


Patients waiting > 6 weeks for diagnostics


Review referral pathway and implement action plan to provide additional clinics General Manager, Hospital &

Ambulance DirectorateAug-15 In progress

August 17

Patients waiting > 6 weeks for diagnosticsThe Trust did not achieve this national performance standard in August for no more than 1% of patients to wait longer than 6 weeks to receive their diagnostic assessment from when the request is made. This was due to a reduction in endoscopy capacity over the last 3 months because of continued nurse and surgeon vacancies impacting on the activity being able to be undertaken.

Recovery actions being progressed include sub-contracting routine activity and gaining Trust approval to a business case for further additional capacity and resources. Importantly, cancer and urgent patients requiring endoscopy procedures continued to be prioritised in the meantime.

Action Plan: Person Responsible: Date: Status:

0.0%

0.5%

1.0%

1.5%

2.0%

Se

p 1

6

Oct

16

No

v 1

6

De

c 1

6

Jan

17

Fe

b 1

7

Ma

r 1

7

Ap

r 1

7

Ma

y 1

7

Jun

17

Jul

17

Au

g 1

7

Target not achieved Target achieved Target

Page 6


Benchmarking of Key National Performance Indicators: Summary ReportAugust 17

Best Worst Eng

Emergency Care 4 hour Standards 95% 100% 77% 90.3% 82.5% 150 / 164 Red Qtr 1 17/18

RTT % of incomplete pathways within 18 weeks 92% 100% 75% 89.5% 92.1% 103 / 185 Amber Red Jul-17

%. Patients waiting > 6 weeks for diagnostic 1% 0% 21% 1.9% 0.8% 95 / 176 Amber Red Jul-17

Ambulance Category A Calls % < 8 minutes - Red 1 75% 76% 55% 67.9% 54.8% 8 / 11 Amber Red Jul-17

Ambulance Category A Calls % < 8 minutes - Red 2 75% 71% 46% 60.5% 65.0% 3 / 11 Amber Green Jul-17

Ambulance Category A Calls % < 8 minutes - Red 1 & Red 2 75% 71% 0% 60.9% 64.4% 3 / 11 Amber Green Jul-17

Ambulance Category A Calls % < 19 minutes 95% 95% 83% 89.7% 89.5% 4 / 11 Amber Green Jul-17

Cancer patients seen <14 days after urgent GP referral 93% 100% 68% 94.4% 97.6% 19 / 150 Green Qtr 1 17/18

Cancer diagnosis to treatment <31 days 96% 100% 82% 96.8% 96.1% 119 / 153 Red Qtr 1 17/18

Cancer urgent referral to treatment <62 days 85% 100% 0% 80.5% 85.6% 57 / 153 Amber Green Qtr 1 17/18

Symptomatic Breast Referrals Seen <2 weeks 93% 100% 12% 90.7% 99.3% 5 / 129 Green Qtr 1 17/18

Cancer Patients receiving subsequent surgery <31 days 94% 100% 77% 96.0% 100.0% 1 / 150 Green Qtr 1 17/18

Cancer Patients receiving subsequent Chemo/Drug <31 days 98% 100% 87% 99.2% 100.0% 1 / 134 Green Qtr 1 17/18

Cancer Patients treated after screening referral <62 days 90% 100% 0% 92.6% 100.0% 1 / 137 Green Qtr 1 17/18

Key: Better than National Target = Green Top Quartile = Green

Worse than National Target = Red Median Range Better than Average = Amber Green

Median Range Worse than Average = Amber Red

Bottom Quartile Red

Data PeriodIW RankNational

Target

National Performance IW

PerformanceIW Status

Page 7


Benchmarking of Key National Performance Indicators: IW Performance Compared To Other 'Small Acute Trusts'August 17

Other Small Acute Trusts

Emergency Care 4 hour Standards 95% 82.5%24

87.6%19

98.2%2

98.4%1

92.7%13

92.3%14

95.4%6

N/A 96.7%4

94.1%10

88.6%18

92.0%15

97.0%3

90.7%16

N/A 95.1%7

95.6%5

N/A 93.7%12

83.9%23

89.7%17

94.7%8

85.6%22

87.0%20

86.3%21

94.6%9

N/A 94.0%11

Qtr 1 17/18

RTT % of incomplete pathways within 18 weeks 92% 92.1%16

93.9%5

94.2%4

82.2%21

97.3%1

N/A 92.3%12

N/A 92.9%11

93.2%10

88.0%18

92.1%15

97.0%2

92.2%14

N/A 85.9%19

89.8%17

N/A 93.6%6

93.5%7

N/A 82.2%20

93.2%9

93.3%8

77.5%22

92.2%13

N/A 96.6%3

Jul-17

%. Patients waiting > 6 weeks for diagnostic 1% 0.8%17

3.5%21

0.9%18

4.3%22

0.7%15

7.4%23

0.3%8

N/A 0.4%9

3.3%20

0.7%16

0.4%12

0.0%1

0.3%6

N/A 0.1%3

0.4%10

N/A 0.1% 7.7%24

0.2%5

0.3%7

0.4%13

0.4%11

0.9%19

0.5%14

N/A 0.0%1

Jul-17

Cancer patients seen <14 days after urgent GP referral 93% 97.6%3

96.4%12

93.8%21

86.2%24

97.4%5

92.4%23

95.4%14

N/A 96.4%10

96.5%9

97.4%4

96.7%7

97.3%6

95.0%18

N/A 94.2%19

0.0%20

94.0%22

93.6%22

98.2%2

95.5%13

95.2%16

95.2%15

96.4%11

96.6%8

95.0%17

N/A 98.4%1

Qtr 1 17/18

Cancer diagnosis to treatment <31 days 96% 96.1%24

98.7%14

97.0%23

98.9%12

99.3%9

98.2%16

98.1%17

N/A 99.1%11

100.0%1

98.7%15

100.0%1

100.0%1

99.2%10

N/A 100.0%1

98.9%13

N/A 97.5%21

97.8%19

97.0%22

98.0%18

100.0%1

99.4%8

100.0%1

97.6%20

N/A 100.0%1

Qtr 1 17/18

Cancer urgent referral to treatment <62 days 85% 85.6%17

64.3%24

85.8%16

85.1%18

97.7%1

87.2%13

86.0%14

n/A 79.9%20

91.8%5

77.8%21

88.9%11

97.6%2

89.4%8

N/A 85.8%15

89.0%10

N/A 77.8%22

94.1%3

84.8%19

89.1%9

93.3%4

88.6%12

90.4%6

90.2%7

50.0%25

71.2%23

Qtr 1 17/18

Breast Cancer Referrals Seen <2 weeks 93% 99.3%2

97.5%6

93.8%16

68.6%22

93.4%18

77.8%21

97.3%7

N/A 95.7%10

99.1%3

97.1%8

96.5%9

N/A 94.3%14

N/A 94.2%15

94.7%13

N/A 42.2%23

92.5%19

89.8%20

95.0%12

99.6%1

98.1%5

93.8%17

95.4%11

N/A 98.8%4

Qtr 1 17/18

Cancer Patients receiving subsequent surgery <31 days 94% 100.0%1

87.5%23

93.2%21

100.0%1

100.0%1

100.0%1

100.0%1

N/A 97.6%19

100.0%1

95.9%20

100.0%1

100.0%1

100.0%1

N/A 100.0%1

100.0%1

N/A 92.9%22

100.0%1

85.7%24

100.0%1

100.0%1

100.0%1

100.0%1

98.4%18

N/A 100.0%1

Qtr 1 17/18

Cancer Patients receiving subsequent Chemo/Drug <31 days 98% N/AN/A

100.0%1

100.0%1

100.0%1

N/A 100.0%1

100.0%1

N/A 100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

100.0%1

N/A 100.0%1

100.0%1

N/A 100.0%1

100.0%1

N/A N/A N/A 100.0%1

100.0%1

100.0%1

N/A N/A Qtr 1 17/18

Cancer Patients treated after screening referral <62 days 90% 100.0%1

50.0%23

100.0%1

100.0%1

98.6%13

66.7%22

100.0%1

N/A 87.5%19

100.0%1

100.0%1

100.0%1

100.0%1

91.8%17

N/A 97.6%15

87.9%18

N/A 78.3%20

100.0%1

100.0%1

100.0%1

N/A 97.8%14

94.0%16

71.4%21

N/A 100.0%1

Qtr 1 17/18

Key: Better than National Target = Green R1F ISLE OF WIGHT NHS TRUST RC3 EALING HOSPITAL NHS TRUST RFW WEST MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST RLT GEORGE ELIOT HOSPITAL NHS TRUST

Worse than National Target = Red RA3 WESTON AREA HEALTH NHS TRUST RCD HARROGATE AND DISTRICT NHS FOUNDATION TRUST RGR WEST SUFFOLK NHS FOUNDATION TRUST RMP TAMESIDE HOSPITAL NHS FOUNDATION TRUST

Target Not Applicable for Trust = N/A RA4 YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST RCF AIREDALE NHS FOUNDATION TRUST RJC SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS TRUST RN7 DARTFORD AND GRAVESHAM NHS TRUST

RBD DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST RCX THE QUEEN ELIZABETH HOSPITAL KING'S LYNN NHS TRUSTRJD MID STAFFORDSHIRE NHS FOUNDATION TRUST RNQ KETTERING GENERAL HOSPITAL NHS FOUNDATION TRUST

RBT MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST RD8 MILTON KEYNES HOSPITAL NHS FOUNDATION TRUST RJF BURTON HOSPITALS NHS FOUNDATION TRUST RNZ SALISBURY NHS FOUNDATION TRUST

Note the large font figure represents the Trusts performance and the small font figure represents the Trust Ranking RBZ NORTHERN DEVON HEALTHCARE NHS TRUST RE9 SOUTH TYNESIDE NHS FOUNDATION TRUST RJN EAST CHESHIRE NHS TRUST RQQ HINCHINGBROOKE HEALTH CARE NHS TRUST

out of the 28 other small acute trusts RC1 BEDFORD HOSPITAL NHS TRUST RFF BARNSLEY HOSPITAL NHS FOUNDATION TRUST RLQ WYE VALLEY NHS TRUST RQX HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

National

TargetData PeriodRLQ RLTRJD RJFRFF RFW RGR RJC RQQRNZRNQRN7RMPIW RBD RBT RBZ RC1RA3 RA4 RQXRJNRC3 RCD RCF RCX RD8 RE9

Page 8


Benchmarking of Key National Performance Indicators: IW Performance Compared To Other Trusts in the 'Wessex Area'August 17

Emergency Care 4 hour Standards 95% 82.5%7

N/A 98.4%2

93.2%5

N/A 93.8%3

87.8%6

78.5%8

93.8%4

99.7%1

Qtr 1 17/18

RTT % of incomplete pathways within 18 weeks 92% 92.1%6

99.4%1

82.2%10

92.5%5

98.4%2

92.0%7

91.0%9

91.5%8

93.3%4

93.6%3

Jul-17

%. Patients waiting > 6 weeks for diagnostic 1% 0.8%6

0.0%1

4.3%9

1.2%8

0.0%1

0.1%4

1.0%7

6.9%10

0.4%5

0.0%1

Jul-17

Cancer patients seen <14 days after urgent GP referral* 93% 97.6%2

N/A 86.2%7

99.3%1

N/A 97.6%3

94.7%6

97.1%4

96.4%5

N/A Qtr 1 17/18

Cancer diagnosis to treatment <31 days* 96% 96.1%7

N/A 98.9%2

100.0%1

N/A 96.1%6

97.4%5

98.4%4

98.6%3

N/A Qtr 1 17/18

Cancer urgent referral to treatment <62 days* 85% 85.6%4

N/A 85.1%5

92.3%1

N/A 88.2%2

81.3%7

82.5%6

87.2%3

N/A Qtr 1 17/18

Breast Cancer Referrals Seen <2 weeks* 93% 99.3%2

N/A 68.6%7

97.8%3

N/A 100.0%1

87.0%6

96.1%4

94.6%5

N/A Qtr 1 17/18

Cancer Patients receiving subsequent surgery <31 days* 94% 100.0%1

N/A 100.0%1

100.0%1

100.0%1

98.3%6

97.8%7

98.4%5

96.7%8

N/A Qtr 1 17/18

Cancer Patients receiving subsequent Chemo/Drug <31 days* 98% N/A N/A 100.0%1

100.0%1

N/A 100.0%1

99.1%6

100.0%1

100.0%1

N/A Qtr 1 17/18

Cancer Patients treated after screening referral <62 days* 90% 100.0%1

N/A 100.0%1

96.3%4

N/A 85.3%7

94.9%5

90.5%6

100.0%1

N/A Qtr 1 17/18

Key: Better than National Target = Green R1F Isle Of Wight NHS Trust

Worse than National Target = Red R1C Solent NHS Trust

RBD Dorset County Hospital NHS Foundation Trust

Note the large font figure represents the Trusts performance and the small font figure represents the Trust Ranking RD3 Poole Hospital NHS Foundation Trust

out of the 10 other trusts in the Wessex area RDY Dorset Healthcare University NHS Foundation Trust

RDZ The Royal Bournemouth And Christchurch Hospitals NHS Foundation Trust

RHM University Hospital Southampton NHS Foundation Trust

RHU Portsmouth Hospitals NHS Trust

RN5 Hampshire Hospitals NHS Foundation Trust

RW1 Southern Health NHS Foundation Trust

RDYNational

TargetIW R1C RBD RD3 Data PeriodRDZ RHM RHU RN5 RW1

Page 9


Benchmarking of Key National Performance Indicators: Ambulance PerformanceAugust 17

Ambulance Category A Calls % < 8 minutes - Red 1 75% 54.8%8

68.2%5

70.4%4

72.4%3

73.1%2

64.7%6

75.5%1

57.5%7

- - - Jul-17

Ambulance Category A Calls % < 8 minutes - Red 2 75% 65.0%3

52.8%7

57.2%5

68.5%2

53.5%6

64.2%4

71.0%1

45.7%8

- - - Jul-17

Ambulance Category A Calls % < 8 minutes - Red 1 & Red 2 75% 64.4%3

53.6%7

58.1%5

68.6%2

54.6%6

64.2%4

71.2%1

46.4%8

0.0%9

0.0%9

0.0%9

Jul-17

Ambulance Category A Calls % < 19 minutes 95% 89.5%4

82.7%8

88.6%5

94.1%2

85.1%7

89.8%3

94.8%1

86.5%6

- - - Jul-17

Key: Better than National Target = Green

Worse than National Target = Red RX9

RYC East of England Ambulance Service NHS Trust

R1F

RRU

RX6

RX7

RYE

RYD

RYF

RYA

RX8 Yorkshire Ambulance Service NHS Trust

North West Ambulance Service NHS Trust

South Central Ambulance Service NHS Foundation Trust

South East Coast Ambulance Service NHS Foundation Trust

South Western Ambulance Service NHS Foundation Trust

West Midlands Ambulance Service NHS Foundation Trust

East Midlands Ambulance Service NHS Trust


London Ambulance Service NHS Trust

North East Ambulance Service NHS Foundation Trust

RX6 Data PeriodRYARX7 RYE RYD RYF RX8National

Target

IW

PerformanceRX9 RYC RRU

Page 10


Data Quality

Analysis:

Investigate the number of missing First Investigation codes in the A&E Dataset Deputy Director of Information Oct 2017 Complete

Investigate the number of missing attendance disposal codes in the A&E Dataset Deputy Director of Information Oct 2017 Complete

August 17

Investigate and correct where appropriate the invalid commissioner codes in the APC CDS files

Oct 2017 CompleteDeputy Director of Information

Commentary:


The information centre carry out an analysis of the quality of provider data submitted to Secondary Uses Service (SUS). They review 3 main data sets - Admitted Patient Care (APC), Outpatients (OP) and Accident & Emergency (A&E).

