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Trust Board Papers

Isle of Wight NHS Trust

Board Meeting in Public

to be held on

Thursday 10 October 2019

at

1.30pm - Conference Room

Level B Main Hospital

(opposite Full Circle Restaurant)

St. Mary’s Hospital, Parkhurst Road,

NEWPORT, Isle of Wight, PO30 5TG

IW NHS Trust Board (Public) 10 October 2019 - Page | 1

27NARU Update NARU Update

Agenda

AGENDA

Timing No. Item Lead Purpose Enc/Verbal 1.30pm Celebration of Mental Health Day Lesley Stevens Receive Pres 1.45pm PROCEDURAL 1 Apologies Chair Receive Verbal 2 Confirmation that meeting is Quorate Chair Receive Verbal 3 Declarations of Interest Chair Receive Verbal 4 Minutes of previous meeting Chair Approve A 5 Matters Arising and Schedule of Actions Chair Receive B 2.00pm STRATEGY 6.1 Chair's Update Chair Receive C 6.2 Chief Executive's Update Maggie Oldham Receive D 6.3 Flu Briefing Maggie Oldham Receive Verbal 6.4 Brexit Preparations Alistair

Flowerdew Receive E

Questions from the public arising from this section

Chair Receive Verbal

2.25pm PERFORMANCE 7.1 Committee Report from Quality

Committee held on 9 October 2019 Caroline Spicer Assurance Verbal

7.2 Quality Performance Report Suzanne Rostron

Assurance F

7.3 Director of Nursing Report Alice Webster Assurance G 7.4 Medical Director’s Report Alistair

Flowerdew Assurance H

7.5 Mortality Report and Update on Learning from Death Framework

Alistair Flowerdew

Assurance I

7.6 Junior Doctors Guardian of Safe Working Report

Alistair Flowerdew

Assurance J

7.7 Committee Report from HR & OD Committee held on 9 October 2019

Anne Stoneham Assurance Verbal

7.8 Workforce Performance Report Julie Pennycook Assurance K 7.9 Freedom to Speak Up Guardian Report Maggie Oldham Assurance L 7.10 Committee Report from Performance

Committee held on 9 October 2019 Tim Peachey Assurance Verbal

7.11 Financial Performance Report Darren Cattell Assurance M 3.25pm Integrated Performance Reports 8.1 Acute Services Joe Smyth Assurance N 8.2 Ambulance Services Joe Smyth Assurance O 8.3 Integrated Urgent & Emergency Services Joe Smyth Assurance P 8.4 Community Services Alice Webster Assurance Q 8.5 Mental Health and Learning Disabilities Lesley Stevens Assurance R

Isle of Wight NHS Trust Board Meeting in Public Date: 10 October 2019 Time: 1.30pm – 4.00pm Venue: Conference Room – Level B Main Hospital (opposite Full Circle Restaurant), St. Mary’s Hospital, Newport, Isle of Wight PO30 5TG

IW NHS Trust Board (Public) 10 October 2019 - Page | 2

Services Questions from the public arising from

this section Chair Receive Verbal

3.50pm CLOSING MATTERS 9 Confidential issues to be covered in

Private • Employee relations matters • Patient Safety matters • Commercial matters


10 Questions from the Public Chair Receive Verbal 11 Any Other Business Chair Receive Verbal 4.00pm 12 The next meeting in Public of the IW

NHS Trust Board will be on: Date: Thursday 14 November 2019 Venue: Conference Room - Level B, St Mary's Hospital, Newport, IW PO30 5TG


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

of Wight NHS Trust Board, meetings and events. • Staff and members of the public are welcome to attend the meeting but must adhere to the rules and standards

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

protocol. Questions for the Board Staff and members of the public are asked to send their questions in advance at least 48 hours prior to the meeting to [email protected] to ensure that as comprehensive a reply as possible can be given. Please can you ensure you clearly identify within the email subject as 'Question for the Trust Board'. 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

•

mailto:[email protected]

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IOW NHS Trust Board Meeting in Public 5 September 2019 1

Minutes of the meeting of the Isle of Wight NHS Trust Board held in public on Thursday 5 September 2019 in the Conference

Room, St Mary’s Hospital, Newport, IW PO30 5TG PRESENT: Non-Executive Vaughan Thomas Chair Kemi Adenubi Non-Executive Director Phil Berrington Non-Executive Director (Non-voting) Dr Paul Evans Non-Executive Director Dr Tim Peachey Non-Executive Director Caroline Spicer Non-Executive Director Anne Stoneham Non-Executive Director Sara Weech Non-Executive Director (Non-voting) Executive Directors Maggie Oldham Chief Executive (CEO) Gary Edgson Deputy Director of Finance (deputising for Director of

Finance, Estates and IM&T & Deputy CEO) Mr Alistair Flowerdew Medical Director (MD) Julie Pennycook Director of Human Resources & Organisational

Development (DHROD) (Non-voting) Suzanne Rostron Director of Quality Governance (DQG) Dr Lesley Stevens Director of Mental Health & Learning

Disabilities (DMHLD) (Non-voting) Dr Nikki Turner Director of Acute & Ambulance Services

(DAAS) (Non-voting) Alice Webster Director of Nursing, Midwifery, AHPs &

Community Service (DNMAC) Attendees Sarah Anderson Associate Director of Corporate Affairs Kirk Millis-Ward Associate Director of Communications Observers Jay Chappell Staff Side Representative Pam Fenna Chair of Patient Council Joanna Smith Healthwatch Representative Nick Gerrard NHSI/E Financial Special Measures Advisor Gina Pickering Inspector - CQC Lawrence Tyler NHSI/E Sue Mortlock Associate, NHS Thames Valley and Wessex

Leadership and Kent Surrey and Sussex Leadership Academy

Jamie Ripman Associate, NHS Thames Valley and Wessex Leadership and Kent Surrey and Sussex Leadership Academy

Dr Jugnu Mahajan Deputy Medical Director Emmanuel Ejii Pharmacist Minuted by Lynn Cave Board Governance Officer (BGO) Members of Staff and Public in attendance:

There were members of staff, public and Isle of Wight Councillors present. There were no media representatives present

The meeting commenced at 1.30pm and closed at 3.35pm No.

Enc A

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PROCEDURAL 19/T/0162 APOLOGIES FOR ABSENCE, CONFIRMATION THAT THE MEETING IS

QUORATE AND CHAIR’S OPENING REMARKS Apologies for absence were received from:

• Darren Cattell, Director of Finance, Estates and IM&T/Deputy CEO • Dudley Delannoy, Healthwatch

The Chair confirmed that the meeting was quorate. The Chair welcomed everyone to the meeting and confirmed that it would be observed by Gina Pickering from CQC, Sue Mortlock and Jamie Ripman from NHSLA who were supporting the board development programme. He welcomed Nick Gerrard who has been supporting the Trust as NHSI/E Financial Special Measures Advisor and confirmed that this would be his last meeting. The Chair extended his thanks during this time for the support and guidance he has provided during this time. He also welcomed Lawrence Tyler from NHSI/E and confirmed that over the past two years a series of meeting had taken place between the regulator and the Trust and that henceforth it had been decided that the regulator would be observing the Quality Committee and Performance Committees as well as Board to ensure that there was one version of the truth. In addition the Chair welcomed Dr Mahajan who is the new Deputy Medical Director and also Emmanuel Ejii who is a Pharmacist and who is shadowing the Chief Executive.

19/T/163 PATIENT STORY The Patient Story has been withdrawn this month.

19/T/164 DECLARATIONS OF INTEREST Declarations of interest were received from:

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

Management (FMLM) • Sara Weech as Chair of Mountbatten

19/T/165 MINUTES OF PREVIOUS MEETING The minutes of the meeting of the Isle of Wight NHS Trust Board held on 4 July

2019 were reviewed and the following amendment was requested:

a) 19/T/155 (TB/379) – Action to be reworded as follows: ‘Technological issues relating to discharge summaries to be considered at ETM and reported to Quality Committee and Performance Committee’

Resolution The Chair requested that the minutes of the meeting held on 4 July 2019 be Approved subject to the above amendment. The motion was carried unanimously.

19/T/166 MATTERS ARISING AND SCHEDULE OF ACTIONS a) Matters Arising:

There were no matters arising

b) Schedule of Actions:

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The following actions were approved for closure: TB/368, TB/369, TB/370, TB/371, TB/372, TB/374, TB/375, TB/376, TB/377 TB/378 and TB/379

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

STRATEGY 19/T/167 CHAIRS UPDATE The Chair presented his report which was taken as read. In addition he provided

updates on the following:

a) £48m Capital Investment: This funding has been awarded by the government to the Island for healthcare and will be discussed in more detail later in the meeting. He thanked partners on the mainland for their support of the bid which was made by the Trust, CCG and HIWSTP. He also thanked Bob Seely, Member of Parliament for the Isle of Wight, who has been instrumental in supporting the bid at Westminster.

b) CQC Report: He thanked all staff for their contributions and hard work

which has resulted in the improved rating which has just been awarded. He highlighted that their commitment to changing practices to ensure that safe high quality care is provided across the organisation has been an enormous achievement given the position the Trust was in a year ago. He stressed that the work needed to continue with the goal to be Good by 2020.

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

19/T/168 CHIEF EXECUTIVE’S UPDATE The Chief Executive presented her report and highlighted the following areas:

a) EU Exit: She reported that a team had attended a briefing in London on

the guidance for overseas staff. The Medical Director also advised that regular regional meetings are taking place where discussions regarding the supply of medicines indicate that there is confidence that there will be no issues and stockpiling of medicines will not be appropriate. He advised that there was concern that a number of EU nationals operating as Doctors in the UK had yet to register to enable them to continue working. The Trust has a complete list of eligible staff and will be monitoring closely.

b) CQC Report: Following the publication of the report the Chief Executive read the following statement:

‘I wanted to take the opportunity of our Trust Board held in public to issue a personal statement in relation to the publication of the CQC Report yesterday. Firstly, I want to thank our staff for their hard work over the last 12 months. The Trust’s overall rating from the CQC has improved from ‘Inadequate’ to ‘Requires Improvement’ and it would not have been possible without their support. We undertook a detailed self-assessment before the CQC inspection in

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May and I am pleased that inspectors agreed with our view that the Trust’s overall rating is ‘Requires Improvement’. Moving up from ‘Inadequate’ is good news for our patients, wider community, and our staff, and volunteers. In particular, we should recognise the success of our Community, End of Life Care, NHS 111 and Urgent Care Service teams who have improved their ratings to ‘Good’. Congratulations also to the Patient Transport Service who retained their ‘Outstanding’ rating for Caring. I am also sorry that we have failed to make the progress in Mental Health Services, which has retained its Inadequate rating. This will be discussed more fully in the board agenda. I and my executive colleagues recognise how vital it is to have ‘Good’ mental health services for our community and we remain committed to improving the services we provide. My immediate thoughts for the improvements that we need to make are that we need to work with wider Mental Health Providers who can support us to provide better more sustainable services. We have worked hard to improve and the CQC have recognised the improvements in Crisis Response, but sadly on our own the pace of change has not been sufficient. We are not celebrating achieving the rating of Requires Improvement and we absolutely recognise we still have a lot to do. However achieving Requires Improvement is an important milestone in our getting to good journey, and is where we expected to be after this year’s inspection. We remain in special measures and the CQC has imposed new warning notices on Acute and Mental Health services. We also face a significant financial challenge. So far this year we have done well, we are working hard to stick to our ambitious Cost Improvement Programme (CIP) and teams across the organisation have responded well. It will get more difficult as the financial year progresses but we will work together to make sure that we take all the necessary steps to improve our financial position, without compromising our ability to achieve quality improvements as well. Our task now is to keep building momentum and to do absolutely everything possible to get us to ‘Good’ in 2020. Our patients and the Island community expect the best possible services and that is what we are going to deliver. We welcome the CQC report. It shows us where we have improved and where we need to focus our energy to bring about the further improvements we need to see. I’m looking forward to the Quality Summit later this month where we will hear more about what the next phase of our recovery looks like. Some of what needs to happen will require us working more closely with our partners. You will have seen that alongside our commissioners and the Council we have published the Isle of Wight Health and Care Plan.

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It sets out a number of priorities for the next three years, which we will work together to deliver and which will help make sure health and care services on the Island continue to improve and are sustainable. A key part of this work will be finding partners to support our work to improve Acute and Mental Health Services. This will help by bringing in expertise, training, support and additional staffing to improve the services provided on the Island. It’s too early to say what these partnerships might look like but they are essential if we are to improve and make our services sustainable. I want to reassure you that everyone at the Trust is fully committed to continue the improvement we have seen and I would like to thank staff in the NHS, primary and social care as well as our partners and stakeholders for their support.’

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

19/T/169 ISLE OF WIGHT HEALTH & CARE PLAN (IWHCP) The Chair confirmed that the update was being received as part of the process of

informing the population of the progress of the plan which is the result of collaborative work between the Trust, IW CCG and Local Authority. The Chief Executive advised the a user friendly version of the plan is being developed and following consultation has been rebranded as the Isle of Wight Health & Care Plan. She confirmed that this will be signed off by the Boards of each organisation and will be uploaded to the various websites. This document will include the high level details to enable the island population to have meaningful discussions about the future of healthcare on the island. She confirmed that together with the Chair, she would be touring the island visiting local groups to discuss the plan as part of the wider promotion programme. The Chair acknowledged that the plans are ambitious and that a clear timeframe for delivery will be implemented. A number of work streams are included within the plan all of which have senior leads from the three organisations that will be driving the delivery of the programmes forward. The Chief Executive reminded the meeting that this is a three year plan of which year one is the Trust’s operating plan which has been approved. There would require in years two and three a change in models of care and improved partnership working ensuring delivery of the plan. The Chair confirmed that the Local Care Board (LCB) which has representation from all three organisations is reframing its governance structure to ensure that this is in place by December. This will enable delivery of the plan and the development of strategies and outcomes to achieve the IWHCP. Resolution The Isle of Wight NHS Trust Board received the update on the Isle of Wight Health & Care Plan.

19/T/170 CAPITAL FUNDING The Deputy Director of Finance presented the report which was taken as read and

highlighted that two areas of capital funding had been approved.

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a) £48m Capital Investment: As previously mentioned the island has been

awarded this money to enable the redesign of acute services and represents a real commitment by the government to invest in the island. The process and the timescale for finalising and drawing down the funding are awaited and the Board will be involved in any decisions and approval of business cases. This will clearly link to the implementation of the IW Health & Care Plan for the system and would include areas such as estates infrastructure, equipment and IT improvement.

b) £3.6m NHS Digital Funding: This funding relates to a successful

business case bid securing £3.6m worth of capital funding to improve IM&T capability. £1.5m is available immediately with the balance available in 2020-21. The three projects identified for this investment are: • Acute Electronic Patient Record Development • Mental Health & Community Electronic Patient Records • Integration & Interoperability across systems

He advised that given the scale of capital funding the governance process for managing and monitoring any programmes and spend would need to be ratified. At present this would fall within the remit of the Performance Committee but additional levels of governance will be considered. The Chair confirmed that the estates plan would be the focus of the Board Seminar in October and this funding would be included. It was also noted that updates should be included in future reporting to the Board. Action Update on capital funding to be provided to the Board Seminar as part of the presentation on Estates plan/governance process. An updated report to be presented to Board.

Action by: DDF Resolution The Isle of Wight NHS Trust Board received the update on the capital funding.

PERFORMANCE 19/T/171 QUALITY PERFORMANCE REPORT & CQC REPORT UPDATE The Director of Quality Governance presented the report which was taken as read.

She confirmed that at the Quality Committee and Board Seminar discussions had taken place in relation to the CQC report. She confirmed that staff would have an opportunity to put any questions relating to the report at the staff quality summit which will be held on 24 September. The full report is also available to the public via the CQC website. An overview of the report findings was presented and it was acknowledged that the hard work by the staff over the past year has enabled the current rating to be awarded and that this is a significant result given the period of time in which it has been achieved. In 2018 the Trust overall rating was <Inadequate> and it is now rated as <Requires Improvement>. Over the five domains the Trust now rates as:

The divisional ratings have also improved with overall ratings of Good for

2019 Ratings

Safe Effective Caring Responsive Well-led Overall

Requires Improvement


Good Requires Improvement



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Community; Requires Improvement for Acute and Ambulance. Mental Health although being rated Inadequate overall was rated good under ‘Caring’ and requires improvement under ‘Responsive’. She confirmed that additional expert support would be provided to Mental Health from mainland partners. She also stressed that within Ambulance the overall rating was very close to being ‘Good’ but due to the pilot of the Integrated Urgent and Emergency Care Division not being completed at the time of the inspection and the Computer Aided Dispatch implementation being in phase 2 the CQC rated the service as Requires Improvement. The team was however commended for their commitment to getting to good, along with all the narrative within the report recognising improvements. The Director of Quality Governance provided a comparative across the various services between the 2018 ratings and 2019 which demonstrated areas of significant improvement. She also gave an overview of the areas across the domains where the CQC had witnessed good practice and highlighted that Patient Transport Service had achieved an Outstanding rating under the Caring domain. The Director of Quality Governance outlined the work which would take place over the next year and highlighted that a zero tolerance approach would be implemented across ten specific areas and confirmed that any breaches would have consequences. The ten areas of zero tolerance are:

1. Bullying & Harassment 2. Hand hygiene 3. Mandatory training compliance 4. Appraisal compliance 5. Resuscitation trolley checks 6. Incident backlogs on DATIX 7. Complaint target timeframes 8. Duty of Candour 9. Documentation – Poor compliance with professional record keeping 10. Discharge summaries

An overview of the accountability framework was presented which would ensure that effective monitoring of progress or any slippage is identified and actioned. The Board discussed the results which were acknowledged to be very encouraging. Phil Berrington highlighted the need not to underestimate the time required to implement effective information technology and information governance systems as these can take considerable time to effectively be implemented and sustained and it was likely that this would not be fully completed by 2020. The Chief Executive advised that the CQC are not seeking perfection but do need to know that clear and effective plans with a clear trajectory to completion are in place in order to demonstrate grip and control before they will adjust their ratings. She stressed that work will continue with partner organisations and through the IWHCP to ensure that the island has an integrated healthcare service. The Chair also confirmed that work will continue with partners who are rated as Outstanding such as Mountbatten Hospice and South Central Ambulance Service and that there needs to be clear directives to facilitate the way forward. Resolution The Isle of Wight NHS Trust Board received the Quality Performance Report and CQC Update. The Chair requested that the Board note the proposed attendance of the Regulators at Trust Committees as outlined in the Quality Report. All were in agreement.

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19/T/172 DIRECTOR OF NURSING REPORT The Director of Nursing, Midwifery, AHPs & Community Services presented the

report which was taken as read and highlighted the following:

a) Workforce: She reported that the overseas nurses had a 100% success rate with their OSCE 1exams which enabled them to work in the UK.

b) Training: The nursing apprenticeships for registered nurses and nursing associates are well subscribed with candidates making good progress. She advised that negotiations with the Open University has enable the registered nurse degree programme to be undertaken within three years rather than four which will enable students to qualify earlier and this will benefit the September 2019 cohort. She confirmed that a new apprenticeship for allied health professionals (AHPs) is being developed to enable individuals access an AHP role in the future.

c) Nurses Conference: On 18 September the first Isle of Wight NHS Nurses Conference will take place with a delegation of 120 nurses scheduled to attend.

d) Unsung Heroes: Week commencing 7 October will be ‘Unsung Heroes’ week which will recognise all the back office staff that work tirelessly to ensure the NHS continues to function, and she advised that there have been 270 nominations to date.

The Chief Executive expressed her praise and gratitude to the overseas nurses and confirmed that a third cohort would be arriving on 13 September and extended her welcome to them. Resolution The Isle of Wight NHS Trust Board received the Director of Nursing Report.

19/T/173 MEDICAL DIRECTOR’S REPORT The Medical Director presented the report which was taken as read and

highlighted the following:

a) Junior Doctors: It was confirmed that the new intake of new foundation doctors had been successful and middle grade trainees had also improved.

b) Appointments: A number of consultant positions have been appointed although there remain a number of vacancies which are being actively recruited to. New consultants have been appointed to Elderly Care and Ophthalmology. Dr Jugnu Mahajan has been appointed to the position of Deputy Medical Director, and Dr Sarah Gladdish has been appointed Lead Medical Examiner. James Adams will be joining the Trust as Associate Dean in conjunction with the Deanery to provide support to the Postgraduate education programme.

c) GMC Action Plan: Progress has been made against the action plan although work still remains to be done to ensure that measures are sustainable. The GMC will be revisiting the Trust on 7 October.

d) Job Planning: This has been discussed at the HR&OD Committee where the updated position was discussed. It was confirmed that the new Deputy

1 Objective Structured Clinical Examination (OSCEs)

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Medical Director together with the divisional Care Group Directors would be undertaking the job planning sessions over the next 2-3 months.

Anne Stoneham, Chair of HR & OD Committee advised that the committee was encouraged by the recruitment progress although remained concerned that plans for full implementation of the GMC action plan would not be completed by the date of the scheduled meeting. The Committee also requested that more rigour is applied to ensuring that job planning is completed. The Chair stated that having job planning undertaken this far into the financial year was not ideal and that focus needed to be made to change this for the next financial year. It was advised that once this has been undertaken subsequent yearly reviews are much easier to complete. Resolution The Isle of Wight NHS Trust Board received the Medical Director’s report.

19/T/174 WORKFORCE PERFORMANCE REPORT The Director of Human Resources & Organisational Development presented the


a) Monthly Staff Survey: Responses have dropped and an analysis of this and other trends is underway. Annual national staff survey will take place in October 2019.

b) Workforce Plan: Overall workforce capacity has increased in month reducing vacancy rates. This has resulted in overall operating costs below budget and it has been agreed that in future overall trajectory data will be included in the report.

c) Rostering: This has been more effective in month which has resulted in effective progress against the recruitment plan and a subsequent decrease in agency usage. The overseas nurses will start to show a positive impact on data from October.

Anne Stoneham, Chair of the HR&OD Committee confirmed that positive work was being seen but that more needed to be undertaken to sustain progress and achieve the plan. The Director of Human Resources & Organisational Development confirmed that as agreed at the HR&OD Committee greater clarity in future reporting would be provided to demonstrate the impact of increased substantive positions against agency and bank usage. These will include the overall variances in month for total staffing against budget and against plan. Resolution The Isle of Wight NHS Trust Board received the Workforce Performance Report.

19/T/175 FINANCIAL PERFORMANCE REPORT The Deputy Director of Finance presented the report which was taken as read and

highlighted the following:

a) Income & Expenditure: The overall month 4 position is on plan at £2.0m deficit against the year to date (YTD) £9.3m deficit. The Trust also achieved its financial plan which will allow payment of the financial support

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PSF2/FRF3 funding of £3.8m to be drawn down in October which reduces the YTD position to £5.5m deficit. He stressed that the Trust is committed to achieving its planned YTD targets and that measures are being taken to mitigate any cost pressures and non-elective contract work undertaken.

b) Forecast: He advised that the divisions are reviewing plans to achieve the potential £7m shortfall of which £4m relates to operational pressures and £3m to high level risk assessment of the current CIP forecast.

Caroline Spicer, Chair of the Performance Committee reported that the Committee acknowledged that the position was on track but noted the underlying risks and trends which could impact on this position. It noted that the use of the contingency fund to cover cost pressures could not be sustained and was encouraged to see that measures to forecast risks and ensure mitigation plans are being developed and implemented. The Chief Executive acknowledged that the Trust was now in a better place than twelve months ago and that work has been undertaken to explore options highlighted by Nick Gerrard, NHSI/E Financial Special Measures Advisor. She confirmed that although Nick Gerrard’s time with the Trust is coming to an end, further support from NHSI/E would be provided to help guide the drive forward to implementation of plans. She stressed that the deficit figure mentioned in the report is not the new year end figure and that this will not be normalised. This position was supported by Caroline Spicer who reassured the Board that the Performance Committee will be monitoring this position closely to ensure that this does not occur. The Chair stressed that the new CQC ratings are not an excuse to see slippage in targets. Caroline Spicer advised that in terms of cash flow the Performance Committee noted that funding is received in arrears and that the Trust would be raising temporary loan funding to cover the interim period and that there would be associate costs. The long term loan arrangements for 2020/21 are still being negotiated with NHSI/E and this is being monitored as a risk. The Chief Executive confirmed that the Director of Finance, Estates and IM&T/Deputy CEO would continue to negotiation with NHSI/E and confirmed that they are supportive of this position. Resolution The Isle of Wight NHS Trust Board received the Finance Performance Report.

INTEGRATED DIVISIONAL PERFORMANCE REPORTS 19/T/176 ACUTE SERVICES PERFORMANCE REPORT The Director of Acute & Ambulance Services presented the report which was

taken as read and highlighted the following:

a) Referral to Treatment Time (RTT): There has been a slight increase against the target in month with plans in place to recover slippage in June and July. Validation of the data is being undertaken which may result in an improved position once completed. Additional treatment sessions are being included within Urology and Orthopaedics are also showing an improved position. Work continues to explore options to work more

2 Provider Sustainability Fund (PSF) 3 Financial Recovery Fund (FRF)

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effectively across seven day working. b) Cancer & Diagnostics: These have achieved that monthly targets c) Finance: There was an underspend of £34k in month due to the allocation

of additional funding from the CCG for Compton Ward activity. d) CIP: Plans are on target e) System Pressures: The super stranded patients who have been in

hospital for over 21 days have reduced down to 23 patients.

Caroline Spicer, Chair of the Performance Committee confirmed that a deep dive into RTT would be considered by the Committee. Resolution The Isle of Wight NHS Trust Board received the Acute Services Performance Report.

19/T/177 AMBULANCE SERVICES PERFORMANCE REPORT The Director of Acute & Ambulance Services presented the report which was

taken as read and highlighted the following:

a) Performance: There is an improving position across all the core standard targets

b) 111: The underperformance of 88.31% against the 111 Call answer target of 95% relates to pressures caused by staff vacancies. Staff undertook training in August and initial data is reported at just over 90%.

c) Patient Transport Service (PTS): The team are working with SCAS4 to resolve issues being experienced within the Computer Aided Despatch (CAD) system although mitigation has been implemented in the form of a manual collection system to ensure that the service continues to report data until an electronic solution is implemented.

Resolution The Isle of Wight NHS Trust Board received the Ambulance Services Performance Report.

19/T/178 INTEGRATED URGENT & EMERGENCY CARE SERVICES PERFORMANCE REPORT

The Director of Acute & Ambulance Services presented the report which was taken as read and highlighted the following:

a) Emergency Care Standard (ECS): There was an under-performance at 78% and challenges continued to be faced during August. There has been a focus on Minors to achieve the 95% minimum target with a range of measures being implemented to support the teams.

b) Estates: Work is being planned with the Estates team to expand the

Minors area

c) Perfect Week: A perfect week event is planned for the Emergency Department during September and this will be supported by Professor Matthew Cooke who is a renowned ED specialist whom NHSI/E have provided to support the team and to provide expertise in this field. It was acknowledged that this would be beneficial and an excellent opportunity for the team.

