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Trust Board Papers

Isle of Wight NHS Trust

Board Meeting in Public (Part 1)

to be held on

Wednesday 26th March 2014

at

09.30am - Conference Room—Level B

St. Mary’s Hospital, Parkhurst Road,

NEWPORT, Isle of Wight, PO30 5TG

Staff and members of the public are welcome

to attend the meeting.

Meeting in public on 26th March 2014 Isle of Wight NHS Trust Board – Page 1

Please note Change of Venue

The next meeting in public of the Isle of Wight NHS Trust Board will be held on Wednesday 26th March 2014 commencing at 09:30hrs.at the INNOVATION CENTRE, ST CROSS BUSINESS PARK, NEWPORT, Isle of Wigh, Staff and members of the public are welcome to attend the meeting. Staff and members of the public are asked to send their questions in advance to [email protected] to ensure that as comprehensive a reply as possible can be given.

AGENDA Indicative Timing

No. Item Who Purpose Enc, Pres or Verbal

09:30 1 Apologies for Absence, Declarations of Interest and Confirmation that meeting is Quorate

1.1 Apologies for Absence: Andy Heyes, Interim Director of Planning, ICT & Integration.

Chair Receive Verbal

1.2 Confirmation that meeting is Quorate Chair Receive Verbal 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.

1.3 Declarations of Interest Chair Receive Verbal 09:35 2 Patients Story 2.1 Presentation of this month's Patient Story CEO Receive Pres 09:55 3 Minutes of Previous Meetings

3.1 To approve the minutes from the meeting of the Isle of Wight NHS Trust Board held on 26th February 2014 and the Schedule of Actions.

Chair Approve Enc A

3.2 Chairman to sign minutes as true and accurate record Chair Approve Verbal 3.3 Review Schedule of Actions Chair Receive Enc B

10:05 4 Chairman’s Update 4.1 The Chairman will make a statement about recent activity Chair Receive Verbal 10:10 5 Chief Executive’s Update

5.1 The Chief Executive will make a statement on recent local, regional and national activity.

CEO Receive Enc C

5.2 Employee Recognition of Achievement Awards CEO Receive Pres 5.3 Employee of the Month CEO Receive Pres

10:20 6 Quality and Performance Management 6.1 Performance Report EDNW Receive Enc D 6.2 Update on Data Quality Underpinning KPIs EDF Receive Enc E 6.3 Minutes of the Quality & Clinical Performance Committee held

on 19th March 2014 QCPC Chair

Receive Enc F

6.4 Minutes of the Finance, Investment & Workforce Committee held on 19th March 2014

FIWC Chair

Receive Enc G

6.5 Board Walkabouts Action Tracker EDNW Receive Enc H 6.6 Staff Story EDNW Receive Pres 11:20 COMFORT BREAK 11:30 7 Strategy and Business Planning 7.1 Business Case -Endoscopy EDNW Approve Enc I

7.2 Workforce Strategy EDNW Approve Enc J 7.3 Operating Plan 2014/15 & 2015/16 inc Corporate Objectives

2014 (Vision, Objectives & Critical Success Factors) CEO Approve Enc K

7.4 Formal Approval of Financial Budgets for 2014/15 EDF Approve Enc L

7.5 FT Programme Update FTPD Receive Enc M 7.6 FT Self Certification FTPD Approve Enc N

Meeting in public on 26th March 2014 Isle of Wight NHS Trust Board – Page 2

12:20 8 Governance and Administration

8.1 Board Assurance Framework (BAF) Monthly update Comp Sec

Approve Enc O

8.2 Standing Orders, Scheme of Delegation, Standing Financial Instructions Update

Comp Sec

Approve Enc P

8.3 Health & Safety Policy EMD Approve Enc Q

8.4 Notes of the FT Programme Board held on 25th February 2014 CEO Receive Enc R 8.5 Minutes of the Charitable Funds Committee held on 11th March

2014 Chair CFC

Receive Enc S

12:55 9 Matters to be reported to the Board Chair 9.1 10 Any Other Business Chair 11 Questions from the Public Chair To be notified in advance 12 Issues to be covered in private. Chair

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.

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

Earl Mountbatten Hospice (EMH) 2014/15 contract Isle of Wight NHS Trust Contracting Strategy 2014/15 and beyond Shared Business Service – Contract renewal Hip, Knee & Trauma Prosthesis – Ratification Report IDAS Re-tender Strategic Estates Partner - Update Reports from Serious Incidents Requiring Investigation (SIRIs) Safeguarding Update Employee Relations Issues Notes of the Audit & Corporate Risk Committee Annual

Performance Review meeting held on 11th March 2014

The Chairman or Chief Executive will indicate if there are any other issues which may be discussed in private without entering into detail about them. Members of the public, the press and members of staff will then be asked to leave the room.

13:00 13 Date of Next Meeting: The next meeting of the Isle of Wight NHS Trust Board to be held in public is on Wednesday 30th

April 2014 in the Conference Room at St. Mary’s Hospital, Newport, Isle of Wight, PO30 5TG.

IOW NHS Trust Board Meeting Pt 1 26th February 2014 1

Minutes of the meeting in Public of the Isle of Wight NHS Trust Board

held on Wednesday 26th February 2014 in the Conference Room, St Mary’s Hospital, Newport, Isle of Wight

PRESENT: Danny Fisher Chairman Karen Baker Chief Executive (CEO) Mark Pugh Executive Medical Director (EMD) Chris Palmer Executive Director of Finance (EDF) Alan Sheward Executive Director of Nursing & Workforce (EDNW) Nina Moorman Non Executive Director Charles Rogers Non-Executive Director (Senior Independent

Director) Peter Taylor Non-Executive Director Sue Wadsworth Non-Executive Director

In Attendance: Jessamy Baird Designate Non-Executive Director David King Designate Non-Executive Director Mark Price FT Programme Director & Company Secretary Andy Shorkey Foundation Trust Programme Management Officer

(for item 14/071) Jackie Skeel Assistant Director for Organisational Development (for

item 14/068) Keith Morey Civil Contingencies Manager (for item 14/070) Brian Johnston Head of Corporate Governance & Risk Management

(for item 14/074) Sally Bailey Midwife Sonographer (for item 14/063) Pamela George Sister NICU (for item 14/063) Monika Driscoll-Abbasi Midwife (for item 14/063) Carole Hewison Midwife (for item 14/063) Joyce Brooks Midwife (for item 14/063) Yvonne Harris Clinical Lead/Midwife (for item 14/063) Sarah Cox Housekeeper, Rehabilitation Team (for item 14/064) Natalie Mew Sister, Rehabilitation Team (for item 14/064) Marie Gasior Matron, Rehabilitation/Stroke (for item 14/064) Sarah Hayward Business Manager, Planned Directorate (for item

14/063) Martin Robinson Associate Director, Planned Directorate (for item 14/063) Richard Knowles Head of Prison Healthcare (for item 14/063) Diane Adams Radiology & Cancer Manager (for item 14/063) William King Consultant Radiologist (for item 14/063) Lisa Street Project Manager (for item 14/063) Observers: Chris Orchin Health Watch Nancy Ellacott Patient Council Emma Topping Communications & Engagement Manager Alison Toney Communications & Engagement Officer Caroline Chipperfield Director, Thames Valley & Wessex Leadership

Academy Sarah Goodson Senior Consultant, Kings Fund Minuted by: Lynn Cave Trust Board Administrator

Members of the Public in attendance:

There were two members of the public present

Enc A


Minute No.

14/057 APOLOGIES FOR ABSENCE, DECLARATIONS OF INTEREST AND CONFIRMATION THAT THE MEETING IS QUORATE

The Chairman welcomed everyone to the meeting. Apologies for absence were received from Andy Heyes – Interim Director of Planning, ICT & Integration and Jane Tabor, Designate Non-Executive Director. Apologies were also received from Andrew Turner MP, Cllr Lora Wilcox and Cllr Gordon Kendall There were no declarations of interest. The Chairman announced that the meeting was quorate.