The latest information is for April 2017 to July 2017. Overall we still have 10 red rated indicators. Five of the red indicators are in the Admitted Patient Care (APC) Dataset, one in the Outpatient Dataset and four in the A&E Dataset.

Admitted Patient Care (APC):Two of the red indicators in the APC dataset are Primary Diagnosis and the HRG4 (Healthcare Resource Grouping). These improved significantly from last month however they remain red due to the high volume of activity on the coding backlog. We also have high number of missing patient pathways. Previous investigation has shown that this relates to Direct Access Endoscopy patients as these are not allocated a pathway at the point of referral for a diagnostic test in accordance with the national guidance. Prior to recording Endoscopies as day cases these patients would have been recorded in the outpatient CDS. THIS IS NOT A DATA QUALITY ISSUE AND NO FURTHER ACTION IS REQUIRED. We also have a higher than usual number of invalid Commission Codes, these will be investigated and corrected where appropriate. The final red indicator in the APC dataset is the NHS number, this relates mostly to prisoners whose NHS number is not always available. The reported figure is in line with previous months.Outpatients Dataset (OP):The red indicator in the OP dataset relates to patient pathways. This has been red since 2015/16 and was investigated, it is due to the number of patients that have an open episode but a closed RTT pathway, it is not considered a data quality issue.A&E Dataset:There are currently four red indicators in the A&E dataset. The red indicators are the Attendance Disposal, Commissioner Code, Conclusion Time and the First Investigation code. The proportion of blank Attendance Disposal codes has been increasing and will be investigated. Proportionally the number of invalid Commissioner Code has not significantly changed from last year. The proportion of missing conclusion times has not change significantly although the national average has improved however the number of missing First Investigation codes has risen considerably and will be reviewed.

Page 11

Isle of Wight NHS Trust Board Performance Report 2017/18AugustGlossary of Terms

Terms and abbreviations used in this performance report

Quality & Performance and General terms QCE Quality Clinical ExcellenceAmbulance category A Immediately life threatening calls requiring ambulance attendance RCA Route Cause AnalysisBAF Board Assurance Framework RTT Referral to Treatment TimeCAHMS Child & Adolescent Mental Health Services SUS Secondary Uses ServiceCBU Clinical Business Unit TIA Transient Ischaemic Attack (also known as 'mini-stroke')CDS Commissioning Data Sets TDA Trust Development AuthorityCDI Clostridium Difficile Infection (Policy - part 13 of Infection Control booklet) VTE Venous Thrombo-Embolism CQC Care Quality Commission YTD Year To Date - the cumulative total for the financial year so farCQUIN Commissioning for Quality & InnovationDFI Dr Foster IntelligenceDNA Did Not AttendDIPC Director of Infection Prevention and ControlEMH Earl Mountbatten Hospice Workforce and Finance termsFNOF Fractured Neck of Femur CIP Cost Improvement ProgrammeGI Gastro-Intestinal CoSRR Continuity of Service Risk RatingGOVCOM Governance Compliance CYE Current Year EffectHCAI Health Care Acquired Infection (used with regard to MRSA etc) EBITDA Earnings Before Interest, Taxes, Depreciation, AmortisationHoNOS Health of the Nation Outcome Scales ESR Electronic Staff RosterHRG4 Healthcare Resource Grouping used in SUS FTE Full Time EquivalentHV Health Visitor HR Human Resources (department)IP In Patient (An admitted patient, overnight or daycase) I&E Income and ExpenditureJAC The specialist computerised prescription system used on the wards NCA Non Contact ActivityKLOE Key Line of Enquiry RRP Rolling Replacement ProgrammeKPI Key Performance Indicator PDC Public Dividend CapitalLOS Length of stay PPE Property, Plant & EquipmentMRI Magnetic Resonance Imaging R&D Research & DevelopmentMRSA Methicillin-resistant Staphylococcus Aureus (bacterium) SIP Staff in PostNG Nasogastric (tube from nose into stomach usually for feeding) SLA Service Level AgreementOP Out Patient (A patient attending for a scheduled appointment)OPARU Out Patient Appointments & Records UnitPAAU Pre-Assessment UnitPAS Patient Administration System - the main computer recording system usedPALS Patient Advice & Liaison Service now renamed but still dealing with complaints/concernsPATEXP Patient Experience PATSAF Patient SafetyPEO Patient Experience Officer - updated name for PALS officerPPIs Proton Pump Inhibitors (Pharmacy term)PIDS Performance Information Decision Support (team)Provisional Raw data not yet validated to remove permitted exclusions (such as patient choice to delay)

Page 12



ON 4th October 2017 Title Quality Performance Report


Dr Barbara Stuttle, CBE, Interim Director of Nursing & Quality Dr Steve Parker, Interim Medical Director

Author(s) SIRI - Karen Kitcher, Quality Assurance Lead and Glenn Smith, Patient Safety Lead. Mortality – Mark Pugh, Executive Medical Director Quality Data – Iain Hendey - Deputy Director of Information

Purpose To provide assurance to the Board on issues relating to Quality within the Trust


Assurance X Approve








Quality Governance Committee 26/09/17 Information & Communications Technology Assurance Committee


Please add any other committees below as needed Board Seminar Patient Safety Experience & Clinical Effectiveness (SEE) Committee 13 September 2017

Integrated Improvement Framework: IIF Workstream Quality

Staff, stakeholder, patient and public engagement: Executive Summary & Analysis:

a) Serious Incidents Requiring Investigation (see appendix 2) This report provides an overview of Serious Incidents Requiring Investigation (SIRI) activity during August 2017. It also contains a description of what we are doing to improve the quality of the reports and the timely recognition and management of cases. It also highlights key incident issues that have been highlighted via the Patient Safety Working Group and key thematic

Enc J


analyses from this working group.

There were 9 SIRI’s reported to the Isle of Wight Clinical Commissioning Group (CCG) during August.

At the time of writing this report there were: 44 open investigations

- 10 of these were with the CCG awaiting consideration for closure - 4 the CCG have declines to close these with requests for further work/information - 8 were overdue within CBU’s; 2 Medicine; 2 Ambulance, Urgent Care & Community, and

4 with Corporate Services - 28 cases were open and still in-time that were under investigations.

The case numbers by CBU are summarized within the report.

During August 2017 and at the time of reporting the IW CCG had closed 3 SIRI case The details of these and the lessons learnt for those closed SIRI cases are detailed within the report. The Board is recommended to receive the SRI report.

b) Mortality Update (see appendix 3) The report highlights the latest SHMI data which relates to the year ending March 2017 and HSMR to the year ending May 17. Both these numbers show and increase, with the SHMI lying within normal limits and the HSMR still lying within a better than national average limit. A deep dive into a spike in the number of deaths during the period of November 2016-January 2017 available as a supplementary document to Trust Board Members.

The report also includes data from the Weekly Mortality Review highlighting the number of likely deaths, care of acceptable standard and the number of patients where the Priorities of Care Plans have been used. The Board is recommended to receive the mortality data.

c) Infection Prevention & Control Annual Report 2016-17 The purpose of this report is to provide the board with a position statement of the Trust’s progress toward meeting its obligations with respect to: Outcome 8 CQC, and the Health and Social Care Act 2008. Further to provide actions being taken to ensure that all of these obligations are met in the coming year. The report outlines progress made, activities and achievements by the Acute, Mental Health, Community and Ambulance Service against their respective infection prevention and control audit programme 1st April 2016 – 31st March 2017.

The primary focus will always remain on patient and staff safety. This will be demonstrated through our continuing audit programme and work plan which will provide assurance to the Board of Directors that all our obligations are met. The whole organisation will ensure incidents of infection are minimised and appropriate action is taken. The Board will receive reports on a quarterly basis and we will continue to embed good practice while meeting our mandatory obligations.

The Quality Governance Committee received and approved the revised Infection Prevention & Control Annual Report 2016-17 subject to a summary being included within the report. A copy of the report is available on request.

d) Quality Data (see appendix 4)

Performance data is provided on the following areas: Pressure Ulcers, Patient Safety, Formal Complaints, Mixed Sex Accommodation and I Want Great Care.


The Board is recommended to receive the Quality Performance report and to receive and agree the recommendations of the Quality Governance Committee.


Attached Appendices & Background papers Appendix 2 – SIRI Report Appendix 3 – Mortality Report Appendix 4 – Quality Data For following sections – please indicate as appropriate:

Trust Goals & Priorities Excellent patient care; positive experience for patients, service users and staff

Principal Risks (BAF) Principal Risk 674 Quality and Harm Legal implications, regulatory and consultation requirements

Adherence to NHS SIRI Framework (2015); completed reports submitted within national timeframe are monitored by IW Clinical Commissioning Group

Date: 28 September 2017 Completed by: Dr Barbara Stuttle, CBE, Interim Director of Nursing & Quality Dr Steve Parker, Interim Medical Director

Serious Incident Requiring Investigation (SIRI) Activity Report

For Patient Safety, Experience and Clinical Effectiveness Committee (& Quality Governance Committee)

August 2017 data

(1) NEW INCIDENTS REPORTED AS SIRIs: During August 2017 there were 9 Serious Incidents for the Trust to report to the Isle of Wight Clinical Commissioning Group (CCG). Clinical Business Unit Area/speciality Summary

Mental Health & Learning Disabilities

Crisis Resolution & Home Treatment

Attempted (apparent) suicide

Clinical Support Cancer & Diagnostics

Coronary Care Unit Unexpected death (death in custody)

Ambulance Urgent Care & Community

Community Rehab patient fall

Medicine Colwell ward patient fall

Clinical Support Cancer & Diagnostics

ITU Incorrect monitoring of Sodium Levels

Surgery Women’s & Children’s Health

General surgery Unexpected Death (GI Bleed)

Mental Health & Learning Disabilities

Improving Access to Psychological Therapies

Attempted Homicide (patient's concerns not escalated to secondary MH Service)


Emergency Department failure to recognise deteriorating patient


Emergency Department Delay in diagnosis (multiple injuries missed)

The Community Rehab Fall reported in August has been clustered as one of three now being investigated as an emerging theme regarding the quality of discharges to community rehabilitation beds. (2) Incident/weekly SIRI Meetings The weekly SIRI & incident meetings continue to be held twice weekly. Topics for discussion are: • All new incidents graded as moderate or above (early recognition and prompt for timely investigation) • Formal decisions and declaration of SIRI reportable incidents • Any incidents graded as minor (low) that may warrant an investigation and possible upgrade of risk

score • Status of all open and overdue SIRI cases • Progress on any outstanding queries waiting to be returned to the Clinical Commissioning Group

(CCG)

Enc J – Appendix 2

(3) PATIENT SAFETY WORKING GROUP The Patient Safety Working Group continues to meet weekly and is well represented from areas across the Trust; individual incidents of moderate harm or above are discussed at the meetings, including any other patient safety related topics that staff wish to raise, or that have arisen recently. The following topics were raised and discussed during August: Falls: 85 falls were reported in August, of which 36 were minor, and 3 were moderate harm. This is a decrease in falls reporting (July 2017, n=94), but an increase in falls causing harm against July 2017.

Pressure ulcers and moisture lesions: 7 pressure ulcers/moisture lesions were reported as deteriorating in August 2017, a slight increase on July 2017.

46 newly acquired pressure ulcers or moisture lesions were reported during August 2017, a decrease on July 2017 (n=59). 14 were moisture lesions, a decrease on July 2017 (n=23).

31 pressure ulcers were reported during August 2017 a reduction on July (n=36). For the third month running, no grade 3 or 4 pressure ulcers were reported, but 4 were reported as ungradeable and may change after review.

Accidental injury to patients: 13 accidental injuries to patients were recorded during August 2017, an increase on July 2017 (n=6). 11 of the 13 were minor harm.

Blood admin/request errors: 8 Blood admin/request errors were reported in August 2017 a reduction on July 2017 (n=11), 6 of these were reported as minor harm.

Clinical Incident near misses: 15 near misses were reported during August 2017, with minor impact recorded in 7 cases and moderate impact in 2 cases. This is an increase on July 2017 (n=6).

Delays in Treatment: 18 delays in treatment were reported during August 2017, a decrease on July 2017 (n=24). 10 were reported as minor harm, and 4 as moderate harm.

Failure to interpret X ray correctly – no incidents related to this were reported in August 2017.

Infection Control: 1 Trust acquired E-Coli Bactaraemia was reported during August 2017. 3 occasions of delayed isolation were also reported.