4 South Central Ambulance Service

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Resolution The Isle of Wight NHS Trust Board received the Integrated Urgent & Emergency Care Performance Report.

19/T/179 COMMUNITY SERVICES PERFORMANCE REPORT The Director of Nursing, Midwifery, AHPs & Community Services presented the


a) Data Variances: It was noted that there are variances between the data shown within the report and that shown within the Workforce report. It was confirmed that this has been now rectified.

b) Finance: An overspend of £117k has been challenged and is being validated by the financial team.

c) Sickness: The sickness rate continues to reduce with the top reason for absence being Cough, Cold and Flu.

d) Recruitment: There are ongoing challenges in recruiting to physiotherapists and community nursing due to recent retirement/leavers. HR is supporting both areas to recruit.

Caroline Spicer, Chair of the Performance Committee highlighted that a new development in the report is the divisional ‘plan on a page’ which enabled the committee to have overall sight of key developments and commended its use to the other divisions. Resolution The Isle of Wight NHS Trust Board received the Community Services Performance Report.

19/T/179 MENTAL HEALTH & LEARNING DISABILITIES SERVICES PERFORMANCE REPORT

The Director of Mental Health & Learning Disabilities presented the report which was taken as read and highlighted the following:

a) Leadership: She reported that there have been a number of changes to the leadership within the division. The Head of Mental Health & Learning Disabilities left the organisation in July and an interim leadership structure has been implemented. An interim Deputy Director of MH&LD/Head of Psychology is now in post. The addition of a Transformation Programme Director who will provide a working link with the CCG has been included which the CCG is funding.

b) Community Mental Health Service: A CQC warning notice is currently in place which is due to end in November. The team are working hard to reduce the caseloads and are focusing on the risks to achieving the target. She confirmed that some risks have been identified which require additional staff development and support is being provided by the Royal College of Psychiatry. The team have written to service users to invite them to attend three locality meetings to discuss the proposed changes and to enable ongoing dialogue during the transition period.

Kemi Adenubi highlighted that there are elements of good practice within all the performance reports and advised that at the Performance Committee it had been suggested that a standardised approach be adopted for data presentation to allow for direct comparisons to be made. She also highlighted that additional forward looking elements be included as currently the reports are all retrospective. The

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Board note the suggestion. Resolution The Isle of Wight NHS Trust Board received the Mental Health & Learning Disabilities Services Performance Report.

COMMITTEE ASSURANCE & GOVERNANCE COMMITTEE RPORTS FROM THE MEETINGS HELD ON 4 SEPTEMBER 2019 19/T/180 QUALITY COMMITTEE Tim Peachey, Chair of the Quality Committee reported that following the meeting

held on 4 September 2019, that in addition to issues discussed elsewhere in the meeting, the following areas were to be brought to the Board’s attention:

a) CNST5: The Committee had received this report and agreed that additional evidence was required prior to submission. The Committee had delegated authority to the Director of Quality Governance and the Deputy Chair to approve the final submission which has now been undertaken. An ongoing monitoring of maternity services was agreed with an additional deep dive provided.

b) Learning from Deaths: The Committee received the report which provided encouraging insight into progress and developments. The report would be presented to the October Board.

c) Patient Council: An update on the past six months activity was received

and it was noted that a leaflet into Cross Solent Travel is in final development by the CCG.

d) CQC Report: A detailed report on the findings of the inspections was presented to the Committee.

e) Patient Safety Sub Committee: This has undergone a restructure and is

now reporting in more detail across its remit.

f) Quality Improvement Board: The Committee requested that a review of the management of the Quality Improvement Plan (QIP) be undertaken following receipt of the CQC inspection report. The Chair of the Quality Committee asked the Executives to consider the use of Patient Safety SubCommittee to monitor elements of the QIP.

Resolution The Isle of Wight NHS Trust Board received the Quality Committee’s report.

19/T/181 PERFORMANCE COMMITTEE

Caroline Spicer, Chair of the Performance Committee reported that following the meeting held on 4 September 2019, that in addition to issues discussed elsewhere in the meeting, the following areas were to be brought to the Board’s attention:

a) Estates & Facilities Sub Committee Report: The Committee noted the

5 Clinical Negligence Scheme for Trusts (CNST)

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significant improvement in reporting which provided assurance on current projects.

b) Emergency Preparedness & Business Continuity Sub Committee: The revised terms of reference were approved.

c) IM&T Sub Committee: An updated report was received which outlined

progress to date in relation to information technology plans and developments within the organisation. Close monitoring will continue on progress of these projects.

d) Data Quality: Reporting continues to be developed and a deep dive will

be received which will consider quality and performance aspects of data collection.

Resolution The Isle of Wight NHS Trust Board received the Performance Committee report.

19/T/182 HR & OD COMMITTEE

Anne Stoneham, Chair of the HR&OD Committee, reported that following the meeting held on 4 September 2019, that in addition to issues discussed elsewhere in the meeting, the following areas were to be brought to the Board’s attention:

a) Culture & Leadership: Work is on track although concerns were raised around the drop in response to the pulse surveys. Regular reporting on staff surveys will be seen by the Committee and will be linked to the Junior Doctors Guardian of Safe Working outcomes.

b) Recruitment & Retention: The Committee noted that it will take time before the impact of recent recruitment will be seen within the data, however plans are in place to ensure implementation and any impact is monitored.

c) Medical Revalidation: The report was received by the Committee who

noted that this is authorised by the Chief Executive. The Committee agreed that the report should be considered overnight and any changes to be submitted today to enable them to be included prior to submission at the end of the month. It was agreed that medical revalidation would be monitored by the Committee on a regular basis to ensure that clinical objectives agreed in the revalidation process are achieved.

d) Junior Doctors Guardian of Safe Working: The Committee received

reports on Q4 2018/19 and Q1 2019/20 and progress was noted. It was confirmed that the Committee would review future reports on a quarterly basis ahead of presentation at Board.

Resolution The Isle of Wight NHS Trust Board received the HR&OD Committee report.

19/T/183 AUDIT COMMITTEE Phil Berrington, Chair of the Audit Committee, reported that following the meeting

held on 4 September 2019, that in addition to issues discussed elsewhere in the

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meeting, the following areas were to be brought to the Board’s attention:

a) Effectiveness of the Audit Committee: It was highlighted that in order for the Committee to be fully effective it required attendance by the relative lead executives to facilitate effective discussions on topics being covered within the meetings.

Action The CEO is to meet with the Chair of Audit Committee to discuss Executive Director attendance at Audit Committee.

Action by: CEO

b) Operational Risk Sub Committee: The Committee felt unable to fully discuss the report due to the absence of the lead executive and therefore it had limited assurance.

c) Policy Management Sub Committee: The Committee felt unable to fully discuss the report in detail due to the absence of the lead executive (although the Committee Chair was present) and therefore it had limited assurance.

d) Board Assurance Framework (BAF): The Committee have requested that the impact of the CQC report be considered and the BAF updated accordingly prior to the submission of the quarterly reports to the committees in October and Board in November.

e) Single Tender Waivers (STW): The report provided limited assurance in view of the number of STW which are included for retrospective approval. The Committee were encouraged that the process has been improved as evidenced by the number of STW and the implementation of the ‘No Purchase Order No Payment’ directive.

f) Internal Audit: The Committee had limited assurance provided by the Q1 progress report and requested that a forward focus be applied to future reports. It was however, encouraged with the progress being made on the action plan.

The Chief Executive explained that as the Audit Committee is a Non-Executive Committee, Executives were required to be invited to attend. She confirmed that she would be undertaking a discussion relating to the matters raised at Audit Committee. Resolution The Isle of Wight NHS Trust Board received the Audit Committee report.

CLOSING MATTERS 19/T/184 CHAIRS CLOSING COMMENTS AND ISSUES TO BE COVERED IN PRIVATE The Chair advised that the following items would be covered in a private meeting

of the Board: • Employee Relations • Patient Safety matters • Commercial matters

19/T/185 QUESTIONS FROM THE PUBLIC Questions were raised during the meeting as follows:

a) Procedural Section: No questions raised b) Performance Section: No questions raised c) Committee Assurance & Governance Section: No questions raised d) Any other questions: There were no other questions raised at this time

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19/T/186 ISSUES RAISE BY OBSERVERS a) Health Watch: No Issues raised

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

19/T/187 ANY OTHER BUSINESS a) Future Mental Health Services: Cllr John Nicholson highlighted the need

for information relating to mental health services and changes to be provided to the IW Council’s Policy & Scrutiny Committee for Health & Social Care for which he is the Chair, to enable a co-ordinated and informed approach to be taken. He also highlighted that the involvement of Public Health needed to be clarified.

The Director of Mental Health & Learning Disabilities confirmed that James Seward is the Transformation Programme Director who will be leading any changes and confirmed that discussions are taking place with other providers of services on the island i.e. the Drug and Alcohol Service and agreed to arrange a meeting to discuss changes.

Action Meeting to be arranged with Cllr John Nicholson regarding update on improvements to MH services

Action by: DMHLD

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

be held in public is on Thursday 10 October 2019. The venue for this meeting will be the Conference Room – Level B Main Hospital – opposite Full Circle Restaurant, St Mary’s Hospital, Newport, IW PO30 5TG

Signed: Vaughan Thomas, Chair Date: 10 October 2019

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Board & Board Committee KEY TO RAG STATUS

ROLLING SCHEDULE OF ACTIONS TAKEN FROM THE MINUTES Action overdue

Action not yet dueAction complete

Name of Meeting Date of Meeting

Minute No. Action No.

Item Action Exec Lead Update & Evidence of Completion Due Date Forecast Date

Progress RAG Date Closed

Board in Public 04-Jul-19 19/T/143 TB/365 National Patient Survey A report on the analysis of the National Patient Survey data to be provided via Quality Committee, to include Trust performance for the period 2016 to 2018

Suzanne Rostron 28/08/19 - The report on the National Patient Survey data is a large piece of work and work is progressing. 01/10/19 – Work is ongoing and it may be better to consider along with the upcoming patient survey. Move the due date to February 2020

10-Oct-19 13-Feb-20 Action not yet due

Board in Public 04-Jul-19 19/T/143 TB/366 Monthly indicator - Friends & Family Test

Develop a monthly indicator using the data provided by the Friends and Family Test to show current progress against In patient survey criteria.

Suzanne Rostron 28/08/19 - The Friends and Family test is under review and new national guidance is due to be released shortly. 01/10/19 – To be considered as part of implementing the new guidance. Propose action is closed

10-Oct-19 10-Oct-19 Propose Action to be closed

Board in Public 04-Jul-19 19/T/144 TB/367 Staffing analysis report to HR&ODC

A report is to be prepared for the HR&OD Committee regarding unavailability of nursing staff given that this is higher than the national averages, together with trend analysis and implementation plan to review trend.

Alice Webster 23/08/19 - External Consultant (Mark Rogerson from Vellum Consulting) has been engaged to work with HR to undertake analysis of hours and mapping01/10/19 – To be included in the performance workforce report. Propose action is closed


Board in Public 04-Jul-19 19/T/148 TB/373 Divisional Reporting to Quality Committee

Divisions to submit quality exception reports through the improved dashboards to Quality Committee

All Execs 28/08/19 - Work is progressing 01/10/19 – to be included by exception as required in performance reports to Quality Committee. Propose action is closed


Board in Public 05-Sep-19 19/T/170 TB/380 Capital Funding Update on capital funding to be provided to the Board Seminar as part of the presentation on Estates plan/governance process. An updated report to be presented to Board.

Darren Cattell 01/10/19 - On Board Seminar agenda and update report going to Performance Committee and Board finance reporting papers. Propose action is now closed


Board in Public 05-Sep-19 19/T/187a) TB/381 Improvements to Mental Health Services

Meeting to be arranged with Cllr John Nicholson regarding update on improvements to MH services

Lesley Stevens 09/09/19 - Meeting arranged to discuss improvements to MH Services23/09/19 - Meeting arranged with Cllr John Nicholson, Paul Thistlewood - IWC and Kirk Millis-Ward for 2 October 2019. Propose action is now closed


Board in Public 05-Sep-19 19/T/183a) TB/382 Executive Director attendance at Audit Committee meetings

The CEO is to meet with the Chair of Audit Committee to discuss Executive Director attendance at Audit Committee.

Maggie Oldham 01/10/19 - The CEO and Director of Quality Governance met with the Chair of the Audit Committee on the 24/9/19. Discussions were held on how the action tracker of the Committee needs to be reviewed by the Director of Finance and Associate Director of Corporate Affairs to ensure all updates are included ahead of the meeting.

Expectations around Executive attendance were also discussed. It was agreed that should any Executive, other than the Director of Finance, be required that this request would be made in advance of the meeting with the purpose of attendance clearly stated. The Audit Committee is a Non-Executive Committee.

Discussions were held around the conclusions of ‘limited assurance’ around committees and the Board Assurance Framework. It was agreed that these levels of assurance were not appropriate as the chairs of the Board Committees (Performance, Quality and HR&OD) were present and could talk to progress against the risks allocated to those committees. The Board Assurance Framework is owned by the Board and not any one Executive Director. The process for the Board Assurance Framework was not in question. The action that the Audit Committee required around review of target risk ratings in light of the latest CQC report has been picked up and directed to Board Committees as part of the Quarter 2 Board Assurance Framework review. Propose that action is closed


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Agenda Item No 6.1 Meeting Trust Board in Public Meeting Date 10 October 2019

Title Chair Report

Sponsoring Executive Director Vaughan Thomas. Chair

Author(s) Vaughan Thomas, Chair

Report previously considered by inc date

n/a

Key Recommendation The Trust Board is recommended to receive the report

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

Link to CQC Domains

Link to Trust Strategic Objectives

Information only Commercial Confidentiality

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

X

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

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

Committee Agreement

Other Exception Circumstances

Responsive X SO 04: Achieve excellence in employment X

Trust Board Approval

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

X

Executive Summary

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

Meetings with Stakeholders and the public: • 24/09/19 - IOW NHS Trust Quality Summit Meetings with partner organisations: • 12/09/19 – IOW Gov – Local Care Board Meeting • 25/09/19 - IOW Gov – Local Care Board Meeting • 25/09/19 - Catherine Mason, Chair, Solent NHS • 01/10/18 - Cllr. Clare Mosdell • 02/10/19 – Cllr. John Nicholson Meetings with Individuals including Trust Executives: • 24/09/19 – Introductory Meeting – Joe Smyth, IOW Chief Operating Officer

Enc D


Title Chief Executive Report

Sponsoring Executive Director Maggie Oldham, Chief Executive

Author(s) Kirk Millis-Ward, Associate Director of Communications and Engagement


n/a

Key Recommendation The Trust Board is asked to consider the report


Link to CQC Domains




X

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


Committee Agreement





X

Improving Staff Engagement The last few weeks have been busy for teams across the Trust and I would like to start my update by thanking them for their efforts. As you know, I am keen for us to do more to recognise our staff and to improve staff engagement. I was delighted to hear that our Unsung Hero Awards received more than 270 nominations. This week there has been a series of visits across the Trust and the winners were announced at a special event on Tuesday. Congratulations to everyone that was nominated and to the worthy winners – thank you for your hard work and support. Improving staff engagement will help us to continue to improve our services. So it was great to see so many nurses get together for the first Nurses Conference last month. Sharing their experience, learning from each other and debating some of the important issues in their everyday practice, I hope people came away feeling proud and inspired. Thank you to those colleagues at Board who have already had their vaccinations. This year the Trust, our commissioners and the local council have teamed up to run a joint flu campaign. Over the coming weeks you will see and hear more about the ‘Protect Together’ campaign as we work together to increase the uptake of flu vaccinations among staff and the wider community. Also launching in the next few weeks is the annual NHS Staff Survey. This provides us with an important snapshot of how people feel about the services we provide and what it’s like to come to work here. This year we’re running a Trust-wide communications campaign, called ‘We Listen, We Care’ to encourage people to have their say. People’s feedback will lead to improvements in how the organisation is run, it will improve our care and their comments are completely anonymous. I would encourage as many people as possible to take part. It’s also fantastic news that we will be launching a new Employee and Team of the Month programme in the coming days which will be part of an exciting Trust-wide Staff Awards that will be held next year. Improving staff engagement is a vital part of our Getting to Good journey, so it is good news that we are making progress.

Changes to the senior leadership team The Trust has made some changes to its senior leadership team to build on its success and increase the pace of improvement following the recent Care Quality Commission (CQC) report. The changes are designed to allow the Trust to work more closely with its Island and mainland partners and to improve its services for patients and the local community. I will spend a part of my week focusing on delivering the Isle of Wight Health and Care Plan and playing an important role in the wider health and care system. Darren Cattell, Director of Finance, Estates and IM&T, will continue in his current role and as the Trust’s Deputy Chief Executive. To strengthen the work being done to improve acute (hospital-based) services, Nikki Turner will take on a new role As Director of Acute Transformation, focusing on improvement rather than day-to-day operational delivery for the next 18 months. Joe Smyth has been appointed as Interim Chief Operating Officer and will oversee the Acute and Ambulance Divisions and provide additional support to Trust Chief Executive, Maggie Oldham. Joe is an experienced NHS Chief Operating Officer, with a background in acute service management and started at the Trust on Monday 23rd September. Operational issues will be escalated through the divisions to the Chief Operating Officer and then to the Chief Executive as required, with Darren stepping into the CEO role in Maggie’s absence. Martin Wakeley, who had been supporting the Board in a Managing Director role will leave the Trust in October after a detailed handover to the new Chief Operating Officer. I would like to formally welcome Joe to the Trust and to take a moment to congratulate Nikki on her new role. My thanks to Martin Wakeley for his support over recent months.

Our Health and Care System

The Local Care Board, which brings together the Trust, commissioners, council, primary care and the community and voluntary sectors, helps to oversee health and care services on the Island. It meets every two weeks and takes decisions about local services to make sure that they meet the needs of local people. In recent weeks the Local Care Board has approved a significant investment in community services. This £800,000 investment will help make sure that health and social care teams work closely together to support people in their own homes, and help people to leave hospital as soon as they are fit to do so. It also agreed funding for on the spot testing for flu in support of an Island-wide campaign to reduce the impact of influenza and to drive up vaccination rates. This testing will mean fewer trips to St Mary’s, reducing pressure on hospital services and quicker results for local people who may have the flu. As we work together to deliver the Health and Care Plan, the Local Care Board will play an important role in shaping the services that we provide and that our community rely on. In the coming months I will provide more updates to the Board on its development as we work towards becoming an Integrated Care Partnership for the Isle of Wight in 2020.

https://www.iow.nhs.uk/news/Isle-of-Wight-Health-and-Care-Plan-to-improve-services.htm

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Title EU Exit Preparations

Sponsoring Executive Director Alistair Flowerdew, Medical Director

Author(s) Tricia Smith, Head of Emergency Preparedness, Resilience and Response


Trust Leadership committee, 26th September 2019

Key Recommendation

The Board is requested to discuss and approve the arrangements put in place for EU Exit


Link to CQC Domains



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

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

Committee Agreement


Responsive x SO 04: Achieve excellence in employment


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

Executive Summary

The Isle of Wight NHS Trust has set up an EU Exit Group to ensure that it is prepared for the forthcoming departure of the United Kingdom (UK) from the European Union (EU) on the 31st October 2019 and the potential issues that may impact upon various areas of the Trust’s service delivery. The degree and nature of any impacts will, to a large extent, be determined by the terms of any departure agreement or a ‘no-deal’ exit. The EU Exit Senior Responsible Officer is Alistair Flowerdew, Medical Director and the EU Exit EPRR Lead is Tricia Smith, Head of EPRR. The Trust EU Exit Group has representatives from all Divisions and Care Groups and ‘Subject Matter Experts’. The CCG and Adult social Care are also represented on the Group and the Head of EPRR links into the wider Local Resilience Forum preparations. The seven key work streams are: supply of medicines and vaccines, supply of medical devices and clinical consumables, supply of non-clinical goods and services, workforce, clinical trials, research & clinical networks, reciprocal healthcare, and data sharing processing and access. The Head of EPRR attended a regional briefing where the key message from Keith Willett, the NHS Strategic EU Exit strategic commander, is that we know substantially more now than we did earlier in the year and there is confidence at a national level about the steps the NHS is taking. However, we are going into the winter period which puts pressure on the system and there is a different demand profile for medicines, vaccines and other medical products and possible service disruption due to poor weather, seasonal illnesses and influenza. The Trust EU Exit Risk Assessment has been updated to put all risks under one overarching risk and this is subject to regular and ongoing review.

Executive Summary

The Trust’s Communications and Engagement Lead has also attended a regional briefing hosted by NHS England and NHS Improvement, which set out the process for communicating and sharing information before, during and after EU Exit. Important information for patients on nhs.uk around continuity of medicines supply if there is a no-deal EU exit has been updated. As well as this, the FAQ for clinicians on the NHS England website has also been updated. These updates explain the Government’s approach to ensure that medicines continue to be available if there is a no-deal EU exit. This information has been shared with all staff, so they can pass this information on to patients. Plans are being developed to look at contingencies in the event of delays at Portsmouth Port. if there are issues with ferries and transport to the Island for key supplies a multi- agency logistics cell will be set up to ensure key supplies to the Island will be prioritised. Medicines and supplies is an area of focus both locally and nationally. The Department of Health and Social Care (DHSC) has put in a multi-layered approach with freight options for NHS supplies through alternative ports. There has been a lot of engagement with key suppliers to ensure continuity of supplies with buffer supplies in place and additional warehouse capacity. Making sure that we have done everything possible to support our workforce is important too. Our Human Resources team is reviewing the number of staff from the EU that have applied for the Government’s settlement scheme, the Trust will be sending updates to any staff that are affected and supporting them through the process. An important point to reiterate is that under UK legislation, EU medical qualifications will still be valid. The Trust’s Communications and Engagement Lead will link with the CCG and local authority, as well as our colleagues in the regional and national NHS to ensure that any issues are escalated and that we share information effectively. The Trust will continue to share information with staff and partners as it becomes available. The Trust will be required to submit daily Strategic Data Collection Service (SDCS) SITREP Reports to NHS England from mid-October to provide continual assurance and highlight any areas of concern. The EU Exit Group will support this process and it is likely that any urgent updates and escalation will be through the regular ‘Bed Meetings’.

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Agenda Item No 7.2 Meeting Trust Board in

Public Meeting Date

10 October 2019

Title Quality Report Sponsoring Executive Director

Suzanne Rostron, Director of Quality Governance

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


More detailed reports have been presented to the Quality Committee

Purpose of the report Information only Assurance Review and discuss X Agreement

Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 Ensure efficient use of resources Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development Lead strategic change on the Isle of Wight Link to CQC Domains Effective X Responsive Caring Well-led

Safe X Executive Summary This report provides a summary of quality improvements, concerns, risks and the subsequent actions being taken to address these risks. Patient Safety There have been 19 Serious Incidents declared to the CCG throughout August. Claims & Inquests The Trust has received two clinical negligence claims in August, alongside 19 Schedule 5 requests from HM Senior Coroner. It is positive to note that the Trust has not received any Regulation 28’s since December 2018. Patient Experience During August the Trust received a total of 24 new complaints, which is a decrease of 40% in the number of new complaints received compared to July. The Trust also received two returning complaints and 187 compliments. The management of these complaints and involvement of the PHSO is detailed within the report. All learning from this feedback is also

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illustrated alongside changes to practice. National Patient Survey This report also highlights results from the National Patient Survey; The Cancer Patient Experience Survey 2018 Results have been published and the outputs from this are detailed in the report. It is important to note that the Trust received two outstanding areas of practice where the Trust has performed above the National average. However, disappointingly, the Trust has performed below average for 9 of the survey results. Friends & Family Test New National Guidance has been published for the FFT and this has results in a change to the wording of one of the questions; this now reads “Overall, how was your experience of our service?” This question is no longer required to be the first question within the survey and time restraints on when these tests can be completed have been modified. CQC Update The Trust shared the findings of the CQC at the Trust Quality Summit which took place on the 24th September. This meeting was attended by External Regulators, Educators and Partners from the Local Authority. Presentations were shared by the Divisions on the outputs from the inspection and the subsequent actions taking place to address any concerns raised. This Summit was positively received and support was offered to aid the Trust in its “Getting to Good” journey. The Trust Board also agreed a number of priority improvement work-streams for inclusion in the Trust-wide quality improvement plan. These areas were selected as it was determined that they would have the highest impact for patients. This is detailed within the report. Quality Improvement A draft Quality Improvement Plan has been presented to the Quality Improvement Board and Quality Committee. This includes the priority areas determined by the Trust Board and all regulatory actions. Key Recommendation

The Board is asked:

- to receive the report

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Trust Board Report – Part One

Quality Governance

Date: 10th October 2019

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

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

3. Patient Safety 3.1 Serious Incidents 19 serious incidents were declared to the Isle of Wight Clinical Commissioning Group (CCG) during August 2019; a detailed summary of these is included in the private board papers. In September, up to 16.09.19, 7 serious incidents have been declared so far. 3.1.1 Ongoing Serious Incident Management As of 16.09.19 the SI status is as follows: 60 Under Investigation; 13 Overdue; 47 Within Timescale; 14 with CCG for review and closure 3.2 Key Performance Indicators The KPI below is set against the SI process, and in line with national requirements.

Apr-19 May-19 Jun-19 Jul-19 Aug-19New SIs reported in month 6 10 14 12 19SI reported in 2 working days (of awareness) 6 10 14 12 18% in 2 working days 100% 100% 100% 100% 95%

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Overview of SI cases submitted to CCG

3.3 Learning Lessons from Events 12 cases were closed in August 2019, all of which have lessons learned documented. A detailed summary of lessons learnt for each closed case is given in part 2 of the Trust Board report.

4. Legal Services 4.1 Claims The Trust received the following two clinical negligence claims in August 2019:

I. General Surgery – alleged delay in gall bladder removal. Notably, the patients’ complaint was upheld and PHSO advised that compensation be paid.

II. Gynaecology – alleged failure in performance of biopsy. 4.2 Inquests During August the Trust received 19 new referrals from HM Senior Coroner for information in support of the Coronial review process. During August the HM Senior Coroner held 2 inquests. The Trust has not received any Prevention of Future Death Reports (Regulation 28’s) from the Inquests heard; the last one received by the Trust was in December 2018

11 cases were due for

submission in August 2019 (agreed timescale)

4 were sent IN-TIME

ONGOING: 3 cases are still being investigated and are

now overdue

4 were sent OUT OF TIME

Of those submitted out of time, 1 case was returned

by the CCG for further assurance

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5. Patient Experience 5.1 Complaints, Compliments & Concerns During August the Trust received a total of 24 new complaints, which is a decrease of 40% in the number of new complaints received compared to July (40). Below is a table showing the new complaints received by the Trust since April 2019; this data includes all new complaints, including those that were subsequently withdrawn.