14/058 PATIENT STORY The Chief Executive introduced the patient story. She advised that there was no film this

month as the planned audio recording was not of suitable audio quality to broadcast. Therefore, the story would be covered using a slide presentation. The Executive Director of Nursing & Workforce explained that the patient concerned had been on Alverstone Ward and had provided the following feedback:

∑ Mixed experience – good and bad ∑ “Flexible visiting times” on the ward – but not in their experience! ∑ Wanted to see my husband when I came back from theatre but was not allowed ∑ Issues with access to side rooms and privacy and dignity ∑ Some staff need to smile more – come across abrupt / rough ∑ Healthcare assistants good ∑ Food is good

The response as a result of this Patient Story is as follows:

• Open visiting not in place due to admission and theatre times – but ward does try to accommodate a flexible approach to visiting for patients with a specific need, as in this ladies case.

• On return from theatre it is essential to ensure that the patient is settled and comfortable and observations taken prior to allowing the relative at the bedside.

• Minimal side rooms are available which are allocated dependent on clinical need. • Side rooms do have blinds on the door and windows. Ward Sister is considering

the purchase of ‘engaged signs’ for the side rooms • Patient did not raise any concerns at the time with the Ward Sister, but did speak

at length to Matron. • Patient and her husband has been asked back to relay their experience to the

ward staff directly. The Executive Director of Nursing & Workforce explained that a “Welcome to the Ward” booklet was being introduced which would provide information to the patient on a range of areas including who to talk to if they have any concerns. Peter Taylor raised the question of the suitability of the Diabetic options within the patients menu choices. The Executive Director of Nursing & Workforce confirmed that the dieticians would be asked to review the current choices. Jessamy Baird also confirmed that this had been discussed at the Quality & Clinical Performance Committee at which an update from the Executive Director of Nursing & Workforce was pending. Action Note: The Executive Director of Nursing & Workforce to follow up with the dieticians and report back on the outcome of the review of diabetic patient meal options.

Action by: EDNW


Peter Taylor also asked about the patient information boards above the beds and could these have the consultants name and lead nurse shown. The Executive Director of Nursing & Workforce confirmed that these were in place in some areas and that the remaining areas would be completed shortly. Action Note: The Executive Director of Nursing & Workforce to update the Board on the progress of the installation of patient information boards.

Action by: EDNW Sue Wadsworth asked for an update on the Ward Information Boards. The Executive Director of Nursing & Workforce confirmed that the format of these was being trialled on Appley Ward and the final touches were being made to the monthly performance notice by the PIDS team. They would then be rolled out across the Trust. Charles Rogers stated that he was pleased to see that the patient would be returning to give direct feedback to the ward team. The Chief Executive stated that it was important to note that the patient had received excellent clinical treatment but that the patients experience should also be about excellent customer care and good communication which is something that the Trust is striving to promote. Sue Wadsworth commented on how useful it was that the Action Plan had been shown on screen and requested that this be done for all future Patient Stories brought to the Board. Action Note: The Executive Director of Nursing & Workforce to arrange for a summary slide to be prepared for all Board Patient Stories.

Action by: EDNW The Isle of Wight NHS Trust Board received the Patient Story

14/059 MINUTES OF PREVIOUS MEETING Minutes of the meeting of the Isle of Wight NHS Trust Board held on 29TH January 2014

were approved. Jessamy Baird asked that for clarity it should be noted that Min No 14/037(v) is an extension of Action No. TB/054 and should be read in conjunction with the updates shown in the Action Plan. Proposed by Peter Taylor and seconded by Charles Rogers The Chairman signed the minutes as a true and accurate record.

14/060 REVIEW OF SCHEDULE OF ACTIONS

a) TB/054 – Discharge Summaries – The Executive Medical Director confirmed that in January 2014 100% of discharge summaries had been completed by the required date and it was planned for all patients to leave hospital with their discharge summary. Peter Taylor commented that this problem had been ongoing for some considerable time and queried if there should be a specific Key Performance Indicator (KPI) within the Performance report to show this. The Executive Medical Director advised that there was a KPI for the clinical directorates and this was monitored at the monthly meetings. The Chairman stated that it was important to note that considerable improvements had been made over the period and the critical factor was having full electronic records in place.

b) TB/055 – Safe Staffing Levels – The Executive Director of Nursing & Workforce confirmed that these would all be completed by the end of March.

c) TB/058 – Funding for the Covered Walk from Helipad – The Executive Director of Finance confirmed that £58k had been agreed for this project.

d) TB/059 – Flu Incentives - The Executive Director of Nursing & Workforce confirmed that the HR team were working on the scheme at present.

e) TB/061 – Board Walkabout Action Tracker – this item is due for 30th April Board meeting.


f) TB/069 – Long Term Financial Model (LTFM) –The Executive Director of Finance confirmed that the final document would be taken to the next Finance, Investment & Workforce Committee in March.

g) TB/071 – Palliative Care/Earl Mountbatten Hospice – it was confirmed that this would be discussed with the Designate Non-Executive Directors after Board.

h) TB/073 – Patient Story Action Tracker – this item is due for 30th April Board meeting.

The Isle of Wight NHS Trust Board received the Review of Schedule of Actions

14/061 CHAIRMAN’S UPDATE The Chairman reported on the following items:

a) Care Quality Commission (CQC) visit – The Chairman confirmed that the CQC

inspection was likely to take place in early June. He stated that the organisation should be ready to be inspected at any time and that it should be business as usual rather than a special occasion.

b) Members – The Chairman reported that there had been a successful Medicine for

Members event which had received good attendance from members and also that the first newsletter had been published. The aim now is to keep members interested and engaged.

c) Peter Taylor – The Chairman advised that it was with sadness that he had to

advise the Board of Peter Taylor’s retirement as a Non- Executive Director. He confirmed that Peter would continue all his current duties until after the 2013/14 accounts had been approved in early June.

d) Non-Executive Director recruitment – The Chairman stated following advice

from the Trust Development Authority the post vacated by Peter Taylor’s departure will be filled by a candidate with good financial experience. He confirmed that it would go out to advertisement this week with a closing date of 24th March. Interviews would be held on 10th April.

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

14/062 CHIEF EXECUTIVE’S UPDATE The Chief Executive presented her report. Areas covered were:

National

• Mental health crisis care concordat • care.data update

Local • Care Quality Commission inspection • Health watch inspections published • Isle of Wight Children’s Trust • Our future workforce given careers advice • Awards

Peter Taylor pointed out that the Outside Gym had been funded by Charitable Funds. He also congratulated the Chief Executive on her effort to promote cycling amongst staff. The Isle of Wight NHS Trust Board received the Chief Executive’s Update

14/063 EMPLOYEE RECOGNITION OF ACHIEVEMENT AWARDS The Chief Executive presented Employee Recognition of Achievement Awards: This

month under the Category:

a) Quality Care & Innovation – Dr William King b) Going the Extra Mile – Lisa Street & Sarah Hayward c) Long Service – Richard Knowles, Monika Driscoll-Abbasi, Sally Bailey, Joyce

Brooks, Carole Hewison and Pamela George


The Chief Executive congratulated all recipients on their achievements. The Isle of Wight NHS Trust Board received the Employee Recognition of Achievement Awards

14/064 EMPLOYEE OF THE MONTH • The Chief Executive presented the Employee of the Month award to Sarah Cox

who is a Housekeeper within the Rehabilitation team. She confirmed that Sarah had been nominated for her excellent work by patients who felt she should be recognised for her work. The Chief Executive congratulated her. The Isle of Wight NHS Trust Board received the Employee of the Month Award

QUALITY AND PERFORMANCE MANAGEMENT

14/065 PERFORMANCE REPORT The Executive Director of Finance presented the Performance report for December.

Highlights

∑ Operational performance is again very good with no Red rated categories ∑ All Cancer indicators maintaining year to date position ∑ Emergency Care 4 hour standard performance remains above target ∑ No grade 4 pressure ulcers reported in hospital during January ∑ No of C.Diff cases on track to achieve year end stretch target

Lowlights

∑ 2nd Hospital acquired MRSA bacteraemia case identified YTD ∑ Staff absenteeism due to sickness remains above target. ∑ Formal complaints show rise in January ∑ VTE assessment recording below plan ∑ CIP targets remain challenging

Key Points:

a) Patient Safety, Quality & Experience: Areas of particular focus regarding patient safety, quality and experience include:

Pressure ulcers: We continue to under achieve our planned reduction across all grades of pressure ulcers, both in the hospital setting and the wider community. A range of actions continues to support hospital and community staff.