Maternity: 10 incidents were reported during August 2017, a reduction since July 2017 (n=15). 5 were recorded as minor harm, and none as moderate.

Medication Incidents: 42 incidents were reported during August 2017 of which 11 were minor harm, and none were moderate harm.

Other: 4 incidents were reported during August 2017 regarding failure of doctor to attend a patient in a timely manner. 1 failure to admit to hospital was reported as was 1 IRMER incident, 1 incident involving a near miss where the wrong site surgery nearly occurred, and 1 anaesthetic error.

CBU Attendance at Patient Safety Working Group.

The meetings have been held weekly throughout August 2017 except for the bank holidays. All the CBUs have sent representation either at ward sister or matron level, or sometimes both.

Thematic discussion at Patient Safety Working Group.

• The Trust has adopted a target of 10% reduction in E Coli Bactaraemias. • The lapses in care related to recent C Diff cases include failure or delay in isolation, and delay in

sampling, and the pathway for C Diff care is incomplete. • Catheter care requires further focus - - ward sisters and matrons to ensure that care plans are up

to date as previous audits have highlighted this gap as has the Safety Thermometer data regarding catheterisation locally.

• Some falls have been linked to patients using bedside trollies to mobilise.

• Ward sisters discussed that there is perceived to be a gap between arranging transport for patients between wards and it actually occurring. Wards have been asked to collate data where this has been perceived to occur and feedback to the Patient Safety Working Group Meeting.

• ITU patient care planning shared as good practice where ITU and ward to which the patient has been discharged shared the care planning and engaged in using a care passport. This case also highlighted how it was necessary to educate both staff, patients and their relatives on the relative change in level of observation and surveillance between ITU and ward care.

• Pharmacy have asked that wards complete the appropriate self administration of medication assessments if wards wish to leave medication on patients lockers after the safety of medications in patients’ bed spaces was raised as an issue on the wards.

(4) CURRENT POSITION: The table below provides the current status of open SIRIs at time of submitting this report

(5) CLOSED SIRI CASES: During August 2017, and at the time of reporting, the IW Clinical Commissioning Group had advised on the closure of 3 cases. (5a) LESSONS LEARNT: Following closure of SIRI cases, the learning is shared across the Trust via various methods: Trust’s monthly Quality reports; organisational and local Quality Governance meetings; audits; newsletters; clinical education, Morbidity & Mortality groups. Outcomes are also captured via quarterly collation of outcomes by themes, e.g. communication, clinical care, education etc., and are available for staff to access via the SIRI page of the Trust’s intranet site. Case 1:

FINDINGS: complication not recognised, leading to emergency surgery

RECOMMENDATIONS: • Daily review of all in patients by either consultant or senior decision maker.

ACTION: this has been communicated via the surgical team meeting and reviewed in M&M meeting (mortality and morbidity).

• Formal handover of all high-risk surgical patients that may require a change in management plan. ACTION: Communicated to surgical team

• Educate ward staff regarding the importance of escalation of a deteriorating MEWS. ACTION: Education of ward staff has now been completed

Case 2:

FINDINGS: accidental disclosure of sensitive person identifiable data. RECOMMENDATIONS: • Ensuring that files are named / labelled/ version controlled in a way which helps to avoid

potential breaches. Access to patient sensitive information must be restricted to staff who are authorised to handle the information ACTION: to be shared with all staff in the department to ensure that other staff members are storing confidential documents securely. Consideration is also being given to conducting an information Governance audit.

• Good practice would be to check e mail attachments before pressing ‘send’ particularly when sending to an organisation or individual outside of the Trust for the first time.

ACTION: Message to go to all staff on the intranet page – “Check before you click” Case 3:

FINDINGS: falls risk assessment not updated and reviewed when patient’s mental state altered and use of bed sensor should have been considered. The JAC (prescribing) system does not prominently display or alert when recent STAT doses have been given. No recognition that excess doses of medication may have caused a bleed that may have been a contributing factor in patient’s change in mental state RECOMMENDATIONS: • JAC system needs to be more user friendly, reducing risk of missed information.

ACTION: Medicine Safety Alert has been sent to all medics and nurses re-iterating importance of reviewing all tabs in the JAC system (whole drug chart) before prescribing a medicine to ensure there is no duplication, especially when being initiated on treatment and when there is a transfer of care between teams or shifts.

• Education to take place around the management of patients displaying increased confusional state (being managed as part of action plan)

(6) OVERVIEW OF SIRI SUBJECTS: This shows a comparison of SIRI subjects over the last 3 years.

0 2 4 6 8 10 12 14 16 18

NEVER EVENTSlip, Trip, Fall

Confidential Information LeakUnexpected Death

SafeguardingOther

Delayed DiagnosisAmbulance IssueSurgical Incident

Sub-optimal care of deteriorating patientPressure ulcer grade 3Pressure ulcer grade 4

Screening IssueFailure to act upon test results

Maternity ServiceAllegation against HC professional

Hospital transfer concernsMedication issue

Hospital Equipment Failure12-hour breachesDelay in treament

2017 - 2018

2016 - 2017

2015 - 2016

Comparison of SIRI subjects over last 3 years (2015 - 2016; 2016 - 2017 and April 2017 - to date)

(7) ACTION PLANS: The Patient Safety, Experience and Clinical Effectiveness Team, together with the Clinical Business Units continue to monitor and update all actions plans arising from previous/current SIRI cases. Upon completion, the action plans are then forwarded to the Quality Governance Committee for review and final sign off. Barbara Stuttle Interim Executive Director of Nursing & Quality Paper produced and prepared by: Karen Kitcher, Quality Assurance Lead (September 2017) and Glenn Smith, Patient Safety Lead.

1 Mortality Report for Trust Board

Mortality Report September 2017

1. Latest SHMI and HSMR Data

The latest SHMI relates to the year ending March 2017 and HSMR to the year ending May 17. Both these numbers show and increase, with the SHMI lying within normal limits and the HSMR still lying within a better than national average limit. Full details are presented in the August Dr Foster report see below. An explanation for the increasing result is a spike in deaths seen in December’ 16 and January ’17. A Dr Foster deep dive was performed in to this peak and is attached after the standard Dr Foster Report, the report did not detail any safety issues but did pick up on a high admission rate during this period, which relatively was higher than comparators, and would explain why we had such an increase in contingency bed use at the time.

SHMI 1.047

HSMR 89.8 Weekday 87.3 Weekend 93.4

Enc J – Appendix 3


2. Latest Dr Foster Data

The Dr Foster data relating to August 2017 has been supplied as a supplementary document to the Trust Board Members.

3. Dr Foster Deep Dive in to spike in deaths in December ’16 and January ‘17

The Dr Foster Deep Dive has been supplied as a supplementary document to the Trust Board Members.

4. Monthly Mortality Data – August 2017

Previously this data has been presented in significant detail, including day of admission, day of death, place of death, this will continue to be reviewed in the Mortality Review Group

There were 33 deaths in August, the causes are listed below:

Acute Myocardial Infarction 1 Acute Myocardial Insufficiency 1 Acute Respiratory Distress Syndrome 1 Bronchopneumonia 1 Cardiogenic Shock 1 Cardiopulmonary Degeneration 1 Congestive Cardiac Failure 2 Cardiac Heart Failure 1 Extensive Subarachnoid Haemorrhage 1 Gram Negative Septicaemia 1 Ischaemic Heart Disease 1 Metastatic Breast Cancer 1 Metastatic Prostate Cancer 1 Metastatic Renal Failure 1 Multi Organ Failure 1 Myocardial Infarction 1 Pulmonary Embolus 1 Pulmonary Oedema 1 Respiratory Failure 3 Respiratory Sepsis 1 Ruptured Abdominal Aortic Aneurysm 1 Sepsis 3 Severe Decompensated Liver Disease 1 Severe Sepsis 1 Type 2 Respiratory Failure 1 Unascertained Pending Further Investigation 1 Upper Gastro-Intestinal Bleed 2


5. Latest Trust Mortality Review Data – Quarter 1 2017/18

Number of Deaths

Death Likely

Recognised Dying

Care of acceptable Standard

Outcome Level

Priorities of Care Plans Used

57 51 49

56 48

39

0

10

20

30

40

50

60

Apr-17 May-17 Jun-17

Number of Deaths Number Reviewed

43

0

37

13

31

2 0

18

0 0

10

20

30

40

50

Apr'17 May'17 Jun'17

Yes No N/A Not answered

50

0

28

0

45

5 5 1 4

0

10

20

30

40

50

60



56

0

35

0

45

2 0 2 0 0 0 2 0

10

20

30

40

50

60



49

0

32

7

46

4 0 3 0 0 0 2 0 0 1

0

10

20

30

40

50

60

Apr-17 May-17 Jun-17

1 2 3 4 Not answered

57 51 49

27

0 14 16

29

8 8 3 13

5 14

4 0

20

40

60

Apr-17 May-17 Jun'17

Number of Deaths Yes

No N/A

Not answered


6. Latest Bereavement Survey Data

There has been a total of 184 responses received up until 31st July 2017. At the time of reporting from the beginning of May 2017 to the end of July 2017 a total of 8 responses have been received from 111 surveys given out, equating to 7.20% response rate. We have received 184 responses from a total of 725 questionnaires given out since the start of the survey in April 2015, equating to 25.37% response rate. The following charts are a sample of the questions and responses received:

9

0

2

1

24

59

23

Disagree

Partially Disagree

Neither agree nor disagree

Partially Agree

Agree

N/A

Don't know / can't remember

A9 - Was your relative / friend cared for using an End of Life care plan?

11

1

2

5

87

15

1

Disagree

Partially Disagree


Partially Agree

Agree

N/A


B5 - As a relative / friend were you asked how and when you would like to be contacted if there was any change

in your relative / friend's condition?


6

2

5

7

77

16

7

Disagree

Partially Disagree


Partially Agree

Agree

N/A


B7 - As a relative / friend were you given support at the time of death?

2

2

2

4

98

2

12

Disagree

Partially Disagree


Partially Agree

Agree

N/A


C1 - Was your relative / friend treated with dignity and respect?

6

0

1

1

44

53

13

Disagree

Partially Disagree


Partially Agree

Agree

N/A


C2 - Was your relative / friend treated according to his / her wishes?


7

1

0

6

75

31

0

Disagree

Partially Disagree


Partially Agree

Agree

N/A


D2 - After your relative / friend's death were you told about the death of your relative / friend in a sensitive

way?

Isle of Wight NHS Trust Board Quality Performance Report 2017/18August 17

Pressure Ulcers

Analysis:

The Patient Safety Working Group continues to meet weekly. The overall trends are encouraging and the recent increases in numbers are more indicative of increased awareness and reporting of lower grades than of increasing incidence. The trend continues to decrease.

Clinical Business Unit Heads of Nursing & Quality

& Tissue Viability Nurse SpecialistAug-17 Ongoing

• Trust wide Pressure Ulcer Prevention Group continues to meet. .• Deep dives for each Business Unit going ahead to look at why expected reductions were not achieved last year.• Action plans for pressure ulcer reduction have been reviewed and are being amalgamated into a single master plan for coming year.• Local monthly Tissue Viability and MUST audits are being established by Tissue Viability Service.• Pressure Ulcer Reporting has been handed to Matrons and Locality leads to supervise to develop local ownership of reporting and understanding the scale of the issue.•Work is also ongoing to identify where patients are admitted from their home address who have been receiving non NHS care assistance.

Clinical Business Unit Heads of Nursing & Quality

& Tissue Viability Nurse SpecialistAug-17 Ongoing

Commentary:General: N.B. Figures for previous months will continue to change as validation occurs during the process of investigation and attribution. Pressure ulcer development contributes to clinical incident numbers and the higher grades contribute to the numbers of Serious Incidents Requiring Investigation. (SIRIs). They also form part of the National Safety Thermometer snapshot audit scheme which is reported nationally. Further details of the Safety Thermometer are available here. http://www.safetythermometer.nhs.ukThe Pressure Ulcer Collaborative continues to review all pressure ulcers that occur in the IW NHS care on a weekly basis. This has focussed further attention on this issue and raised awareness in the Business Units. Whilst there has been a rise in the overall reporting, this has been mainly in the area of grade 1 and 2 pressure ulcers and is consistent with national trends. There are a number of ungradable pressure ulcers that are still under review, the numbers will continue to change following investigation and validation of all lesions as attribution is more accurately assessed and learning shared with the appropriate teams. A recent trial with hand held Tissue Scanners has demonstrated early detection of tissue damage up to 10 days prior to development of a visual lesion. This has indicated that the majority of ulcers developed within 10 days of admission have already passed the preventable stage prior to arrival on the wards and has proved a more reliable indicator than the current system scoring of risk. The scanners are able to detect small changes in potential damage and whether interventions are making an effective change. Work is ongoing to fully evaluate the scanners and the benefit to patients so that a business case for investment in scanners for all wards can be taken forward and extended into the community.

Community: Pressure ulcer development contributes to clinical incident numbers and the higher grades contribute to the numbers of Serious Incidents Requiring Investigation. (SIRIs). The Clinical Directorates took full responsibility for the management of pressure ulcer incidents in June including approval status and checking for duplicates. This is a move away from overall final responsibility for pressure ulcers incidents sitting with the Nutrition and Tissue Viability Service. Increased awareness is continuing to lead to increased numbers being reported. The Pressure Ulcer collaborative is also looking at the community and in this setting no grade 3 pressure ulcers and 2 grade 4 pressure ulcers have been reported and attributed to NHS care during the review period. The trend overall is encouraging, and the reviews are now focussing on the root cause analysis and cluster review of grade 2 pressure ulcers as the Trust has set itself the target of reducing the occurrence of this grade of pressure ulcers by 50% in the next year. The overall trend across 2016/17 was decreasing incidence across all grades and this is generally continuing. The report now separates out Ungradable pressure ulcers as a distinct reporting line so that it is clear that these ulcers (which were previously counted as grade 4s) have not yet been assigned a grade and do not automatically mean that this is an incident that has resulted in patient harm. Numbers will continue to change over several months as investigation continues validation and correct attribution.