The number of managed concerns received in August was 73, compared to 85 in July 2019. The Patient Experience Team had a sudden staff absence at the beginning of June 2019; which resulted in a delay in data being captured, whilst most of the data has now been input into the Datix System, further data will be retrospectively added in respect of concerns, comments and compliments, and will be reflected in future results. The data below is more reflective of the actual numbers of complaints, concerns and compliments received since 1 June 2018 to 31 August 2019. As can be seen from the data below the Trust received 7 compliments for each complaint received in August 2019, as the Trust begins to see improved capture of compliment data.

0

5

10

15

20

AcuteDivision -

CSCD

AcuteDivision -

MED

AcuteDivision -

SWCH

AcuteDivision -

IUEC

CommunityDivision

MentalHealth &Learning

DisabilitiesDivision

QualityGovernance

Division

OperationsDivision

Complaints recieved by division

Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019

Jun2018

Jul2018

Aug2018

Sep2018

Oct2018

Nov2018

Dec2018

Jan2019

Feb2019

Mar2019

Apr2019

May2019

Jun2019

Jul2019

Aug2019

Total Complaints 38 24 42 25 31 37 37 30 38 29 21 36 53 40 24Total Concerns 82 105 79 64 68 80 70 61 64 73 63 76 29 85 73Total Compliments 17 15 10 37 53 66 79 86 110 140 151 158 131 175 187

020406080

100120140160180200

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5.1.1 Returning Complaints: In respect of returning complaints, the Trust again received 2 returning complaints this month, the same number as received in July, which is a 66% decrease on the same month last year, when the Trust received 6 returning complaints. Both returning complaints were in relation to the Acute Division, and in both cases the complainants felt that the Trust had not fully addressed the concerns raised in the initial response. 5.1.2 Ongoing Complaint Management

During the month of August the Trust closed a total of 32 complaints, this number includes complaints that have been awaiting response and have been overdue, forming the Trust backlog. For those managed in month, at the time of reporting, 6 have been reported on Datix as having been managed within the timescale, it must be remembered that this is subject to change as the month progresses. The table below shows the current compliance for August by division, as well as July 2019 for received and managed in month compliance as at the time of reporting.

Division

Closed (August)

August Percentage Compliance

Percentage compliance

Closed (July) Clinical Support, Cancer and Diagnostic Services

0 out of 1 0% 66%

Medicine 2 out of 2 100% 83% Surgery, Women’s and Children’s Health

1 out of 7 14% 40%

Integrated Urgent and Emergency Care

3 out of 11 27% 33%

Community 0 out of 1 0% 100% Mental Health and Learning Disabilities

0 out of 2 0% 28%

As can be seen from above a number of areas are still not achieving the 75% response within timescales target in respect of complaint handling. Information in respect of the backlog of complaints is included in Part 2 of the Board report. 5.1.3 Parliamentary Health Service Ombudsmen (PHSO)

During August the PHSO advised they would be investigating one complaint (16698) which relates to care provided under Surgery, Women’s and Children’s Health.

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At the time of reporting the Trust are working with the PHSO on the following cases: Case Ref

Date request received

Service Current status

14085 07/03/2018 Rheumatology Under investigation – still awaiting contact from PHSO

13760* 18/09/2018 Alverstone Ward (was also an SI)

Report received 23rd August 2019 Partly upheld complaint – final recommendations given to division.

13612 22/10/2018 Appley Ward Report received 21st June 2019 – Partially upheld – signed letter sent to complainant following recommendations.

15372 15/11/2018 Medicine Report received 21st June 2019 – Complaint Upheld

14639 27/11/2018 Surgery Awaiting further contact from PHSO 13565 31/01/2019 MHLD Under investigation. Awaiting contact

from PHSO 14580 08/03/2019 Colwell Ward Under investigation. Awaiting contact

from PHSO 13827 02/05/2019 Medicine Awaiting further contact from PHSO 15798 17/05/2019 Integrated Urgent

& Emergency Care 20th August 2019 Draft report received - Not upheld; awaiting final report.

16698 30/07/2019 Surgery PHSO propose to investigate –asked for

any comments by 29th August 2019. The PHSO issued a decision on one case in August 2019 (13760*). This complaint received in July 2017, was also the subject of a serious incident investigation which occurred in 2017; the PHSO have partially upheld the complaint. The PHSO have made a number of recommendations in relation to this case which are currently with the Clinical Business Unit to undertake, this also includes a recommendation of payment under financial remedy. The Trust also upheld the complaint following their investigations. Actions implemented following the serious incident/complaint investigation included:

• Improved compliance with NEWS Training for all ward staff. • Improvements discussed in relation to ensuring high quality documentation • Ward Sister to ensure that discharge documentation is fully completed; including post

discharge observations • Development and adoption of Enhanced Recovery after Surgery (ERAS) programme

for Orthopaedic patients; with a standard operating process in place to ensure that patients are appropriately managed.

As part of the Trust’s response to the PHSO and complainant, the Trust will ensure that an updated action plan and recent audit data of actions taken is submitted with our letter of apology. 5.2 Learning from Feedback: Following the complaints received and managed in August the following learning and actions have been taken:

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• A formal conversation has taken place with the Registered Nurse about their behaviour following escalation to the line manager.

• The expectation of Professional Behaviour by all staff has been raised by the Matron to the area concerned.

• Support given to enable complainant to have access to patients medical records. • Member of staff provided further training and supervision to ensure similar situation

does not re-occur. • Matron for Medicine identified an issue where staff were collecting in folders and

documenting the patients care all at one time rather than at the time and point of care. We have requested that staff do not continue with this practice as it leads to errors and incorrect information in patient’s records.

• Ward Sister has spoken to all of the staff regarding the importance of the pain relief checks and acting on results.

• Wards are working hard on reducing noise particularly at night, a decibel monitor has been requested to ensure staff are aware when noise levels breach the set level.

• Since January 2019, when the patient was on the ward; the ward has been decluttered and reorganised, The ward has since had several visits by the Executive Team who have commented on how the ward seem calmer and tidier.

• Having acknowledged that there were issues with attitudes and behaviours on the ward, these have been dealt with under Trust policies and procedures on an individual basis by the Ward Sister.

• The Ward Pharmacy Technician has been advised to issue patient’s own medication wherever possible.

• Posters have been displayed in each bay identifying the Ward Sister and Matron with contact details to ensure patients / relatives know how to raise concerns. The Message to Matron box and postcards requesting feedback is used to provide feedback to the teams and individuals and the ward operates the national friends and family feedback scheme. All staff are aware of the PALS office contact details if unable to resolve issues at a local level.

The Quality Governance Team is working with the Clinical Divisions to ensure that learning from feedback is further strengthened and that this learning is shared across the Trust and is not just focussed on the individual clinical area. It is acknowledged that in some complaints actions do arise that relate to individual staff behaviour or competency, and this addressed through Trust policies and procedures accordingly. 5.3 National Patient Surveys 5.3.1 Emergency Department: The results of the national survey will be published on the Care Quality Commission (CQC) website on Wednesday 23 October; and until that point remain under Embargo. The Trust has been reviewing the data via the Patient Experience Sub-Committee to ensure that lessons are learnt. 5.3.2 Cancer Patient Experience Survey 2018 Results The results of the survey were published on 4th September. Overall the report is good with two new outstanding areas of practice (above national average) which the Trust has not received before. These were:

• Patient given the name of the CNS who would support them through their treatment 98% (national average 91%)

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• Hospital staff told patient they could get free prescriptions 93% (national average 81%)

The Trusts overall score was 8.7. Disappointingly the Trust did have 9 questions which were outside the expected range compared to 2 in 2017. These were: Q12 Patient felt that treatment options were completely explained = 76%. Lower limit of expected range 77%; national average 83%. Q15 Patient definitely told about side effects that could affect them in the future = 47%. Lower limit of expected range 49%; national average 56%. Q16 Patient definitely involved in decisions about care and treatment = 71%. Lower limit of expected range 73%; national average 79%. Q21 Hospital staff gave information about impact cancer could have on day to day activities = 75%. Lower limit of expected range 76%; national average 83%. Q29 Patient had confidence and trust in all doctors treating them = 70%. Lower limit of expected range 78%; national average 85%. Q31 Patient had confidence and trust in all ward nurses = 62%. Lower limit of expected range 67%; national average 75%. Q33 All staff asked patient what name they preferred to be called by = 53%. Lower limit of expected range 57%; national average 69%. Q34 Always given enough privacy when discussing condition or treatment = 78%. Lower limit of expected range 79%; national average 86% Q58 Taking part in cancer research discussed with patient = 18%. Lower limit of expected range 19%; national average 31% An action plan will be developed led by the Consultant Lead Cancer Nurse, which will be presented to and monitored by the Patient Experience Sub-Committee. 5.3.3 Friends & Family Test (FFT) New guidance has been published by NHS England regarding the revisions to FFT guidance which become effective from 1 April 2020 in summary this includes: A New Question which is Overall, how was your experience of our service, and a new response Scale. The question no longer needs to be the first question on surveys. There are changes to timing requirements, the requirement to collect feedback at discharge or within 48 hours has been removed for general and acute inpatients and A&E; and feedback can be given at any time including whilst they are receiving care, at discharge or a few days / weeks after discharge. In relation to maternity services, previous specified times have been removed, women should still be able to feedback on each of the four stages separately and 2 weeks after childbirth is

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recommended to collect feedback about the birth. Response rates will no longer be calculated or published by NHS England; as there is now no limit how many times patients can feedback in their journey. However, responses collected in context of size of the service will be published The requirement for responses for the Ambulance – See and Treat service can be removed; however there should be a commitment to an annual co-produced patient experience project, a quarterly report provided to the services quality governance group. Trusts are required to continue to publish data locally but this can be flexible. It helps to tell patients and colleagues how the Trust uses feedback and how services have improved because of it. The Trust is making preparations to ensure that the required changes are in place for the 1st April 2020 deadline. 6 Health, Safety & Security 6.1 RIDDOR The Health, Safety & Security Department has received two reportable RIDDOR’s in September and these are detailed below:

Reported Date

Reportable Completed Date Ref. Reason Status

07.09.19 Yes Yes 19.09.19 D712014B15 Injury to shoulder and stomach from assault from patient U.T.I

Closed

08.08.19 Yes Yes 19.09.19 I5C14B1011 Member of staff being hit by a full linen trolley with enough force to knock the staff member sideways into the door frame

Closed

7 Compliance CQC Update As presented to the last meeting of the Trust Board, the Trust has now moved from an overall rating of ‘inadequate’ to ‘requires improvement’. This is broken down as below:

2019 Ratings

Safe Effective Caring Responsive Well-led Overall



Good Requires Improvement



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The Trust shared the findings at a Quality Summit held on the 24 September 2019. This was a well-attended event with representatives from members for medicine, patients council, local authority, councillors, education providers, staff, Health Education England and the Care Quality Commission. The clinical teams shared their response to the findings along with the key actions in place to improve further and achieve our aim of ‘getting to good by 2020’. The CQC issued 83 regulatory actions in response to breaches in legislation. Full improvement plans are in place for all regulatory (must do) and should do actions; these were submitted to the CQC on the 27 September 2019. These will now be monitored via a number of routes, detailed in the diagram below:

In addition to the regulatory actions, the Trust Board also agreed a number of priority improvement work-streams for inclusion in the Trust-wide quality improvement plan. These areas are where it is deemed there will be most impact for patients and staff: • Delivery of Isle of Wight Health and Care Plan • Deteriorating patient (including VitalPac implementation) • Documentation (including Medical Audit implementation) • Physical health in mental health settings/mental health in physical health settings

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• Learning – incidents, deaths, serious incidents, complaints, claims, inquests, audits • Dementia • Trust strategy • Staffing levels These are the areas that will take priority when allocating the limited dedicated Quality Improvement support internally. Some projects, such as the deteriorating patient and others involving implementation of a system, will include project management support in their outline cases. Additional support has been requested from NHSI in delivering practitioner level quality improvement training to our staff whilst we are waiting for our own training capacity to become available in November 2019 (this is when 2 members of Trust staff will be accredited to deliver NHSI’s Quality Service Improvement and Redesign programme). The Board will receive assurance reports via the Quality Committee in terms of the quality improvement plan and regulatory actions. 8 Risk Management The Audit Committee requested that all Board Committees consider the target risk ratings in light of publication of the CQC inspection reports. This request has been included in all BAF reports to the Quality, Performance and HR&OD committees this month. The outputs of this will be reported to the Board in the Quarter 2 BAF report at the November 2019 meeting. 9 Quality Improvement The Quality Improvement Board received a draft Quality Improvement Plan. This takes into consideration the CQC inspection reports (September 2019) and the quality improvement priorities agreed by the Board. The Quality Improvement Plan was presented to the Quality Committee (9/10/19); feedback will be provided verbally to the Trust Board and incorporated into the final version of the plan for the November meeting.

Enc G


Title Director of Nursing, Midwifery, AHPs and Out of Hospital Services report to Trust Board

Sponsoring Executive Director Alice Webster, Director of Nursing, Midwifery, AHPs & Community Services

Author(s) Judy Dyos Deputy Director of Nursing


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

Receive this report and consider its contents


Link to CQC Domains



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

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

Committee Agreement


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

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

Executive Summary The purpose of this paper is to inform the Board of activities within the Corporate Nursing The purpose of this paper is to inform the Board of activities within the Corporate Nursing Directorate over the month of September 2019 ross the organisation. Corporate Nursing has overarching responsibility for the nursing workforce of the organisation. It is a small but diverse area of the organisation that embraces several services alongside its corporate responsibilities; including Medical Electronics, Adult and Children’s Safeguarding, Children in Care Team, Infection Prevention and Control, Dementia and End of Life Care. It has corporate responsibility for the nursing workforce across the organisation

Workforce stabilisation – September ( not adjusted for leavers and local recruitment ) • Cohort three of the overseas

recruitment arrived on the 15th September 2019

• 100% pass rate of OCSE assessment by overseas RNs has been achieved

• Cohort 2 of the Apprenticeship to Registered Nurse commenced

• Cohort 3 of the Apprenticeship to Associate Nurse commenced

• Projections based on current overseas recruitment takes the vacancy for the acute division to 8.0WTE by March 2020

Safety thermometer

• Incorrect data inputting by

the Community nursing team has made us an outlier for harm free care as seen in the safety thermometer and model hospital

• We ran a workshop to ensure all inputters are following the same processes

• Next round data will be reported in for October

• West and central DN versus Stroke

National audit of Dementia 2018/19

• Dementia activity boxes on key wards • Provision of twiddlemuffs across the

wards • Renewed focus on “This is me“

document • Provision of coloured blankets to allow

patient to recognise their beds and see the edge of the bed. A knitters request is going out via social media

• Blue plates being used on key wards • Dementia friendly foods available 24

hours being planned and launch of the benefits in November

• All acute wards being assessed using the Kings Fund environmental audit tool

• Collaborative working with CCG , 3rd sector and IOW council in progress to improve dementia care across all services

Model hospital –Safe • Good levels of VTE

assessment • Performing well on

Clostridium Difficile and MRSA bacteremia control

• Increasing levels of E Coli and MSSA reflective of national picture

AHP Update

• The 14th October 2019 is AHP Day. We will be celebrating the achievements and

contribution of our AHP workforce; showcasing our progress against AHPs Into Action and inspiring further innovation, transformation and service improvement

• Our last Wessex AHP Steering Group focused on apprenticeships as a mechanism through which to address the risk to future AHP workforce with declining registrant training numbers. The steering group is supporting Occupational Therapy as a trail blazer to procure a regional apprenticeship programme to start in September 2020

• Since establishing the HIOW STP AHP Council earlier this year we have; established STP AHP governance, a place based plan (focused on future workforce, system wide secondment and rotation opportunities, a collaborative programme of support and development and new and emerging roles), an AHP social prescribing offer to feed into PCNs, a national pilot site for simulated work experience and a system wide AHP occupational code guide for ESR departments

• We are looking forward to an AHP workforce modelling workshop facilitated by Sue Hill, HEE Workforce Transformation Lead, on the 16th October. This will help us to develop and transform our workforce to meet the future demands and maximise AHPs contribution

Maternity Update

August saw a significant reduction in term admissions of 2% the team have worked extremely hard to keep the mums and babies together We have successfully recruited to our Maternity Voices chair this post will be invaluable in the co production of maternity services We will shortly be interviewing for our better Births midwife which has been funded by the LMS to provide a strategy for continuity of carer

Quality performance reviews

In September we launched the Quality Performance Review framework The meetings will run weekly on a Tuesday 2 - 4 - Attendance by HONs and Corporate Nursing Team will be every week. The Director of Quality Governance and Head of Service improvement will also be in attendance. On a cyclical basis the Ward Sisters and their Matrons are expected to attend in their collective groups i.e. Week 1 Surgery and Maternity Week 2 ED and Medicine. The meeting will be structured around discussion and representation from the areas but is supported by the completion of the attached paperwork which is similar to that presented at the IPR’s . The ward sisters will present their data, challenges and progress and are held to account.

Professional Development

The Corporate Nursing team held a Nursing conference at Lakeside Hotel on the 18th September Speakers included Christine McKenzie Facilitator of Professional Learning & Development for the Royal College of Nursing, setting the national picture for nursing in the future years We also heard two moving patient stories sharing experiences of cancer care and the challenges of being a dementia carer The audience enjoyed debates by senior nurses challenging the pros and cons of clinical guidelines and the argument for reduced glove usage Finally we were challenged to examine ourselves as a body that values diversity by Ricky Somal.

Sue Ward Award

This year is the first year in which the Sue Ward Award for Excellence in Nursing has been given. This award is in memory of Sue Ward, a nurse who sadly passed away a several years ago but whose family wanted her remembered . Sue was a kind, compassionate and caring nurse for whom everything centered around the patient, and who displayed excellent leadership skills in her role within the Community Stroke Rehab Team. Corporate Nursing are proud to announce that the joint winners of this award for 2019/20 are Shane Moody for his work on end of life care, and Samara Lamb for her leadership of the CCU team and management of the deteriorating patient training . The winners were announced at the Nurses Conference and it is envisaged that the actual award will be presented at Trust Board in the near future.

Patient safety week Corporate Nursing were proud to take part in patient safety week • The IPC team promoted hand

hygiene and information on reducing the risk of infection spreading

• While Jan Appell leading clinical standards raised the profile of NEWS 2 scoring and fluid and hydration recording.

• The Clinical Nutrition Nurse Specialist Tracy undertook a sessions on the safe management of Nasogastric tube placement with her trusty manikin

• The Tissue Viability Lead was educating staff on the risk of pressure injures and the work we are doing with the Stop the Pressure collaborative

Enc H


Title Medical Directors Report – October 2019

Sponsoring Executive Director Mr Alistair Flowerdew, Medical Director

Author(s) Mr Alistair Flowerdew, Medical Director Jugnu Mahajan, Deputy Medical Director


HR and OD Committee, 9 October 2019

Key Recommendation The Trust Board is asked to note the report and be aware of the challenges facing the Trust with regard to the recruitment and retention of medical workforce. The challenges clearly have an impact on various aspects of providing a high quality working environment for doctors and the Medical Director will work with the new senior medical leadership, our partner trusts and Medical HR to address the needs of the Trust.


Link to CQC Domains



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

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


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

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

Executive Summary

The Trust Board has requested that a monthly Medical Director’s report is submitted for consideration. The Annual Revalidation submission for the Trust has been submitted, as required by 25 September 2019 and has been included for information. It should be noted the excellent appraisal performance by medical staff in the Trust for the 2018-2019 period. It has been agreed that the Appraisal Lead for the Trust will look at developing the quality assurance framework for appraisals during 2019-2020 to meet the aspirations of ‘Getting to Good 2020’. In spite of two excellent consultant appointments notified last month there is continuing considerable difficulty in recruiting to substantive positions and indeed the issue is becoming more difficult in employing locum consultants with special interests. Dr James Adams, consultant geriatrician at UHS, has commenced as Associate Postgraduate Director for the trust and the island. He will provide two days a week to support the ongoing work to improve training of doctors and develop training for other professional groups supporting the work for the doctors in the trust The GMC is revisiting the trust on October 8 to review the progress that has been made in meeting the requirements of Enhanced Monitoring. Verbal feedback should be possible at the Board meeting. Further job planning has not been undertaken since last month on account of new appointments that have been made and familiarisation of their departments has been acquired.

Medical Directors Report 1. Appraisal and Revalidation The annual return for Appraisal and Revalidation has been submitted following scrutiny by the HR and OD committee. It should be noted that the high level of appraisals has been commended by the Regional Medical Director for the South East of England. Work will commence on developing a quality assurance framework to enhance the value of appraisals and this will require the Lead Appraiser, with the support of the new revalidation administrative officer to take this work forward. The HR and OD committee have requested a quarterly update for appraisal and revalidation and this will be aligned with the annual return in the future. 2. GMC Action Plan Further to the report last month, the Trust is preparing for the review by the GMC when they visit with the Deanery on 8 October 2019. Evidence has been assimilated to present to the inspection. The Trust has been subject to GMC Enhanced Monitoring since October 2018. Significant improvements were acknowledge following their visit in March 2019 particularly with regards to: • Culture of bullying and harassment • Support of trainees in MAU due to more stable senior medics • Implementation of Hospital at Night • Improved training experience in many specialties. However, the GMC had significant concerns and required the Trust to take specific actions regarding: • Support to FY2’s at night (Surgery, Orthopaedic, Gynaecology rota) • Improve stability of senior medical workforce • Out of hours escalation policies in the Medicine specialty • Educational and Clinical supervision

Medical Directors Report An action plan has been reviewed in readiness for the GMC visit on 8th October 2019. This has included a review of the recent induction programme, monitoring of Hospital at Night and a meeting with the new trainees with the new Associate Postgraduate Dean for the Trust. Changes have been made to address the following requirements: • Reviewing the middle grade rota’s in General Surgery and Orthopaedics to improve support of FY2’s during the night • Re-defined pathways for the referral of acutely ill surgical and orthopaedic patients at night • Regular meetings of the Hospital at Night Board • Improved local induction • Increase in the number of educational supervisors 3. Recruitment – hard to fill posts The substantive vacant consultant posts continue to cause considerable strain on clinical services. Interview dates have been scheduled for a number of posts. The Trust is seeking support from neighbouring acute trusts to explore the possibility of joint recruitment to certain posts and this will hopefully attract applications of suitably qualified doctors. There does, nevertheless need to be a strategic plan in conjunction with partner trusts to demonstrate to potential applicants the viability of certain specialty services. The consequence of difficulty in recruiting continues to place considerable pressure of Care Group budgets for medical staff as a result of employing locums to fill critical areas. There are currently significant challenges in Stroke Medicine and Gastroenterology. NHSI/ NHSE and Hampshire and IOW STP are aware of these challenges.

Medical Directors Report

4. Job Planning There has not been significant increase in job planning since the last report in September. This is on account of the responsibility of the outstanding job plans lying with the new Deputy Medical Director and Urgent and Emergency Care Care Group Director. They both need to become familiar with the departments before commencing job plans in conjunction with respective ADO’s. General Surgery and Orthopaedic specialties acute service configuration is currently under review through the support of Mr Ian Bailey who has been providing advice on adapting the acute surgical pathways. Changes to the pathways would entail a review of all the respective job plans. Currently, Anaesthetics is the main outstanding department without a designated clinician to undertake service and job plan reviews. The Medical Director is seeking suitable external support to undertake the role. 5. Medical Leadership The final two day module for medical leadership development provided by the Faculty of Medical Leadership and Management (FMLM) has been completed. This was a particularly successful module as the group was confined to Medical Directors and Care Group Directors. The programme specifically spent time to review their roles and responsibilities within the organisation. There was clarity that the way that Care Group Directors needs to align more closely to the their job description and there was a real appetite to take up the challenge. This approach is very much supported by the new Chief Operating Officer (COO). As a consequence, the COO will attend the regular meetings of the Medical Director with the Care Group Directors at the new weekly rearranged time on Tuesdays at midday. There are a number of appointed roles that are coming to the end of their tenure and the posts will become vacant. In addition, a review of the clinical leadership roles within specialties require review and clarity of what is expected of the position.

Medical Directors Report 6. Partnership working The Trust, through ongoing discussions with mainland trust Medical Directors in Acute and Mental Health Care are actively looking at opportunities to work in collaboration which enhance the quality of care for our respective populations. This may lead to joint appointments and looking at periods of secondment to enhance skills, experience and maintain competences in areas that are not frequently encountered in a small population. 7. Medical Examiner System / Changes to Referrals to the Coroner In advance of the changes in the law the trust continues with the development of the Medical Examiner System and 3 Medical Examiners (ME’s) have now been appointed one of which will act as Lead Medical Examiner. They will develop the role over the coming months in line with national guidance from NHSE and the Chief Medical Examiner for England , which relates to the Coroners and Justice Act 2009, where the flexibility of a non-statutory process will be used to deliver a system that will provide proportionate scrutiny to all non-coronial deaths. This will be delivered in a phased roll out for deaths in secondary care by the end of March 2020, and for all deaths by the end of March 2021. As part of the process set out above, the Notification of Deaths Regulations 2019 were laid before Parliament on 15th July 2019 will come into force on 1st October 2019 which standardises nationally referrals that are made to the Coroner. Work has commenced by the Lead ME to facilitate this change internally with the Registrar’s Office and HM Coroner IW. 8. Seven Day Service Standards Board Assurance Process (7DS BAF) The first 7DSBAF in the revised format was submitted in June 2019 (Winter Audit-time period) following sign off from Acute Board and Quality Committee as per the report that went to Trust Board in July 2019. NHSE have now notified the Trust that the next submission date for the next 7DSBAF is the w/c 25th November 2019 (Summer Audit time period) which is sooner than anticipated this has meant the work has commenced at pace to update the 7DSBAF and to undertake the clinical audit that forms part of this in time to ensure that the relevant committees are sighted so this can be signed off prior to submission. A request has been made to NHSE for a submission timetable for future reporting so that we can effectively plan this into business as usual.