Venous Thrombo-Embolism (VTE) risk assessment: The recorded percentage of patients that have a VTE risk assessment increased slightly but remains below target for January (90.8%). The system upgrade to enforce compliance has now been completed and improved results are expected to be reflected in February.

Health Care Acquired Infection (HCAI): We are currently within both our nationally set threshold and our local stretched target for Healthcare Acquired Clostridium Difficile infection, remaining at 6 YTD, with no cases reported during January. There was 1 case of Healthcare Acquired MRSA bacteraemia identified in January, 2 YTD.

b) Operational Performance: Performance against our key operational performance indicators is again mainly green for the month with only 2 amber indicators.

We achieved 93% again this month against our stretched target of 95% for high risk TIA fully investigated and treated within 24 hours. Although still under achieving, we consistently exceed the national target of 60%.


All cancer targets are again green for year to date, although the provisional figures indicate 1 amber (Subsequent Drug Treatment within 31 days) for January. This breach was due to patient choice. Across all cancer measures, 18 of the 23 breaches this month were patient led. A range of actions continue to maintain the performance of these indicators.

c) Workforce: The total pay bill for January (£9.86m) is above plan (£9.54m). The number of FTEs in post is also currently higher than plan. The HR Directorate are closely monitoring and supporting the Clinical directorates with their workforce plans, in particular their control over their spend on variable hours.

Sickness absence increased slightly in January (3.86%) and remains above plan. Specific problem areas are identified and challenged at directorate performance review meetings.

d) Finance & Efficiency:

Overall we have slightly over-achieved our financial plans for January and based on the new measure, the Continuity of Service Rating, introduced by Monitor on 1st October 2013, our overall rating is 4.

Despite recognising forward banked CIP schemes of £681k and Trustwide Transformation schemes of £1,479k, the YTD CIP target of £6,830k has not been achieved by £662k. In order to mitigate any carry forward of CIP into 14/15 recurrent savings of £1,776k still need to be identified.

The following areas were raised in discussion:

i. Pressure Ulcers – Peter Taylor requested an update on planned action to reduce the number of ulcers. The Executive Medical Director confirmed that the Tissue Viability team were going out into the community to ensure competency of NHS staff, with community nurses providing similar assessments in other areas. The Executive Director of Nursing & Workforce stressed the need to ensure that when staff visit a patient at home, that a full assessment is carried out on all potential risk elements instead of just attending to the specific area covered by the visit. He confirmed that work was being undertaken with the local authority and other providers. David King asked if this was being extended into the private sector and the Executive Director of Nursing & Workforce advised that this was not happening as yet but the plan was to cover the entire island with a standard process. Charles Rogers asked how progress would be reported, and Mark Price asked, on behalf of Jane Tabor, if a deep dive on the area would be covered. It was advised that this would be covered in depth by the Quality & Clinical Performance Committee. Jessamy Baird stated that patient education on the prevention of pressure ulcers was important as was gaining their co-operation in notifying health visitors if they have any concerns. The Executive Medical Director advised that it was important to record any specific instructions given to patients and to check their understanding before leaving in order to effectively gain their compliance.

ii. Stroke/TIA Patients Declined Appointments – Sue Wadsworth asked if having

a transportation problem should be a reason for declining an appointment. She wondered why more flexibility was not available in these incidences. The Executive Medical Director advised that if a patient was unable to attend due to transportation issues this would be included within the data and he stressed that nationally we were in the top 10% and were doing very well within this area.

iii. Benchmarking Update – David King asked why the percentage of patients


admitted through A&E was higher than the national average. The Executive Medical Director explained that it was due to the way in which A&E was used. The data would include patients waiting to be assessed and discharged within the day as well as those who remain within the hospital for longer periods. He explained that having the Beacon centre on site helped to filter these short term patients down but did not exclude them completely. The Executive Director of Nursing & Workforce confirmed that improved ambulatory pathways to assess patients before they arrive could help in reducing the numbers being admitted to MAU for less than one day. He advised that within the new A&E unit there were two spaces for ambulatory trolleys and also the refurbished MAU would have a further 5 spaces which would assist in reducing the level of admissions via A&E.

iv. Risk Register – David King asked for an update on why the Safeguarding

Children Training was still on the register. The Executive Medical Director advised that discussions with other local providers were in progress to increase the level of face to face training opportunities. Sue Wadsworth asked why this could not be done via eLearning. The Executive Director of Nursing & Workforce confirmed that level 1 training was via eLearning but that level 2 training and above required face to face sessions. He confirmed that a further 10 training sessions had been arranged and discussions were in place with other Trusts to develop an eLearning programme for level 2.

Jessamy Baird stated that some of the description of the risks were very generic and could result in a permanent position on the risk register. She asked if these could be reviewed. The Executive Medical Director advised that when staff-assess a risk it is on a local level which to them will seem a high risk but at Board level it may not rate as high. The Executive Director of Nursing & Workforce advised that the directorates had been asked to review these more rigorously to ensure that appropriate risk scores were made. Peter Taylor stated that he felt that this part of the performance report needed further development. David King agreed and stated that it should be showing the strategic imperative of each to Board against operational and strategic risk. The Executive Director of Finance confirmed that the Capital Investment Group did undertake a full risk review on capital schemes. Peter Taylor stated that an additional area showing the actions approved by the Capital Investment Group would be helpful. Action Note: The Executive Director of Finance to review possible additional data to be included for future reports.

Action by: EDF Sue Wadsworth requested that an update on the Ophthalmic Case note risk be brought to the Quality & Clinical Performance Committee. Action Note: Executive Director of Nursing & Workforce to arrange for a report to be presented at the Quality & Clinical Performance Committee.

Action by: EDNW

v. Sickness Absence – Jessamy Baird asked if details of seasonal variation could be shown in future reports. Charles Rogers advised that these were reviewed at Finance, Investment & Workforce Committee meetings and took into consideration the previous 3 years statistics.

vi. KPI Finance – David King challenged the green rating for Capital. He stated that in his experience he had not seen so much money still to spend and so little time in which to achieve it. The Executive Director of Finance agreed that the rating should perhaps be amber, but assured the meeting that all the capital spend would be achieved by the end of the financial year. Peter Taylor reminded the meeting that the capital plan had changed mid-year and the Executive Director of Finance agreed that this had caused some delay. The Board agreed that the risk rating should be amber.


The Company Secretary tabled a question from Jane Tabor which asked if next year’s capital spend report could show planned spend by month or by quarter. The Executive Director of Finance confirmed that the capital plan was already being prepared and would be presented to the Finance, Investment & Workforce Committee. A discussion took place surrounding how the capital plan would be shown and how it would link to the Long Term Financial Model and the Clinical Strategy, and it was agreed that capital spend would be brought back to Board Seminar for more discussion. Action Note: The Executive Director of Finance to prepare a presentation with the Interim Director of Planning, ICT & Integration for Board Seminar on the capital plan.

Action by: EDF/IDPII

vii. QIPP Programme Monitoring – Jessamy Baird asked if the use of the work Senility was appropriate. The Executive Medical Director confirmed that this was still used as an ICD101 coding criteria.

viii. Falls - Charles Rogers asked if falls which fall outside the category of “resulting in significant injury” could be shown. The Chairman confirmed that this was a category which was included within the Board Walkabout questionnaire and Sue Wadsworth confirmed that these were also looked at in detail at the Quality & Clinical Performance Committee (QCPC). The Executive Director of Nursing & Workforce advised that a total review of the annual total number of falls would be added to the agenda of the QCPC. Action Note: Executive Director of Nursing & Workforce to arrange for a full report on Falls to be presented at the QCPC committee.

Action by: EDNW ix. Compliments – The Company Secretary asked on behalf of Jane Tabor, if in

future the level of compliments could be added to the report. The Executive Director of Finance confirmed that this was in hand and would appear in the next report. Action Note: The Executive Director of Finance to ensure that the level of compliments be added to the performance report.