Pressure Ulcers benchmark


The graph shows improving trend. In June the Trust has been above the national average.

Quality Account Priority 2 & National Safety Thermometer CQUIN schemes Prevention & Management of Pressure Ulcers

Page 1

Enc J - Appendix 4

Isle of Wight NHS Trust Board Quality Performance Report 2017/18

Patient Safety

Commentary: Analysis: Clostridium Difficile infections against national and local targets


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

Acute Target 0 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0 0 0

Ongoing IPCT

CompletedOngoing

Continuing

DIPC as team lead. HONQ and Ward Sisters to drive at ward level with support from

IPCT

Aug-17

Continued use of HPV terminal environmental decontamination post discharge/transfer of patients with active Clostridium difficile infection or colonisation.

Hotel Services manager Aug-17 Continuing

August 17

Clostridium difficileThere was no case of Trust attributed Clostridium difficile infection (CDI) in August. The objective for 2017/18 remains at no more than 7 cases across the year and this has now been exceeded. Root cause analysis is undertaken both for Trust attributed CDI cases and those cases attributed to the CCG where the patient had been admitted to IWNHS Trust within the 3 months before diagnosis. There is no agreement between the Trust and CCG as to what constitutes a lapse in care however and this needs to be agreed (discussion with CCG requested). As a result of recent investigations, the catheter care pathway is being revised and further investigation into the use of antimicrobials undertaken.

Whenever there is an inpatient with CDI, the ward is expected to undertake CDI management audit, regardless of whether or not the bacteraemia is hospital or community acquired. The IPCT undertake regular CDI audit at such times for assurance that IPC management is effective. The IPC Nurse undertakes a weekly CDI and C Difficile colonised patient review weekly with the pharmacist taking a lead in antimicrobial therapy. Continued actions to drive CDI reduction include education regarding management of loose stools and utilisation of hydrogen peroxide vapour (HPV) for terminal environmental decontamination post discharge/transfer of patients with active Clostridium difficile infection or colonisation.

A team from IWNHS participated in a national NHS Improvement programme in the year 16/17 and focused on improved bed space cleaning methodology with the aim of introducing a standardised approach to bed space cleaning following patient discharge/transfer within the organisation. A training video was developed to support staff.

Methicillin-resistant Staphylococcus Aureus (MRSA)There have been no cases identified as Healthcare acquired infections during August.

Action Plan: Status:Person Responsible: Date:

End of August 2017

Ongoing

Ward SistersContinued drive to improve and maintain stool sampling in accordance with policy

Organisational roll Participation in National 90 day improvement programme with results discussed at national meeting. This has now resulted in a tutorial bed space cleaning video shared across the trust.

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

Total cases 1 4 7 8 8 8 8 8 8 8 8 8

National Target 1 1 2 2 3 3 4 4 5 6 6 7

0

2

4

6

8

10

Isle of Wight NHS Trust C. Difficile cases (Cumulative)

Page 2


Formal Complaints

Analysis: Complaints only

Jun-17 Jul-17 Aug-17 RAG rating

2 0 0 ��

2 3 0 ��1 1 0 ��6 6 2 �0 0 0 ��6 8 6 �0 0 0 ��1 0 0 ��0 1 3 �0 0 1 �0 0 0 ��0 1 0 ��

2 1 0 ��1 1 1 �1 2 2 �0 0 0 ��0 1 0 ��

1 1 0 ��

0 0 1 �

3 7 3 �

0 3 0 ��

In Progress

Mortuary

Other (Use with Caution)

Privacy, Dignity and Wellbeing

Prescribing

Person Responsible: Date: Status:

Patient Care

Restraint

Staff numbers

Trust admin/Policies/Procedures

The Datixweb complaints module has commenced roll out and the Clinical Business Units in conjunction with the Complaints Team continue to work to improving timeliness and quality of complaint responses

Executive Director of Nursing / Patient Experience Lead

Oct-17

Commentary:

Action Plan:

Access to treatment or drugs

Admissions and discharges

Appointments

Clinical Treatment

Integrated Care

Facilities

Primary Subject

Values and Behaviours (Staff)

Communication

Waiting Times

There were 19 formal Trust complaints received in August 2017 (36 in the previous month) with 264 compliments received by letters and cards of thanks for the same period. In addition to the 19 formal complaints, a further 61 concerns (64 in the previous month) were raised.

Across all complaints and concerns in August 2017: Top subjects were: - Communication (31) - Clinical Treatment (11) - - Values and Behaviours (Staff) (10) Top areas of complaints and concerns were: - OPARU (11) - Emergency Department (6) - Diagnostic Imaging (6) - Surgical wards (6)

Commissioning

Transport (Ambulances)

August 17

Consent

End of Life Care

Page 3

Isle of Wight NHS Trust Board Performance Report 2017/18

Mixed Sex Accommodation


Analysis:

Daily review of situation with increased reviews as alert status escalates. Executive Director of

Nursing / Senior Clinical Capacity Manager

Aug-17 Ongoing

August 17

Mixed Sex Accommodation


There were 7 mixed sex accommodation breaches during August that involved sleeping/personal care accommodation. However, there were 2 additional incidents of ACP endings over 4 hours where the patient was unable to be returned to ordinary level care and personal care facilities were not of the standard required. All 9 of the MSA breaches during August involved lack of available stepdown beds at the end of Acute Care Pathways and were on either ITU or CCU. A potential MSA breach was able to be avoided on the MH wards by moving one patient so that both the existing and new patient had individual and unshared bathrooms adjacent to their personal sleeping rooms. Critical care areas such as Acute Coronary Care or Intensive (High Dependency) Care are exempt from the accommodation/bathroom requirements as highly specialised critical care needs take priority and patients are generally too unwell to manage their own personal care or mobility at this time, making facilities for self-care un-necessary. However, when the critical care period ends the patient should be returned to a stepdown/general ward with the appropriate facilities as privacy and dignity (of both those both recovering and still requiring critical care) could otherwise be compromised. This is now reported as an ACP end breach if there is no appropriate bed available and obviously has an added effect of blocking beds for needed for critical care use such as acute cardiac events, sepsis, following major surgery or trauma. This converts to MSA breach after 24 hours without a suitable bed on a reduced level care area. There is a risk of recurrence during periods of high bed occupancy levels and delayed discharges despite the permanent increase in the number of available beds and the opening of further contingency beds in periods of high demand. Although every effort is made to avoid the situation, the changing patient mix remains challenging as isolation requirements and care of the dying has to take priority and may require movement of some patients to accommodate the greater needs of others. Work is underway to redesign the day surgery unit so that privacy and dignity standards can be updated to those currently applicable but this is a long term project and will involve rescheduling of future surgery for the period of rebuilding. More detailed auditing of patient moves now in place will give further data towards understanding the increased operational needs.

0

2

4

6

8

10

12

14

Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Jan 17 Feb 17 Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17

Page 4


I Want Great Care

Clinical Business Unit Reviews Average Score

% Likely to

Recommend Clinical Business Unit Cleanliness Staff

Dignity/R

espect Information

Surgery, Women's and Children's Health 268 4.84/5 95.5% Surgery, Women's and Children's Health 4.92/5 4.93/5 4.89/5 4.77/5

Medicine 62 4.77/5 98.4% Medicine 4.80/5 4.84/5 4.85/5 4.65/5

Clinical Support, Cancer and Diagnostic Services 836 4.88/5 95.8% Clinical Support, Cancer and Diagnostic Services 4.89/5 4.93/5 4.93/5 4.87/5

Ambulance, Urgent Care and Community Services 484 4.74/5 86.4% Ambulance, Urgent Care and Community Services 4.71/5 4.87/5 4.85/5 4.65/5

Mental Health & Learning Disabilities 7 4.23/5 85.7% Mental Health & Learning Disabilities -/5 4.57/5 4.43/5 3.71/5

August 17

75.0%80.0%85.0%90.0%95.0%

100.0%

Surgery,

Women's

and

Children's

Health

Medicine Clinical

Support,

Cancer and

Diagnostic

Services

Ambulance,

Urgent Care

and

Community

Services

Mental

Health &

Learning

Disabilities

% of Reviewers Likely to Recommend by CBU

% Likely to

Recommend

I Want Great Care reports split by Clinical Business Unit to show reviews received in August, the average score each Business Unit received and how many of those reviewers are likely to recommend. There are Business Unit breakdowns of best reviewed service and worst reviewed service within that business unit.

Ambulance, Urgent Care and Community ServicesTop three services (with 5 reviews or more)

Podiatry 5.00/5

Physiotherapy 4.96/5

Laidlaw Day Hospital 4.95/5

Bottom three services (with 5 reviews or more)

Emergency Department 4.58/5

District Nurses 4.55/5

Orthotics 4.50/5

Clinical Support, Cancer and Diagnostic ServicesTop three services (with 5 reviews or more)

Endoscopy 5.00/5

Chemotherapy 4.97/5

Coronary Care Unit 4.93/5


OHPiT 4.89/5

Pre-assessment and Admissions Unit (PAAU) 4.86/5

Diagnostic Imaging 4.52/5

MedicineTop three services (with 5 reviews or more)

General Rehabilitation 5.00/5

Community Stroke Rehabilitation Team 5.00/5

TIA Clinic 4.94/5


TIA Clinic 4.94/5

Stroke Unit 4.81/5

Appley Ward 4.33/5

Mental Health & Learning DisabilitiesTop one service (with 5 reviews or more)

Community MH services 4.23/5

Bottom one service (with 5 reviews or more)

Community MH services 4.23/5

Surgery, Women's and Children's HealthTop three services (with 5 reviews or more)

Postnatal Ward 5.00/5

Labour Ward 4.98/5

Children's Ward 4.93/5


Gynae Outpatient Department 4.71/5

Colposcopy 4.69/5

Whippingham Ward 4.60/5

Page 5



ON 4th October 2017 Title Workforce Performance Report August 2017


Julie Pennycook, Director of HR & OD

Author(s) Mark Elmore – Deputy Director HR Amy Rolf – Senior HR Manager Calum Robertson – Workforce Planning & Information Officer Barbara Fitch – Workforce Information Officer

Purpose To provide assurance and overview of workforce metrics including sickness absence, overpayments, e-rostering & staffing usage


Assurance X Approve










Please add any other committees below as needed Board Seminar Other (please state) Integrated Improvement Framework: IIF Workstream HR & OD Workstream 6.1 - 6.8

Section/Clause

Section/Clause

Section/Clause

Staff, stakeholder, patient and public engagement: N/A

Enc K



Headlines from this report are:

• Total fte staffing level is under budgeted establishment by 101 FTE although costs are higher than budget due to use of agency.

• Workforce profile and recruitment planning is underway to address workforce deficits • Active recruitment is in place to reduce vacancies and corresponding use of Bank & Agency

staffing • Sickness absence has increased to 4.40% in month (4.52% rolling 12 month period) increases

within Acute, MHLD & Ambulance. Individual case management in place with monthly scrutiny. Training has been delivered to support improved management capability in management of absence.

• Anxiety, stress and other psychiatric illnesses remains the highest cause of absence followed by musculoskeletal, although absence due to back problems has significantly reduced through Occupational Health & Wellbeing intervention.

• Agency usage has exceeded the NHSI ceiling due in the main to medical and nursing resources required to cover for vacancies and higher acuity and additional activity.

• The Trust appraisal compliance is 46.93% in month reflecting the appraisal “reset” in April in line with the business cycle. Actions are in place to improve to 2016 rates

• Staff Turnover is stable at 9.5% (rolling 12 months) • Mandatory Training compliance has improved slightly again this month to 81%. • Flu Campaign 2017 has commenced.


N/A

Attached Appendices & Background papers N/A For following sections – please indicate as appropriate:

Trust Goals & Priorities Cost effective, sustainable services. Work with others to keep improving our services.

Principal Risks (BAF) RISK 671 Human Resources - Workforce


Date: 27 September 2017 Completed by: Mark Elmore – Deputy Director HR Amy Rolf – Senior HR Manager Calum Robertson – Workforce Planning & Information Officer Barbara Fitch – Workforce Information Officer

1

WORKFORCE PERFORMANCE REPORT

1. Workforce Information

Staff in post i.e. substantive staff (SIP) for month 5 is 2660 fte, an increase of 27 fte in month. Total staffing (SIP & additional staffing) is 2875 against a budgeted establishment of 2977 fte therefore under budgeted establishment by c100 fte, of which 90 fte are vacancies in substantive staffing.

Active recruitment into 255 fte positions across the Trust is underway to support a reduction in the use of premium cost Agency staffing.

Additional staffing (Bank, Agency, Excess and Overtime) equated to 215 fte in month 5. This is a reduction of 6 fte from the previous month. Agency usage within MHLD is due to an increase in activity. General Medicine, Ambulance and Urgent Care Clinical Business Units have high Bank usage covering vacancies.

Workforce profile and recruitment planning is underway to address workforce deficits into critical posts.

The Trust employs 3064 (headcount) substantive staff and approximately 400 bank worker supported by 187 volunteers.

The breakdown of substantive and additional staffing is 92.52% substantive and 7.48% additional staffing.

Tables 1 & 2 show that whilst staffing levels are under budgeted establishment, costs are over due to the high cost of agency and in particular medical staffing

Table 1

Table 2

2

2. Agency Information

Agency usage in month was predominantly to cover vacancies or provision of additional capacity to match activity/acuity. Medical usage increased in month and nursing usage has seen a slight reduction due to Whippingham and Stroke reducing their rota requirements. Workforce profiling is underway to develop a recruitment plan as part of the Integrated Improvement Framework.