Medical Directors Report Its worthy of note that one aspect of what is required (Case Note Audit) has already started to ensure the results are available to incorporate into the BAF and this is being undertaken by Clinical Effectiveness to expedite. A cohort of patients have been identified from the latest week possible in the summer period(first week in August) and the audit has just finished to allow for full audit and data analysis to take place. It is therefore unlikely that these case notes from August 19 patients will reflect all changes identified in the action plan that’s been developed but the Trust does still have the opportunity to make sure that the action plan is as robust and accurate in terms of progress by the time the actual 7DSBAF is submitted. We will also ensure that the associated report reflects this especially if the audit does not demonstrate improvement. Whilst some updates have been received as requested from services there are still some outstanding which Clinical Effectiveness will require in order to update the 7DSBAF and write the associated reports, further request has been made to strengthen the information required As before if there is any area in which services do not meet the standards but there is mitigation this will be reflected. The 7DSBAF is a self -declaration for trusts and services across the 7 day spectrum have been highlighted as having gaps in the most recent CQC report which makes the accuracy of the next submission of significant importance. At present the ‘sign off process’ will follow a similar format to before please note important dates below: • 30th September ALL updates on the 7DSBAF and associated evidence of sustained or improved performance must be with

Carlton Symonds by that date. - Clinical Effectiveness will coordinate and undertake the audit, update the 7DSBAF and draft the report from

information provided • 24th October- Acute Board - First draft of 7DSBAF & outline for the report to go to Acute Board (to cross over with IUEC).

- Clinical Effectiveness will make any updates to the 7DSBAF/ the report from any update or information provided • Care Group Director ‘drop in ‘ session to be tabled (as requested previously) to review the information. • 13th November Quality Committee - Final papers to Quality Committee for ‘board sign off’ (QC Board subcommittee) • 21st November Acute Board – For minuting and governance the ‘signed off’ Final 7DSBAF and associated reports will be

noted • w/c 25th November and by 29th November at the latest 7DSBAF/Report submission to NHSE. • Confirmation of submission to the deadline together with the BAF and report will go to the soonest Trust Board after

submission.

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A Framework of Quality Assurance for Responsible Officers and Revalidation Statement of Compliance

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Contents

Introduction: ................................................................................................................ 3

Designated Body Annual Board Report ....................................................................... 5

Section 1 – General..................................................................................................... 5

Section 2 – Effective Appraisal .................................................................................... 6

Section 3 – Recommendations to the GMC ................................................................ 7

Section 4 – Medical governance ................................................................................. 7

Section 5 – Employment Checks ................................................................................ 9

Section 6 – Summary of comments, and overall conclusion ....................................... 9

Section 7 – Statement of Compliance ....................................................................... 10

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Introduction: The Framework of Quality Assurance (FQA) for Responsible Officers and Revalidation was first published in April 2014 and comprised of the main FQA document and annexes A – G. Included in the seven annexes is the Annual Organisational Audit (annex C), Board Report (annex D) and Statement of Compliance (annex E), which although are listed separately, are linked together through the annual audit process. To ensure the FQA continues to support future progress in organisations and provides the required level of assurance both within designated bodies and to the higher-level responsible officer, a review of the main document and its underpinning annexes has been undertaken with the priority redesign of the three annexes below: • Annual Organisational Audit (AOA): The AOA has been simplified, with the removal of most non-numerical items. The intention is for the AOA to be the exercise that captures relevant numerical data necessary for regional and national assurance. The numerical data on appraisal rates is included as before, with minor simplification in response to feedback from designated bodies.

• Board Report template: The Board Report template now includes the qualitative questions previously contained in the AOA. There were set out as simple Yes/No responses in the AOA but in the revised Board Report template they are presented to support the designated body in reviewing their progress in these areas over time.

Whereas the previous version of the Board Report template addressed the designated body’s compliance with the responsible officer regulations, the revised version now contains items to help designated bodies assess their effectiveness in supporting medical governance in keeping with the General Medical Council (GMC) handbook on medical governance1. This publication describes a four-point checklist for organisations in respect of good medical governance, signed up to by the national UK systems regulators including the Care Quality Commission (CQC). Some of these points are already addressed by the existing questions in the Board Report template but with the aim of ensuring the checklist is fully covered, additional questions have been included. The intention is to help designated bodies meet the requirements of the system regulator as well as those of the professional regulator. In this way the two regulatory processes become complementary, with the practical benefit of avoiding duplication of recording.

The over-riding intention is to create a Board Report template that guides organisations by setting out the key requirements for compliance with regulations and key national guidance, and provides a format to review these requirements, so that the designated body can demonstrate not only basic compliance but continued improvement over time. Completion of the template will therefore:

a) help the designated body in its pursuit of quality improvement,

b) provide the necessary assurance to the higher-level responsible officer, and

1 Effective clinical governance for the medical profession: a handbook for organisations employing, contracting or overseeing the practice of doctors GMC (2018) [https://www.gmc-uk.org/-/media/documents/governance-handbook-2018_pdf-76395284.pdf]

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c) act as evidence for CQC inspections.

• Statement of Compliance: The Statement Compliance (in Section 8) has been combined with the Board Report for efficiency and simplicity.

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Designated Body Annual Board Report Section 1 – General:

The board of The Isle of Wight NHS Trust can confirm that:

1. The Annual Organisational Audit (AOA) for this year has been submitted.

Date of AOA submission:

Action from last year:

Comments:

Action for next year:

2. An appropriately trained licensed medical practitioner is nominated or appointed as a responsible officer.

Yes

3. The designated body provides sufficient funds, capacity and other resources for the responsible officer to carry out the responsibilities of the role.

Yes

4. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is always maintained.

Yes

5. All policies in place to support medical revalidation are actively monitored and regularly reviewed.

Yes

6. A peer review has been undertaken of this organisation’s appraisal and revalidation processes.

Not undertaken

7. A process is in place to ensure locum or short-term placement doctors working

in the organisation, including those with a prescribed connection to another organisation, are supported in their continuing professional development, appraisal, revalidation, and governance.

All Doctors with a prescribed connection to the Trust are offered an annual appraisal with suitable support to undertake this, including those on very short term contracts. Doctors who do not have a prescribed connection will have access to educational support and involvement in professional development and quality improvement projects. The appraisal is arranged through their designated body.

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Section 2 – Effective Appraisal 1. All doctors in this organisation have an annual appraisal that covers a doctor’s

whole practice, which takes account of all relevant information relating to the doctor’s fitness to practice (for their work carried out in the organisation and for work carried out for any other body in the appraisal period), including information about complaints, significant events and outlying clinical outcomes.

All Doctors where the Isle of Wight’s NHS Trust is their designated body have an annual appraisal. Enhanced mechanisms to ensure the entirety of complaints and significant events are reported in appraisals are developing.

2. Where in Question 1 this does not occur, there is full understanding of the reasons why and suitable action is taken.

n/a

3. There is a medical appraisal policy in place that is compliant with national policy and has received the Board’s approval (or by an equivalent governance or executive group).

Yes

4. The designated body has the necessary number of trained appraisers to carry out timely annual medical appraisals for all its licensed medical practitioners.

Yes. The Trust has 25 trained Appraisers and is the designated body for 195 doctors. This means all Appraisers carry out either 7 or 8 appraisals per year. There has been successful recruitment of new appraisers during the year and further recruitment will be undertaken on a regular basis.

5. Medical appraisers participate in ongoing performance review and training/ development activities, to include attendance at appraisal network/development events, peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers2 or equivalent). Yes. The following activities take place: - Externally delivered Appraisers update training annually. - Quarterly Appraisers’ informal meeting take place - An annual audit of appraisal quality conducted by lead appraiser is

undertaken and individual feedback given to all Appraisers. - All appraisers will be required to undertake external skills assessment

course within the next 3 years

6. The appraisal system in place for the doctors in your organisation is subject to a quality assurance process and the findings are reported to the Board or equivalent governance group.

Quarterly appraisal compliance reports are reported to the Board. Following recent changes of board sub committees, appraisal performance and quality assurance has been reported to the HR and OD committee

2 http://www.england.nhs.uk/revalidation/ro/app-syst/ 2 Doctors with a prescribed connection to the designated body on the date of reporting.

http://www.england.nhs.uk/revalidation/ro/app-syst/

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Section 3 – Recommendations to the GMC

1. Timely recommendations are made to the GMC about the fitness to practise of all doctors with a prescribed connection to the designated body, in accordance with the GMC requirements and responsible officer protocol.

All Doctors with revalidation due are reviewed two months prior to revalidation to ensure the Trust has all information required to make recommendations to the GMC by the Responsible Officer by the revalidation date. Recommendations by the Responsible Officer are regularly reported in advance of the due date.

2. Revalidation recommendations made to the GMC are confirmed promptly to the doctor and the reasons for the recommendations, particularly if the recommendation is one of deferral or non-engagement, are discussed with the doctor before the recommendation is submitted.

All positive recommendations are made directly to the Doctor by the GMC. In cases of deferral or non-engagement, these are discussed directly with the Doctor either by the Lead Appraiser or Responsible Officer before the GMC are notified.

Section 4 – Medical governance

1. This organisation creates an environment which delivers effective clinical governance for doctors.

Action from last year

- Improved Learning from deaths.

- Active participation in Mortality group by doctors

- Presentation of clinical audits and participation in the regular quarterly Clinical Effectiveness subcommittee

- Participation and authors of serious incident investigations

- Participation in GIRFT deep dive reviews and undertaking action plans

- Learning from coroners inquests

- Regular mortality and morbidity departmental meetings

- Participation in Medical Leadership programme

Actions for next year:

- Discharge summaries to be completed on day of discharge

- Greater supervision of doctors in training by senior doctors

- Maintain professional clinical competencies whilst working in a low volume acute and mental health care setting

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2. Effective systems are in place for monitoring the conduct and performance of all doctors working in our organisation and all relevant information is provided for doctors to include at their appraisal. Evidence of involvement or non-involvement with SI’s and complaints must be documented in the appraisal with email evidence from the Quality team. This is explicitly stated in the appraisal policy. Doctors know who to contact to provide this information to their appraiser. Issues relating to conduct are highlighted to Lead Appraiser to ensure that conduct issues are covered in an appraisal.

3. There is a process established for responding to concerns about any licensed medical practitioner’s1 fitness to practise, which is supported by an approved responding to concerns policy that includes arrangements for investigation and intervention for capability, conduct, health and fitness to practise concerns.

The Trust has updated its Conduct, Capability, Ill Health Policy and Procedure which addresses how we would manage any doctor with fitness to practice concerns.

The policy is in line with MHPS

4. The system for responding to concerns about a doctor in our organisation is subject to a quality assurance process and the findings are reported to the Board or equivalent governance group. Analysis includes numbers, type and outcome of concerns, as well as aspects such as consideration of protected characteristics of the doctors3.

Action from last year: Findings are reported to the private section of the main board. There is a designated non-executive director specifically responsible for oversight of investigations relating to conduct and capability of doctors. Whenever a doctor is excluded, the designated Non-executive is alerted by the Medical Director. He is then updated at regular intervals on the progress of the investigative process as long as the exclusion pertains.

Comments: The introduction of the new HR and OD committee will consider what form of reporting structure will be best suited

Action for next year; review reporting process:

5. There is a process for transferring information and concerns quickly and effectively between the responsible officer in our organisation and other responsible officers (or persons with appropriate governance responsibility) about a) doctors connected to your organisation and who also work in other places, and b) doctors connected elsewhere but who also work in our organisation4.

Yes. This is embedded into our recruitment and selection processes. Where areas of concern are reported, the RO is alerted.

4This question sets out the expectation that an organisation gathers high level data on the management of concerns about doctors. It is envisaged information in this important area may be requested in future AOA exercises so that the results can be reported on at a regional and national level. 4 The Medical Profession (Responsible Officers) Regulations 2011, regulation 11: http://www.legislation.gov.uk/ukdsi/2010/9780111500286/contents

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The Medical Practice Information Sharing Transfer (MPiT) form is only used when employing doctors who have worked in the UK before joining the Trust.

The MPiT form is also used for sharing information with organisations of doctors who work elsewhere.

6. Safeguards are in place to ensure clinical governance arrangements for doctors including processes for responding to concerns about a doctor’s practice, are fair and free from bias and discrimination (Ref GMC governance handbook).

Action from last year: Considerable investment has been undertaken to ensure processes and entitlements are free of bias. SAS doctors are entitled to the equivalent 1.5 SPA allocation for appraisal and continuing professional development subject to demonstrating proper use of the time. Considerable emphasis is placed on fair treatment and active monitoring of bullying by pulse surveys are regularly undertaken

Comments: The trust has improved its rating in the national trainee annual survey

Action for next year: Ongoing pulse surveys to be undertaken by the trust

Section 5 – Employment Checks

1. A system is in place to ensure the appropriate pre-employment background checks are undertaken to confirm all doctors, including locum and short-term doctors, have qualifications and are suitably skilled and knowledgeable to undertake their professional duties. When employing doctors directly the Trust follows the NHS Employment Check standards. When working with locum agencies, for temporary locums (ad hoc shifts) it is a requirement of our Master Vendor that they undertake pre-employment checks to the NHS Employers standard. Doctors employed via a recruitment agency are managed by the Medical HR team who undertake all pre-employment checks.

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Section 6 – Summary of comments, and overall conclusion

Please use the Comments Box to detail the following: - General review of last year’s actions: Excellent organisational work

undertaken by Appraisal lead and revalidation administrator. Regular monitoring and supporting doctors for appraisals with very few deferrals due to delayed process

- Increase in number of appraisers and improving quality assurance of appraisal process.

- Actions still outstanding; Nil - Current Issues: - New Actions: Enhance quality assurance process Overall conclusion: An excellent year of bedding down process and compliance of doctors to undertake appraisals in a timely manner. Further work to ensure all appraisers are maintaining excellent appraisals and have the necessary skills and development opportunities to improve further.

Section 7 – Statement of Compliance:

The Board of the Isle of Wight NHS Trust has reviewed the content of this report and can confirm the organisation is compliant with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013).

Signed on behalf of the designated body

[(Chief executive or chairman (or executive if no board exists)]

Official name of designated body: Isle of Wight NHS Trust

Name: Maggie Oldham Signed:

Role: Chief Executive

Date: 25th September 2019

Learning from Deaths/Mortality Report-Medical Director Page 1

Agenda Item No 7.5 Meeting Trust Board in Public Meeting Date

10 October 2019

Title Learning from Deaths-Mortality Quarterly Report

Sponsoring Executive Director

Alistair Flowerdew, Medical Director

Author(s) Lisa Reed, Associate Director of Clinical Effectiveness Sarah Gladdish, Consultant Physician


Medical Director /Chair of Mortality Review Group - 7th August 2019 NB there was no August meeting Quality Committee- 4th September 2019

Purpose of the report Information only Assurance X

Review and discuss Agreement

Trust Board Approval is required

Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality

Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development Lead strategic change on the Isle of Wight Link to CQC Domains Effective Responsive Caring Well-led Safe X Executive Summary The report was received by Quality Committee on the 4th September 2019 it contains the mandated reporting together with updates the on the Learning from Deaths Framework (LfDF) and the Mortality Review processes.

• Reporting period April 2019-June 2019 there were 146 acute in patient deaths, in the same time period for 2018/19 there were 142.

• 25 of the 146 were referred for case note review /Structured Judgement review(SJR) with a similar conversion rate to previous reports

• 8 are being investigated via the Serious Incident process

• The HSMR remains statistically ‘significantly lower than expected’- for the reporting period April 2018 to March 2019 with month 12 data at 73.8(CI: 67.3-81.2).

• The SHMI is at 1.03 within ‘banding’ 2 an as expected for the time period April 2018-March 2019 (CI: 0.85-1.18) this is stable and well within where the trust is expected to be.

Enc I


• Weekend/weekday admission shows that both emergency weekdays relative risk is statistically still ‘below expected’ compared to acute non-specialist trusts across England.

• There are no new themes identified in respect of ‘key’ issues or learning these still follow national and similar patterns identified in Serious Incidents. However improvements are being seen in some documentation for Do Not Attempt Resuscitation (DNACPR) and notable earlier consideration that patients are approaching the end of life.

• Issues or observations identified at SJR is now collated monthly and put onto the shared drive to enable the Care Groups to access the information easily.

• Work is underway at a Care Group specialty level to incorporate this into their individual processes and as this evolves and the Care Groups/ specialities attend the Trust Mortality Group (TMG) to share their information the TMG will be able to explore if the learning led to changes in practice and whether improvements can be evidenced.

• Next steps are in discussion about ensuring learning from all process are able to be triangulated workshop planned to look at trust processes in the first instance for October 19

• The LfDF is more embedded and work now will focus on the learning rather than process.

• There is no backlog of SJR’s and significant effort is being made to screen deaths within the same week of death and the greater majority of these are undertaken within 24 hours.

• Since Quality Committee the trust has recruited to all the Medical Examiner posts (ME) of which there are 3. One of these will be the Lead Medical Examiner for the Trust work to incorporate the role within job plans has begun.

• A board seminar on LFDF including case reviews focussing on the learning took place September 5th 2019.

Key Recommendation The Trust Board is recommended to receive assurance that the information provided by the Mortality Review Group is an accurate, clear and fair account of the IWNHS activity related to LfDF and its mortality processes. The paper contains all mandated reporting Level of Assurance This report is intended to provide the Committee with the following level of assurance: Substantial Assurance Limited Assurance Positive Assurance X Negative Assurance


Isle of Wight NHS Quality Committee

Learning from Deaths – Mortality Report

September 2019

This report contains figures pertaining to Quarter 1 (April 2019-June 2019) for actual deaths.

1 Introduction and update on Learning from Deaths Framework

1.1. The trust continues to build on and improve its ‘Mortality Review’ processes in response to the National Quality Boards and the Care Quality Commission (CQC) report ‘Learning, Candour and Accountability’ and the subsequent Learning from Deaths Framework(LfDF) 2017. This is overseen by the Medical Director via the Trust Mortality Group (TMG). This mandated report is provided quarterly to Quality Committee. This report also serves as the report for the Trust Board.

1.3 Interviews were held in conjunction with Her Majesty’s Coroner (HM Coroner) in August 2019

for the role of Lead Medical Examiner and Medical Examiner which the trust was successful in appointing to. By September/October (job planning permitting) the Trust will have three Medical Examiners in post.

1.4 The Trust is still awaiting information on the ‘dataset’ that will be required in respect of ME activity.

1.5 The National Guidance for Ambulance trusts for Learning from Death has now been received

and IWNHS Ambulance Service representative(s) have attended the relevant workshops. The process to support and implement the recommendations from the guidance is in development.

1.6 As an Integrated Trust, the reporting for ambulance will be included in this report. Ambulance

trusts should publish their first set of data in Quarter 1 (Q1) of 2020/2021, covering data extracted from reviews undertaken of deaths that occurred in Q4 2019/2020. Following this Ambulance Trusts are expected to formally report every quarter.

1.7 Over the next year this report will be revised to include the specific information relating to

ambulance.

1.8 The TMG also intend to provide more specific information and detail in future reports in respect of Mental Health & Learning Disabilities (MH&LD) and Community to reflect the breadth of services in this trust and provide more accurate reporting.

1.9 Junior Doctor (FY1&2) Induction was identified as having some ‘gaps’ in knowledge, following a

forum with some junior doctors. The learning material has been reviewed and updated induction has since been provided for the new intake of doctors FY 1&2 in August 2019. The 2 30 minute slots covered key areas including verification of death, certification of death, referral to the Coroner and ongoing responsibilities for patients who die in our care. Further sessions are already timetabled and have been enhanced and updated which will be led by the Lead Medical Examiner/Chair of the TMG and Associate Director of Clinical Effectiveness. The Inquest Team and Head of Legal (when in post) will also provide enhanced teaching around the coronial process including providing a statement to the HM Coroner, Inquest proceedings and the legal aspects of this process.


1.10 There is now a specific section on the Junior Doctor portal for key documents related to the

death of a patient. This will be monitored by TMG

1.11 HM Coroner has also been approached to provide teaching and date is yet to be confirmed.

2 Overview and outcomes of Learning from Death/Mortality Reviews.

2.1 This trust still aspires to review all acute ‘in patient’ deaths in some way. If issues are identified at Mortality Screening or a more in depth review is required then a ‘case records review’ is requested that utilises a structured method known as a Structured Judgement Review (SJR).

2.2 The SJR is not an investigation and whilst based on a ‘clinical’ review of the notes it is intended

to identify learning and utilises the ‘judgment’ of the reviewer as to the learning and ‘avoidability’ of death with an outcome score applied. A guide to the differences between an SJR, SI and Witness Statements for the Coroner has been developed as there has been some confusion in recent months and it’s important to understand the differences.

2.3 Routine screening and the trust incident processes identifies early whether there are concerns /

issues that warrant ‘investigation’ as opposed to a ‘case note review’ and if this is identified at screening an incident form (via the Datix system) is now completed in order to be able to trigger and track the case. This Datix would then be reviewed at the Weekly Patient Safety Summit (WPSS) as per process for level of investigation (if any) and if it meets SI threshold.

2.4 If an SI is declared this process is prioritised and the SJR element is put on ‘hold’. Last year

determining the numbers of deaths that were reviewed/ investigated and as a result ‘considered more likely than not due to problems in care’ were aligned more closely to the SI process. Over the last few months a core team from the Trust Mortality Group have begun to review the SI findings more routinely against the ‘avoidability of death judgement score’ to assist in the overall reporting of deaths. These then go to the monthly TMG for final sign off. Whilst the numbers of deaths in ‘our care’ are reported (currently acute in patient deaths) not all SI’s involving the death of a patient would automatically infer that the death was as a result of ‘problems in care’, as multiple issues may have been identified but the death itself was unavoidable. Learning is still extrapolated but the death may not fit the reporting criteria. The application of the avoidability of death judgement score enables the trust to consider consistently if the findings from the SI’s demonstrate that the death is ‘considered more likely than not to be due to problems in care’. For the purposes of reporting the Trust Mortality Group have decide that any death that scores 3, 2 or 1 would be formally reported as it would be considered that more likely than not problems in care contributed to the outcome. See scoring table below.

Avoidability of death judgement score, ranging from 1 – 6, based on the case note review or investigation outcome, correlate from the following scale:

Score Tick Judgement Score 1 Definitely avoidable Score 2 Strong evidence of avoidability Score 3 Probably avoidable (more than 50:50) Score 4 Possibly avoidable but not very likely (less than 50:50) Score 5 Slight evidence of avoidability Score 6 Definitely not avoidable

A score of 1, 2 or 3 meets the threshold (considered to be more likely than not due to be problems in care) for reporting in the quarterly reporting to the Quality Committee and thereafter to the Trust Board

2.5 From September 2019 once TMG have confirmed that a death meets criteria to be reported and

be included in the board report TMG will notify the Mortality Lead for the specialty, the Care Group Director and the Head of Nursing and Quality. The Trust Mortality Group will monitor how


this is working in practice and it may evolve as the ME’s come into post and become more established.

2.6 As per previous reports the process within the community setting for patients on the District Nurse Caseload has been developed and now operational with the first reports having been to the TMG. This process will now expand to include patients in ‘community beds’ when their health care needs are delivered by services in this trust i.e deemed to be ‘in our care’ such as Community Rehabilitation.

2.7 There are well established Mortality Review processes in the MH&LD. Mental Health services

have now formally adopted the Royal College of Psychiatrists (RCPsych) SJR methodology (NB this does differ from the Royal College of Physicians approach as its more specific to the client group and there is no ‘avoidability’ score) and they have refined their process further and it aligns with both the Incident Review/SI process and the overarching trust processes for mortality. MH&LD continue to attend the Trust Mortality Group on a regular basis and their reporting will start to be included more specifically in this report going forward.

2.8 Patients with a known Learning Disability who die in the acute trust are reviewed as any other

patient would be, but also referred for Learning Disabilities Mortality Review (LeDeR) to date the trust has received no information or report regarding these referrals.

2.9 Regardless of the LeDeR referral the trust continues to undertake screening/SJRs on all

patients who die and have a diagnosis of the defined Learning Disabilities for the LeDeR process (unless of course and incident/SI takes priority).

2.10 The issues relating to the lack of LeDeR output has been followed up with the Clinical

Commissioning Group (CCG) who lead on these reviews. The LeDeR Local Area Contact (LAC) for Isle of Wight (IW) CCG (like many CCG LACs) has struggled to engage local reviewers in undertaking the reviews of reported deaths of people with a learning disability.

2.11 The LAC has advised that they currently have 20 cases requiring review; 16 cannot be assigned for review as there are no reviewers available/making themselves available. One review is nearing completion, and they have requested one case to be removed from the IW list as the review has identified it has been incorrectly assigned to the Island.

2.12 As advised by the LAC the backlog of reviews is a national challenge as many of the staff committed to become reviewers on top of their day jobs. The national LeDeR programme has set aside £4-5m to address the backlog and regional LeDeR programme managers are working through the detail of how this will happen. A Wessex-wide ‘backlog’ audit has recently been completed which highlights the extent of the work required to complete reviews. It is anticipated that reviewers will be recruited specifically to undertake the backlog of LeDeR reviews.

2.13 In the meantime we are looking at how the trust could assist the LAC/CCG in a pragmatic approach to utilising the screening, case note review/ SJR’s to determine whether a full review is required (specifically for those deaths in hospital) in part the principal for LeDeR is to establish if the Learning Disability prejudiced care in any way and identify any learning.

2.14 Actual Deaths for Quarter 1 April 2019 – June 2019 – see Figure 1 &2


• Figure 1 : Actual deaths screened, SJR or SI

April 2019

May 2019

June 2019

Deaths 55 54 37

Deaths Screened 52 45 36

Deaths referred for SJR 7 8 10

SI’s declared 1 2 5

• Figure 2 : Rolling SJR Outcomes

3 Mortality comparator indicators for the Isle of Wight NHS Trust

These remain consistent with nothing of concern to note. The most recent Dr Foster report for July 2019 (reporting period April 18-March 2019) is summarised below:

3.1 Hospital Standardised Mortality Ratio (HSMR) & Standardised Mortality Ratio (SMR)

• HSMR remains statistically ‘significantly lower than expected’- 73.3 (CI :66.3-80.8) and has

reduced since the last report which was 78.8 (CI: 71.7-86.5) • Weekday deaths remain ‘below expected’ • Weekend deaths remain ‘below expected’ • The SMR remains statistically ‘significantly lower than expected’ at 75.5 (Cl:60.0-82.5)

3.2 Summary Hospital-level Mortality Indicator-SHMI

• The most recent SHMI for the Trust is 1.03. This has remained within ‘banding’ 2 and as expected for the time period April 2018-March 2019 (CI: 0.85-1.18).

0 3 2

8 6

43

SJR Outcomes Rolling Year

July 18 - June 19

0 1

0

2

2 6

SJR Outcomes Quarter 1 19/20

April 19 - June 19

1 - Definitely avoidable

2 - Strong Evidence ofavoidability

3 - Probably avoidable(more than 50:50)

4 - Possibly avoidablebut not very likely (lessthan 50:50)5 - Slight evidence ofavoidability

6 - Definitely notavoidable


• The crude rate for the SHMI has continued to reduce: September 2018= 100.88 -crude rate 5.1% December 2018=99.39 -crude rate 4.9% January =99.33 19 -crude rate 4.8% February =100.27 -crude rate 4.7%

3.3 The trust (acute) was expected to have 830 deaths during the year and had an observed figure

of 830. The SHMI is calculated by dividing the observed deaths with the expected. 58.57% of deaths occurring in hospital 43.43% outside of hospital (died within 30 days) this is rolling 1 year’s period which is 5 months in arrears (NHS Digital).