Action by: EDF The Isle of Wight NHS Trust Board received the Performance Report

14/066 MINUTES OF THE QUALITY & CLINICAL PERFORMANCE COMMITTEE Sue Wadsworth reported on the key points raised at the last meeting held on 19th

February 2014.

a) Min No.14/052 - Special Measure Process Paper: The Deputy Director of Nursing explained how special measures would work in future and highlighted the issues and challenges identified by the risk review

b) Min No.14/057 – Audit Results of Non-Medical Prescribing Assessment: The Committee received an update on the results and will receive this information annually

c) Min No.14/061 - Outpatient Appointments and Records Unit : The Committee received an update on auto-discharge issues

d) Min No. 14/068 – Joint Safeguarding Steering Group Report: The Committee received an update on the current status for Adult and Children’s safeguarding including an overview of open cases.

e) Min No. 14/073 – Health watch Visits – Summary Report: The Committee received the summary report following the visits and noted there were recommendations

1 The National Clinical Coding Standards ICD-10


f) Min No. 14/075 – TDA2 Self Certification: The Committee challenged Board Statement 13 regarding the management capacity in place but after debate concluded it could support compliance.

The Isle of Wight NHS Trust Board received the minutes of the Quality & Clinical Performance Committee

14/065 MINUTES OF THE FINANCE, INVESTMENT & WORKFORCE COMMITTEE Charles Rogers reported on the key points raised at the last meeting held on 19th February

2014

a) Min No 14/026 – Workforce: The Committee received the draft Workforce Strategy.

b) Min No 14/026 – Workforce: Overspend on pay through Bank staff, Locums and overtime.

c) Min No. 14/027 - Financial Performance: The Committee received assurance that based on the Month 10 position the end of year surplus will be met.

d) Min No. 14/028 - Contracts Update: The Committee received a detailed Contract Status report and timetable to provide assurance that the Contracts/Heads of Terms would be signed by 28th February deadline.

The Isle of Wight NHS Trust Board received the minutes of the Finance, Investment & Workforce Committee

14/066 BOARD WALKABOUT ACTION TRACKER The Executive Director of Nursing & Workforce presented the report and advised that this

programme of Board visits had now been in operation for a year. At the time of reporting, 177 visits have taken place (141 Clinical, 36 non-clinical), from these 170 actions have been identified:

∑ 143 are complete, ∑ 11 are still within timescale, ∑ 16 remain overdue against the original date for completion set, with 1 showing as

overdue against both board and directorate revised timescale, these actions are progressing.

The Executive Director of Nursing & Workforce confirmed that a number of the open actions were linked to the capital plan and the work was currently being undertaken. He also advised that from April the walkabout questionnaires would be based on the KLOE3 criteria for CQC4 inspections The Isle of Wight NHS Trust Board received the Board Walkabout Action Tracker

14/067 PATIENT STORY ACTION TRACKER The Executive Director of Nursing & Workforce confirmed that following discussion it had

been agreed to withdraw this item from the agenda for this meeting.

14/068 STAFF STORY The Executive Director of Nursing & Workforce introduced the Assistant Director for

Organisational Development who would be presenting her story. The Assistant Director for Organisational Development outlined her development from leaving school with limited qualifications, to joining the NHS via the staff bank in 2000. She outlined how, through hard work and undertaking a range of qualifications, she developed her teaching and management skills which she has used to develop a wide range of learning opportunities for other staff, as well as progressing professionally to her

2 Trust Development Authority 3 Key Lines Of Enquiry 4 Care Quality Commission


current role. She stated that she hoped that her story would be an inspiration to others to show that although they may not start out with the best opportunities and qualifications, it is possible to develop yourself to achieve greater attainment than would originally have been predicted. Peter Taylor suggested that this story might be useful to pass onto the schools as a role model for what can be achieved. The Isle of Wight NHS Trust Board received the Staff Story

STRATEGY AND BUSINESS PLANNING

14/069 2012 – 2013 REFERENCE COSTS The Executive Director of Finance presented the outcome of the 2012/13 Reference Cost

Index which had been received from the Department of Health. She explained that these figures were assessed on data a year in arrears. She outlined how the index scores were arrived at and the implication for the Island. She highlighted that there had been a considerable amount of work carried out over the year to improve the accuracy of the data to ensure that the index score was as accurate as possible. Peter Taylor stressed how important Service Line Reporting (SLR) was and the need for accurate input. The Executive Director of Finance stated that SLR had been available for the past 2 years and was now in the position to be able to be used for decision making to a limited extent. The Company Secretary asked, on behalf of Jane Tabor, if it would be possible for more consideration to be given to this subject in a seminar. The Board agreed this proposal. Action Note: The Company Secretary to arrange for a seminar on Service Line Reporting and Reference Costs to be added to the Board Seminar Forward Planner.

Action by: CS The Executive Director of Finance confirmed that the Trust would be working closely with the Commissioners and other outside bodies. The Isle of Wight NHS Trust Board received the 2012-13 Reference Costs

14/070 INCIDENT RESPONSE PLAN (EMERGENCY PREPAREDNESS, RELIANCE & RESPONSE ASSURANCE ASSESSMENT)

The Civil Contingencies Manager presented the Incident Response Plan and explained that this was a statutory requirement. He outlined where there would be joint working with other agencies including the Police and Fire Service. The Company Secretary confirmed that this item had been covered in more depth at the previous Board Seminar. It was confirmed that the full plan would be added to the intranet for reference once approved by Board. Proposed by Peter Taylor and seconded by Charles Rogers The Isle of Wight NHS Trust Board approved the Incident Response Plan

14/071 BUSINESS PLANNING PROCESS The Foundation Trust Programme Management Officer confirmed that the business

planning process was required by the Trust Development Authority to be approved by the Board. This document lays out the processes which will be used to develop the Operating Plan 2014/15 & 2015/16, and the full Integrated Business Plan (IBP) and its supporting strategies. Proposed by Peter Taylor and seconded by Sue Wadsworth The Isle of Wight NHS Trust Board approved the Isle of Wight NHS Trust Business Planning Process


14/072 FT PROGRAMME UPDATE The FT Programme Director presented the monthly update:

a) Timeline

∑ Chief Inspector of Hospitals visit will take place in June 2014 ∑ FT status achievable by March 2015

b) IBP/LTFM work ongoing to deliver draft for 4 April submission ∑ Detailed feedback received from TDA

c) Membership Recruitment campaign ∑ Current Membership at 3754. ∑ The membership data based has been reviewed and cleansed. ∑ “Medicine for Members” repeated 31 January 2014 ∑ Governor development day held 10 February 2014

Nina Moorman stressed the importance that any anxiety the senior management teams may have surrounding the Chief Inspector of Hospitals inspection should not be transferred to the staff. The Chief Executive stated that support would be given to staff to prepare for this visit. The Executive Director of Nursing & Workforce confirmed that it should be business as usual and this is just what we do on a daily basis. The Isle of Wight NHS Trust Board received the Foundation Trust (FT) Programme Update.

14/073 FT SELF CERTIFICATION The FT Programme Director presented the monthly update stating that there was a slight

correction to Appendix 1B Condition G4 - change date from 31 January 2014 to 31 March 2014. Proposed by Charles Rogers and seconded by Sue Wadsworth The Isle of Wight NHS Trust Board approved the FT Self Certification

GOVERNANCE & ADMINISTRATION

14/074 BOARD ASSURANCE FRAMEWORK (BAF) DASHBOARD & SUMMARY REPORT Head of Corporate Governance & Risk Management presented the report and advised

that there were now no principal risks rated as Red, and 6 new risks had been introduced in January. The Company Secretary asked, on behalf of Jane Tabor, if risk CSF8.2 should remain as Amber instead of the recommended upgrade to Green. A discussion to place and it was agreed that this item would stay as Amber. Action Note: CSF8.2 should remain as Amber instead of the recommended upgrade to Green.

Action by: HCG Proposed by Sue Wadsworth and seconded by Peter Taylor The Isle of Wight NHS Trust Board approved the Board Assurance Framework (BAF) Dashboard & Summary Report

14/075 MINUTES OF THE AUDIT & CORPORATE RISK COMMITTEE

Peter Taylor reported on the key points raised at the last meeting held on 4th February 2014

a) Min No. 14/007 - Annual Report & Quality Account Timetable 2013/14: The editor when appointed should drive the co-ordination of the Report with the respective committees to ensure that production of the Report is aligned with Annual Accounts and that a substantial draft Annual Report be available for the Board Seminar on the 13th May 2014. A timetable slip would be unacceptable this


year. b) Min No. 14/008 - Budget Setting Framework 2014/15: The purpose of the

Budget Setting Framework is to ensure a sound and consistent approach to budget setting and that realistic and deliverable budgets are set and delivered.

c) Min No. 14/010 - Statement on Going Concern 2013/14: Assurance could be provided to the Trust Board and External Audit that the Going Concern concept had been reviewed and agreed that it was appropriate for the Accounts to be prepared on that basis.

d) Min No. 14/016 - Internal Audit Service: Assurance could be provided to the Trust Board on the continuity of the internal audit service following the sale of Deloitte & Touche Public Sector Internal Audit Limited to Mazars Limited.