Table 3

Agency Use: Breakdown of agency staff groups actual spend:

2017/18 ACTUAL SPEND Apr May Jun Jul Aug TOTAL £'000 £'000 £'000 £'000 £'000 £'000 Medical 402 487 501 473 513 2,376 Nursing 106 188 408 341 334 1,377 Clinical 16 30 1 32 26 104 Administration 4 6 9 1 43 63 Other 8 7 5 0 0 20 Total spend - month 536 718 924 847 916 3,940 Total spend - cumulative 536 1,254 2,177 3,024 3,940 Ceiling - month 413 414 414 416 416 4,128 Ceiling - cumulative 413 827 1,241 1,657 2,073 2,073 Variance to ceiling 123 304 510 431 500 2,055

Highest users of Medical Agency staff: General Medicine, Psychiatry Adult and Ophthalmology. Highest users of non-Medical Agency staff: Mental Health & Acute Nursing

3. Compliance with NHSi Agency Ceiling

IOW NHS Trust is currently exceeding the NHSi Agency ceiling. Month 5 £2,073k above year to date ceiling, and £500k in month. Table 4 shows forecast spend based on current trajectory of spend, resulting in the Trust overspending by £2,621k by the end of 17/18.

Table 4


Actual - cumulative 2016/17 682 1,506 1,924 2,763 3,255 4,136 4,623 5,055 5,681 6,312 6,957 7,611

Ceiling - cumulative 413 827 1,241 1,657 2,073 2,489 2,905 3,321 3,738 4,155 4,572 4,990

Actual - cumulative 536 1,254 2,177 3,024 3,940

Forecast - no change based on currentmonth 536 1,155 2,177 3,024 3,940 4,855 5,771 6,686 7,602 8,517 9,433 10,348

Forecast with 10% reduction 449 1,155 1,919 2,722 3,546 4,370 5,194 6,018 6,842 7,665 8,489 9,313

0

2,000

4,000

6,000

8,000

10,000

12,000

£'00

0

Total Agency spend 2017/18

3

0.00%1.00%2.00%3.00%4.00%5.00%6.00%

Sickness YTD

Sickness

Action to address:

• Workforce profile and recruitment planning to address vacancies underway • Increase workforce focus at monthly CBU Performance Reviews • Triangulation of workforce data and other key indicators such as Quality, SIRIs and

Complaints to be undertaken as business as usual at Performance Reviews • Continuous safe staffing analysis and 6 monthly reporting to Board • Focus on more effective e-rostering – clinical lead appointment • Effective agency authorisation controls • Weekly reporting for Executive visibility of agency usage • Targeted recruitment drives and planned recruitment activity including:-

o Attendance at Recruitment Fair for Mental Health - October o Attendance at Southampton University Recruitment Fair - November o Attendance at RCN Recruitment Fair, Southampton - December.

4. Sickness

Trust sickness absence rate: 4.40% in month (increase from 4.17%). Top reasons for absence: Anxiety/Stress/Depression, which equates to a loss of 117 days. There has been an increase in musculoskeletal problems, although back problems have seen a significant reduction since April.

Acute, Ambulance and MHLD all exceeded absence KPI in month. During August and September, the HR Team have worked with individual CBU Management Teams to review sickness absence rates and trends. Targeted training and/or additional coaching has been delivered to help improve management capabilities in dealing with absence management.

Table 5

4

Table 6

5. Staff turnover

Staff turnover is stable with month 5 at 0.59%, rolling 12 month % is 9.51%.

6. Mandatory training

Trust position slightly improved in month at 81% against the target for 17/18 of 85%. This includes Bank Staff. Reporting data has reverted back to percentage of total requirements achieved instead of % staff above 85%. Demand and capacity analysis has been conducted for all mandatory training courses for 2018 and sent to Subject Matter Experts to enable activity planning. Medical & Dental staff group compliance remains lowest %. Comprehensive mandatory training data is now provided for CBU performance reviews. Resuscitation service staffing increased from 1.6 WTE to 3.0 WTE increasing availability of spaces on courses. Prevent training was added at the end of July, compliance has improved by 24% on last month.

Trust Information Governance training compliance is 92% against the target of 95% by April 2018.

Table 7

5

Table 8

7. Appraisals

Rolling 12 month appraisal compliance at month 5 is 46.93%, the drop in recent months is representative of appraisals that were held 12 months ago and due for renewal. Weekly appraisal compliance reporting by cost centre has been introduced to ensure Business Units are aware of their appraisal compliance rates. Performance will be reviewed monthly at CBU Performance Review meetings.

Going forward % compliance will be aligned with annual business planning cycle with the expectation that all appraisals should be completed within the first quarter of the financial year

Table 9

8. Occupational Health & Wellbeing

Flu Campaign 2017 Update – planning and setting dates, times and places for Flu sessions. Vaccine ordered. Update –

• Flu PGD awaiting ratification from Clinical Standards Group on 29th September • Due to commence campaign 2nd October; ongoing planning. • Well supported campaign from Chief Exec.

6

• Initiative of ‘have a jab, give a jab’ to be promoted as part of campaign. Trust to donate 1 tetanus/diphtheria/polio vaccine per flu vaccine administered to staff, through charity; Unicef. – Incentive approved by NICE guidelines.

• Training sessions of flu champion vaccinators commencing first week of Oct.

9. e-Rostering

The Trust uses Allocate HealthRoster. The system has recently moved to the cloud which enables wider access for employees to be able access the system from home. A significant benefit of this wider access will enable bank staff to confirm their availability and/or book shifts directly via the system which will enable the temporary staffing team to focus on those ‘hard to fill shifts’ and sourcing a larger pool of workers to join the staff bank. Arrangements for the go live are underway and it is anticipated that it will be launched in Quarter 3 of FY17/18. Roadshows will be used to communicate this improvement to the system and to support individuals to understand how to access the system.

E-Rostering Clinical Lead interviews are booked for early October 2017. This post holder will work with services to improve the quality of rosters, fully utilize staffing and work on supporting the Safer Staffing agenda. 10. Next Month: Recruitment Planning, Organisational Development and Equality & Diversity Updates


ON 4 OCTOBER 2017 Title Financial Performance Report – Month 5


Darren Cattell – Interim Turnaround Chief Financial Officer

Author(s) Gary Edgson – Deputy Director of Finance

Purpose To provide an update and limited assurance on the Trusts financial performance


Assurance X Approve




Trust Leadership Committee/Executive Group

14 Sept 2017 Run rate off financial plan phasing. CIP plans not fully developed. Unplanned and unmitigated cost pressures. Short term financial recovery plan actions are required.








Please add any other committees below as needed Board Seminar Other (please state) Integrated Improvement Framework: IIF Workstream Finance

Section/Clause 5.5 - To ensure final 17/18 budgets and the financial plan is delivered thus

providing value for money services Section/Clause

Section/Clause


Enc L



The Trust has a cumulative deficit of £10.710m as at 31 August 2017. This is an adverse variance of £1.382m behind the Board approved deficit plan. The control total for 2017/18 is a deficit of £0.366m.The current cumulative deficit is £9.170m behind the control total to date. The adverse variance to date against the Board approved plan is due to the increased additional expenditure on both agency and the Quality Improvement Plan (QIP) and for the first time this year, CIPs behind plan. QIP expenditure year to date is £1.9m, forecast to be £5.2m by year end. The Board agreed an outline sum of £2.4m for investments in Quality when the deficit plan was agreed. This is clearly a cost pressure. Year to date, CIP savings of £2.150m have been achieved, which are behind plan by £0.224m. Forecast year end position

o Best case £18.8m o Likely case £23.0m o Worst case £26.3m

Based on the current run rate, the Trust is on track to deliver the £26.3m worst case deficit scenario (£30m was identified in the KPMG report but included a further c£4m of CCG QIPP not delivered but transferred to the Trust). This includes a projected shortfall in CIP achievement of £4.1m and the net impact of QIP unmitigated cost pressures of £3.4m. Currently, the most likely forecast outturn is c£23m. This assumes a further improvement in the current run rate forecast of £3.3m; this includes mitigating cost pressures, increasing CIP plans and discussions with Commissioners to ensure that the Trust is paid for the activity that it undertakes. A Financial Recovery Plan (FRP) is being developed. The critical first six actions of this FRP are outlined below.

ACTION 1. All CBUs and Corporate departments are required to produce plans to reduce QIP spending levels to at least the available funding ensuring that all proposed decisions follow the approved Quality Impact Assessment (QIA) process. ACTION 2. All budget holders are required to develop recovery plans for unplanned cost pressures ensuring that all proposed decisions follow the approved QIA process. ACTION 3. All Budget holders are required to develop further CIP plans to an aggregate level total to 31st March 2018 of at least £4m. Again all proposed decisions must follow the approved QIA process. ACTION 4. It is possible that further mitigations may be required. The iCFO will lead the development of mitigation plans. Currently the best case scenario is the planned £18.835m deficit. Capital Planning Update At the Trust Board Seminar on 15th August, the capital priorities and major projects for this year were approved at a value of £8.3m. Since then the Trust has received a funding allocation of £0.7m to enhance the Urgent Care environment for our Emergency Patients. Plans are being finalised to realise these improvements. As at 31 August, £0.771m of capital allocation has been spent. Spending the remainder of the Capital allocation to improve the equipment and infrastructure for our Patients and Staff before 31st March 2018 will require a focused and prioritised effort. This is the responsibility of the Capital Investment Group (CIG) and they have readily accepted this challenge! ACTION 5. CIG to ensure that the Capital allocation is planned and committed in line with the Board agreed plan for 2017/18. This includes ensuring all aspects of the Capital plan to enhance the Trust in


readiness in support of the “Winter Plan” are prioritised. Cash Update The cash position for the Trust remains a key risk because funding in the form of loans were agreed with the DH up to the value of our planned deficit. It is therefore critical we return to our planned deficit level to mitigate the cash risk and we are able to return to planned level of borrowings. ACTION 6. The Finance team has increased efforts to manage working capital under the auspices of the FRP. The Trust’s Use of Resources Rating is a score of 4 (1 being best and 4 being worst).


It is recommended that the Board note the deteriorating financial performance to date for 2017/18 and agree the proposed Executive actions as outlined in the paper.


Finance Report, as at 31st August 2017 For following sections – please indicate as appropriate:

Trust Goals & Priorities Cost effective, sustainable services Principal Risks (BAF) Risk 712 Financial Resources


Achievement of Statutory Financial Duties

Date: 21 September 2017 Completed by: Gary Edgson – Deputy Director of Finance

Finance Report as at 31 August 2017

1

Executive Summary The Trust has a cumulative deficit of £10.710m as at 31 August 2017. This is an adverse variance of £1.382m behind the Board approved deficit plan. The control total for 2017/18 is a deficit of £0.366m.The current cumulative deficit is £9.170m behind the control total to date. The adverse variance to date against the Board approved plan is due to the increased additional expenditure on both agency and the Quality Improvement Plan (QIP) and for the first time this year, CIPs behind plan. The worst case scenario the Trust will deliver a £26.3m deficit. This includes a projected shortfall in CIP achievement of £4.1m and a projected net impact of QIP unmitigated cost pressures of £3.4m. This is in line with the worst case deficit of c£30m identified in the KPMG report (the £30m included a further c£4m of CCG QIPP not delivered). Currently, the most likely forecast outturn is c£23m. This assumes a further improvement in the current run rate forecast of £2.4m, this includes mitigating cost pressures, increasing CIP plans and discussions with Commissioners to ensure that the Trust is paid for the activity that it undertakes. A Financial Recovery Plan is being developed. The best case scenario is the planned £18.835m deficit. This assumes that all QIP expenditure is offset by uncommitted centrally held funding. Year to date, CIP savings of £2.150m have been achieved, which are behind plan by £0.224m. As at 31 August, £0.771m of capital allocation has been spent. This is behind plan by £3.680m. At the Trust Board Seminar on 15th August, the capital priorities and major projects for this year were approved. The total Capital Resource Limit is £9.034m. The cash position for the Trust remains a key risk, with monthly approvals of uncommitted loan funding required.

Key Financial Risks Key risks can be summarised as follows: 1. Achievement of deficit plan of £18.835m

With risks, opportunities and mitigating actions the likely scenarios are Best case £18.8m Likely case £23.0m Worst case £26.3m Any risks to the revised forecast need to be mitigated by identification of further opportunities.

2. Recurrent Cost Improvement Programme

Plans for the CIP programme are now behind schedule. This is having a negative impact on achieving the 2017/18 financial plan. The Trust is currently identifying a shortfall in plans of £4.071m.

3. Cash A deficit position of the planned £18.835m results in reliance on uncommitted loans from Department of Health and associated interest payments. Current borrowing is £7.279m in 2017/18 and £14.030m carried forward from previous years. A further £3.639m will be received in September and £1.399m has been requested for October.

4. Full use of Capital Resource Limit

The confirmed CRL is £9.0m (including £714k from DH for ED upgrading) with capital priorities approved by the Trust Board during August 2017. Business cases are being developed and final costs determined with further projects dependant on any funding not committed. To date only £0.771m has been spent.


2

Income and expenditure To date the Trust is reporting a deficit of £10.71m against a deficit plan to date of £9.328m, a negative variance of £1.382m. This is based on the Board approved deficit plan of £18.835m for 2017/18. Included in this is £1.894m of expenditure related to Quality Improvement Resource, and this is a c£150k increase spend above plan when compared to last month. CIPs for the first time are reporting behind plan, in month this was almost £250k. The in-month position is a deficit of £2.484m, a negative variance of £0.897m against plan. A summary of the income and expenditure position to date is set out in the table below.