3.4 Overall the SHMI remains stable, the marginal increase from last quarters report (0.99) is the difference of 5-10 patients and investigations suggest this still relates primarily to the ‘palliative care coding’ improvements which was mentioned in previous reports, the latest data correlates with the changes in End of Life (EoL) care and the ‘advent’ of the Integrated Palliative Care Team (IPET). The trust is confident the coding is robust and reflects a truer picture of care being provided as there has been significant improvements in recognition of patient approaching the end of their life, faster referral to IPET and the care they are given, this means that coding for palliative care is correct and also getting them to their preferred place to die( still in our figures if they die within 30 days) if at all possible however recent information form the IPET team suggest that ‘choice of place of death’ has seen a shift to patients preferred place being the hospital.

3.5 The SHMI covers all deaths reported of patients who were admitted to non-specialist acute

trusts in England and died either while in hospital or within 30 days of discharge. Bandings indicating whether the SHMI is ‘higher than expected’, ‘as expected’ or ‘lower than expected’ are also provided. The statistical models are derived using a three-year dataset from trusts throughout England. Data from the final year of this period are used to calculate the SHMI and accompanying contextual indicators for each individual trust see Figure 3

Figure 3 : SHMI Banding

4 Learning Lessons and information sharing

4.1 Outcomes from screening and SJR’s is now collated monthly and are available via the ‘shared drive’ so that the relevant people in the Care Groups can access the information when they wish to.

4.2 Main themes still mirror those identified from SI’s however there is the beginning of a ‘shift’ for the earlier recognition that patient may be approaching the end of their life and the involvement of the IPET team being requested sooner.

4.3 Now the process and governance is clearer time will be spent to explore the learning as a whole not just learning where death is considered more likely than not to be due in to problems in care, as the SI process in the trust identifies these issues well already. The outcome and the

IW NHS Trust


learning from case record reviews is now shared which is what distinguishes it from historic practice.

4.4 The main themes for Q1 2019 still mirror that of findings from Serious Incidents and Incident reviews namely:

Theme 1: Could the patient have been identified earlier that they were nearing the end of their life

• Whilst this still remains a theme its steadily improving. IPET are starting to make significant difference once involved and ‘qualitatevely’ this appears to be happening sooner.

• The most recent results from the National End of Life Care Audit demonstrate significant improvement in respect of this.

Theme 2: Could/ should a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) have been completed earlier

• SJR reviewers have noted that early decision making has improved and the DNACPR documentation is improving. Lots of work has been undertaken to improve on this area culminating in a ‘Learning to Improve Bulletin’ being circulated in April 19 which summarises remedial action to date:

• Improve adherence to the DNACPR policy by embedding a culture of openness where staff feel comfortable to ask patients if they have an existing DNACPR form

• Devise a standard operating procedure (SOP). Adult patients will have a DNACPR section completed by their Lead Consultant. The SOP for the Retrieval and Recording of existing DNACPR decisions not brought into Hospital at time of admission has been developed and was ratified in Q1.

• 100% of patients with a DNACPR form will have the information uploaded on to e-Care Logic and will therefore be on the hand-over sheet;

• 100% of patients with a DNACPR form will have the proforma on the front of their notes • 100% Training compliance for DNACPR learning will be implemented. • The Resuscitaion Service continue to monitor and await national changes to the DNACPR

form in due course.

Theme 3: Recognition of deterioration sooner and quicker escalation

• The trust was aware of issues relating to this from SI’s and the findings from SJR’s.There has been significant work undertaken in improving the early recognition of deteriorating patients and the National Early Warning Score ( NEWS2) is now fully implemented.

• Escalation is noted to have improved response to esalation is continuing to be monitored by the Critical care Outreach Team

4.5 As mentioned, work is being done to collate the learning identified from the SJR process together with the stats and monthly updates are now being provided for care groups/specialities on the shared drive. An example from May 2019 is shown below:

Issues identified

End of life

• Entries to suggest it had been difficult for juniors to get counter signature on DNACPR form- NB this is one of the things that will be changing nationally

• Challenging situations with families’ wishes being at odds with medical teams recommendations – well managed thought.

• Delays in recognising dying – even when there was a plan for de-escalation.


Documentation

• Written notes not scanned into symphony, so not available to review- not enough entries in the electronic system to give information about attendance.

• One extremely poor admission clerking.

Quality of Care

• Two examples where the documentation gave concern around the we may not have met the care needs of people living with dementia.

• Haloperidol was prescribed to someone who was agitated but no evidence of examination or assessment by doctor; 90 mins later he was catheterised because of retention – likely to have been cause of agitation earlier and might have been found and treated if examined, without need to give haloperidol?

Notable Practice

• Many excellent examples of good decision making regarding EOLC and early, high quality discussions with families.

• Some examples of excellent multi-speciality working and decision-making • Well documented and appropriate use of weekend handover

Learning

Related to patient care:

• It is essential to assess and examine patients with new delirium or agitation to try and identify a reversible cause before prescribing medications like haloperidol.

• There is no excuse for poor quality admission clerking’s – it is typically the only point when there is time to take the full history, subsequent decisions often made on basis of it.

• As a system we still struggle to recognise and manage the fact that someone is dying – the planned work by IPET and EOLC steering group will support the changes required here.

5 Conclusion

5.1 The TMG is now confident that the mechanisms are in place either by the incident reporting, SI or Mortality Review Process to identify areas of concern around a patients death.

5.2 The ME’s commence their role and whilst much of their focus will be on the ‘non coronial’ patients there is an expectation that the service will develop alongside the coronial processes and improve information for families and the Coroner alike. Key focus at the outset will be to support doctors in completing the Medical Certificate Cause of Death(MCCD); providing scrutiny and an opportunity to discuss circumstance leading to death. This will not negate the role of the Consultant as ultimately they will remain responsible for all legal requirements for the patient however its anticipated that the extra level of scrutiny will reduce unecessary delay and ensure that each case the cause of death is scrutinised in a way that is robust, proprtionate and consistent.

5.3 Overall the LfDF process is embedded. The ongoing learning, refinement of the use of the outcomes and reporting together with the development of the ME role will continue to be the focus.

Report Author

Lisa Reed Associate Director of Medical/Clinical Effectiveness

August 2019


NB A glossary is available (previously circulated) to assist with background information, abbreviations, acronyms or commonly used language/terms in the mortality process.

Enc J


Title Guardian of Safe Working Hours for Junior Doctors – Annual Report

Sponsoring Executive Director Alistair Flowerdew, Medical Director

Author(s) Mr. Sreeshyla Basavaraj - Guardian of Safe Working


HR & OD Committee 9 October 2019

Key Recommendation • Senior clinical support – especially in General medicine, Stroke & MAU.

• Senior clinician to understand New Junior Doctors contract (terms and conditions) & support juniors accordingly

• Safe staffing levels : fill all the senior and middle grade vacant post. Unfilled post have extra burden on juniors in training.

• Address Surgical middle grade rota, until then consultants to support middle grades in providing sufficient rest to uphold patient safety.

• Discharge summaries should be addressed by each unit – junior doctors are not solely responsible to uphold discharge summary policy.


Link to CQC Domains



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

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

Assurance Staff Confidentiality Safe SO 03: Achieve patient standards

Committee Agreement


Responsive SO 04: Achieve excellence in employment


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

Executive Summary Essential Data ( Junior doctors in new contract): 01 August 2018 - 5th August 2019. Total number of Doctors at juniors level (excluding SAS) in the trust varies between 83-85. Number of training Posts (total) : 83 -85 (varies 83-85) Number of doctors in training: 73 Number of Non-trainee’s: 10-12 Number of training post vacant: 7 (some were vacant only for 6 months)

JDF: addressed to resolve following problems with help of management • Phlebotomy service on the weekends. • Remote access to Radiology imaging for surgical and orthopaedic middle grades. • Junior doctor mess (inside the hospital)

Needs to address following • Engagement of clinical leads, service leads and management with juniors to address day to day problems • Encourage exceptional reporting by juniors without fear of discouragement or threat to fail ARCP by their clinical supervisor.

Exceptional reports -

August 2018 To August 2019

Safety concerns Service support Educational opportunity x

Rest Overtime

FY1 GEN MED 20 57 10 1 5151

FY2 BST 2 0 3 1 2525

FY1 SURGERY 1 3 6 2 6666

CT / ST SURGERY

2 1 3 1 2020

A & E 0 0 0 0 0101

FY2 /CT/ST MEDICINEST1MED

2 0 0 0 1010

SUBTOTAL 27 61 22 6 173173

TOTAL EXCEPTIONAL REPORTS IN 12 MONTHS : 288. PENALTY : none

Page | 1

Agenda Item No 7.8 Meeting Trust Board in Public Meeting

Date 10 October 2019

Title Workforce Performance Report Sponsoring Executive Director

Julie Pennycook, Director of HR & OD

Author(s) Rowena Welsford, Interim Deputy Director of HR Jacqui Skeel, Associate Director of OD


HR & OD Sub Committee 9 October 2019 Performance Committee 9 October 2019

Purpose of the report Information only Assurance x Review and discuss Agreement Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 x Ensure efficient use of resources x Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development x Lead strategic change on the Isle of Wight x Link to CQC Well Led Domains Effective x Responsive x Caring x Well-led x Safe x Executive Summary Headlines from this report are: • International Nurse Recruitment activity positive – October impact on temporary staffing • Turnover 11.7% is below regional average • Rostering compliance has showed significant improvement at ward level • Reduction in agency spend £108k in M5 • 1st and 2nd Cohorts of international nurses arrived (21 nurses) and Cohort 3 (9 nurses) will be

arriving 13 September 2019. Targeted recruitment and social media campaigns in the UK in progress, together with further international campaign leads to pursue to address the shortfall

• Total Bank and agency usage is decreasing and the spend on nursing is starting to reflect the reduced rates that are achieved by early roster approval.

• Trust sickness absence rate: 4.84% in month (decrease from 5.2% M4). Impact BP’s of sickness deep dive. Highest reasons for absence: Anxiety, Stress & Depression – action to address in place

• Mandatory Training compliance – 84% • Appraisal rate reset from 1st April 2019, currently YTD 72%. Key Recommendation The Trust Board is asked to receive the report

Enc K

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

Workforce Performance Report

September 2019

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


Headlines • Turnover increased in month (MARs impact) albeit remaining below regional average. Exit review for nursing shows 6.6 leavers M5 (Vs 12 in M4) . Reasons for

leaving 1 Retirement, 1 Flexi-retirement, 2 Relocations, 1 work life balance, 1 personal. • Reduction in agency spend £108k in M5 • Substantive staffing has increased in month in part due to Junior doctors rotation appointments and the transition of overseas nurses from supernumerary

HCA’s to substantive Registered Nurses • Sickness – remains over target, although lowest level over past 12 months. Stress Anxiety maintains highest cause of sickness absence • 30 overseas nurses now deployed with a further 43 in process. A further International Recruitment trip confirmed for October 19

Headlines: M5 Data

HEADCOUNT: 3281 (2827 FTE)

VACANCY RATE: 11.7 %

SICKNESS ABSENCE: 4.84%

APPRAISAL: 72% TURNOVER RATE: 11.32 %

TEMPORARY STAFFING USAGE FTE: BANK 159 / AGENCY 80



Workforce FTE Budget

Establishment:3102 In-post : 2827

Bank Usage: 159 Agency Usage: 80

TOTAL: 3066 Variance: -36

Sickness Absence:

4.84% 4% Target

Turnover: 11.32%

(Rolling 12 months)

Appraisal Compliance:

72% 95% Target

Mandatory Training:

84% 85% Target

Vacancy Factor: 11.7%

August 2019 data (Finance data includes CIP within establishment)

• The Trust employs 3281 (headcount) substantive full and part time staff, 400 bank workers with additional support provided by 300 volunteers

• Sickness absence rate: 4.84% in M5 (5.22% M4). Lowest level in year. Stress Anxiety & Depression remains the highest cause of absence, with 30% of total Trust sickness (29% M4)

• Mandatory training currently at 84% • Total Bank and agency usage decreasing and spend on

nursing agency is continuing to reflect the reduced rates achieved by early roster approval

• 72.9% of temporary staff utilisation (bank& agency) is within the Nursing staff group.

• 73 overseas nurses are in process. 1st cohort of 9 nurses deployed 19 July 2019. Cohort 2 of 12 nurses deployed 16 August 2019. Cohort 3 of 9 nurses arrived 13 September 2019 and Cohort 4 due to arrive 18 October. Targeted recruitment and social media campaigns in the UK in progress to address any shortfall

• Further overseas trip booked mid October • Turnover increased to 11.32%,( impacted by MARs)

remains lower than regional average of 14%, revised exit review underway to understand reasons for leaving

• Vacancy Factor: 11.7% a reduction against M4 (12.%)

Workforce Trust level Metrics: M5




Well-Led: Culture & Leadership Programme Update

• Leadership Development Framework – • All programmes underway

• Senior Leaders • Middle Leaders • Medical Leaders • Team Leaders & Supervisors • Fundamentals for personal growth at work (all other staff)

• Cohort 5 Middle Leaders Programme commences 26.09.19. Positive feedback received from cohorts 1-4 • Band 6 and 7 Nurse Leaders programmes commenced • Review of provision for Leadership Development for 2020 • Evaluation of senior & middle leaders and medical leaders programmes underway

• Human Factors Training -

• Internal faculty training completed mid-September. Scheduled programme of 1-day workshops for all staff throughout 2019/20 to be published.

• Leadership Conference 2020 – booked 19.03.20, Northwood House - Focus on ‘Inclusive Leadership and Quality’



Monthly Survey • Increase in responses this month. • Monthly survey data is disaggregated and reported at Divisional Boards • No significant increases/decreases in month:

• ‘Care of patients service users organisations top priority’ and ’Would know how to report unsafe clinical practice’ both increased by 3% • ‘I am able to make suggestions to improve work of team/dept’ down by 4%. • ‘Communication between senior management and staff is effective’ down by 3%.

• Monthly staff survey will not take place during October and November as the national annual staff survey will be underway.

Staff Engagement: Monthly Staff Survey

Nov Dec Jan Feb Mar April May June July Aug 162 130 362 177 200 265 360 317 319 355

Response rates:



• Overall organisational compliance is below target at 71.99%

• Outstanding appraisals are booked for staff throughout August to achieve 95% target by the end of Q2.

• Quality of appraisal evaluation survey underway to end of September.

• Medical & Dental Appraisal Compliance at 31st August 2019 - Appraisals due for completion and completed June 2019 – August 2019 = 100%

• Support in hand to areas of low compliance

Training & Development: Appraisal

Trust compliance at 29.08.19 (excl. medical/dental)

Clinical Divisions



• Organisation compliance has remained at 84% and is just below Trust target of 85%. • Demand and capacity planning in place for all classroom based courses including clinical induction and mandatory training refresher for 2020/21 Outlier staff groups: • Junior doctors - Medical Education team working with the new cohort to ensure individuals are 85% compliant by 31.10.19. • Bank staff - Action plan underway to improve compliance for bank staff to 85% by 31.10.19. • Trust administration – competency profiles provided for this staff group, anticipated improvement in compliance by 30.09.19. Outlier courses: • Resuscitation – Issues with late cancellations, commonly attributed to staff levels/patient dependency. Alternative methods of delivery being explored.

Training & Development: Mandatory Training



Workforce Metrics – M1 Plan FTE £ (000’s)

• Agency utilisation is 80 wte in month 10% reduction from month 4.

There has been an increase in the fill rate for bank for both HCA and nursing requests

• There is a continued reliance on temporary staffing due to 1:1 care, high sickness levels and vacancies in the Acute and MH areas. However we are starting to see a decrease due to the impact of overseas recruitment.

• Substantive staffing has peaked in month due to Junior doctors rotation appointments and the deployment of the overseas nurses into HCA positions prior to NMC registration. Work continues to reduce nursing vacancies through targeted advertising campaigns and pursuit of additional overseas recruitment opportunities

• Month 5 sickness rate is 4.84% and is the lowest rate over the past 12 months. This is a reduction compared from M4 (5.22%)

Workforce Metrics: M5



Reduction in Agency Spend M5 = £108k Nursing: • Registered Agency Nurses fill rate

August 19 = 88% • Agency nurse spend has reduced. Improved

rostering and earlier agency requests has helped achieve reduced rates. Work to improve rostering is continuing through the System Sustainability Programme.

Medics: • Spend has increased due to an increase in

specialist consultant requests which is predominantly due to :

– Challenges in sourcing consultants for Stroke, Gastro and Respiratory (this is a national challenge)

Bank Activity: • 5 HCA new bank starters • 1 Medic new bank starter • 1 RN new bank starter • 1 CT Psychiatrist new bank starter • 8 HCA appointments following interviews • Bank Nursing & Midwifery % fill rate:

82.24%

Workforce Metrics – Agency/Bank Headlines

0

200

400

600

800

1,000

1,200

1,400

Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19

£'00

0

Monthly Agency spend per month

Medical Nursing Clinical Administration

Other TOTAL NHSI CEILING Linear (TOTAL)



Workforce – Vacancy/Recruitment

Successes Process Improvement Planned activity

• Overseas Nurses:: Total 73 • Cohort 1 July - 9 nurses – OSCE exams passed • Cohort 2 August - 12 nurses – OSCE exams passed • Cohort 3 September - 9 nurses • Cohort 4 October – 11 nurses • 4 wte Nurse and HCA new starters in August: - 1 RM/ 1 RMN/ 3 MH STR • Medic starters in August: - 1 LAS FY1, 4 LAS FY2, 3 FY2, 6 FY2 (WAST), 7 GPST, 3 CT, 8 ST3+ - Deputy Medical Director - Specialty Doctor Obstetrics & Gynaecology - Specialty Doctor General Medicine • Medic offers in August: - LAS Core Medical Trainee - LAS Core Trainee, Psychiatry - Consultant Physician with interest in Elderly Care - Associate Specialist General Adult Psychiatry - Trust FY2 Emergency Medicine

• Targeted early pre-screening of professional applications to increase the pace of recruitment is now active – 4 successful placements from this activity

• Review of further benefits of NHS Jobs, to include candidate pooling

• Trip to Philippines confirmed for October 19

• Interviews with a second supplier for additional overseas recruitment planned mid-September

• Attendance at Southampton University for 1st year students and AHP’s

• National advert for domestic recruitment for Medical and Clinical roles - go live mid-September

Recruiting and Retaining a Motivated Workforce

Decrease from 12% vacancy gap in M4 Variance in budgeted establishment & active recruitment allows for temporary staffing headroom and CIPs *In post FTE reflects position following Junior doctor turnover to avoid understating vacancy gap

Staff Group Budgeted Establishment FTE

In post FTE

Variance against budgeted

establishment FTE Nursing & Midwifery Registered

918.5 753.49 165.01

Medical & Dental 282.27 * 236.41 45.86

Allied Health Professionals 239.74 216.41 23.33



Workforce – Medical Vacancy/Recruitment Recruiting and Retaining a Motivated Workforce – Medical Recruitment Trajectory

• Trajectory takes into account the recruitment of doctors in training who joined the Trust in August 2019.

• Offers have been made to 9 doctors in month, 6 have accepted and start dates being worked toward. Further planned interviews and AACs for September.

• Contributory factor in the variance between funded establishment is due to 10 unfilled doctor in training post. Recruitment to gaps has been very successful, with further plans to reduce vacancies.

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Medics Inpost FTE 236.74 239.74 237.74 241.74 249.74 255.74 Medics Inpost Trajectory - Impact of Planned Recruitment Activity 255.74 259.74 262.74 265.74 267.74 268.74 268.74 Medics Budget Establishment 281.17 281.17 281.17 281.17 281.17 281.17 281.17 281.17 281.17 281.17 281.17 281.17

210220230240250260270280290

Medical Recruitment Trajectory Medics Inpost FTE

Medics Inpost Trajectory - Impact of Planned Recruitment Activity

Medics Budget Establishment



Recruiting and Retaining a Motivated Workforce - KPIs

Recruitment KPI’s – August 19 KPI target

Average days

Time vacancy applications are in review 2 11

Time between Shortlisting sent and shortlisting outcome received 3 6

Time vacancy awaiting interview outcome 2 10

Time for pre-employment checks 15 8

Time for references complete 5 6

TIME TO RECRUIT - Band 1-4 (Avg days) 49 20

TIME TO RECRUIT - Band 5-6 (Avg days) 70 31*

TIME TO RECRUIT - Band 7 and above (Avg days) 91 30*

Time to Hire for all bands has reduced significantly this is due to the automation of the recruitment process allowing the Resourcing Team improved control over the entire recruitment process * These averages will include internal appointments

Actions to improve performance against KPI’s

To reduce time taken by recruiting managers: • Review of applications • Time taken to shortlist • Time to communicate

interview outcomes Resourcing Officers to attend Divisional team meetings to support Recruiting managers improve performance Introduction of NHS Jobs user group to provide ongoing support for recruiting managers Introduction of pre-screening for clinical applications to reduce time to hire Data has been compiled using NHS Jobs, using data set from the last three months Jun 19 – Aug 19.


Page | 1

Agenda Item No 7.9 Meeting Trust Board in Public Meeting

Date 10 October 2019

Title Freedom to Speak Up Guardian Report Quarter 1 (April-June) 2019/2020 Sponsoring Executive Director

Maggie Oldham, Chief Executive Officer

Author(s) Leisa Gardiner, Trust Freedom To Speak Up Guardian Report previously considered by inc date

HR&OD Committee 9 October 2019

Purpose of the report Information only Assurance X Review and discuss Agreement Trust Board Approval is required Reason for submission to Trust Board in Private only (please indicate below) Commercial Confidentiality Staff Confidentiality Patient Confidentiality Other Exceptional Circumstance Link to Trust Strategic Objectives Provide safe, effective, caring and responsive services – ‘Good’ by 2020 X Ensure efficient use of resources Achieve NHS constitutional patient access standards Achieve excellence in employment, education and development X Lead strategic change on the Isle of Wight Link to CQC Domains Effective X Responsive X Caring X Well-led X Safe X Executive Summary

The Freedom to Speak Up independent review into creating an open and honest culture in the NHS (2015) recommended the widespread introduction of the Freedom to Speak Up Guardian (FTSU) role in each NHS organisation. The Trust has appointed Leisa Gardiner as the Freedom To Speak Up Guardian. The FTSU Guardian/Team received 44 concerns for Quarter 1 (April-June 2019). Of the 44 concerns raised during this Quarter 2 related to patient safety and Quality and 42 related to behaviours in particular bullying and harassment. The biggest staff group to raise concerns were nurses. When a concern is raised the Freedom To Speak Up Guardian, a Freedom To Speak Up Advocate or Anti Bullying Advisor meets with the member of staff to hear the concern, provide support and escalate when appropriate including having direct access to the Chair and CEO. The intension of this FTSU report is that it will be submitted quarterly to be in the public domain. Key Recommendation The Board is asked to consider the following recommendations:

To receive and have assurance given by the report that there is a robust policy and structure which allows our staff to safely raise concerns, to be supported in doing so and to ensure they are treated according to the principles outlined by Sir Robert Francis.

Enc L

FREEDOM TO SPEAK UP REPORT

1 Purpose

1.1 This report outlines activity and progress to date of the Freedom To Speak Up Guardian (FTSU) role and provides a summary of concerns raised for Quarter 1 (April-June 2019).

2 Background

2.1 The Freedom to Speak Up independent review into creating an open and honest culture in the NHS (2015) recommended the widespread introduction of the Freedom to Speak Up Guardian (FTSU) role in each NHS organisation.

2.2 The standard NHS contract requires all trusts and foundation trusts to nominate a Freedom to Speak Up Guardian by October 2016.

2.3 Leisa Gardiner, took up this Guardian role in October 2016. Prior to this as part of her role as Lead for LiA (Listening into Action) staff approached her to raise their concerns and she encouraged staff to speak up and well as providing support.

2.4 This report outlines activity and progress to date and provides a summary of concerns raised for Quarter 1.

3 Structure of the Freedom to Speak Up Model

The Trust has a nominated Freedom To Speak Up Guardian who is supported by a team of Freedom To Speak Up Advocates and Anti-Bullying Advisors. The team will provide support for the workforce to raise and respond to concerns in relation to patient safety, bullying and harassment and any other concerns by ensuring an environment of trust, openness and respect. The Freedom to Speak Up Guardian will help to raise the profile of raising concerns in the organisation. Provide confidential advice and support to staff in relation to concerns they have and/or the way their concern has been handled. Facilitate the raising concerns process where needed. Ensure the organisational policies are followed correctly.

3.1 When a staff member raises a concern either through the Freedom To Speak Up route or via an Anti Bullying Advisor, a meeting is arranged to meet with the staff member. At the meeting the concern is heard, the member of staff is supported and options how their concern can be dealt with are discussed. Where appropriate, concerns are escalated and direct access is available to the Chair and CEO. Ongoing contact and support is available to the staff member until they feel their concern has been addressed or resolved. A feedback form is sent to the staff member who has raised the concern to ask whether they felt supported and would raise a concern again.

4 Communication plan

The Freedom To Speak Up Guardian attends staff induction (including Student Nurse and Junior Doctor inductions) and attends the Junior Doctors Forum and staff team meetings to provide updates on Freedom To Speak Up. Speaking up forms part of a wider programme of work in helping to create an open and transparent culture. It is important that we provide different mediums of communication for all staffing groups. Plans for the FTSU Guardian to attend staff meetings to ensure that staff from all areas get an opportunity to hear about speaking up.

5 Freedom to Speak Up Activity in the Trust

5.1 Concerns raised in Quarter 1

There have been a total of 44 concerns raised to the FTSU Guardian/Advocates and Anti Bullying Advisors during Quarter 1 (April – June 2019)

5.2 Concerns were raised by the following staff groups

Doctors Nurse Administrator AHP Corporate

4 14 7 8 11

Concerns were categorised as follows

Patient Safety and Quality

Behavioural including Bullying and Harassments

Other

2 42 0

5.3 Data

Isle of Wight NHS Data on “Speaking Up”

0

10

20

30

40

50

60

70

80

90

100

Qu 117/18

Qu 217/18

Qu 317/18

Qu 417/18

Qu 118/19

Qu 218/19

Qu 318/19

Qu 418/19

Qu 119/20

Total No. of patient concerns

Patient safety related concerns

Behavioural/Bullying/Harrassment

Other

National Speak Up October month 2018 and increase in FTSU Guardian hours

It is a requirement for all FTSU Guardians to submit data to the National Guardian Office and the graft above shows the total number of concerns raised and the number by category. There was an initial peak in Quarter 3 which was (October-December 2017) when we launched the first Freedom To Speak Up Advocates and Anti Bullying Advisors. There was a significant increase in Quarter 3 (October-December 2018). Specifically in October 2018 alone the total number of concerns recorded was 31 concerns. The increase relates to the Freedom To Speak Up Guardian’s hours were increased and October 2018 was the first National Speak Up month campaign where the picture nationally was one of a rise during this time period.