The Isle of Wight NHS Trust Board received the minutes of the Audit & Corporate Risk Committee

14/076 RECOMMENDATIONS FROM THE AUDIT & CORPORATE RISK COMMITTEE

Peter Taylor presented the recommendations raised at the last meeting held on 4th February 2014

a) Min No. 14/017 - Internal Audit Report – Payroll Workforce Transactions – Limited Assurance: As a result of the continuing concern over procedures within the HR Department, the Committee recommend that a Risk Summit is undertaken on the HR Department.

b) Min No. 14/021 - Consolidation of Charitable Fund Accounts: The Committee

recommended not to consolidate Charitable Fund Accounts in the 2013/14 Trust Accounts for presentation to the Trust Board for approval

c) Min No. 14/023 - Board Assurance Framework (BAF): The Committee

recognised that significant improvement had been achieved during the year and recommended that the in-year targets within the BAF be used as the framework for the content of the Trust’s Annual Report

The Executive Director of Nursing & Workforce advised that in respect of recommendation a) shown above, a repeat audit would be carried out by internal audit with an option of carrying out a risk summit if deemed necessary. He had discussed this with the Audit Committee members after their meeting on 4th February and this had been agreed. It was confirmed that the internal audit visit would be unannounced. Proposed by Nina Moorman and seconded by Sue Wadsworth The Isle of Wight NHS Trust Board approved the recommendations of the Audit & Corporate Risk Committee with the caveat to (a) described in the minute above.

14/077 CONSOLIDATION OF CHARITABLE FUNDS ACCOUNTS

The Executive Director of Finance outlined the need for this measure and formally requested that this be approved. Proposed by Peter Taylor and seconded by Charles Rogers. The Isle of Wight NHS Trust Board approved the recommendation NOT to consolidate the 2013/14 Charitable Funds Accounts within the 2013/14 IW NHS Trust Annual Accounts.

14/078 VICE CHAIRMAN OF CHARITABLE FUNDS COMMITTEE The Chairman asked that formal approval be given for Sue Wadsworth to be appointed

Vice Chairman of the Charitable Funds Committee. Proposed by Charles Rogers and seconded by Peter Taylor. The Isle of Wight NHS Trust Board approved the appointment of Sue Wadsworth as the Vice Chairman of the Charitable Funds Committee


14/079 MATTERS TO BE REPORTED TO THE BOARD None

14/080 QUESTIONS FROM THE PUBLIC There were no questions received from the public.

14/081 ANY OTHER BUSINESS

a) Chemotherapy/Haematologist Consultant Vacancy - The Chairman invited Nancy Ellacott, Vice Chair of the Patient Council, to speak. She asked for an update on succession planning for the Consultant Haematologist. The Executive Director of Nursing & Workforce confirmed that suitable locum support had been arranged whilst the substantive post was being recruited to. He also confirmed that partnership working in this area with other local Trusts was being actively explored.

b) CQC Training Event – The Executive Medical Director confirmed that the training

event on 27th February would be held in the Education Centre.

c) Sub Committee attendance – The Company Secretary advised that a TDA induction event for new Non-Executive Directors would be held on 19th March which coincided with the main Board sub- committee meeting day. He requested that all remaining Non-Executive Members involved in these meetings confirm their attendance as soon as possible to ensure that a quorum is achieved.

14/082 DATE OF NEXT MEETING The Chairman confirmed that next meeting of the Isle of Wight NHS Trust to be held in

public is on Wednesday 26th March 2014 in the Conference Room, St Mary’s Hospital, Newport, Isle of Wight. The meeting closed at 12:40 Signed…………………………………. Chair Date:…………………………………….

Enc B

20/03/20141 of 3

ISLE OF WIGHT TRUST BOARD Pt 1 (Public)ROLLING SCHEDULE OF ACTIONS TAKEN FROM THE MINUTES

Date of Meeting

Minute No. Action No. Action Lead Update Due Date Forecast Date Progress RAG Date Closed Status

27-Nov-13 13/261 & 14/037(v)

TB/054 Discharge Summaries - Sue Wadsworth also reported that she had attended the Directorate Performance Review meeting on 22nd November which had resulted in her being concerned about the level of outstanding discharge summaries. The Executive Medical Director assured her that these were being monitored closely and improvements would be seen once the JAC system was fully operational. He noted that there had been a data spike in August when the new doctors had joined the Trust. He also noted that ISIS programme had had teething problems which had also resulted in a data spike. He confirmed that he would be monitoring this area.

EMD Executive Medical Director to update the Board on the levels of outstanding discharge summaries. 16/12/13 - Discharge summary completion rates are part of the directorate performance updates 20/01/14 There continues to be a level of non completed discharge summaries by the cut off date for payment, although these are all completed eventually. EMD in discussion with Acute Directorate to move to patients not leaving hospital unless the summary is completed. 29/01/14 - Item raised again under minute 14/037(v). 26/02/14 - The Executive Medical Director confirmed that in January 2014 100% of discharge summaries had been completed by the required date and it was planned for that all patients to leave hospital with their discharge summary. Also confirmed was that there was a KPI for the clinical directorates and this was monitored at the monthly clinical directorate meetings.

26-Feb-14 Completed 26-Feb-14 Closed

27-Nov-13 13/264 TB/055 Safe Staffing Levels - The Deputy Director of Nursing confirmed that a report onSafe Staffing Levels would be presented every 6 months to the QCPC. She alsoconfirmed that if the principles were approved today then a detailed plan wouldbe drawn up with the Transformation and Quality Improvement team to movethe project forward with an update report in February. The Executive Director ofFinance requested that the Executive Director of Nursing and Workforce bringthis report to the FIWC at the appropriate time.

EDNW Executive Director of Nursing and Workforce bring update report on Safe Staffing Levels and the costs involved to FIWC. 16/12/13 - reporting going to FIWC for 22 Jan 2014. 21/01/14 - Going to QCPC & FIWC in March. 26/02/14 - The Executive Director of Nursing & Workforce confirmed that these would all be completed by the end of March. 19/03/14 - will be a Board Seminar agenda item on 8 April 2014

29-Jan-14 26-Mar-14 Completed 19-Mar-14 Closed

08-Jan-13 13/283e TB/058 Funding for Covered Walk from Helipad: The Executive Director of Finance wished to clarify the funding position mentioned in this minute. She confirmed that an offer of funding had been made for the covered walk to the helipad but stated that to date no funding had been requested by the Trust. The Chairman stated that as this was the case could the Chief Executive to pursue the funding.

IDPII Chief Executive to formally pursue the funding to allow the creation of the covered walk to the helipad. 13/02/14 - CEO advised that this has been passed to the Interim Director of Planning, ICT & Integration to progress. 26/02/14 - The Executive Director of Finance confirmed that £58k had been agreed for this project.

26-Feb-14 26-Mar-14 Completed 26-Feb-14 Closed

08-Jan-13 13/288vi TB/059 Flu Incentives: The Executive Director of Nursing & Workforce commented that Hull Trust used incentives to get staff to take up the vaccine and had almost 100% staff covered. He stated that if staff have 0% sickness absence, all mandatory training completed and flu vaccine they get the incentive which he wanted to explore.

EDNW The Executive Director of Nursing & Workforce to explore staff incentives linked to flu vaccination. 21/01/14 - DDW reviewing this suggestion. 26/02/14 - The Executive Director of Nursing & Workforce confirmed that the HR team were working on the scheme at present.

26-Feb-14 26-Mar-14 Progressing Open

08-Jan-13 13/293 TB/061 Board Walkabouts Action Tracker: Annual report requested. EDNW The Executive Director of Nursing & Workforce to arrange for an annual report be submitted to Board in April 2014.

30-Apr-14 30-Apr-14 Progressing Open

29-Jan-14 14/037-ix TB/069 Long Term Financial Model (LTFM) – Peter Taylor requested that the revised version of this document be presented to the Finance, Investment & Workforce Committee.