YEARPlan Plan Actual Variance Plan Actual Variance£000s £000s £000s £000s £000s £000s £000s

Income 163,312 14,102 13,936 (166) 68,099 68,287 188 Pay (122,672) (10,729) (11,122) (393) (52,711) (53,595) (885) Non Pay (49,018) (4,097) (4,476) (379) (20,450) (21,291) (841) EBITDA (8,378) (724) (1,662) (938) (5,062) (6,599) (1,537) Depreciation & Amortisation (6,676) (556) (537) 19 (2,775) (2,683) 92 PDC (3,068) (256) (256) 0 (1,278) (1,278) 0 Interest Receivable/(Payable) (749) (58) (41) 17 (247) (203) 44 Bank Charges (10) (1) 0 1 (4) (2) 2 RETAINED SURPLUS / (DEFICIT) (18,880) (1,594) (2,495) (900) (9,367) (10,766) (1,399) Receipt of Charitable Donations for Asset A 0 0 0 0 0 0 0 Impairment 0 0 0 0 0 0 0 Depreciation - Donated Assets 45 8 11 3 39 56 17 REVISED RETAINED SURPLUS / (DEFICIT) (18,835) (1,586) (2,484) (897) (9,328) (10,710) (1,382)

IN MONTH YEAR TO DATE

The Trust control total for 2017/18 was a deficit of £0.366m. The phased plan to date for this control total is a deficit of £1.540m. The current cumulative deficit is £9.170m behind this control total, as follows:

YEARPlan Plan Actual Variance Plan Actual Variance£000s £000s £000s £000s £000s £000s £000s

REVISED RETAINED SURPLUS / (DEFICIT) (366) (173) (2,484) (2,311) (1,540) (10,710) (9,170)



3

An overall summary of the income and expenditure position by Business Unit and directorate is set out in the table below YEARPlan Plan Actual Variance Plan Actual Variance

SLA INCOME £000's £000's £000's £000's £000's £000's £000'sNHS Isle of Wight CCG 132,154 11,072 11,044 (28) 55,111 55,307 197 NHS England 8,560 723 701 (22) 3,579 3,440 (139)Isle of Wight Council 4,554 386 380 (6) 1,932 1,933 1 Commissioning Support Unit 301 25 26 0 125 128 2 Non Contractual Activity 1,360 480 258 (222) 701 592 (109)Sustainability & Transformation Funding 0 0 0 0 0 0 0 Southampton University Hospitals FT 80 7 7 1 33 46 13

SLA INCOME TOTAL 147,009 12,693 12,416 (278) 61,481 61,445 (35)

BUSINESS UNITS & OTHER EXPENDITUREOperational Division

Surgery, Women's & Children's Health (22,147) (1,995) (2,126) (132) (10,197) (10,295) (97)Medicine (13,947) (1,313) (1,505) (192) (6,520) (6,949) (429)Clinical Support, Cancer & Diagnostics (35,894) (3,396) (3,575) (179) (17,206) (17,622) (416)Ambulance, Urgent Care and Community (28,130) (2,385) (2,698) (313) (12,100) (12,898) (798)Mental Health and Learning Disabilities (15,983) (1,342) (1,643) (302) (6,952) (7,746) (794)Chief Operating Officer (1,635) (139) (156) (16) (693) (703) (9)

Operational Division (117,736) (10,570) (11,703) (1,133) (53,668) (56,212) (2,544)

Corporate DivisionFinancial & Human Resources (3,094) (295) (237) 58 (1,305) (1,185) 121 Nursing (2,361) (222) (230) (8) (1,058) (1,037) 21 Transformation & Integration (12,695) (997) (1,029) (32) (5,285) (5,373) (89)HR and Organisational Development (2,167) (154) (297) (143) (897) (1,124) (227)Trust Administration (6,134) (559) (623) (64) (2,622) (2,907) (285)

Corporate Division (26,450) (2,228) (2,417) (189) (11,167) (11,626) (458)

OtherResearch & Development 0 (0) 0 0 (0) (0) (0)Capital Charges (9,744) (812) (792) 19 (4,054) (3,961) 92 Finance Costs (759) (59) (41) 18 (251) (205) 46 Centrally held funding (11,455) (635) 43 678 (1,725) (207) 1,518

204 16 (16) 18 (18)Donated Asset income 50 0 0 0 0 0 0

BUSINESS UNITS & OTHER TOTAL (165,890) (14,288) (14,910) (623) (70,847) (72,211) (1,364)

RETAINED SURPLUS / (DEFICIT) (18,880) (1,594) (2,495) (900) (9,367) (10,766) (1,399)

Impairment and donated assets 45 8 11 3 39 56 17

ADJUSTED RETAINED SURPLUS / (DEFICIT) (18,835) (1,586) (2,484) (897) (9,328) (10,710) (1,382)


Remaining CIP target to be allocated including procurement savings


4

+

Clinical Business Unit Financial Performance A summary of the expenditure position by Clinical Business Unit is set out in the table below.

Finance PerformanceBudget Actual Variance Budget Actual Variance£'000 £'000 £'000 £'000 £'000 £'000

Operational DivisionPay 8,637 9,693 1,056 44,139 46,568 2,429

Non Pay 2,850 3,039 189 13,692 14,254 562

Misc Income (917) (1,029) (113) (4,163) (4,610) (447)

Total Position Operational Division 10,570 11,703 1,133 53,668 56,212 2,544

Surgery, Women's & Children's HealthPay 1,829 1,977 148 9,399 9,629 230

Non Pay 331 313 (18) 1,624 1,561 (63)

Misc Income (165) (164) 1 (826) (895) (69)

Total Position Surgery, Women's & Children's Health 1,995 2,126 132 10,197 10,295 97

MedicinePay 1,136 1,379 242 5,585 6,137 552

Non Pay 366 325 (41) 1,829 1,814 (15)

Misc Income (190) (199) (9) (894) (1,001) (108)

Total Position Medicine 1,313 1,505 192 6,520 6,949 429

Clinical Support, Cancer & DiagnosticsPay 2,058 2,201 142 10,664 10,900 237

Non Pay 1,568 1,666 98 7,527 7,682 155

Misc Income (230) (292) (61) (984) (960) 24

Total Position Clinical Support, Cancer & Diagnostics 3,396 3,575 179 17,206 17,622 416

Ambulance, Urgent Care and CommunityPay 2,158 2,416 258 10,931 11,635 704

Non Pay 471 536 65 2,154 2,358 204

Misc Income (244) (254) (11) (986) (1,095) (110)

Total Position Ambulance, Urgent Care and Community 2,385 2,698 313 12,100 12,898 798

Mental Health and Learning DisabilitiesPay 1,268 1,528 260 6,615 7,295 679

Non Pay 103 157 54 505 665 160

Misc Income (30) (42) (12) (168) (214) (45)

Total Position Mental Health and Learning Disabilities 1,342 1,643 302 6,952 7,746 794

Chief Operating OfficerPay 187 193 5 945 973 27

Non Pay 11 42 32 53 174 121

Misc Income (59) (79) (21) (305) (444) (139)

Total Position Chief Operating Officer 139 156 16 693 703 9

In Month YTD

In total the Operational Division is overspent by £2.544m, however QIP funding has not been allocated to individual budgets. This equates to £1.293m of the current overspend, which is mainly attributable to pay. This leaves a cost pressure of £1.2m YTD. The agency premium funding has been allocated to the CBU’s from centrally held funds. Medicine is overspent as a result of the premium costs and mitigating risks with the Urgent Care Service (£0.278m). Negotiations are underway with the CCG. Overachievement on income relates to:- Surgery, Women’s & Children’s Health improved income position on Mottistone, an 8% increase on last year. Both Ambulance and Urgent Care and Community have seen an increase in income associated with over performance of CCG non-contractual income for non-Island residents. Variances on income for the Chief Operating Officer are matched to overspends on both pay and non-pay relating to EMH and MLaFL, with a nil impact on the bottom line.


5

Corporate Directorate Financial Performance A summary of the expenditure position by Corporate Directorate is set out in the table below.

Finance PerformanceBudget Actual Variance Budget Actual Variance£'000 £'000 £'000 £'000 £'000 £'000

Corporate DivisionPay 1,312 1,345 32 6,563 6,571 8

Non Pay 1,364 1,513 149 6,843 7,005 161

Misc Income (449) (441) 8 (2,238) (1,950) 288

Total Position Corporate Division 2,228 2,417 189 11,167 11,626 458

Finance & Human ResourcesPay 191 128 (63) 687 614 (73)

Non Pay 142 138 (3) 805 727 (78)

Misc Income (37) (29) 8 (187) (157) 30

Total Position Finance & Human Resources 295 237 (58) 1,305 1,185 (121)

NursingPay 176 177 2 894 880 (15)

Non Pay 58 48 (10) 219 199 (19)

Misc Income (11) 5 16 (55) (42) 13

Total Position Nursing 222 230 8 1,058 1,037 (21)

Transformation & IntegrationPay 563 573 10 2,928 2,859 (69)

Non Pay 528 542 14 2,822 2,949 127

Misc Income (94) (86) 8 (465) (434) 31

Total Position Transformation & Integration 997 1,029 32 5,285 5,373 89

HR and Organisational DevelopmentPay 228 305 77 1,261 1,293 32

Non Pay 231 275 45 1,159 1,045 (114)

Misc Income (304) (283) 22 (1,522) (1,214) 308

Total Position HR and Organisational Develop 154 297 143 897 1,124 227

Trust AdminstrationPay 155 161 6 793 926 133

Non Pay 406 510 104 1,839 2,084 246

Misc Income (2) (48) (46) (9) (103) (94)

Total Position Trust Adminstration 559 623 64 2,622 2,907 285

In Month YTD

The significant in-month movement for HR and Organisational Development is due to the CIP target phasing with a lower than expected delivery. In total Corporate division is overspent by £0.458m, however QIP funding has not been allocated to individual budgets, this equates to £0.304m. A residual overspend of £160k remains. Income is not achieving against planned budget for both Car Parking (£0.030m) and NHS Creative (£0.416m). NHS Creative reduction in income is partly offset by reduction in both pay and non pay expenditure. Overall NHS Creative is £0.034m below plan. Additional unplanned expenditure has been incurred in August relating to: Overseas recruitment £74k Provisions for Industrial Tribunals £30k


6

Income Overall, income is £0.188m better plan to date. As the main CCG contracts for 2017/18 are on a block contract basis there are currently no variances against expected income, however the CCG have stated that they will support additional expenditure incurred for the Urgent Care Service. The walk in service did not cease until the end of June 2017, this was a QIPP scheme for the CCG and was a recurrent reduction of income to the base line of £0.400m. Therefore it is assumed the CCG will support the income for the first quarter, at £0.100m. NHS England is underperforming against contract this relates to Neonatal, Breast Screening and Secondary Dental. To date this equates to £248k. Income variances of £0.097m & £0.109m in relation to pass through drugs and cost per case services are offset by funds held centrally.

YEARPlan Plan Actual Variance Plan Actual Variance

£000's £000's £000's £000's £000's £000's £000'sNHS Isle of Wight CCG

Service Level Agreements 127,453 10,621 10,621 0 53,105 53,205 100 Pass through Drugs 4,348 377 380 3 1,830 1,927 97 Other services & investments 353 74 42 (31) 175 175 (0)

NHS EnglandService Level Agreements 5,665 472 376 (96) 2,360 2,112 (248)Pass through Drugs 2,895 251 325 74 1,219 1,328 109

Isle of Wight Council 4,554 386 380 (6) 1,932 1,933 1 Commissioning Support Unit 301 25 26 0 125 128 2 Non Contractual Activity 1,360 480 258 (222) 701 592 (109)Sustainability & Transformation Funding 0 0 0 0 0 0 0 Southampton University Hospitals FT 80 7 7 1 33 46 13

SLA INCOME TOTAL 147,009 12,693 12,416 (278) 61,481 61,445 (35)

Business Units and other income 16,303 1,409 1,521 112 6,618 6,842 224

TOTAL INCOME 163,312 14,102 13,936 (166) 68,099 68,287 188



7

Income and activity performance Isle of Wight CCG Contract As at 31 July 2017 activity is slightly ahead of plan, equating to £0.082m over performance against income. However, this is a block contract and this positive financial variance is not shown in the overall Trust financial position. Elective services continue to over perform as the Trust delivers the 18 week RTT, this is now c£1.2m at month 5. However the over performance on CCG income relates to the Urgent Care Service, the closure of the GP walk in centre was delayed by 3 months and the Trust is seeking funding to support the additional costs incurred. The current income assumes total CQUINs funding will be received and no adjustments for fines will take place in 2017/18 under the block contract. There is a risk of 0.5% of the CCG CQUINs funding being withheld to form a risk reserve. Discussions are ongoing between the Trust and CCG with NHSI and NHSE. This equates to £0.585m full year, £0.244m year to date. NHS England Contract The table below shows the activity and financial variance to plan for the NHS England contract as at 31 August 2017. This shows that activity is behind plan to date, equating to £0.248m under performance against income, this trend has continued over the 5 months. NHS England SLA

Plan Plan Variance VarianceActivity £000's Activity £000's

Thames Valley Area Team 10,810 466 (35) 23Wessex Area Team - Specialist Services 159 561 (17) (2) Chemotherapy Delivery 9,632 1,365 (41) (13) Neonatal Critical Care 1,490 823 (171) (100)Wessex Area Team - Secondary Dental Care 9,035 1,404 (472) (91)Wessex Area Team - Public Health 10,908 1,020 (969) (65)Wessex Area Team - Other Services 25 0 0

Total Income 42,034 5,664 (1,705) (248)

Full Year Year to Date


8

Quality Improvement Resource (QIP) Year to date In May 2017 the Board approved an indicative £2.4m of additional expenditure in addition to the £18.835m deficit, in respect of Quality Improvement Resources identified to address the issues raised by the Trust being placed into Special Measures. To date £1.894m of this expenditure has been incurred, and is included in the current year to date deficit position. Much of this has been at agency costs. At present this is shown as an overspend in CBU& Corporate Division financial positions. The expenditure has been incurred in the following areas:

• £1.069m Mental Health & Learning Disabilities • £0.355m Ambulance, Urgent Care and Community • £0.021m Clinical Support, Cancer & Diagnostics • £0.453m Corporate Directorates

Forecast outturn At present, it is estimated that the expenditure on QIP for 2017/18 will be £5.2m. This is forecast to be incurred in the following areas:

• £2.511m Mental Health & Learning Disabilities • £1.158m Ambulance, Urgent Care and Community • £0.067m Clinical Support, Cancer & Diagnostics • £0.017m Surgery, Women’s & Children’s Health • £0.017m Medicine • £1.282m Corporate Directorates

The forecast year end position indicates that there will be £3.886m of uncommitted centrally held funding. This would be used to offset the QIP expenditure. However, this leaves £1.308m net cost pressure from QIP. Work has started to review this in line with quality benefits expected. In addition, a further £2.1m worth of currently unmitigated cost pressures have been forecast. Work has started to reduce these.