6 Themes of concerns raised

There isn’t much change to the previous report in that the much majority of cases related to poor behaviours and or bullying/harassment. There were low number of cases raised relating to patient safety concerns. It is felt that staff are confident in raising patient safety concerns and know the process to raise these concerns i.e. through their line managers and this is often supported with the completion of a Datix. This is also evidenced in the staff survey

7 Monthly Staff Pulse Surveys

Number of staff (%) who responded positively to Question 8 of the pulse survey that states have not personally experienced harassment, bullying or abuse in the last month.

8 Lessons learnt

8.1 The number of concerns being raised by staff has increased slightly by 3 from the previous quarter with the majority of concerns relating to poor behaviours. There needs to be a continued focus on delivering the new values and Behaviours Framework to all staffing groups.

8.2 The monthly staff pulse survey results show us that there has been a very slight decrease in the % of staff who have responded positively that they have not experienced harassment, bullying or abuse. We need to monitor this against the number of concerns raised in relation to poor behaviours and encourage more staff to complete the survey to get an improved overall picture.

9 Activity and progress to date

9.1 FTSU Guardian signed off to deliver Human Factors training and dates are planned monthly from December 2019

66

68

70

72

74

76

78

80

82

Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19

% of staff who responded positively

% of staff who respondedpositively

9.2. Supported Junior Doctors training sessions with the GMC regional liaison advisor to ensure doctors know when and how to raise concerns.

9.3 Planned “Speak Up October” campaign for the Trust

9.4 Regular weekly 1:1 sessions with the CEO

9.5 Presented at University College London Hospital on the work being undertaken at the Trust in relation to Freedom To Speak Up processes and the Anti-Bullying Advisors.

9.6 Monthly supervision sessions with the FTSU Advocates and Anti-Bullying Advisors

9.7 Attendance at the monthly staff wellbeing MDT meetings

10 National and Regional Developments and updates

10.1 July 2019 Publication of supplementary Freedom To Speak Up information

10.2 August 2019 Publication of National guidelines on Freedom To Speak Up training in the health sector in England

10.3 Training and refresher training for FTSU Guardians

10.4 Invite from the National Guardian Office for attendance at a FTSU celebratory event on the 8th October 2019 in London

11 Next Steps and future priorities

11.1 Deliver the “Speak Up October” month campaign including a communication plan of events. Green ribbons will be worn during the campaign to support and raise awareness about speaking up.

11.2 Following feedback sought from staff during the “Speak Up October” campaign review the role of the anti - bullying advisors and FTSU advocates,

11.3 FTSU Guardian to undertake Exit interviews to support staff

11.4 With the support of the FTSU Advocates and Anti Bullying Advisors continue to engage with staff to make Freedom to speak up more visible and encourage staff to raise concerns.

11.5 Following review of the monthly Staff Pulse Survey results and annual staff survey work with teams around increasing staff confidence around speaking up about unsafe practice

11.6 Support the CEO and Non Executive lead for Freedom To Speak Up in reviewing and implementing any changes from the July 2019 Publication of supplementary Freedom To Speak Up information

11.7 Review the National guidelines on Freedom To Speak Up training in the health sector in England and create an action plan to support delivery

11.8 Work alongside staff to understand and experience their concerns first hand

11.9 Attendance at regional and National meetings

12.10 Continue to provide reports to the National Office

12.11 Continue to provide quarterly reports for the Trust Board and contribute to the Annual Quality Account Report

Enc M


Title Financial Performance – Month 5 2019/20

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

Author(s) Gary Edgson – Deputy Director of Finance


Performance Committee, 9 October 2019

Key Recommendation To receive the Month 5 Trust performance against the 2019-20 financial plan.

The Board is asked to note the reasonable assurance on the Trusts overall financial performance but note the ongoing actions required to achieve current year plan and the inherent risks at Trust and Divisional level that require mitigation.


Link to CQC Domains



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

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

Committee Agreement


Responsive SO 04: Achieve excellence in employment



Executive Summary

Income & Expenditure • The required in month position for July was £1.8m deficit, year to date (YTD) £11.2m deficit • The Trust’s in month financial position is £1.8m deficit, YTD £11.2m deficit • As the Trust has achieved its financial plan to date, financial support PSF/FRF of £5.0m has been assumed - the reported YTD

position is therefore £6.2m deficit • The Trust remains committed to achieve its year end deficit plan of £4.0m (after PSF/PRF) support Whilst there were cost pressures incurred in month, these were mitigated by other actions that realised benefits. Further recovery actions are required to continue to mitigate these cost pressures. Year End Forecast (Q1) • A year end forecasting exercise at divisional level (using information available as at Q1) indicates a potential £7m shortfall against the

Trust’s planned year end position • £4m of the shortfall being driven by operational pressures e.g. staffing costs in the emergency department and the balance of £3m

based on a high level risk assessment of the current CIP forecast • Divisions have been tasked with developing mitigating actions/recovery plans to enable the Trust to achieve its planned position • These actions/recovery plans will be challenged and approved at Financial Recovery Board, to ensure all risks are mitigated • The Trust remains committed to achieving the planned deficit position whilst acknowledging the current degree of risk that requires to

be mitigated • The Trust’s year end forecast will next be refreshed following Q2 reporting

Cost pressures Recovery actions

ED staffing • Business case developed to implement a revised model of service provision • Mitigate through cost reductions in other areas to offset – these will be challenged and

approved at Financial Recovery Board Levels of non-elective activity • Implementation of sustainability plan work stream actions (patient flow, community care)

• negotiation of additional income • Defer investments

Executive Summary

Pay and Agency • Pay pressures continue in the Emergency Department and are also reflected in the cost year to date position as a result of Compton

Ward being open in Q1 - Centrally held funds have been utilised to offset the former and additional income has been received from the CCG in respect of the latter

• M5 agency costs £1.0m – an increase in month as a result of higher agency medical costs • Efficiency plans for 2019/20 aimed at improving productivity and reducing reliance on agency staff. Enablers include overseas

recruitment and increased focus on consultant job planning. Progress to date against CIP delivery • £1.8m planned delivery to date • £2.1m actual delivery to date • Delivery includes £1.0m of non-recurrent savings CIP Forecast • £10.5m baseline plan • Currently £9.9m forecast delivery (at divisional level) for 2019/20 • The closing of the outstanding gap is being driven through the weekly check and challenge meetings and the financial recovery board

(FRB) • The FRB continues to drive performance delivery, to identify recovery actions, CIP mitigations and consider required investment

decisions.

Executive Summary

Capital Investment Update • Available capital funding for the year is £6.1m • This is a reduction of £0.3m from the £6.4m previously available due to the decision to re-life some IM&T assets • The sale of a Trust property could see up to £0.4m returned to the capital programme • As at Month 5, capital investment year to date is £0.6m – marginally ahead of plan (<£0.1m) • Following the return of the £1.2m previously ‘top sliced’ from its capital allocation and an updated assessment of priorities has taken

place and the revised capital programme has been agreed • The Trust is in receipt of £3.6m HLSI IM&T funding, £1.5m in this year. Plans are well developed to realise the benefits • The Trust will receive up to an additional £48m of capital to support the sustainability of acute services however the process to access

and the associated timings have yet to be finalised • The Board is asked to note the revised Capital allocation following Executive agreement and Performance Committee assurance Cash update • Loans of £6.6m for April-August (there was no cash draw down in August) have been secured from DHSC – this reflects the revised

deficit plan • Remaining cash support will be in the form of PSF & FRF funding, access to which is dependent on achieving financial plan • Outstanding creditors over 30 days are reducing to £3.7m from a level of £5.0m at Month 4 • Repayments of cash loans are expected to begin in April 2020 Use of Resources rating • The Trust’s Use of Resources Rating (UoR) has remained at a score 4 (1 being best and 4 being worst) • As the Trust is under Financial Special Measures the UoR rating will default to 4


Area Key issues Current month (ytd)

Previous month (ytd)

Overall Plan The Trust is reporting a deficit of £6.2m as at the end of August, which is on plan. This position assumes the receipt of £5.0m PSF/FRF funding. A risk of c. £7m to the planned year end position has been highlighted, following the Q1 forecasting exercise. Actions to mitigate the underlying risks are being developed.

On plan (ytd). £7m risk to be mitigated

On plan (ytd). £7m risk to be mitigated

Income Income is £0.8m favourable to plan, £0.2m of this is income that has been accrued to offset the marginal costs of providing additional non elective activity.

£0.8m fav to plan

£0.7m fav to plan

Expenditure Expenditure is £0.8m adverse to plan as at the end of August. This is mainly the result of additional staffing costs in the Emergency Department and the cost of additional non elective activity. This has been partially offset by the use of central funding.

£0.8m adv to plan

£0.7m adv to plan

CIP As at the end of the August the Trust has delivered £2.1m of CIP against a plan to deliver £1.8m (£1.1m of this is recurrent, £1m is non-recurrent). The Trust is currently forecasting to deliver £9.9m of its £10.5m CIP target before further actions.

£0.3m fav to plan

£0.2m fav to plan

Capital Capital expenditure is still marginally ahead of the YTD planned position due to the expenditure incurred to refurbish Shackleton earlier this year. The exact timing and process for accessing the additional £48m of capital is still to be confirmed.

£0.0m adv to plan

£0.1m adv to plan

Cash At the end of August the Trust’s cash balance was £3.9m, which is a decrease on the previous month’s balance by £2.0m. The reduction is the result of the decision to avoid drawing down loan support in August, saving interest costs.

£3.9m Cash

Balance

£5.9m Cash

Balance

Financial risk rating (UoR)

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

Overall score 4

Overall score 4

Month 5 Executive Summary



Month 5 Overall Financial Performance

Summary Service pressures continue to exert financial pressures, most significantly in ED & MAU. Additional non-elective activity (above the block contract value) and projects relating to delivering financial recovery and transformation have also impacted planned levels of expenditure. The use of centrally held funding, and a further balance sheet review, have been required to deliver the budgeted position. Further details on variances have been provided to the Performance Committee.

The adverse financial impact of service

pressures have been offset by non-recurrent

actions. This has enabled the Trust to achieve its planned

year to date position at the end of August

NB – Variances may not sum exactly due to roundings

Year (£m)

Plan Actual Variance Plan Actual Variance PlanIncome 15.1 15.2 0.1 75.2 76.0 0.8 178.6Pay -11.4 -11.5 -0.1 -58.5 -59.4 -0.9 -137.8Non Pay -4.5 -5.0 -0.5 -22.5 -24.1 -1.6 -52.9Centrally Held Funding -0.3 0.2 0.5 -1.4 0.2 1.6

EBITDA -1.0 -1.1 -0.1 -7.2 -7.3 -0.1 -12.1Post EBITDA -0.8 -0.8 0.0 -3.9 -3.8 0.1 -9.4

Pre PSF/FRF -1.8 -1.9 -0.0 -11.1 -11.1 0.0 -21.5PSF/FRF 1.2 1.2 0.0 5.0 5.0 0.0 17.5

Surplus/(Deficit) -0.7 -0.7 -0.0 -6.2 -6.2 0.0 -4.0

In Month (£m) Year to Date (£m)



Month 5 Divisional Performance

Summary There are pressures at divisional level which are reflected in the table above. The key adverse variances are as follows: • Integrated Urgent & Emergency Care – agency staffing costs in the Emergency

Department/MAU, CIP under delivery and additional work to support patient flow • Acute Services – costs relating to additional activity and CIP under delivery These costs have currently been mitigated by small under spends in other areas and the use of centrally held funding. The latter will impact on funds available for investments in 19/20. NB – Variances may not sum exactly due to roundings *Further details have been provided to the Performance Committee

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

Acute Services -7.3 -7.4 0.0 -37.8 -38.3 -0.5 -81.8Community Services -1.4 -1.4 0.0 -7.0 -6.8 0.2 -16.3Mental Health and Learning Disabilities -1.5 -1.6 0.0 -7.9 -8.1 -0.2 -18.4Integrated Urgent & Emergency Care -1.6 -1.9 -0.3 -8.2 -9.6 -1.4 -19.1Finance, Information & Estates -1.5 -1.4 0.0 -7.4 -7.1 0.2 -17.0Trust Administration -0.5 -0.5 0.0 -2.6 -2.9 -0.3 -6.1Human Resources and Organisational Development -0.2 -0.4 -0.2 -1.2 -1.4 -0.3 -2.5Nursing, Midwifery, AHP -0.1 -0.2 0.0 -0.7 -0.7 0.0 -1.7Medical Director 0.0 0.0 0.0 -0.2 -0.1 0.1 -0.4Quality Governance -0.2 -0.2 0.0 -0.8 -0.7 0.1 -1.9

Total (Divisions) -14.4 -14.9 -0.6 -73.8 -75.8 -2.1 -165.4

Non devolved income/expenditure/finance costs Plan Actual Var Plan Actual Var PlanIncome (not devolved) 14.7 14.8 0.0 73.0 73.3 0.3 179.3Capital Charges -0.6 -0.6 0.0 -3.0 -3.0 0.0 -7.2Finance Costs (inc donated asset income/depreciation) -0.2 -0.2 0.0 -0.9 -0.8 0.1 -2.2Centrally Held Funding* -0.3 0.2 0.5 -1.4 0.2 1.6 -8.5

Total 13.7 14.2 0.5 67.6 69.7 2.1 161.4

Trust Total -0.7 -0.7 0.0 -6.2 -6.2 0.0 -4.0

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



Plan Actual Plan Forecast Plan Forecast Plan Forecast

Deficit Plan (7.334) (7.334) (1.965) (1.965) (1.831) (1.831) (11.130) (11.130)

Variances to planCost Improvement Programme 0.321 (0.077) 0.021 0.265 ED & MAU (0.651) (0.226) (0.305) (1.182) Additional costs to deliver activity (0.196) (0.077) (0.040) (0.313) Costs of financial recovery (0.054) (0.036) (0.016) (0.106) Costs to deliver transformation programme (0.192) (0.047) (0.166) (0.405) Shackleton Ward & mainland placements (0.126) (0.019) (0.000) (0.145) Quality Investment funding 0.381 0.161 0.099 0.641 Medical staff pay award 0.117 0.035 0.040 0.192 NCA & RTA activity 0.117 0.037 0.014 0.168 Balance sheet review 0.065 0.210 0.275 Financing & Capital Charges 0.094 0.013 0.013 0.120 Non elective activity over performance 0.157 0.157 Other 0.168 0.081 0.088 0.337

Pre PSF/FRF (7.334) (7.289) (1.965) (1.963) (1.831) (1.874) (11.130) (11.126)

PSF/FRF 2.625 2.625 1.167 1.167 1.167 1.167 4.959 4.959

Surplus/(Deficit) (4.709) (4.664) (0.798) (0.796) (0.664) (0.707) (6.171) (6.167)

YTD position(£m)

M4 position(£m)

Q1 Actual(£m)

M5 position(£m)

Cost pressures continued into Month 5

Financial balance sheet reviews were necessary to offset costs and remain on plan

Month 5 Financial Performance (by Issue)

The table below summarises the YTD financial performance by the underlying issues which are driving the position. It highlights both areas of pressure and areas providing mitigation. The latter are ensuring that the Trust remains ‘on plan’ overall.



Month 5 CIP

CIP YTD DELIVERY & FORECAST (12-09-19) YTD CIP Delivery As at month 5 £2.1m

of savings (£1.1m recurrent and £1.0m non recurrent) have

been delivered against a phased plan of £1.8m

(overall delivery is ahead of plan).

CIP Forecast The latest divisional level CIP forecast is that £9.9m of CIP will be delivered by the end of the financial year. This is against a target to deliver £10.5m (forecast is £0.6m below target). The table (bottom left) analyses forecast delivery by division and by risk rating. 75% of the £10.5m CIP target is now either rated ‘Blue’ (delivered) or ‘Green’ (will deliver). Actions are ongoing to improve this.

Variance to Plan (over)/underRisk to deliveryRisk will be mitigatedProject will deliverDelivered

DIVISIONCIP Target

£'000Plan £'000

BLACK RED AMBER GREEN BLUETotal

Recurrent £'000

Non-Recurrent

Pipeline Est

£'000

Acute 4,526 3,993 515 - 431 2,711 869 4,011 681 937 Ambulance 309 314 43 158 108 266 11 Community 561 520 51 293 217 510 99 Corporate Nursing 51 45 0 3 70 73 27 ED 1,200 510 917 283 - 283 125 Estates & Facilities 381 536 53 210 118 328 265 475 Finance 145 344 0 16 687 703 70 HR&OD 322 386 122 192 8 200 5 IM&T 123 213 0 118 26 144 35 Medical 11 10 0 - 11 11 14 Mental Health 1,125 112 0 870 328 1,198 115 Performance Info 80 257 27 41 12 53 5 100 Quality 94 159 40 30 24 54 128 170 SWTT 13 13 0 13 - 13 - Trust Admin 166 200 0 68 144 212 - SUB TOTAL 9,108 7,612 1,049 - 431 5,006 2,622 8,059 1,580 1,682 Stretch 1,350 0 227 - 227 - TOTAL 10,458 7,612 2,172 - 431 5,233 2,622 8,286 1,580 1,682



Month 5 Balance Sheet

Summary The key balance sheets movements are as follows: • Reduction to Fixed Assets - reflects the low

capital expenditure so far in year • Increase in Debtors* - mainly due to accrued in

year non-tariff drugs and Acute activity over performance which is included as additional income above plan in the I&E position, and 5 months of PSF/FRF

• Decrease in Creditors* - mainly invoiced creditors, due to loan funding allowing payment of some overdue creditors

• Increase in Borrowings > 1 year – Because of delays in issuing the PSF/FRF short term loans equal to the amount due of £6.125m have been agreed and will be paid back on receipt of the earned allocation

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

Update for Month 5 required

Balance SheetM12

18/19Month

4Month

5In Month

Movement

Fixed Assets 111.5 110.0 109.6 -0.5

Stock 2.3 2.1 2.1 0.0Debtors 10.8 18.8 19.0 0.3Cash 4.5 5.9 3.9 -2.0

Creditors -18.9 -26.7 -25.4 1.3Capital creditors -2.2 -0.6 -0.5 0.0PDC dividend creditor 0.0 -0.4 -0.5 -0.1Interest payable creditor -0.2 -0.4 -0.3 0.0

Provisions < 1 year -0.2 -0.2 -0.2 0.0Borrowings < 1 year -0.1 -0.1 -0.1 0.0Net current assets/(liabilities) -4.1 -1.5 -2.0 -0.5

Provisions > 1 year -0.2 -0.1 -0.1 0.0Borrowings > 1 year -68.2 -74.9 -74.9 0.0Long term liabilities -68.4 -75.0 -75.0 0.0

Net assets 39.0 33.5 32.6 -0.9

Taxpayer's equityPublic dividend capital 7.9 7.9 7.9 0.0Retained earnings -2.4 -7.9 -8.8 -0.9Revaluation reserve 33.6 33.6 33.6 0.0Other reserves 0.0 0.0 0.0 0.0Total tax payer's equity 39.0 33.5 32.6 -0.9



Summary The cash balance held at the end of August is £3.9m, a £2.0m decrease on the previous month. This is mainly due to the decision not to request loan funding in August in order to keep interest costs down, and the need to maintain the £1m balance. The Month 5 cumulative I&E deficit of £6.2m is adjusted for depreciation (£2.5m) as it does not impact on cash. The charges for Interest Payable/Receivable (£0.8m) and PDC Dividend (£0.5m) are also added back as the amounts actually paid for these expenses are shown lower down for presentational purposes. This generates a YTD cash ‘Operating Deficit’ of £2.4m. The net impact of changes in working capital, payments for capital expenditure and an increase in working capital loans combine to generate the £2.0m overall reduction in the cash position. The Trust has requested a draw down of £3.5m in lieu of PSF & FRF in order to support the cash position and maintain the minimum £1m cash balance.

Month 5 Cash



Summary As at month 5 capital expenditure is marginally (£0.03m) ahead of the year to date plan. A decision to re-life IM&T Assets has the effect of reducing available capital spend by £0.3m. However the sale of The Gables could reinstate £0.3m from the Net Book Value of the property once NHSI approval has been received. Plans for the £48m allocated to the Trust will be decided in due course with process and timings of the funding yet to be confirmed.

Month 5 Capital

2019/20 Capital Programme

Source of Funds Original Plan'£k

20% Reduction

Plan '£k

Revised Plan '£k

CRL based on depreciation 6,337 6,337 6,337Depreciation Re-Lifing (327)National Reduction (1,106) (1,106)Return of National Reduction 1,106Donated Assets 50 50 50

Total Source of funds 6,387 5,281 6,060

Application of Funds £k £k £kIM&T RRP & New Schemes 500 677 710Equipment RRP 500 549 648Backlog Maintenance 651 546 542Shackleton interim 200 330 330Shackleton reprovision 800DSU 1,040ED Paediatrics 200 696 696Backup Generators 916 917 917Relocation CMHS 1,300Fire Compartment Remediation 230Urgent Care 300 300OPD Relocation 950 1,020Staff Capitalisation 200 200Unallocated 66 647Donated Assets 50 50 50

Total Application of Funds 6,387 5,281 6,060



The Trust’s Use of Resources Rating is a ‘4’. This is against a score of 1 being best and 4 being worst. The Trust is currently achieving all UoR ratings as per its financial plan (table top left) however as the Trust is under Financial Special Measures the overall UoR rating will override to 4.

As the Trust is under Financial Special

Measures the overall UoR rating will default to ‘4’.

Finance & Use of Resources Risk Rating

Use of resources risk rating summaryPlan

RatingActual Rating Var

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

Overall Risk Rating 3.2 3.2

Risk rating after overrides 4.0 4.0


Enc N Agenda Item No 8.1 Meeting Trust Board in Public Meeting Date 10 October 2019

Title Acute Performance Report for Month 5 August 2019

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


Acute Performance Committee Oct 2019 Retrospectively due to change in board meeting timetable from October Acute Board meeting October 2019 Retrospectively Performance Committee 9 October 2019

Key Recommendation The Acute Division Monthly Summary Report is set out in the attached presentation and provides an overview of activity and performance within the Division for August 2019 (month 5). This monthly Summary Report is produced from a number of data sources, which are all reported through the Acute Division’s Quality, Performance and Board meetings. The Trust Board will continue to receive separate reports for each area, i.e. Acute, Ambulance and Integrated Urgent and Emergency Care (IUEC) The Trust Board are asked to receive the monthly Acute performance summary for Month 5 (August 2019) for assurance.


Link to CQC Domains




X

Review & discuss

Patient Confidentiality

Caring X SO 02: Ensure efficient use of resources X

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

Committee Agreement





Executive Summary RESPONSIVE – Constitutional Targets RTT Position at M5 70.4% – The Trust continues to hold its current level of performance against the RTT incomplete target. The achievement of planned levels of activity combined with the other actions previously outlined have stabilised the position. A plan has been agreed to over-perform in orthopaedics and urology over the next three months to make further progress. The System Recovery Plan is predicated on improving the RTT incomplete standard, reducing treatment waiting times initially, by December 2019 to a maximum wait of 40 weeks and eliminate 52 week waits in all specialities. Key objectives • The elimination of >52 week waits for patients in all specialties • Improvement of booking efficiency from 50% to 70%; • The reduction of average waiting times from the current 75th percentile of 28 weeks to 18; • Improve Theatre throughput by 20%; • A validated waiting list; • The reduction of “on the day” cancellations across all specialties by 50%; • Improvements in patient experience and the patient journey; • Facilitate choice for long wait patients where possible; • Achieve compliance with the Choice of Faster Treatment 26 Weeks by 31st of March 2020. CANCER In August 2019 the Trust provisionally achieved all measurable Cancer Waiting Times standards with the exception of 62 day target. 58 treatments are recorded for August. This is an increase on the average of 40-45 per month and has positively impacted on performance against the 62 Day standard. 79% is currently achieved against the trajectory of 80% and the 85% standard. This is better than the same period in 2018/19. 12 breaches were recorded: 9 local and 3 shared with tertiary centres. These figures are provisional pending upload at the beginning of October and are subject to change based on the submission of the shared breaches by the tertiary centres. Various actions continue to ensure the cancer target for the 62 day standard, which include extra prostate clinics now reserved for 2ww patients to avoid delays. Improved collaboration with PHT to discuss long waiting times for Prostate investigations and treatments. The Wessex Cancer Alliance Inter-Provider Transfer Group are working towards a policy to regulate waiting times for investigations and treatments at tertiary centres. Additional capacity in Endoscopy agreed to reduce pathway delays. Future actions include the Implementation of local Prostate fusion biopsy service planned for November 2019. A straight to Test Colorectal pathway to commence November 2019 and Site Specific MDT Co-ordinators commenced new roles in September 2019.

Executive Summary continued

RESPONSIVE – Constitutional Targets DIAGNOSTIC WAITING TIMES The diagnostic target achieved 98.4% against a trajectory of 98.3% and a target of 99%. The diagnostic return has shown an improvement each consecutive month over last year’s figures. Overall capacity within Endoscopy is still the main concern with regard to achieving and sustaining the Diagnostic target. Two weekends lists of additional of Endoscopy patients has been undertaken by an outsourcing service however additional lists are required due to maintain flow within the service. The business case for additional resource in endoscopy was approved in principle at the Trust Leadership Committee and Financial Recovery Board in August. Confirmation from the CCG in support of the additional finance is needed for approval. FINANCE The Division at Month 5 were overspent by £515k year to date and are overspent in month by £35k and have seen a reduction in non pay spend compared to M4 and an underspend on pay MDT income – Negotiation continues to secure correct funding from NHSE - £224k FYE Over-performance of Acute SLA on non elective activity continues - £157k YTD Year-end Forecast to be remodelled with additional income and improved position of Acute Management CIP reporting for Month 5 has indicated yearend over delivery of £303k Additional CIP plans required as 7% further CIP stretch has been allocated to acute WELL LED Staff Engagement - the Division have now implemented weekly visits to services by Senior Managers to receive feedback and be available to talk to staff. Monthly drop in sessions have also been put in place for the First Monday of each month 9-10am in the Conference Room for staff to come along and talk to senior managers. A communication plan is underway to promote this. A recent JAG visit was undertaken in Endoscopy to re-evaluate their accreditation. A full report will be expected in the next 6- 8 weeks once this has been through their Quality Assurance process. Initial feedback from the assessors on the day was positive in terms of the accommodation, safe practice, patient care and care group leadership. Whilst it was identified that development for nurse Endoscopists was established, development within the rest of the team required improvement. A 10 week improvement plan has also been implemented. It is anticipated the outcome will be a potential deferment of accreditation for a period of 6 months.