EDF The Executive Director of Finance confirmed that once the LTFM has been updated this would happen. 19/02/14 - confirmed that this will return to FIWC once produced. 26/02/14 - The Executive Director of Finance confirmed that the final document would be taken to the next Finance, Investment & Workforce Committee in March.

26-Mar-14 26-Mar-14 Progressing Open

29-Jan-14 14/041 TB/070 Mortality Data - Peter Taylor asked if it was possible to break down the mortality data by age and benchmark the Island’s figures nationally. The Executive Medical Director agreed to look into this for his next quarterly report.

EMD Executive Medical Director to review age trends for next quarterly report.


Designate Non Executive Directors: David King (DK) Jane Tabor (JT) Jessamy Baird (JB)

Executive Medical Director (EMD) Executive Director of Nursing & Workforce (EDNW) Deputy Director of Nursing (DDN)

Non Executive Directors: Danny Fisher (DF) Sue Wadsworth (SW) Peter Taylor (PT) Charles Rogers (CR) Nina Moorman (NM)

Key to LEAD: Chief Executive (CE) Executive Director of Finance (EDF)

Foundation Trust Programme Director/Company Secretary (FTPD/CS) Trust Board Administrator (BA) Head of Communication (HC) Executive Director of Finance Deputy (EDF Dep)

Interim Director of Planning, ICT & Integration (IDPII) Head of Governance & Assurance (HOG)

Enc B

20/03/20142 of 3

Date of Meeting


29-Jan-14 14/041 TB/071 Palliative Care - it was suggested that the new Designate Non- Executive Directors visit the hospice and also the clinical coding department to better understand the process.

CS The Company Secretary to arrange a visit for the new Designate Non- Executive Directors to be arranged to the Hospice and also Clinical Coding Department. 11/02/14 - Hospice visit to be arranged. Clinical Coding to be included on Board walkabout programme for March. 26/02/14 - it was confirmed that this would be discussed with the Designate Non-Executive Directors after Board. 19/03/14 - Company Secretary requested a visit. Dates to fit in with Board walkabout schedule.

26-Mar-14 26-Mar-14 Completed 19-Mar-14 Closed

29-Jan-14 14/044 TB/073 Patient Story Action Tracker - These were reviewed by the Quality & Clinical Performance Committee monthly and an end of year report would be made to the Board.

EDNW The Executive Director of Nursing & Workforce to present the End of Year Patient Story report at the April Board meeting. 19/03/14 - Patient Story action Tracker to be reviewed to ensure it encompasses the actions taken, and a year end position will be submitted to Board.


26-Feb-14 14/058 TB/074 Diabetic Meal Choices - Peter Taylor raised the question of the suitability of theDiabetic options within the patients menu choices. The Executive of Nursing &Workforce confirmed that the dieticians would be asked to review the currentchoices. Jessamy Baird also confirmed that this had been discussed at theQuality & Clinical Performance Committee at which an update from theExecutive Director of Nursing & Workforce was pending.

EDNW The Executive Director of Nursing & Workforce to follow up with the dieticians and report back on the outcome of the review of diabetic patient meal options. 20/03/14 - Menu choices are assessed by Dieticians for there suitability, and diabetic patients are able to choose from the main menu. Additional items have been added to the menu some of which are suitable for Diabetics. The patient menu has been the subject of review from the speech and language service and it has been agreed to review the menu with the input of SALT, Dietetics and catering.

26-Mar-14 30-Apr-14 Progressing Open

26-Feb-14 14/058 TB/075 Patient Information Boards - Peter Taylor also asked about the patient information boards above the beds and could these have the consultants name and lead nurse shown. The Executive Director of Nursing & Workforce confirmed that these were in place in some areas and that the remaining areas would be completed shortly.

EDNW The Executive Director of Nursing & Workforce to update theBoard on the progress of the installation of patient informationboards. 19/03/14 - The Patient Information boards are beingreviewed and work is progressing in ensuring that all areas have aboard in place that identifies the Consultant and Lead nursenamed.

26-Mar-14 26-Mar-14 Progressing Open

26-Feb-14 14/058 TB/076 Patient Story Action Plan Slide - Sue Wadsworth commented on how useful itwas that the Action Plan had been shown on screen and requested that this bedone for all future Patient Stories brought to the Board.

EDNW The Executive Director of Nursing & Workforce to arrange for asummary slide to be prepared for all Board Patient Stories.19/03/14 - completed - patient story action slide provided forboard on 26th March 2014.


26-Feb-14 14/065 (iv) TB/077 Risk Register Definitions - Jessamy Baird stated that some of the description of the risks were very generic and could result in a permanent position on the risk register. She asked if these could be reviewed. The Executive Medical Director advised that when staff-assess a risk it is on a local level which to them will seem a high risk but at Board level it may not rate as high. The Executive Director of Nursing & Workforce advised that the directorates had been asked to review these more rigorously to ensure that appropriate risk scores were made. Peter Taylor stated that he felt that this part of the performance report needed further development. David King agreed and stated that it should be showing the strategic imperative of each to Board against operational and strategic risk. The Executive Director of Finance confirmed that the Capital Investment Group did undertake a full risk review on capital schemes. Peter Taylor stated that an additional area showing the actions approved by the Capital Investment Group would be helpful.

EDF The Executive Director of Finance to review possible additionaldata to be included for future reports.

Progressing Open

26-Feb-14 14/065 (iv) TB/078 Ophthalmic Case note risk - Sue Wadsworth requested that an update on theOphthalmic Case note risk be brought to the Quality & Clinical PerformanceCommittee.

EDNW The Executive Director of Nursing & Workforce to arrange for areport to be presented at the Quality & Clinical PerformanceCommittee.


26-Feb-14 14/065 (vi) TB/079 Capital Plan - A discussion took place surrounding how the capital plan would be shown and how it would link to the Long Term Financial Model and the Clinical Strategy, and it was agreed that capital spend would be brought back to Board Seminar for more discussion.

EDF/IDPII The Executive Director of Finance to prepare a presentation with the Interim Director of Planning, ICT & Integration for Board Seminar on the capital plan. 19/03/14 - This has been scheduled for 13 May Board Seminar.

13-May-14 13-May-14 Completed 19-Mar-14 Closed

26-Feb-14 14/065 (viii) TB/080 Falls - Charles Rogers asked if falls which fall outside the category of “resulting in significant injury” could be shown. The Chairman confirmed that this was a category which was included within the Board Walkabout questionnaire and Sue Wadsworth confirmed that these were also looked at in detail at the Quality & Clinical Performance Committee (QCPC). The Executive Director of Nursing & Workforce advised that a total review of the annual total number of falls would be added to the agenda of the QCPC.

EDNW The Executive Director of Nursing & Workforce to arrange for a full report on Falls to be presented at the QCPC committee.


Enc B

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Date of Meeting


26-Feb-14 14/065 (ix) TB/081 Compliments – The Company Secretary asked on behalf of Jane Tabor, if in future the level of compliments could be added to the report. The Executive Director of Finance confirmed that this was in hand and would appear in the next report.

EDF The Executive Director of Finance to ensure that the level of compliments be added to the performance report.

Progressing Open

26-Feb-14 14/069 TB/082 Reference Costs & Service Line Reporting - The Company Secretary asked, onbehalf of Jane Tabor, if it would be possible for more consideration to be givento this subject in a seminar. The Board agreed this proposal.

CS The Company Secretary to arrange for a seminar on Service LineReporting and Reference Costs to be added to the Board SeminarForward Planner. 19/03/14 - This has been scheduled for 8 JulyBoard Seminar.

08-Jul-14 08-Jul-14 Completed 19-Mar-14 Closed

26-Feb-14 14/074 TB/083 CSF8.2 - The Company Secretary asked, on behalf of Jane Tabor, if risk CSF8.2 should remain as Amber instead of the recommended upgrade to Green. A discussion to place and it was agreed that this item would stay as Amber.

HOG SF8.2 should remain as Amber instead of the recommended upgrade to Green.