9

Forecast outturn

Detailed forecasts have been prepared by the Business Units and Corporate Directorates. This shows a worst case scenario of £26.341m deficit for 2017/18

Total year end positionForecast as at 31 March 2018

EXPENDITURE Plan Forecast VarianceOperational Division £000's £000's £000's

Surgery, Women's & Children's Health (23,264) (24,737) (1,473)Medicine (15,025) (16,445) (1,421)Clinical Support, Cancer & Diagnostics (39,998) (42,068) (2,070)Ambulance, Urgent Care and Community (28,365) (30,668) (2,303)Mental Health and Learning Disabilities (16,015) (18,547) (2,532)Chief Operating Officer (1,703) (1,909) (206)

Operational Division (124,370) (134,375) (10,005)

Corporate DivisionFinance (2,962) (2,929) 33 Nursing (2,675) (2,948) (273)Transformation & Integration (12,883) (12,962) (79)Human Resources and Organisational Development (2,245) (2,701) (457)Trust Administration (6,327) (6,993) (666)

Corporate Division (27,092) (28,534) (1,443)

OTHERResearch & Development (0) (0) (0)

Capital Charges (9,744) (9,510) 234 Finance Costs (759) (660) 98 Donated Asset income 50 50 0

Centrally Held Funding - Cost Pressures (535) (456) 79 - Pass through costs 295 (295)- Investments (3,769) (243) 3,526

EXPENDITURE TOTAL (165,923) (173,728) (7,805)

INCOMENHS Isle of Wight CCG - Contract 127,453 127,553 100

- Pass through costs 4,348 4,528 180 - Cost per case 387 388 1

NHS England - Contract 5,665 5,512 (152)- Pass through costs 2,895 3,011 115

Isle of Wight Council 4,554 4,561 7 Commissioning Support Unit 301 303 2 Non Contractual Activity 1,360 1,360 (0)Sustainability & Transformation Funding 0 0 0 Southampton University Hospitals FT 80 92 12

INCOME TOTAL 147,043 147,308 265

RETAINED SURPLUS / (DEFICIT) (18,880) (26,421) (7,540)

Impairment and donated assets 45 80 35

ADJUSTED RETAINED SURPLUS / (DEFICIT) (18,835) (26,341) (7,505)

This is an adverse variance to the £18.835m deficit plan of £7.505, and can be summarised as:

£m £m QIP forecast expenditure 5.2 Offset by centrally held funding (3.9) Net QIP pressure 1.3 Unplanned CIP 4.1 Budget cost pressures 2.1 Variance to plan 7.5

Currently, the most likely out turn forecast is around £23m deficit. This is as a result of a refresh of the Cost Improvement Programme, and discussions with Commissioners to ensure that the Trust is paid for the activity that it undertakes. The best case out turn is the planned £18.835m planned deficit. This assumes that all QIP expenditure is offset by uncommitted centrally held funding.


10

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TOTAL£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Monthly deficit plan 2,366 2,087 1,719 1,569 1,586 1,591 1,399 1,432 1,407 1,221 1,224 1,234 18,835Monthly deficit actual/Forecast 1,762 1,955 2,179 2,329 2,484 2,256 2,079 2,134 2,180 2,235 2,259 2,489 26,341

QIP expenditure 108 284 378 648 482 441 462 492 481 472 470 477 5,195 (included in overall deficit)

Key

Actual QIPActual deficit (excl QIP)

Forecast QIPForecast deficit (excl QIP)

0

500

1,000

1,500

2,000

2,500

3,000


£'000

2017/18 Monthly deficit plan and actual/forecast

The phasing of the worst case scenario of £26.341m deficit, against the deficit plan is shown below.


11

Income & Expenditure Run Rate The table below shows the monthly income and expenditure run rate for the last 14 month period, both including and excluding STF funding.

2016/17 2017/18

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

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Pay (10,344) (10,275) (10,416) (10,179) (10,300) (10,266) (10,414) (10,325) (9,917) (10,332) (10,516) (10,724) (10,913) (11,122) Non Pay (3,719) (3,991) (3,939) (3,782) (4,220) (4,227) (3,962) (3,502) (4,554) (3,975) (4,302) (4,342) (4,185) (4,476) Misc Income 1,752 1,850 2,006 1,671 1,543 1,466 1,591 1,555 1,498 1,177 1,373 1,526 1,246 1,521 Business Units & Directorates (12,312) (12,415) (12,349) (12,289) (12,977) (13,027) (12,786) (12,272) (12,973) (13,130) (13,445) (13,540) (13,852) (14,077)

Patient Related Income 12,461 12,546 12,514 12,562 11,999 11,890 11,881 11,938 13,771 12,190 12,311 12,182 12,347 12,416 STF 255 255 256 218 (200) 91 0

EBITDA 404 385 421 491 (1,178) (1,047) (905) (334) 798 (940) (1,134) (1,358) (1,505) (1,662)

Capital Charges (812) (812) (812) (812) (811) (834) (811) (703) (903) (781) (781) (781) (781) (781) Finance Costs (24) (35) (16) 2 (44) (21) (4) (26) (35) (40) (40) (41) (43) (41)

Actual Surplus / (Deficit) (431) (461) (408) (319) (2,033) (1,901) (1,720) (1,063) (140) (1,762) (1,955) (2,179) (2,329) (2,484)

Actual Surplus / (Deficit)Excluding STF

(686) (716) (664) (537) (1,833) (1,992) (1,720) (1,063) (140) (1,762) (1,955) (2,179) (2,329) (2,484)

11,000

11,500

12,000

12,500

13,000

13,500

14,000

14,500

Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17

£'00

0

Business Units & Directorates - Expenditure Run Rate

Actual run rate Run rate excluding QIP Linear (Actual run rate)

This shows that expenditure in total for Clinical Business Units and Corporate Directorates has been rising each month since February 2017. August is the first month where operational expenditure has risen above £14m in a month, and pay has exceeded £11m in a month. The increased patient related income in March 2017 related to the additional Transition funding received from the CCG. In the graph, the additional expenditure of £1.984m relating to the QIP expenditure has been shown separately to show the underlying run rates.


12

Agency The in-month spend on agency staff is £0.915m. Cumulative agency spend is £3.940m, which is £1.867m above the NHSI ceiling of £1.657m Actual agency spend is above year to date expenditure for 2016/17 despite having Poppy Unit open in 2016/17. This is mainly due to the additional QIP expenditure. Actions

• Several CIP plans, cost avoidance initiatives have been implemented for 2017/18. However the Trust is not seeing an overall reduction in agency usage.

• All areas have been tasked with

reducing the agency spend and reviewing agency is part of the IIF

2017/18 ACTUAL SPEND

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TOTAL£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Medical 402 487 501 473 513 2,376

Nursing 106 188 408 341 334 1,377

Clinical 16 30 1 32 26 104

Administration 4 6 9 1 43 63

Other 8 7 5 0 20

Total spend - month 536 718 924 847 915 3,940

Total spend - cumulative 536 1,254 2,177 3,024 3,940 3,940 3,940 3,940 3,940 3,940 3,940 3,940

Ceiling - month 413 414 414 416 416 416 416 416 417 417 417 418

Ceiling - cumulative 413 827 1,241 1,657 2,073 2,489 2,905 3,321 3,738 4,155 4,572 4,990

Variance to ceiling 123 304 510 431 499 1,867

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarActual - cumulative 2016/17 682 1,506 1,924 2,763 3,255 4,136 4,623 5,055 5,681 6,312 6,957 7,611Ceiling - cumulative 413 827 1,241 1,657 2,073 2,489 2,905 3,321 3,738 4,155 4,572 4,990Actual - cumulative 536 1,254 2,177 3,024 3,940Forecast - no change based on current month 536 1,155 2,177 3,024 3,940 4,855 5,771 6,686 7,602 8,517 9,433 10,348Forecast with 10% reduction 449 1,155 1,919 2,722 3,546 4,370 5,194 6,018 6,842 7,665 8,489 9,313

0

2,000

4,000

6,000

8,000

10,000

12,000

£'00

0

Total Agency spend 2017/18


13

CIP Performance

Business Unit

CIP Targetyear to date

£'000

CIP achievedyear to date

£'000

Over / (Under) Target

year to date£'000

Medicine 227 45 (182) Surgery, Women's & Children's Health 249 155 (94) Ambulance, Urgent Care and Community 329 649 320 Mental Health and Learning Disabilities 176 242 66 Clinical Support, Cancer & Diagnostics 632 282 (350) Chief Operating Officer 22 27 5 Finance 166 238 72 HR & OD 70 18 (52) Nursing 85 84 (0) Transformation & Integration 285 357 73 Trust Administration 49 54 5 Trust Reserves 85 0 (85) All 0 0 0 To be identified 0 0 0 Drand Total 2,374 2,150 (224)

Business Unit

CIP Target2017/18

£'000

CIP achievedyear end forecast

£'000

Over / (Under) Target

forecast£'000

Medicine 1,120 411 (709) Surgery, Women's & Children's Health 1,475 349 (1,126) Ambulance, Urgent Care and Community 1,095 1,091 (4) Mental Health and Learning Disabilities 422 296 (127) Clinical Support, Cancer & Diagnostics 2,639 761 (1,878) Chief Operating Officer 90 39 (52) Finance 398 493 95 HR & OD 168 55 (113) Nursing 203 139 (65) Transformation & Integration 683 726 43 Trust Administration 116 60 (56) Trust Reserves 203 202 (1) All 0 0 0 To be identified 0 0 0 Drand Total 8,613 4,621 (3,992)

Cumulatively there is an achievement of £2.150m against a target of £2.374m year to date. This is behind plan by £0.224m. The full year requirement for 2017/18 is £8.613m. At present there are schemes identified for £4.621m, this would result in a shortfall of £3.992m. All CIP targets have been removed from operational budgets. Steps being taken to bridge the current shortfall are:

• CBU & Corporate Workshops scheduled 2 October and 7 December • Attendance at Regional CIP Workshop 25 September • Monthly Performance Reviews to drive delivery and maintain focus • Additional resource in place to support in year delivery from Cost Base

Review exercise • Additional resource to support QIPP • Acute Service Redesign (ASR) and Local Care Plan (LCP) outputs to

support 2018/19 delivery The tables on the following page identify the schemes currently in place across Clinical Business Units and Corporate Directorates.


14

CIP performance The following table identifies the £4.621m CIP schemes currently in place across Clinical Business Unit and Corporate Directorates.

YE PlanYE

ForecastYE

VarianceYTD Plan

YTD Actuals

YTD Variance

£'000 £'000 £'000 £'000 £'000 £'000Agency Reduction 336 0 (336) 32 0 (32) 01-Aug-17 R No plan in place.AUCC Non Pay 0 1 1 0 (12) (12) 01-Apr-17 B DeliveredCommunity Cost Base Review 766 747 (19) 319 309 (10) 01-Apr-17 G Delivery on track. QIA signed off 4 JulyCorporate Vacancy Review 888 951 63 370 516 146 01-Apr-17 R QIA signed off 4 July.CSCD Non Pay 35 41 6 15 17 2 01-Apr-17 B DeliveredDiscretionary Spend 616 582 (34) 257 253 (4) 01-Apr-17 G Delivery on track. QIA signed off 4 JulyHospital Car 20 0 (20) 8 0 (8) 01-Oct-17 R No plan in place.IIF Efficiencies 407 0 (407) 39 0 (39) 01-Aug-17 R No plan in place.Job Planning 305 0 (305) 29 0 (29) 01-Aug-17 R Interviews to be completed end Qtr3. QIA outstandingMental Health Cost Base Review

365 238 (127) 152 218 66 01-Apr-17 RQIA signed off 4 July. Ongoing analysis of costs and activity to influence service delivery

Oral Surgery 100 100 (0) 42 25 (17) 01-Apr-17 B Delivered. QIA signed off 4 JulyPathology Review 270 219 (51) 112 68 (44) 01-Jun-17 A Delays with implementationPay savings AUCC 0 415 415 0 382 382 01-Apr-17 B Delivered. Fortuitous savingsPay savings GM 0 36 36 0 13 13 01-Apr-17 B Delivered. Fortuitous savings

Procurement 204 204 0 85 2 (83) 01-Apr-17 ADelays with implementation, mitigated by new schemes being developed. QIA signed off 4 July

Sickness Reduction 558 0 (558) 53 0 (53) 01-Aug-17 R No plan in place.Theatre Project 282 212 (70) 117 0 (117) 01-Jun-17 A Delays with implementation. QIA signed off 4 JulyUnidentified 2,175 1 (2,175) 208 0 (208) 01-Apr-17 R No plan in place.Urgent Care Walk In 298 298 0 124 0 (124) 01-Jul-17 G Delivered, subject to QIA sign off 17 JulyZero Base Budget 988 577 (411) 412 358 (54) 01-Apr-17 R QIA signed off 4 JulyTotal Plans 8,613 4,621 (3,992) 2,374 2,150 (223)

SchemeFinancial Delivery

From:

BRAD Rating

Rationale for BRAD Rating


15

Cash The cash balance held at the end of August is £3.077m which is £0.577m more than the adjusted plan. However, the actual cash balance has reduced in year by £4.2m reducing from £7.3m to £3.1m at the end of August. The major movements in cash are as follows:- Operating Deficit Cash (£7.0m) Increased Debtors mainly due to Payments in Advance and Accrued Income (£4.1m) although Invoiced Debtors has reduced in month from £3.2m to £2.5m Payments for Capital items due to higher than planned Capital Creditors at the end of 2016/17 (£3.5m) Uncommitted Loan receipts £7.3m Increase in Creditors due to restrictions on creditor payments £2.8m Payment are being managed to ensure critical payments can be made and this resulted in BPPC figures of 93% for volume and 83% for value for the year to July.