Executive Summary Continued………….

SAFE - A Never Event was reported in the Division within Endoscopy that has been declared as a Serious Incident (SI). Immediate Root Cause Analysis (RCA) process was undertaken and initial findings indicate that processes were not adhered to and further investigations to establish how are now being completed. The Acute Quality Committee will receive an assurance report to ensure that all areas within the division are following required processes. Serious Incidents for the Division reported were a total of 28 open with 9 overdue and the care groups continue to focus on ensuring these incidents are responded to within the required timelines. No Grade 3 or 4 pressure ulcers were reported for the Division. Duty of Candour compliance levels continue to increase with Clinical Support, Cancer and Diagnostics (CSCD) meeting 100%, Medicine at 100% and Surgery Women’s and Children’s Health (SWCH) 90% as at August 2019. Complaints for the Division at the end of August totalled 16 open with 4 overdue, this is an improved position. Monthly Pulse Survey results since April 2019 have shown an increase in the number of responses received. Communication between managers and staff remains one of the areas of concern and staff engagement visits and drop-in sessions will improve this. Divisional sickness rates for August has seen a decrease overall reporting at 4.65% which still remains above the trust target but has decreased from 5.26% last month. WORKFORCE - There are currently 171.5 FTE vacancies across the division. Looking forward, the resourcing triangulation data for each care group will be provided from next month’s report. It will detail the number of vacancies and impact to performance, quality and finance for the division. Job Planning status across the Division as at 2 August is CSCD at 100% for all Job Plans, SWCH 41% and Medicine 53%. Those remaining are all in the discussion phase. This is monitored through the Care Group Directors Forum by the Medical Director and the Acute Board . A case for additional support to support SWCH has been requested by the Executive Team. EFFECTIVE - Appraisal compliance rate for the Division at the end of August was 91%. This performance continues to be closely monitored through the Divisional Board. The few appraisals that remain outstanding are booked in with relevant managers. Mandatory training compliance rates remains above 89% across the division and has consistently remained above the trust target of 85% across all care groups. The area below the target for compliance is resuscitation training and further sessions have been provided for staff to improve compliance levels. We are looking at providing further training sessions utilising trained qualified staff internally to increase the availability of this training. Discharge summaries - There has been an improvement in completion rates since August. 75% of summaries were achieved within 24 hours but within a few days the completion rate rose to 96%. This suggests that summaries are continuing to be completed soon after discharge if not on the day. There remains hot spot areas within Medicine, MAU and SDEC. The medical director has also put in additional medic support. CARING - Patient Survey (MES) results. Quality Governance are working with the communications team to do a campaign to encourage feedback using different mechanisms to do this. ACUTE RISKS - There were 4 new risks rated 12 and above for August 2019 and 4 closed in month. The top risks rated 15 and above for each of the care groups were reviewed at the Acute Board and by care group are;

• Medicine - Stroke Services impacted by workforce issues and unable to deliver sustainable service • CSCD- Oncology -Oncology Service Contract between providers / CSCD - CAFT / 6 week backlog / PIDS reporting issue – Lack of

Capacity within Endoscopy • SWCH - Risk that Inadequate Capacity Within Paediatric ADHD Service impacts patient standards and staff

Responsive- RTT Incomplete Performance Commentary:

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

18/19 84.1% 85.2% 85.1% 84.5% 82.0% 81.1% 80.8% 81.0% 81.6% 80.6% 79.3% 77.2%

19/20 75.7% 73.3% 71.4% 71.7% 70.4%

Target 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0% 92.0%

Trajectory 78.5% 77.5% 79.1% 78.3% 77.7% 77.9% 77.4% 77.3% 74.6% 75.0% 75.9% 75.7%

Referral to Treatment Times

Issue:Position at M5 70.4% – The Trust continues to hold its current level of performance against the RTT incomplete target. The achievement of planned levels of activity combined with the other actions previously outlined have stabilised the position. A plan has been agreed to over-perform in orthopaedics and urology over the next three months to make further progress.

Actions - the Trust/CCG Executive Led Planned Care Transformation Board continues to meet and has agreed a programme of work. Focus has been on identifying schemes, working up plans and diverting resources to deliver quick wins and higher impact schemes.

The actions previously reported to improve the elective activity levels continue to be implemented, in particular:• Bed Capacity remains ring fenced on Mottistone avoiding delays to Orthopaedic surgery. Ring fenced elective surgery capacity will be created by the start of October. • The Trust will continue to work closely with its partners to expedite discharges of medically fit patients• The plan for long waiting patients is reviewed at patient level on a weekly basis to monitor any variation to plan• 6:4:2 theatres scheduling meeting to ensure optimal booking of lists in urgent and date order

Additional actions include:Promoting choice for existing long waiting patients and new referrals.Ensuring improvements are made in booking patients in order for elective surgeryAdditional validation support (three external validators now working on the PTL).

Target - Within normal variation so may be achieved but not consistently

Trajectory - Within normal variation so may be achieved but not consistently

(4.0%)

(2.0%)

-

2.0%

4.0%

Perf

orm

ance

M

ovem

ent

Rese

t Usi

ng 1

7/18

as

base

line Winter pressure

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Perf

orm

ance

Data Average Upper Lower Outside Relative to Average Movement Target Trajectory

Responsive – System Recovery Plan

Commentary: The plan is predicated on improving the RTT incomplete standard, reducing treatment waiting times initially, by December 2019 to a maximum wait of 40 weeks and eliminate 52 week waits in all specialities. Key objectives • The elimination of >52 week waits for patients in all

specialties • Improvement of booking efficiency from 50% to 70%; • The reduction of average waiting times from the current

75th percentile of 28 weeks to 18; • Improve Theatre throughput by 20%; • A validated waiting list; • The reduction of “on the day” cancellations across all

specialties by 50%; • Improvements in patient experience and the patient

journey; • Facilitate choice for long wait patients where possible; • Achieve compliance with the Choice of Faster

Treatment 26 Weeks by 31st of March 2020.

Inpatient Long Wait Recovery Trajectory

Day Case Long Wait Recovery Trajectory

Responsive - Cancer Targets Commentary:


18/19 73.4% 66.7% 72.6% 81.8% 70.5% 77.0% 76.7% 71.1% 76.5% 80.0% 72.9% 65.5%

19/20 62.9% 67.8% 77.9% 75.6% 78.6%

Target 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0%

Trajectory 67.5% 70.0% 72.5% 75.0% 80.0% 82.5% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0%

Cancer urgent referral to treatment <62 days*

Issue: In August 2019 the Trust provisionally achieved all measurable Cancer Waiting Times standards with the exception of 62 day.

58 treatments are recorded for August. This is an increase on the average of 40-45 per month and has positively impacted on performance against the 62 Day standard. 79% is currently achieved against the trajectory of 80% and the 85% standard. This is better than the same period in 2018/19. 12 breaches were recorded: 9 local and 3 shared with tertiary centres. These figures are provisional pending upload at the beginning of October and are subject to change based on the submission of the shared breaches by the tertiary centres.

The 62 Day standard is recognised as a huge challenge across the Wessex Region and nationally.

Actions:• Friday morning Prostate clinics now reserved for 2ww patients to reduce pathway delays• Improved collaboration with PHT: monthly strategy meetings and weekly telephone conversations to discuss long waiting times for Prostate investigations and treatments• Wessex Cancer Alliance Inter-Provider Transfer Group working towards a policy to regulate waiting times for investigations and treatments at tertiary centres.• Additional capacity in Endoscopy to reduce pathway delays

Additional actions include:• Implementation of local Prostate fusion biopsy service planned for November 2019• Straight to Test Colorectal pathway to commence November 2019• Site Specific MDT Co-ordinators commenced new roles in September 2019



(30.0%)(20.0%)(10.0%)

-10.0%20.0%30.0%

Perf

orm

ance

M

ovem

ent

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

110.0%

Perf

orm

ance


Responsive -Diagnostic Waiting Times Commentary:


18/19 97.9% 97.5% 95.2% 90.3% 91.5% 96.1% 98.6% 98.8% 98.0% 92.0% 92.0% 93.8%

19/20 95.4% 94.9% 96.8% 97.9% 98.4%

Target 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0% 99.0%

Trajectory 89.2% 90.5% 93.5% 97.6% 98.3% 98.7% 99.0% 99.4% 99.6% 99.2% 99.6% 99.1%



Patients waiting > 6 weeks for diagnostics

The diagnostic return achieved 98.4% against a trajectory of 98.3% and a target of 99%. The diagnostic return has shown an improvement each consecutive month over last year’s figures. Overall capacity within Endoscopy is still the main concern with regard to achieving and sustaining the Diagnostic target.

Actions:

Two weekends lists of additional of Endoscopy patients has been undertaken by an outsourcing service however additional lists are required due to maintain flow within the service.

The business case for additional resource in endoscopy was approved in principle at the Trust Leadership Committee and Financial Recovery Board in August. Confirmation from the CCG that they will support the additional finance for both additional endoscopy lists to maintain this position and the resource required within the business case is needed for approval.

(8.0%)(6.0%)(4.0%)(2.0%)

-2.0%4.0%6.0%

Perf

orm

ance

M

ovem

ent

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

Perf

orm

ance


WL 6+ Wks % <6 WksMagnetic Resonance Imaging 108 0 100.0%Computed Tomography 249 0 100.0%Non-obstetric ultrasound 288 1 99.7%Barium Enema 0 0DEXA Scan 0 0Cardiology - echocardiography 53 0 100.0%Neurophysiology - Nerve conduction studies 38 0 100.0%Respiratory physiology - sleep studies 62 0 100.0%Urodynamics - pressures & flows - Urology 8 3 62.5%Urodynamics - pressures & flows - Gynae 8 0 100.0%Colonoscopy 174 11 93.7%Flexi sigmoidoscopy 46 3 93.5%Cystoscopy 42 1 97.6%Gastroscopy 90 0 100.0%Total 1166 19 98.4%

Area Service

Imaging

Physiological Measurement

Endoscopy

Aug-19

Use of Resources – Acute Division – Month 5

Next Steps: • Weekly check &

challenge meetings monitor financial expenditure and identify further CIP opportunities

• Continue to develop the pipeline of opportunities to close the recover the financial position

• Identify plans to deliver against the Trust revised financial plan and additional 7% CIP stretch target

HEADLINES: • The Division are overspent in month by £35k

and have seen a reduction in non pay spend compared to M4 and an underspend on pay

• MDT income – Negotiation continues to secure correct funding from NHSE - £224k FYE

• Over-performance of Acute SLA on non elective activity continues - £157k YTD

• Year-end Forecast to be remodelled with additional income and improved position of Acute Management

• Assumes CIP delivery of £5,354k against plan of £4,526k = £828k over delivery

• CIP reporting for Month 5 has indicated yearend over delivery of £303k

• Additional CIP plans required as 7% further CIP stretch has been allocated to acute

YTD Plan £37.8m Actual £38.2m Variance £0.5m

Other £0.2m

£300k Increase in

baseline income from

NHSE

£428k income for Compton

£35k overspent in

month

£200k Activity

driven costs

KPI Budget In-post Variance

In post v Budgeted FTE

1425.75 1302.43

-123.32

In month YTD Trust In Month

Trust YTD

Turnover 1.91% 11.52% 1.97% 11.32%

In month YTD KPI Target RAG

Sickness * 4.76% 5.52% 3.5%

Appraisal** 91.03% 91.03% 85%

Mandatory Training ***

89% 89% 85%

Care Group % Compliance

CSCD 95%

Gen Med 88%

SWCH 88%

Acute Overall 91%

Appraisal Compliance 31 Aug 19

Actions taken to support management plans of absence; Deep dives with the HR Business Partner into the management of absence continue across the division. HSDU (28th August), ITU (30th August), Appley, Colwell and Stroke scheduled for 2nd/3rd October. Outcome of deep dives; Management plans in place, a number of cases assigned to HR Officer Team for ongoing support, OH advice sought on a number of cases

Sickness

Vision: To Become a Centre of Excellence for Care of the Elderly

Acute Division ‘Operational Plan on a Page’

WORKFORCE

• Development of workforce model

• Workforce Structure

• Development of Staff Engagement Strategy

• Increasing staff morale to improve retention levels

• Recruitment of Overseas Nurses by July 2019

PERFORMANCE

• Operational Model to be agreed and implemented by 31.3.2020

• Systems Resilience through demand and capacity modelling

• Contract Negotiation to improve cancer services and demand growth

• Improve Sickness Absence levels to trust targets

IMPROVED FINANCIAL CONTROL

• Achievement of

financial recovery by Sept 2019 and reducing reliance on locums and agency

• Cost improvement plans fully realised and in place by September 2019

• System opportunities through redesign of service areas within Acute through system sustainability plans

• Capital plans improving productivity with planned improvements to service areas

PARTNERSHIP WORKING

• Integrated

service delivery with key stakeholders to improve patient flow

• Support the Island’s development of Primary Care Networks

• Work with Community to support out of hospital onwards care strategy

DRIVING DEVELOPMENT OF DIVISION AS PART OF INTEGRATED

TRUST • Reconfigured &

reduced inpatient bed base to meet patient demand and support transition to community

• Digital maturity in our back office functions

• Sustainable, locally developed workforce

• Centre of excellence for care of the elderly

We will achieve this through:

Measures of Success: • 30% reduction in Divisional vacancies • 40% reduction in use of Agency/Locum • Reduction in staff turnover • Improved utilisation of acute estate • IT strategy and implementation plan in place to improve IT support across Division • 10% improvement in staff survey results in key improvement areas • Effective financial management – operate within financial allocation in 2019/20

IMPROVING QUALITY

• Quality Improvement training for all staff

• Audit programme plan by end of Q1

• Acute Urgent & Emergency care improvement programmes

• Patient Engagement Strategy

• GIRFT engagement to support efficiencies and ongoing reviews of services

• Accreditation of Diagnostic Services

Enc O


Title Ambulance Service Trust Board Report

Sponsoring Executive Director Joe Smyth, Chief Operating Officer, Acute and Ambulance Services

Author(s) Victoria White, Head of Ambulance


Ambulance Divisional Board – 20 September 2019 Performance Committee 9 October 2019

Key Recommendation The Trust Board is asked to receive this report.


Link to CQC Domains


Information only X Commercial Confidentiality


X

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


Committee Agreement





X

Executive Summary

The division’s Quality, Performance and Divisional Board Meetings took place 20th September 2019. The purpose of this report is to provide an overview of the key current opportunities, issues, challenges or risks affecting the division. Key Items of Information for Trust Board: Quality and Safety:

• The service remains non-compliant with National Ambulance Resilience Unit/NHS England cores standards. The ambulance service and trust Emergency Planning, Resilience and Response lead have met with NHSE to review the 167 re-written core standards. A draft Service Level Agreement has been received by South Central Ambulance Service which will address a number of the non-compliant areas. Areas that remain unresolved are numbers of trained staff required for MTA; medical forward plan and sign off of Service Level Agreement.

• Ambulance appraisal at 64.92% and mandatory training at 83% . • No new Serious Incidents declared in August, no new risks opened, no new complaints received in month. • The service has experienced continued issues with the telephony and connectivity of the electronic patient care record. Whilst

they have currently been addressed and actions are in place to mitigate, the current telephony system does not support the requirements of a modern 999/111 control room. A business case is being written to replace the system.

• In the CQC Inspection Report the NHS 111 service was rated Good, Urgent and Emergency Care service rated Good, Emergency Control Centre and Patient Transport service rated Requires Improvement

2 Must Do’s raised in the recent inspection report (both PTS) • Ensure PTS vehicles are clean and safe to use for intended purpose • Processes in place to assess, monito and improve quality and safety of service

Actions plans regarding these and the 11 should do’s have been put in place. Operational Performance: The August performance for the 999 Ambulance Response Programme standards and NHS111 standards are attached as appendix 1 and were discussed in detail at the Ambulance Divisional Performance subcommittee and Ambulance Divisional Board. In summary;

• Performance for 999 has deteriorated over the summer, although August has seen a slight improvement across all standards. Standards are not being met consistently.

Executive Summary • The service commissioned a capacity modelling report through South Central Ambulance Service which demonstrates that the

service is under capacity in relation to fleet/crews in order to meet the national standards consistently. • The service has planned a perfect week w/b 5th October to model the resourcing advised in the modelling report and will

measure the impact on performance and business as usual during this week. • The NHS111 performance standards are also attached in appendix 1 and demonstrate a slight improvement in the call handling

standards. The service has further vacancies which will impact on performance. Recruitment is underway to fill these positions. • The Patient Transport Service continues to operate with a manual workaround for their Computer Aided Dispatch which has

been in place since October 2018 in place since the 999 Computer Aided Dispatch implementation and has now implemented a manual collection of reporting data. Progress is underway to implement the Patient Transport Service Computer Aided Dispatch

Programme items:

• The programme to implement the new Patient Transport Service Computer Aided Dispatch system has now commenced • Integration of Electronic Patient Care Record to the Computer Aided Dispatch is now complete although there have been

significant connectivity issues recently. A review is underway to determine cause and sustainability. • A business case is being written to replace the 999/111 telephony system in conjunction with South Central Ambulance

Service. An initial meeting between the 2 services is being planned to review the specification. • The National Programme to replace use of radio communications used by ambulance, police and fire is underway. The IOW will

be the first ambulance service in the country to go live. First step in the programme is the implementation of a new control room solution which will take place before December 2019.

• The Quality Improvement Programme has been reset, and consists of 6 work streams including National Ambulance Resilience Unit, CQC, Carter review recommendations. Workforce, training and development plan, divisional/staff communications. First workshop relating to communications is planned for 3rd October.

Key Items of Risk: • Information Technology capacity to support the significant upcoming Ambulance programmes and day to day operations. • 999/111 performance. • Patient Transport Service capacity to support increased in mainland transfers/ timely discharges. • Sickness levels across the service and subsequent impact on resilience, performance and staff capacity. • Appraisal rates.

Performance Summary

Initial Performance report August 2019

Overall Position – M5 2019/20

Subjective

Class Budget Actual Variance Budget Actual Variance

PAY 633 631 (2) 3,190 3,238 48

NON-PAY 191 181 (10) 924 903 (21)

INCOME (27) (25) 2 (135) (134) 1

Grand Total 797 786 (10) 3,980 4,008 28

In month (£000s) YTD (£000s)

In month £15k adastra

adjustment = revised position, M5 underspend £15k and YTD

overspend £13k

CIP Plan M5 CIP Actual M5

£33k £44k

Working with our Island partners and others, we will be national leaders in the delivery of safe, high quality, and compassionate integrated care; putting those who use our services at the centre of all

we do

IOW Ambulance Service, 'Operational Plan on a Page’

WORKFORCE

• Development of workforce model to meet operational model and Integrated Urgent Care agenda


• Implementation of Staff Engagement Strategy


PERFORMANCE

• Operational Model to be agreed and implemented by 31.3.2020

• Systems Resilience through demand and capacity modelling

• Contract Negotiation to improve 999, 111 and patient transport services services and demand growth

• Improve sickness absence levels to trust targets

IMPROVED FINANCIAL CONTROL • Achievement of

financial recovery by Sept 2019

• Achievement of Cost improvement plans

• System opportunities through redesign of service areas within ambulance through system sustainability plans and partnership working


PARTNERSHIP WORKING

• Integrated

service delivery with key stakeholders to identify alternate appropriate clinical pathways

• Support the Island’s development of Primary Care Networks

• Work with Community to support out of hospital onwards care strategy


TRUST • Reduce

conveyance to emergency department, increase hear and treat and see and treat rates by working with system partners to identify alternate pathways of care

• Digital maturity in our back office functions

• Sustainable, locally developed workforce


Measures of Success: • Reduction in sickness • Increase in hear and treat • Increase in see and treat • Increase in conveyance to non emergency department • Information technology strategy and implementation plan in place to improve information technology support across service • 10% improvement in staff survey results in key improvement areas • Effective financial management – operate within financial allocation in 2019/20

IMPROVING QUALITY

• Quality Improvement training for all staff

• Audit programme plan by end of quarter 1.

• Patient Engagement Strategy

• Education and continuing professional development Programme for staff


Ambulance Business Plan 2019-20 Summary timeline

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Workforce Recruitment &

retention

Quality Improvement Schemes

Financial recovery & Cost Improvement

Plans

Performance Improvement

[Milestone – FTE out]

[Milestone – FTE in]

[Milestone – Investment (£)] [Dependency / link]

[Project / Scheme] [Milestone – Improvement achieved]

[Milestone – Cost out (£)]

Operational model

Volunteer recruitment

Contract renegotiation

Sickness management

Education programme

Audit

Patient engagement strategy

CP development

Staff Engagement Strategy

Workforce structure

Workforce Model

Staff Morale

Financial Recovery (income)

CIP plans

System Opportunities

Capital Plans


Enc P


Title Urgent and Emergency Care Report for August 2019

Sponsoring Executive Director Joe Smyth, Chief Operating Officer Acute and Ambulance

Author(s) Liz Wells, Interim Associate Director of Operations/Michaela Morris, Operations Manager and Rachel Buswell-Green, Operational Support Officer for ED and MAU


Integrated Urgent & Emergency Care Team Meeting on 1st October 2019 Performance Committee 9 October 2019

Key Recommendation The Trust Board are asked to note the fall in Emergency Care Standard (ECS) performance over the month of August to 67.72% and the actions in place to rectify this position. It also is of note, the continued high use of agency which is the main factor for the £1.3m overspend YTD.


Link to CQC Domains




X

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


Committee Agreement





Executive Summary

There continues to be a challenge in relation to the Organisational delivery of the Emergency Care Standard, particularly within August, which saw the very high number of 4 hour and 12 hour breaches reported due to high patient attendances and low patient flow throughout the Trust. However, friends and family test results continue to recognise the standard of care provided to patients in times of extreme pressure. Safe: • 6 complaints and 8 concerns received for August. Common themes for complaints include: Clinical care, admissions & discharges,

staffing numbers and patient care • 108 Incidents reported for Emergency Department (ED) and 42 reported for Medical Assessment Unit (MAU) and 0 incident reported for

the Urgent Care Service (UCS) • 164 outstanding incidents for ED and MAU • 27 - 12 hour breaches reported for August • 67.72% ECS compliance for August (77.1% Year to Date) Caring: • 5 compliments received for August • 64.2% family and Friends testing (ED) • 95.4% for MAU and SDEC family and Friends testing • Common themes are in relation to staff being friendly, compassionate and helpful • 93 positive feedback comments for the Urgent Care Service Effective: The current appraisal rate for ED remains challenging at 58% completed for August. Work is taking place with the support of the Matron and Nurse Consultant to ensure that there is a robust plan in place for the division to be 100% by the end of December 2019. The ability to undertake appraisals has been directly affected by patient flow and staffing shortages. The UCS are 100% compliant for appraisals. Mandatory training compliance has increased to 83%. Support is being offered by the Matron to improve this. Well-led: Current absence rate across ED / MAU stands at 4.86%, which has increased since June. A deep dive into all department sickness by the Matron with support from HR is taking place. Finance: The budget is currently £1.3 million overspent. This is mostly due to high agency usage. Weekly finance checkpoint meetings are taking place with the Interim Associate Director of Operations.

Urgent and Emergency Care Report for August 2019 Front Door Metrics:

Key Area Metric Reported Figure Target Rationale Target 03/08/2019 10/08/2019 17/08/2019 24/08/2019 31/08/2019 07/09/2019 14/09/2019

ED 4 Hour Performance - All Types 7 Day Rol l ing Average National 85% 77.4% 79.7% 72.1% 72.6% 71.9% 75.2% 70.3%

Emergency Care 4 Hour Standard - Admitted 7 Day Rol l ing Average Local ly Defined 85% 34.2% 35.1% 14.1% 13.4% 17.9% 24.5% 16.6%

Emergency Care 4 Hour Standard - Non Admitted 7 Day Rol l ing Average Local ly Defined 85% 88.5% 91.8% 85.2% 86.2% 83.2% 86.3% 86.8%

Bed Occupancy % (based on agreed local definition) 7 Day Rol l ing Average Local ly Defined 92% 98.1% 99.5% 101.0% 98.4% 97.6% 98.1% 98.3%

90th Percentile Length of Stay in MAAU (hours) 7 Day Rol l ing Average Local ly Defined < 48 Hrs 42:42 47:44 70:48 69:43 52:09 86:35 54:19

Number of patients streamed away from ED 7 Day Rol l ing Average Local ly Defined 17% 8.0% 7.1% 6.8% 8.6% 7.3% 6.2% 4.8%

Average Time to Triage (Minutes) 7 Day Rol l ing Average Local ly Defined 15 Mins 30 20 59 51 59 35 48

Average time from Triage to Exam (Majors) 7 Day Rol l ing Average Local ly Defined 45 Mins 77 62 151 73 86 68 77

Average Time from Exam to Referral (Minutes) 7 Day Rol l ing Average Local ly Defined 90 Mins 109 105 104 113 111 108 91

Average Time from Referral to Response

Average Time from Specialty Response to DTA

Average Time from Exam to Dishcarge (Non Admitted) 7 Day Rol l ing Average Local ly Defined 180 Mins 123 116 127 144 145 138 145

Average Time from DTA to Admission 7 Day Rol l ing Average Local ly Defined 30 Mins 241 247 519 434 270 233 326

% Safety Huddles Conducted

Number of Hours > 30 Patients in ED / Day 7 Day Average Local ly Defined 5 Hours 15 10 20 16 19 13 17

Number of Days of Suboptimal ED Staffing

GP Direct Admissions to MAAU/SDEC 7 Day Tota l Loca l ly Defined TBC 9 2 2 2 1 1 1

All Admissions to SDEC 7 Day Tota l Loca l ly Defined TBC 50 55 49 41 45 50 55

Surgical Admissions to SDEC 7 Day Tota l Loca l ly Defined TBC 5 5 1 7 5 2 2

Length of Stay MAAU < 48 Hours 7 Day Rol l ing Average Local ly Defined 95% 86.4% 88.8% 69.8% 74.2% 87.1% 74.7% 80.6%

Number of patients IATed 7 Day Rol l ing Average Local ly Defined

Cumulative Weekly Discharges 7 Day Tota l Loca l ly Defined 250 216 190 155 200 188 177 186

Average Time of Discharge from Ward 7 Day Rol l ing Average Local ly Defined <14:15 15:35 16:17 15:32 15:53 15:43 16:06 15:46

Cumulative Weekly Use of Discharge Lounge 7 Day Tota l Loca l ly Defined 80 26 29 36 39 27 37 35

% of Patients with a Valid EDD Weekly Snapshot Loca l ly Defined 98% 91.1% 93.2% 93.2% 94.3% 91.1% 94.4% 91.7%

Patients with a >7 Day LOS 'Stranded Patients' Weekly Snapshot Loca l ly Defined 124 109 114 119 105 107 109 109

Patients with a >21 Day LOS 'Super Stranded Patients' Weekly Snapshot National 39 50 49 43 40 45 43 43

No Data

Front Door

No Data

No Data

No Data

Trust

No Data

Inpatients

Urgent and Emergency Care Report for August 2019 Performance:

Action plan to recover performance: • Matthew Cooke is supporting the team to implement quality improvements e.g. urgent care floor estates plans • Sue Everington and Helen Armstrong are working on improving nursing competencies and implementing staffing and

department changes to improve efficiency • A new Clinical Care Group Director will be joining the Trust in September to support with clinical leadership • The Trust has a robust action driven system for managing Long Length of Stay (LLOS) with daily reviews and executive

oversight. The Trust is able to identify and escalate internal and external concerns to system partners. NHSI gave positive feedback during their visit on 18th October. LLOS continues to see a steady improvement

• Home for lunch continues to require improvement – highlighting patients for discharge 72 hours in advance is critical to ensuring safe and proactive early discharge with all members of multi disciplinary teams progressing the discharge plan

• The discharge lounge see’s an average of 8 people per day, this improves with registered nursing oversight however this funding is not approved

• An average of 58 patients per week are being streamed to Same Day Emergency Care. New referrals guidance is being completed with the aim to increase this figure in September

• The Urgent Treatment Centre will be functional from 19th November and will support the streaming and treatment of minors patients away from ED, which will see an improvement in the ECS compliance

Urgent and Emergency Care Report for August 2019 Performance – Medical Assessment Unit (MAU): Average length of stay (more than 48 hours) for August: 81.26% (target: 95%) One of the main reasons for this is due to poor patient flow experienced by the Trust during August, which saw unprecedented numbers of ED attendances and low level of patient discharges from wards. The table below shows the number of admissions, transfers and discharges recorded by MAU for August 2019. The number of discharges shown below includes patients deaths whilst on the ward.