1

REPORT TO THE TRUST BOARD (Part 1 - Public) ON 26TH MARCH 2014

Title Chief Executive’s Report Sponsoring Executive Director

Chief Executive Officer

Author(s) Head of Communications and Engagement Purpose For information Action required by the Board: Receive P Approve Previously considered by (state date): Trust Executive Committee Mental Health Act Scrutiny

Committee

Audit and Corporate Risk Committee

Nominations Committee (Shadow)

Charitable Funds Committee Quality & Clinical Performance Committee

Finance, Investment & Workforce Committee

Remuneration Committee

Foundation Trust Programme Board

Please add any other committees below as needed Board Seminar Other (please state) Staff, stakeholder, patient and public engagement: This report is intended to provide information on activities and events that would not normally be covered by the other reports and agenda items. Executive Summary: This report provides a summary of key successes and issues which have come to the attention of the Chief Executive over the last month. For following sections – please indicate as appropriate: Trust Goal (see key) All Trust goals Critical Success Factors (see key)

All Trust Critical Success Factors

Principal Risks (please enter applicable BAF references – eg 1.1; 1.6)

None

Assurance Level (shown on BAF)

Red Amber Green

Legal implications, regulatory and consultation requirements

None

Date: 19 March 2014 Completed by: Andy Hollebon

Enc C

2

NATIONAL NHS Pay It is disappointing that the Government have rejected advice and decided that NHS staff this year will receive either their annual increment where appropriate or a one per cent rise but not both. This does recognise the difficult financial times faced by all public sector organisations but at the same time it doesn’t feel as if we are being appreciated fully for what we do although I know that we are all committed to ensuring that patients receive the best possible care. NHS Change Day 2014 is the second year that a national NHS Change Day has been promoted. This is a frontline led campaign with a mission to inspire us all to do something better together to improve care for people. This national initiative works by individuals and teams making a simple pledge to make a change that matters in every day practice. As an Executive Team, we pledged to the organisation that: We are committed to improving two-way communication between staff at all levels in order to help reduce their daily working life stress levels. You can still get involved in NHS Change Day - you have until 31 March to make your pledge by visiting www.changeday.nhs.uk. LOCAL CQC Inspection Preparation In June we expect the Care Quality Commission to undertake a large inspection of services at the Trust. As part of our preparation for this important event we have held the first peer review-style pseudo inspection of services across the Trust Our mock inspectors identified many areas of good practice and some areas that need work. The process will help us all to achieve our aim, together, of creating an excellent organisation that gives excellent patient care. This is a real opportunity to genuinely improve our services, not just for the CQC inspection this June, but beyond. My Life a Full Life News – Spring 2014 The My Life a Full Life programme is a collaboration between the Clinical Commissioning Group (CCG), Isle of Wight NHS Trust, Isle of Wight Council and the Voluntary Sector. It aims to deliver a more coordinated approach to health and social care services for people needing care and support on the Island. The fourth edition of the My Life a Full Life quarterly newsletter is now available. It contains lots of information about the changes taking place on the Island which are already making a difference to people’s lives such as Better Care funding, improving information sharing, local integrated working, helping people to support and care for themselves and more. The newsletter can be downloaded at www.iwight.com/My-Life-a-Full-Life. Norovirus Outbreak As this report is written St. Mary’s Hospital is continuing to face very serious challenges with patients and staff experiencing Norovirus which causes diarrhoea and vomiting. Over 40 patients have been directly affected and 20 per cent of the Trust’s 236 hospital beds are affected. The main areas affected by the Outbreak have been:

3

∑ Appley Ward ∑ Colwell Ward ∑ General Rehabilitation Unit ∑ Stroke Neuro Unit

∑ Whippingham Ward ∑ Medical Assessment Unit (MAU) ∑ St. Helens Ward

The Trust has taken a range of measures to enable more resources to be diverted into resolving the issue, including:

∑ All visiting to the main hospital (not just to the wards closed to new admissions) is restricted to essential visiting only and a time to visit must be agreed with the Ward Manager. Wards should be contacted via the Hospital Switchboard.

∑ All scheduled in-patient operations, apart from some for urgent care such as cancer and orthopaedics, have been cancelled until 22/3/14. The operations will be rescheduled as soon as possible.

∑ Access to the main hospital for patients and visitors is only via the main entrance. It is

therefore better to park closer to the main entrance if you have mobility issues or arrange to be dropped at the main entrance before cars are parked.

∑ Visitors and patients are asked to ensure they cleanse their hands on entering and leaving

the hospital and entering and leaving clinical areas.

∑ No more than two visitors per patient.

∑ Children under the age of 16 and elderly or vulnerable adults should not visit unless necessary.

∑ Anyone who has had symptoms, such as vomiting and diarrhoea, must not come into the

hospital until they have been clear of those symptoms for at least 48 hours.

∑ Patients visiting the Beacon Health Centre and Emergency Department should only be accompanied by one other person if possible.

Where possible the Trust has tried to ensure that day surgery, outpatient appointments or clinics remain unaffected and patients were asked to attend as normal. The team managing the outbreak are meeting twice a day and the outbreak has been designated an ‘Internal Incident’ to ensure that resources are redeployed to manage the issue. We have also been working with and are grateful for the support of partner agencies including Isle of Wight Council (adult social care, public health and education), General Practice and our colleagues in the nursing and residential care home sector. I would like to apologise for the inconvenience this is causing patients and visitors at St. Mary’s but I hope everyone will understand the need for us to get this nasty bug under control.

4

Allergy and Asthma Centre I’ve been inspired by the work of the Asthma and Allergy Centre. We have as part of our organisation one of only 6 centres across the country doing cutting edge research and service provision in this area. The passion of the team and the opportunities they provide us with are incredible. Hospital Porters raise money for Cancer Clinical Nurse Specialists Well done to 14 Porters at St Mary’s Hospital who have raised £600 after letting their moustaches run wild throughout November 2013, during the Movember campaign which helps raise awareness among men of the warning signs of prostate cancer. The hospital porters however wanted to donate locally and donated to the Cancer Clinical Nurse Specialists (CNS) for education and equipment. After collecting all of their sponsorship, the porters presented the cheque to Lead Cancer Nurse, Anne Snow.

Karen Baker Chief Executive Officer 19 March 2014

Isle of Wight NHS Trust Board Performance Report 2013/14February 14

Title

Sponsoring Executive Director

Author(s)

Purpose

Action required by the Board: XPreviously considered by (state date):

Quality & Clinical Performance Committee

Isle of Wight NHS Trust Board Performance Report 2013/14

Chris Palmer (Executive Director of Finance) Tel: 534462 email: [email protected]

Iain Hendey (Assistant Director of Performance Information and Decision Support) Tel: 822099 ext 5352 email: [email protected]

To update the Trust Board regarding progress against key performance measures and highlight risks and the management of these risks.

Receive Approve

Trust Executive Committee Mental Health Act Scrutiny Committee

Nominations Committee (Shadow)

19/03/2014

Audit and Corporate Risk Committee

Charitable Funds Committee

Assurance Level (shown on BAF)

Legal implications, regulatory and consultation

requirements

Trust Goal (see key)

Critical Success Factors (see key)

Principal Risks (please enter applicable BAF references – eg 1.1; 1.6)

For following sections – please indicate as appropriate:

Quality, Resilience,Productivity & Workforce

CSF1, CSF2, CSF6, CSF7, CSF9

Staff, stakeholder, patient and public engagement:

Executive Summary:

This paper sets out the key performance indicators by which the Trust is measuring its performance in 2013/14. A more detailed executive summary of this report is set out on page 2.

Remuneration Committee

Quality & Clinical Performance Committee 19/03/2014Charitable Funds Committee

Finance, Investment & Workforce Committee

Foundation Trust Programme Board

19/03/2014

Other (please state)

Please add any other committees below as needed

None

Date: Thursday 20th March Completed by: Iain Hendey

�� Green�� Amber�� Red

Page 1 of 28

Enc D


Executive Summary

Patient Safety, Quality & Experience:

Pressure ulcers: We continue to under achieve our planned reduction across all grades

of pressure ulcers, both in the hospital setting and the wider community. A range of

actions continue to support improvements in this area.

VTE: Risk assessment figures from 4th February show an underperformance (94% vs

95% target), this figure is based on the final month of manual data capture. Pharmacy

are now confident that the new upgrade to their system during February has eliminated

previous data collection problems and we are now achieving 100%, exceeding both the

local and national targets of 95%.

HCAI: We are currently within both our nationally set threshold and our local stretched

target for Healthcare Acquired Clostridium Difficile infection, remaining at 6 YTD, with

no cases reported during February.