Previous Month Year to date Movement inJul-17 Aug-17 Month£000s £000s £000s

Cash Flows from Operating ActivitiesOperating Surplus/(Deficit) (7,077) (9,274) (2,197)Non-cash income and expense:Depreciation and amortisation 2,147 2,683 536(Increase)/decrease in trade and other receivables (3,545) (4,082) (537)(Increase)/decrease in inventories (4) 115 119Increase/(decrease) in trade and other payables 2,001 2,790 789Increase/(decrease) in provisions (152) (166) (14)Net Cash Inflow/(Outflow) from Operating Activities (6,630) (7,934) (1,304)Cash Flows from Investing ActivitiesInterest received 4 5 1Purchase of intangible assets (267) (274) (7)Purchase of property, plant and equipment and investment property (2,869) (3,229) (360)Net Cash Inflow/(Outflow) from Investing Activities (3,132) (3,498) (366)NET CASH INFLOW/(OUTFLOW) BEFORE FINANCIND (9,762) (11,432) 1,670Cash Flows from Financing ActivitiesLoans from Department of Health - received 5,686 7,279 1,593Capital element of finance lease rental payments (52) (52) 0Interest paid (3) (3) 0Interest element of finance lease (10) (10) 0Net Cash Inflow/(Outflow) from Financing Activities 5,621 7,214 1,593NET INCREASE/(DECREASE) IN CASH AND CASH EQUIVALENTS (4,141) (4,218) (77)Cash and cash equivalents at start of period 7,295 7,295 0Cash and cash equivalents at end of period 3,154 3,077 (77)


16

Capital programme Our initial CRL is based on forecast depreciation of £6.570m plus the £1.7m slipped from the capital programme in 2016/17 and £50k expected Charitable Donations. This gives an initial CRL of £8.32m. The Department of Health has now confirmed the Trust has been successful in its bid for £714k of A&E Streaming funding and so this will give us capital funds of £9.034m for 2017/18. In month spend: £366k Year to Date spend: £771k At the Trust Board Seminar on 15th August, the capital priorities for this year and major projects including the following were approved:-

• Sevenacres CQC Compliance • DSU Improving Patient Flow • Ambulance CAD Hardware • Paediatric Assessment Unit • Ophthalmology Satellite Unit • Maternity Utility Area • Mottistone upgrade • Level C DDA Compliance • LIMS Telepath upgrade

The schemes that form the programme have been reflected in the forecast full year column. As the Capital Investment Group were awaiting the outcome of the Board seminar no business cases were approved at August's meeting. Outstanding cases that have been approved in principle by Board will now be brought forward to future meetings.

Plan £k

Actual £k

Variance £k

Plan £k

Forecast £k

Variance £k

SOURCE OF FUNDSInitial Capital Resource Limit 4,451 771 3,680 6,570 6,570 0Slipped Funding from 2016/17 0 0 0 1,700 1,700 0Current Capital Resource Limit 4,451 771 3,680 8,270 8,270 0

Property Sales 0 0 0 0 0 0Donated Funds 0 0 0 50 50 0Other 0 0 0 714 714 0Total Funds Available 2017/18 4,451 771 3,680 9,034 9,034 0

APPLICATION OF FUNDSPlan

£kActual

£kVariance

£kPlan

£kForecast

£kVariance

£kStrategic SchemesCarbon Energy Fund 763 0 763 813 600 213Service Developments - Strategic 0 42 (42) 0 895 (895)IM&T New Schemes - Strategic 0 75 (75) 714 394 320

763 117 646 1,527 1,889 (362)Operational SchemesService Developments - Operational 0 152 (152) 152 1,699 (1,547)IM&T RRP 550 0 550 1,500 1,165 335IM&T New Schemes - Operational 100 0 100 292 415 (123)IM&T and Estates Staff Capitalisation 0 70 (70) 0 400 (400)Equipment RRP 488 292 196 1,563 1,160 403Mental Health Estates CQC 0 65 (65) 0 1,054 (1,054)Estates Schemes 300 76 224 1,000 750 250Contingency/Unallocated 0 0 0 500 300 200GS1 550 0 550 750 92 658Other 0 0 0 0 60 (60)Donated Assets 0 0 0 50 50 0Slipped Schemes - actuals included within the categories above 1,700 0 1,700 1,700 0 1,700

3,688 654 3,034 7,507 7,145 362

Total Expenditure 2017/18 4,451 771 3,680 9,034 9,034 0

Year to Date Full Year


17

Use of Resources Rating NHS Improvement’s new Single Oversight Framework and Use of Resources Rating were introduced from 1 October 2016, replacing the Financial Risk Rating.

Table 1Plan Rating

Actual Rating Variance

Capita l Service Capaci ty 4.0 4.0 0

Liquidi ty (days ) 4.0 4.0 0

I&E Margin 4.0 4.0 0

Dis tance from financia l plan 1.0 4.0 3

Agency spend 1.0 4.0 3

Overall Use of Resources Rating 2.8 4.0 1

The Trusts Use of Resources Rating as at 31 August is set out below. Against the NHSI Control Total, the Trust’s Use of Resources Rating is a score of 4 (Table 1) Against the Board approved deficit plan, the Trust’s Use of Resources Rating is a score of 4 (Table 2) This is against a score of 1 being best and 4 being worst.

Table 2Plan Rating

Actual Rating Variance

Capita l Service Capaci ty 4.0 4.0 0

Liquidi ty (days ) 4.0 4.0 0

I&E Margin 4.0 4.0 0

Dis tance from financia l plan 1.0 4.0 3

Agency spend 1.0 4.0 3

Overall Use of Resources Rating 2.8 4.0 1



ON 4th October 2017 Title Acting Chair of Quality Governance Committee Report


David King, Non- Executive Acting Chair of Quality Governance Committee

Author(s) David King, Non- Executive Acting Chair of Quality Governance Committee

Purpose To inform the Board of the key issues raised by the Quality Governance Committee


Assurance X Approve










Please add any other committees below as needed Board Seminar Other (please state) Integrated Improvement Framework: IIF Workstream Quality

Section/Clause Staff, stakeholder, patient and public engagement: N/A Executive Summary & Analysis:

Following the meeting of the Quality Governance Committee on Tuesday 26th September, the following issues are being brought to the attention of the Board: We are still work in progress to have the top 3-5 quality issues faced by the trust under regular and deep scrutiny, collage is still too wide and the papers to long and often not leading the members to the evidence and proposals that need scrutiny From the meeting

• Infection control is a concern as infection rates are increasing beyond our annual target and patients are at increased risk due to this trend.

Enc M


• The team were not assured that SIRI tracking and scrutiny is at the level we seek, we need a new process to track from first reporting to final closure and lessons learned

• Section 17 and 31 evidence and progress appears good, the team would like a feedback process from the regulator to insure we are meeting the expectations of our key stakeholders

• Emergency response plan is presented at board to day and the winter plan was reviewed but is a work in progress now.


The Board is recommended to receive the assurance and recommendations of the Quality Governance Committee.


Trust Goals & Priorities All Principal Risks (BAF) Principal Risk 674 – Quality & Issue 1085, CQC Section 31

Warning Notice: Legal implications, regulatory and consultation requirements

Date: 27th September 2017 Completed by: David King, Non- Executive Acting Chair of Quality Governance Committee



ON 4th October 2017 Title Chair of Finance, Investment, Information & Workforce Committee Report


Charles Rogers, Non- Executive Chair of Finance, Investment, Information & Workforce Committee

Author(s) Charles Rogers, Non- Executive Chair of Finance, Investment, Information & Workforce Committee

Purpose To inform the Board of the key issues raised by the Quality Governance Committee


Assurance X Approve







26/09/17






Following the meeting of the Finance, Investment, Information & Workforce Committee on Tuesday 26th September, the following issues are being brought to the attention of the Board: Human Resources

• Mandatory Training. The Trust position at Month 5 is 81% compliance (target 85%). This figure includes Bank staff and is now based on total requirements achieved. Efforts are needed to continue to improve these numbers and especially where compliance is low, for example Bank (66%) and Medical and Dental (62%).

• Appraisals. The rolling 12 month appraisal percentage at Month 5 is 46.93%. The Committee

Enc N


recognised that a dip was expected as measurement moved to a rolling average but the sharp reduction is an indicator that the important focus on individual annual appraisal completion is not continuing from last year and the Committee recommends that there is renewed attention given to this item.

• Additional Staffing. The use of Bank, Agency and Overtime amounted to the equivalent of 215 FTE in Month 5.

Limited Assurance. Financial

• Finance Performance Report. The Committee acknowledge the work that has taken place to improve the quality and the presentation of the information in the report.

• The Trust has a cumulative deficit of £10.710m as at 31 August 2017. This is an adverse variance of £1.382m behind the Trust Board approved deficit plan. This adverse variance against plan is due to the increased additional expenditure on both Agency and the Quality Improvement Plan and for the first time this year Cost Improvement Plan’s (CIP’s) are behind plan. This is the first month where operational expenditure has risen above £14m in a month and pay has exceeded £11m in a month. The Committee consider that there is a significant risk that the Trust will not meet its planned £18.835m planned deficit for the year. Therefore it is proposed that a meeting of the Board and CBU leaders is arranged as a priority to consider what actions can be taken to reduce spend in the short term and impact the end of year out turn.

• Cash. The cash position for the Trust remains a key risk with monthly approvals of uncommitted loan funding required.

• Agency. The spend on Agency staff in August was £0.915m. Cumulative Agency spend this year is £3.940m which is £1.867m above the NHSI ceiling of £1.657m. Several CIP plans, cost avoidance initiatives have been implemented for 2017/18, however, the Trust is not seeing an overall reduction in Agency usage.

• Capital. The Trust Board agreed the Capital Programme in August. Additionally the Trust has received confirmation of A&E Streaming Funding of £714k. The total Capital fund for 2017/18 is now £9.034m. At the end of August the year to date spend is £771k. The Committee is concerned that most of the Capital spend is falling into the second half of the year and that there may be capacity constraints to complete the work.

Limited Assurance. Data Quality.

• The Committee are concerned that little progress is being made in reducing outstanding discharges as well as the level of coding activity. There are also doubts about the quality of some of the data. The Interim Turnaround Chief Financial Officer agreed to undertake a detailed review of data quality.

Limited Assurance.


The Board is recommended to receive the assurance and recommendations of the Finance, Investment, Information & Workforce Committee.


Trust Goals & Priorities All Principal Risks (BAF) Principal Risk 712 – Financial Resources; Risk 671, Human

Resources Legal implications, regulatory and consultation requirements

Date: 27th September 2017 Completed by: Charles Rogers, Non- Executive Chair of Finance, Investment, Information & Workforce Committee



ON 4th October 2017 Title Chair of Mental Health Act Scrutiny Committee Report


Jessamy Baird, Non- Executive Chair of Mental Health Act Scrutiny Committee

Author(s) Jessamy Baird, Non- Executive Chair of Mental Health Act Scrutiny Committee

Purpose To inform the Board of the key issues raised by the Mental Health Act Scrutiny Committee


Assurance X Approve












Following the meeting of the Mental Health Act Scrutiny Committee on Tuesday 26th September, the following issues are being brought to the attention of the Board:

a) Mental Health Act Scrutiny Committee (MHASC) Annual Report: The Committee discussed the report and it was agreed that consistent Service User representation; Serenity information and the implementation of biennial MHARMs appraisals were to be included.

b) Operation Serenity: The Committee received an update on the Serenity service which operates

for 6 nights a week and has proven very successful whith the S136 admission numbers continuing

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to fall with 6 in the first half of 2017. The SIM (Serenity Integrated Monitoring) part of the Serenity project has been nominated in three categories for this year’s Health Service Journal (HSJ) Value in Healthcare Awards.

c) ‘Learning from Outstanding Mental Health Services’ Conference in London on 17/07/2017:

The Committee received an update on the conference and were advised that it was based on learning lessons and sharing good practice from Mental Health Services rated outstanding in CQC inspections.


The Board is recommended to receive the assurance and recommendations of the Mental Health Act Scrutiny Committee.


Trust Goals & Priorities All Principal Risks (BAF) Risk 677, Local Health and Social Care Economy Resilience:


Date: 27th September 2017 Completed by: Jessamy Baird, Non- Executive Chair of Mental Health Act Scrutiny Committee



ON 4th October 2017 Title Chair of Audit & Corporate Risk Committee Report


David King, Non-Executive Director Chair of Audit & Corporate Risk Committee

Author(s) David King, Non-Executive Director Chair of Audit & Corporate Risk Committee

Purpose To inform the Board of the key issues raised by the Audit & Corporate Risk Committee


Assurance X Approve





Audit & Corporate Risk Committee 08/08/17





Please add any other committees below as needed Board Seminar Other (please state) Integrated Improvement Framework:


Following the meeting of the Audit & Corporate Risk Committee on the 8th August 2017, the following issues are being brought to the attention of the Board:

a) Financial Resilience – 2017/18 Financial Recovery Plan: The Committee received the framework of immediate actions. The Committee supported the proposed approach. The Committee acknowledged that the organisation faced a complex problem, however was doubtful that there was, globally, sufficient competency within the organisation to manage and effect change. In particular, the Committee considered that empowerment through training and support

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particularly to the CBUs was essential, with devolvement of responsibilities being managed and phased accordingly. The Committee requested regular updates on progress.

b) Internal Audit – Consultants Private Work Compliance – Limited Assurance – Consultants’ Job Plans: The Executive Medical Director to provide a report to the February 2018 meeting of the Committee in order to provide assurance that the job planning process has been completed in time for the 2018/19 financial year. In addition, internal audit to undertake a follow up audit and report back to the subsequent 2018 meeting.

c) Internal Audit – Seven Day Working: The Committee was not assured on the implementation of

the seven day working week and agreed that a report be presented to the November 2017 Trust Board by the Executive Medical Director.

d) Sub-Committees’ Annual Reports 2016/17 – Membership of Sub-Committees: NED

membership of the sub-committees was a challenge given the limited number of NEDs. The Committee was not assured that sub-committees could provide the required in depth assurance to the Trust Board due to lengthy agendas and the sheer volume of material presented.

e) Review of Statutory and Formal Roles: TLC to review and once the roles have been agreed, to

be circulated to members of the ACRC for agreement prior to submission to the Trust Board for approval and adoption.


The Board is recommended to receive the assurance and recommendations of the Audit & Corporate Risk Committee.


Trust Goals & Priorities All Principal Risks (BAF) All


Date: 27th September 2017 Completed by: David King, Non-Executive Chair of the Audit & Corporate Risk Committee

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