August 2019 Number of admissions Number of Transfers Number of discharges

527 289 238

Plan YTD £3.47M Actual YTD

£4.48M Variance YTD

£1.01M

Nursing Agency

Premium £145K

Medical Agency/Locum

Premium £641K

ACP/ENP Vacancies

(209k)

Agency Jr Dr cover for flow

£73K

24/7 Nursing agency cover

for flow £147K

External Consultancy

£165K

Overspent is as a result of high agency usage, covering 7-day services and increased length of stay Plan: • Review and amend nursing and medical

cover for ED, MAU and Urgent Care Service

• Gain support from HR with recruitment to current vacancies

• Begin budget planning for 2020/21 • Weekly finance check points meetings

are taking place to maintain grip and control of the financial position

Finance:

Urgent and Emergency Care Report for August 2019

HR:

Appraisal status for August 2019 (as held by the Division): Org L4 Assignment

CountAppraisals booked

% booked Appraisals Completed

Completed %

ED J6123O 38 10 26.32% 10 26.32%

MAU J61231 33 25 75.76% 30 90.91%

ED-Non Cl inica l J61238 13 11 84.62% 9 69.23%

ED - MAU Management J61239 2 2 100.00% 1 50.00%

Urgent Care Service 14 14 0.00% 14 100.00%

86 48 55.81% 50 58%

Action Plan: • Support offered by the Interim Consultant

Nurse in undertaking appraisals for staff who remain outstanding

• New tracking methods are being put in place so those without an appraisal are easy to identify

• Ward sisters are being supported in ensuring they complete their teams appraisals by the end of December 2019

Vision: To Become a Centre of Excellence for Urgent and Emergency Care

Integrated Urgent & Emergency Care Division ‘Operational Plan on a Page’

WORKFORCE

• Development of workforce model


• Development of Staff Engagement Strategy


• Improve Sickness Absence levels to trust targets

• Developing capability of the teams

PERFORMANCE

• Ensure all staff are familiar and practice the Internal Professional Standards regarding the Emergency Care Standard

• Better utilization of Same Day Emergency Care and the Urgent Treatment Centre

• Alignment to National best practices

IMPROVED FINANCIAL CONTROL

• Reducing reliance

on locums and agency

• System opportunities through redesign of service areas within the Division through system sustainability plans


• Begin exploring pipe line Cost Improvement Plans for 2020/2021

PARTNERSHIP WORKING

• Increase

streaming to Same Day Emergency Care

• Integrated working with the Mental Health teams within ED and MAU

• Social worker already based ED and MAU

• Better integration of UTC regarding joint working and rotation of staff


TRUST • Reconfigured

Urgent Care Floor • Sustainable, locally

developed workforce

• Centre of excellence for urgent and emergency care

• Urgent Treatment Centre


Measures of Success: • Achieving the 95% Emergency Care Standard target • 0 12 hour breaches reported each month • 20% reduction in use of Agency/Locum • Reduction in short and long term sickness • Improved staff recruitment and retention • 10% improvement in staff survey results in key improvement areas • Effective financial management – operate within financial allocation in 2019/20

IMPROVING QUALITY

• Acute Urgent & Emergency care improvement programmes

• Getting It Right First Time engagement to support efficiencies and ongoing reviews of services

• Engaging in the Same Day Emergency Care acceleration programme

• Plans being explored to increase Friends and Family Test engagement

Enc Q


Title Community Division Performance Report

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

Author(s) Nicola Longson, Deputy Director of Out of Hospital Services


Community Divisional Board (20.09.19) Community Quality and Performance Meeting (20.09.19) Performance Committee 9 October 2019

Key Recommendation The Trust Board is asked to: • Note the update provided • Receive assurance on performance in relation to CQC key lines of enquiry


Link to CQC Domains




X

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


Committee Agreement





X

Executive Summary

SAFE • Mandatory training compliance rates are reported at 92% (July data provided by HR). The Division continues to perform above the

target of 85%. • Of the 85 incidents of harm reported for July, upon investigation 68% came to no harm and 32% minor harm, there were no incidents

above minor. • Discussions with UHS regarding Multiple Professional Triage Team clinical supervision are ongoing and supported by the Trust

Medical Director. • Continuing the excellent performance in relation to Duty of Candour, the Division has held 100% compliance the last eight months. • The Regaining Independence Service (Community Rehabilitation) and the Orthotics & Prosthetics Service have no Rehabilitation

Consultant cover since recent staff changes. Work underway to mitigate the risk. • The annual Fire Evacuation at Ryde Health & Wellbeing Clinic on 12th September found concerns. It was unclear how many staff were

working in the building therefore not possible to check at the assembly point if everyone had vacated the building. Working with Trust Health & Safety lead to address concerns and ensure lessons learnt across wider community sites.

• The Dietetics Service is experiencing challenges due to lack of consultant support for adults with eating disorders and no mental health eating disorder pathway in place.

• Work on the Air Flow system at Ryde Health &Wellbeing Clinic is complete. Current building temperature is acceptable, associated risk to be closed.

• The recent tender process for the 0-19 Service pulled together staff from across the Community Division and corporate services, to successfully submit the tender on time. A great example of positive leadership culture and support from wider corporate services.

2

Executive Summary

RESPONSIVE • A deep dive is underway to explore the use of ‘Therapy fit’ criteria for discharge delay. • The recently escalated risk around the Podiatry Service (Capacity and demand resulting in increased caseloads and waiting times

posing a risk to staff wellbeing and patient safety) is now seeing a reduction in wait times from 12 to 8 weeks for high risk cases. • The TEC Service has delivered on targets set as part of the Community Division strategy to increase roll out of Telehealth to Island Care

Homes. There are currently 18 Care Homes supported by Telehealth with a stretch target to achieve roll out to 32 homes by end of 2019/20. In addition, Teleswallowing training has been completed for 3 homes and a further 3 homes planned. Train the trainer also completed with plan to extend to other homes. The following 3 slides show the early impact of this work.

• Work is underway across Adult Speech & Language Therapy and Catering (following staff changes) regarding the further work required on kitchen menus to ensure the trust is IDDSI compliance.

• The Children’s Speech & Language Therapy Service have carried out Makaton sign training on Children’s ward with support to develop effective visuals to support children with communication needs. The service plans to rollout to further wards.

• Continence Awareness day held on 25th September in Trust Conference Room, responding to a patient safety alert around DRE. CARING • Children’s Speech & Language Service are using MES for all initial appointments and using a child feedback form. • Community Nursing Personalisation – Teams are reviewing care plans to incorporate the persons own goals. The plan is to then audit

outcomes. • The Dietetics Service has received a number of verbal compliments for listening, supporting and being a patient advocate. • In Orthotics & Prosthetics , the team spoke with patients in the Laidlaw amputee clinic who were overwhelmingly positive about the

care they had received. One patient told them they had given up on trying to walk, but through recent consultation with the councillor and support from the team he was now healthier and fitter and was being supported with walking again.

• The RACR team recently received positive feedback from EMH for caring and holistic management of a palliative patient.

3

Calls to 111 Calls to 111 service per bed are broadly consistent between homes with TeleHealth and those without..

4

ED Attendances ED Attendances per bed are lower for those homes supported by TeleHealth (0.06, 19/20 YTD) than for those who are not (0.07 19/20 YTD). If TeleHealth were rolled out across remaining care beds this could save 241 ED attendances per year with a financial impact of £91k assuming all patients are conveyed by Ambulance.

5

ED Attendances

The potential to reduce ED activity following the introduction of TeleHealth is illustrated by Solent Grange Nursing Home who have seen their volume of ED attendance halve since TeleHealth was introduced in January’19.

6

Executive Summary

EFFECTIVE • Regaining Independence (RI) pathway has continued to develop the referral process with 107 referrals made in August from acute

Trust to RI - 40% assessed and accepted for RI beds and 60% identified as alternative discharge pathways. This performance, has in turn, led to increased flow through RI beds resulting in a reduced LoS (under 42 day standard).

• Over the last four months, the Dietetics team have led cows milk allergy clinics – performance to date shows 27% patients discharged without need for consultant, 16% patients booked to see consultant, 14 consultant new appointment slots saved to date.

• The Children’s Speech & Language Therapy Service have reviewed the Isle Play approach based on patient feedback, new model is now being implemented.

• The termination notice on the Sexual Health Service received. Staff conversation has taken place regarding the changes of provider and work underway to ensure successful transition to the new provider.

• Community Clinics are continuing to escalate issues around clinic time lost due to space booked not being fully utilised (Clinicians either failing to arrive (DNA) or arriving at clinic early and not using time booked). For August this equated to a total of 162.5hrs of unused clinic space, breakdown below: o East Cowes – DNA – Mental Health totalled 37.5hrs o Cowes – 2.5hrs left early o Ryde Health & Wellbeing Clinic – DNA – Mental Health 10hrs , other 12hrs, Midwives DNA 15.5hrs , OT DNA 20hrs, Chronic Pain

DNA 12hrs, Continence 12hrs, Urology DNA 4hrs, Gastro DNA 37.5hrs Work underway within Division to work with other clinical divisions to ensure better utilisation and processes in place.

7

Executive Summary

WELL-LED • Appraisal compliance rates for the Division remain at 95.9% . The service areas with outstanding appraisals are Podiatry &

Community Rehab and there are a number of known factors contributing to this underperformance. Mitigation is in place to ensure all are completed over next two months.

• The monthly Pulse Survey response rates in August (67) have slightly increased from July (53). Further discussion planned with staff at Community Conversations planned for November 2019.

• A Leadership development session took place in September with Community Service Leads to discuss ‘Professional Curiosity & Accountability’. A framework will now be developed.

• The Physiotherapy Service reported that staff felt well supported following a recent loss of a colleague. • The Community Division quality improvements continue via application of a 10-week improvement plan for each service. Phase 5 of

QI plans are now in place, reflecting the ‘must-do’s’ and ‘should-do’s ‘ from the 2019 CQC inspection. • The 0-19 Service contract bid was submitted to Hampshire County Council Public Health on 23rd September and a gap in Trust capacity

and capability has been identified regarding limited specialist knowledge for contracting/bid-writing within the Trust which puts the organisation in a vulnerable position for future bids.

COMMUNITY RISK The Division currently has no high scoring risks to escalate.

8

Executive Summary

WORKFORCE & INNOVATION • As set out on the following slide, there has been a general, decreasing trend around divisional sickness absence rates over recent

months. In July sickness absence rates have increased to 3.62% from 2.60% (June data). Deep dives continuing to ensure the Division is focused on improvement, supported by our HR Business partner.

• The Division continues to improve its vacancy position seeing positive reductions from 72.77 vacancies in December 2018 down to 39.95 in July 2019. Vacancy levels are now in line with expected vacancy levels for Divisional average turnover rates.

• In terms of recruitment, there are ongoing challenges to the recruitment of Physiotherapists nationally which is negatively impacting the service . A new recruitment approach has been developed and is being supported by HR.

• The 0-19 team have supported NHS Rainbow Badges for Equality & Diversity. Wider roll-out planned via Community Conversations in the autumn.

• Onwards Care & Independence investment agreed, full year effect circa £800K, supporting transformation and reduction in bedded care. Implementation progress is being made, however the Division has experienced recruitment delays which is being looked in to.

• Orthotist-Prosthetist achieved Distinction in 1st year MSc (95% in Lower Limb Biomechanics). FINANCES • The month 5 financial position of the Division sees a small underspend against the planned YTD budget and the division are on track

with delivery of CIP. Further work underway to ensure end of year forecasts are accurate. • There is no capital allocation for the Division for 2019/20. Concerns have been raised specifically regarding the Orthotics & Prosthetics

environment as this will continue to fail annual IPC audits and Fire Risk Assessments. A Business Case is being developed for review at Capital Investment Group to explore opportunities to mitigate this risk.

• The Committee is asked to note that there is limited financial management support for the Community Division since August 2019 due to staff shortages within the department. Alternative short term solutions are being explored with Finance.

9

COMMUNITY DIVISION SICKNESS ABSENCE

Division July 2019

June 2019

May 2019

April 2019

March 2019

February 2019

January 2019

December 2018

November 2018

October 2018

Community 3.62% 2.60% 3.85% 4.07% 4.18% 5.61% 4.55% 3.51% 4.45% 4.97%

• Sickness absence has increased in July (3.62%) • Highest reason for sickness absence Stress/Anxiety/Depression – (17.7%) • LTS absence policy compliance audit being undertaken by HR • Key Activity:

• Deep dive arranged for 27 September with SW locality • Deep dive arranged for 27 September with Podiatry

• Dates for short term sickness absence workshops is being currently scoped

Long Term 1.53%

Short Term 2.09%

0

1

2

3

4

5

6

Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19

Sickness Absence Rates %

10

Enc R


Title Performance Report - Mental Health & Learning Disabilities Services

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

Author(s) Sue Nelson, Business Manager MH/LD


Performance Committee 9 October 2019

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


Link to CQC Domains



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

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


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

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

Executive Summary

• A new MH&LD Divisional dashboard has been implemented at service and divisional levels in order to

strengthen governance arrangements in the Division. The dashboard is used in this report to highlight any concerns and positive practice.

• Following publication of the CQC report the Division held a workshop on 16th August with team leaders, service managers and the senior leadership team. Action plans have been completed at team level for all must do’s and should do actions in the report. Cross cutting themes have been picked up in an additional Division wide action plan. Action plans will be monitored at team level Integrated Performance Reviews with an overarching report to be submitted to the Divisional Quality and Risk Committee.

• There is significant focus on quality improvements in the Community Mental Health Team (CMHT), in order to address concerns raised by the CQC in the warning notice. Improvements have been made, and the team is benefiting from a great deal of external support from mainland partners, regulators and the national Mental Health Safety Improvement Programme in delivering the improvements.

• Work to identify a strategic partner for mental health and learning disability services is progressing, and a recommendation will go to the Trust Board in private.

Performance Summary – Effective

some cover in place. Need to review. Following review of the divisional governance arrangements, the Mental Health and Learning Disability service level integrated performance meetings have been restructured to provide greater consistency and transparency of reporting. A new dashboard has been developed at service and divisional level. These will be further developed in services to ensure the appropriate performance metrics are included for the specific services, and to strengthen service user experience and outcome measures. This performance report is based upon the new dashboard, and will develop as the service level dashboards improve.

• Number of people followed up within 7-days of inpatient care - Two breaches in July resulted in performance under required

95%. One of these patients was discharged following assessment and wanted no involvement from the service, refusing numerous attempts to follow-up. The other was a Shackleton patient discharged to residential placement.

• % of MH admissions that had access to CRHTs - Improvements to ensure CRHT involvement in the assessment of patients brought in under S136 have resulted in achievement of the gatekeeping indicator in July.

Performance Summary - Safe Following publication of the CQC report the Division held a workshop on 16th August with team leaders, service managers and the senior leadership team. Action plans have been completed at team level for all must do’s and should do actions in the report. Cross cutting themes have been picked up in an additional Division wide action plan. Action plans will be monitored at team level Integrated Performance Reviews with an overarching report to be submitted to the Divisional Quality and Risk Committee. There are currently no overdue Serious Incident Investigations within the Division. The Division is undertaking several RCA investigations for incidents that did not meet criteria for SI but following the rapid review process it was decided undertake a full investigation to identify learning. This is an improvement to ensure safe and effective services. The CMHS data is discussed in slides 10 and 11.

The Division is closely monitoring poor performance against the clinical/caseload supervision target. It is believed issues continue with under reporting and Service Managers are working with Team Leads to ensure robust reporting processes.

Performance Summary - Caring

• All complaints open during July were being managed within required timescales. • The Division has limited service user experience data, and is working with our service user engagement co-

ordinators and service user and engagement forum to address this. • The Division wanted to highlight to Board the compliment received from a SENCO re the EIP team:- “I just wanted to take a moment to write to thank the EIP team for all of your efforts and support over this academic year. As a team, you have continuously gone over and above any expectation I could ever have had. Your professionalism, your passion and your dedication shines through everything you all do. There are several learners who may well have completely disengaged from education and purpose if it had not been for you all making every effort to support these young people, from picking up and dropping off, to being on the end of the phone when they are having a bad day, we have been able to rely on your team from day 1. I have never worked alongside another professional team who have been so available with support, advice and guidance, for both learners directly and us as professionals supporting learners experiencing psychosis/early signs of psychosis. It has been an absolute pleasure and I will miss working with you all hugely, You are a wonderful team of people”

Performance Summary – Well-Led CC • The Division is closely monitoring the poor performance against the management supervision target. It

is believed issues continue with under reporting of supervision and Service Managers are working with Team Leads to ensure robust reporting processes.

• Appraisal performance is improving but slow progress is a concern. Performance is being closely

monitored at team level and Divisional Board.

• A workforce skill mix review meeting held in Acute Services has identified funding within Osborne and Seagrove budgets that can be released to recruit a Psychological Therapist and an Assistant Psychologist. The recruitment process in underway, and this will have a hugely positive impact on the care provided, and will address CQC concerns. Workforce skillmix review meetings are planned for Single Point of Access, Home Treatment and Afton Ward teams in the coming month.

Performance Summary – Responsive (1)

• Clear communication and briefing to other MH teams regarding timely referral has resulted in significant

improvement in access rates to EIP in July.

• The CAMHS Eating Disorder quarterly target becomes mandatory from 2020 and we are working towards compliance. There was one urgent referral breach reported at 6-7 weeks. This was the first urgent case reported so no previous trends.

• Two long waits for routine referrals breached the standard in Q1, one was due to staff training undertaken during March impacting on clinical time and resulted in a breach during Q1, the second was due to a DNA and the case being very complex.

Performance Summary – Responsive (2)

• An unusual under target RTT performance for CAMHS was noted and validation undertaken. There was

one breach which has now been validated as incorrect due to an administrative error. The system will be corrected and the breach removed from future data.

• There was only one patient on an RTT pathway in July for Adult Mental Health and this patient had waited longer than 18 weeks resulting in poor performance.

• RTT performance for Older People’s Mental Health (OPMH) remains a challenge. The Dementia Pathway is under review and will include redesign to address issues around assessment and diagnosis. The current Locum Agency Consultant has given notice and if the service are unable to replace quickly the waiting times for new patients requiring diagnostic work is likely to increase.

Performance Summary - Finance

• CMHT no longer has any agency staff. It has achieved it's CIP target and is within budget.

• Deep dive to be undertaken into the Adult

MH Medics as it is believed some agency costs have not been invoiced and are therefore not included in Month 5 position.

• One to one observation of inpatients

continues to be a cost pressure – discussion underway with CCG regarding funding to cover these costs.

• Significant overspend on Shackleton budget due to mainland placements during the refurbishment. Risk of further cost pressures associated with this following closure of the ward. The Older People’s mental health service are liaising closely with the mainland provider in order to ensure timely discharge and return to the island occurs.

Community Mental Health Team (CMHT) warning notice progress

Actions to address the CMHT warning notice are progressing, including: • Workshop to review progress with warning notice was held on 11/9/19, with

NHSE/I and CCG support, and agreed actions to strengthen communications with staff, service users and stakeholders, strengthen data collection, and to increase team capacity for completion of risk assessments.

• A team development programme has been planned with the national Mental Health Safety Improvement Programme (MHSIP) and Richard Tyler (executive and senior leadership programme coach) for the CMHT, Wellbeing Service and Division leadership on 4th October and for the whole team on 8th November 2019.

• Solent NHS Trust has agreed to deliver a mock CQC inspection in October. NHSI/E will contribute to this.

• The Trust QI team has started to work with the CMHT administration team, and have developed an improvement plan to ensure consistent delivery of admin processes to support service improvements.

• Team risk assessment and management training, led by the Head of Psychology was delivered on 23rd September.

Community Mental Health Team (CMHT) warning notice progress

Data as at 16/9/19

Caseload reduction continues in line with trajectories. All individuals on CPA are now allocated to a care co-ordinator, and there is focussed work progressing to ensure all have a risk assessment – the gaps are associated with new staff members. For non-CPA service users we have 202 individuals who do not have a risk assessment. All have had a desk-top review of their care, and arrangements made to complete the risk assessment, The majority are in the following parts of the service: • Consultant caseload - Recruitment of fixed term agency

Consultant Psychiatrist into vacant position has enabled increased capacity to review Consultant caseloads and discharge or transfer to the Mental Health Wellbeing Service as appropriate.

• Nurse Led Clinic – the clinic will be temporarily suspended for three weeks in October to review the caseload, and ensure risk assessments have been completed.

The Division has recognised the hard work and successes of the team in improving the position with regards to the achievement of trajectories.

Shackleton Ward

Following the Trust Board decision to close Shackleton ward and redesign the service on 5th September 2019, the following actions have been taken: • Communication with consultants, ward staff, Trust staff, stakeholders and

the public was undertaken the week after Trust Board. • A project team has been established to oversee the redesign and

implementation of the Home Treatment team, with support from CCG and NHSI/E. External mental health provider support will be identified via the mental health partnership agreement.

• There are currently 5 individuals in mainland placements, and all have regular review by the island Older People’s Mental Health service to ensure timely discharge is achieved.

Strategic Developments and Service Transformation

Work to identify a strategic partner for mental health and learning disability services is progressing, and a recommendation will go to the Trust Board in private. The transformation programme for mental health and learning disability services is progressing and is summarised in Appendix 1. The following service developments were agreed in the September MH&LD Board:

• A new service specification for an Integrated Adult Health and Social Care Community Learning

Disabilities Team to meet the needs of people with learning disabilities and their families was discussed and agreed by the MH&LD Divisional Board in September. The integrated team will act as a single island-wide service to support people with learning disabilities and their families. The vision is that the new integrated service will be operating by March 2020 and staff co-located into a new Learning Disabilities hub during the first quarter of the new financial year.

• Work to progress transfer of Crisis Calls to the mainland 111 mental health triage hub continues. The information sharing, funding and Paris training issues are being taken forward as a priority.

• Plans were agreed at MH&LD Divisional Board to stop smoking across inpatient and community Mental

Health sites. This decision, in line with the Mental Health Forward Plan, NICE and Public Health England guidance, takes into account health inequalities, physical health needs of mental health patients and supports the right for a hazard free environment for all patients and staff.

Type of Workstream

Workstream Summary Expected Impact

Implementation Workstreams

Community Mental Health & Wellbeing Service

• The Community MH Wellbeing Service will better support individuals in the community, reducing the CMHT Caseload, thereby allowing a reduction in CMHT Agency Staff, and improved accessibility and responsiveness of CMHT for people with SMI and in MH crisis.

• £88.5k Pump Prime Funding to increase the pace of this shift of caseload, reducing risk and delivering recurrent benefits to the system.

• To include Older Person’s MH provision • Integrated SPA and Crisis to be included in this workstream

• Improvement in quality of provision • Reduction in Caseload from 1700 to 450 • Reduction in Agency Spend • Investment transfer to community based services • Improved community based response to people in MH

crisis • Reduction in required admissions • Reduction in MH Acute beds once robust CMHWS in place

Living Well with Learning Disabilities

• Development and delivery of an integrated (Health and Social Care) provision for learning disability under a multi disciplinary service and estates bids

• Improvement in quality of provision • Evidence of delivery of national golden threads of LD values

Transformation Workstreams

Rehabilitation and Reablement Services

• De-register the current inpatient rehabilitation service. • Scope continuing requirement for hospital bed-based provision, and

options for delivery. • Development of intensive community rehabilitation service(s) based on

supported living framework and community based support • Work with local authority to reduce the use of sec 117

• Reduction in inpatient beds and associated overhead costs. • Investment transfer to community based services • Further reduce OOA rehab placements • Reduce number of people subject to s117

Acute Provision • Remodelling acute mental health services (including Home Treatment, Afton, Osborne and Seagrove wards), in order to increase home treatment capacity for people with acute mental illness, and reduce use of beds.

• Identify networked opportunities with mainland strategic provider partner(s)

• Address potential interdependencies with CYP and rehabilitation workstreams.

• Improvement in quality of provision • Investment transfer to community based services • Reduction in agency spend • Reduction in admissions • Reduction in MH Acute beds once robust community

provision in place

CAMHS & Transforming MH Provision for 14 – 25 Year Olds

• Work with CAMHS commissioners, children’s services, paediatrics and third sector partners to develop a community based integrated mental and physical health offer for 0-13 year olds.

• Work with CAMHS commissioners, children’s services, EIP, CMHWS, MH acute services and third sector partners to develop an integrated mental health offer for 14-25 year olds

• Improvement in quality of provision across the system • Development of CYP focussed services • Improvement in transition between CYP and adult services • Strengthened community based MH crisis response for

young people

Integrated Onward Care Workstreams

Living Well with Dementia

• Development of Dementia Outreach Service • Development of long term options for transformation of dementia

provision working with acute, community and MH divisions of Trust, local authority and third sector partners.

• Improvement in quality of provision across system • Investment transfer to community based services • Reduction agency spend • Reduction in acute hospital and MH admissions • Reduction in acute hospital and MH Acute beds

Appendix 1: Mental Health Sustainability Transformation Programme Workstreams

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