Workforce:

The total pay bill for February (£9.83m) is above plan (£9.55m). The number of FTEs in

post is also currently higher than plan (10). The HR Directorate are closely monitoring

and supporting the Clinical directorates with their workforce plans, in particular their

control over their spend on variable hours.

Sickness absence increased again in February (4.65%) and remains above plan at

3.77% YTD. Specific problem areas are being identified for investigation and are

challenged at directorate performance review meetings.

HCAI:

no cases reported during February.

There were no cases of Healthcare Acquired MRSA bacteraemia identified in February,

remaining at 2 YTD.

Mental Health:There was a single breach in Child & Adolescent Mental Health but the

extremely low numbers have an exaggerated impact on percentages.

Operational Performance:

Performance against our key operational performance indicators is again mainly green

for the month, the only red flag being referral to treatment times for non-admitted

patients. TIA reporting figures are not yet available for February (as at 19/3).

All cancer targets are again green for month and year to date. Provisional figures

indicate that 40% of breaches during February were due to capacity issues.

From April 2014 this Performance report will be revised to include a wider range of

measures and a clearer reporting structure for Acute, Community and Mental Health

and Ambulance services which will give a more balanced reflection on our performance

as the only fully integrated Trust in the country.

Finance & Efficiency:

Overall we have slightly over-achieved our financial plans for February by £214k and

based on the new measure, the Continuity of Service Rating, introduced by Monitor on

1st October, our overall rating is 4.

The target YTD CIP target of £7,547k has been under-achieved by £1,151k, and

recurrent savings of £1,478k still need to be identified. However, there is an increasing

risk that this carry forward figure is significantly higher. Directorates are continuing to

review opportunities to mitigate this balance with a view to eliminating any carry forward

into next financial year.

Page 2 of 28


Balanced scorecard

GRR

ref:Patient Safety, Quality & Experience

Annual

TargetYTD

Performance

Month TrendSparkline

Year end

forecastWorkforce

In

Month YTD

Performance

Month Trend YTD plan

Quality Acct #1 Summary Hospital-level Mortality Indicator (SHMI)* Jul-12 - Jun-13 1.00 1.1160 Q3 N/A � 1.105 Total workforce SIP (FTEs) 2,670.0 2,680 Feb-14 n/a �

Quality Acct #1Hospital Standardised Mortality Ratio (HSMR) Jul-12 - Jul-13 100 103.47 Q3 N/A � 102.90 Total pay costs (inc flexible working) (£000) £9,545 £9,831 Feb-14 £106,411 � £103,987

Quality Acct #2 Patients admitted that develop a grade 4 pressure ulcer 0 2 Feb-14 16 � 17 Variable Hours (FTE) 139 186.00 Feb-14 1,590 � 1541

Quality Acct #2 Patients admitted that develop a grade 2 or 3 pressure ulcer 60 12 Feb-14 93 � 102 Variable Hours (£000) £87 £615 Feb-14 £6,139 � £675

Quality Acct #3 Reduction in communication complaints/concerns 150 15 Feb-14 151 � 165 Staff sickness absences 3% 4.65% Feb-14 3.77% � 3%

Quality Acct #4 Amber care bundle (now implemented - no audited results as yet) - - - - - Staff Turnover 5% 0.61% Feb-14 8.96% �

Child & Adolescent Mental Health (CAMHS) seen within 18 weeks referral to treatment 100% 95% Feb-14 98% � 98% Mandatory Training 80% 77% Feb-14 74% �

VTE (Assessment for risk of) >95% 94% Feb-14 90% � 90% Appraisal Monitoring (cumulative) 100% 63.9% Feb-14 63.9% �

MRSA (confirmed MRSA bacteraemia) 0 0 Feb-14 2 � 2 Employee Relations Cases 0 40 Feb-14 149 (live)

14 C.Diff (confirmed Clostridium Difficile infection - stretched target) 8 0 Feb-14 6 �� 6

Clinical Incidents (Major) resulting in harm (confirmed & potential, includes falls & PU G4) 48 2 Feb-14 53 � 55

Clinical Incidents (Catastrophic) resulting in harm (confirmed & potential) 8 2 Feb-14 9 � 10

Falls - resulting in significant injury 11 1 Feb-14 8 � 9

Delivering C-Section 70% 74% Feb-14 68% � 68%

Breast Feeding at Delivery (Target reduced February 2014) >80% 72% Feb-14 75% � 75%

Formal Complaints 1% 2.16% Feb-14 2.16% �

High risk TIA fully investigated & treated within 24 hours (National 60%) 95% 93% Jan-14 83% �� 82% Liquidity ratio days =>15 39 Feb-14 39 �

8b Symptomatic Breast Referrals Seen


Highlights

All Cancer indicators maintaining year to date position

Emergency Care 4 hour standard performance remains above target

No of C.Diff cases are on track to achieve year end stretched target

Reduction in formal complaints during FebruaryReduction in formal complaints during February

Marked improvement in VTE risk assessment recording

Page 4 of 28


Lowlights

Drop in Admitted 18 weeks referral to treatment time for January

Staff absenteeism due to sickness remains above target

Pay costs/variable hours remain challenging

CIP targets remain challengingCIP targets remain challenging

Drop in Non-admitted 18 weeks RTT for February.

Page 5 of 28


Pressure Ulcers

Analysis: Quality Account Priority 2 - Prevention & Management of Pressure UlcersCommentary:

General:There has been a change in the reporting process whereby numbers are

reviewed for both the current and previous month and there may be changes to

previous figures once validated. These figures are also included within the clinical

incident reporting and where any rise is also reflected.

Hospital acquired:There were 2 x grade 4 pressure ulcers reported in the hospital

during February, showing a YTD position of 16 against 21 at the same point last

year. Grade 2 numbers stand 89 YTD against 103 for the same period with grade 3

numbers at 4 YTD against 15 in 2012/13.

Community acquired: There has been marked improvement in grade 4 incidence

over recent months despite an initial increase on the baseline from last year. Both

grade 2 and 3 pressure ulcers numbers have reduced from 2012/13, with the

reduction in grade 3s achieving the 50% decrease required of the target. 2

4

6

8

10

12

14

16

18

Nu

mb

er r

ep

orte

d

G2 Community Acquired Pressure ulcer incidence

2012.13 2013.14

Target 3/12 average

1

2

3

4

5

6

Nu

mb

er r

ep

orte

d


2012.13 2013.14 Target 3/12 Average

1

2

3

4

5

Nu

mb

er r

ep

orte

d


2012.13 2013.14 Target 3/12 Average

0

1

2

3

4

5

6

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

Nu

mb

er r

ep

orte

d

Month

G3 Hospital Acquired Pressure ulcer incidence

2012.13 2013.14 Target 3/12 average

0

2

4

6

8

10

12

14


Nu

mb

er r

ep

orte

d

Month


2012.13 2013.14 Target 3/12 average

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5


Nu

mb

er r

ep

orte

d

Month


2012.13 2013.14 Target 3/12 average

Explanation of RAG Rating

Red=Any G4 or 2 G3 or 5 any in rol ling 3 month period

Amber=1G3 or increase/no change in G2 in rol ling 3 month period

Green=No G3 or G4 and decrease in G2 or 2 or less of any grade (1&2) in roll ing 3 month period

Status:Date:

The Clinical Nurse Specialist continues to support the wards with management of complex wounds

and assessment of Pressure Ulcer Competency standards across all front-line staff within the trust. Executive Director of Nursing & Workforce/ Tissue Viability Specialist Nurse Mar-14 In progress

Action Plan: Person Responsible:

Work continues to raise awareness and improve prevention.

A 'deep-dive' exercise has reviewed all Community grade 4's over the past months. One area of

concern is patient compliance. Action plans are being discussed and developed from this. Executive Director of Nursing & Workforce/ Tissue Viability Specialist Nurse Mar-14 In progress

The Clinical Nurse Specialist & Director of Nursing are working with Communication & Engagement to

develop a Pressure Ulcer Campaign across the wider healthcare economy. Executive Director of Nursing & Workforce/ Tissue Viability Specialist Nurse Spring 14 In progress

Issues have been highlighted,relating to the use of appropriate care plans and this will form part of the

ward accountability process. Matrons are working to summarise care delivery standards for patients

at risk, in order to streamline analysis of PUs once identified.

In progressMar-14Executive Director of Nursing & Workforce/ Tissue Viability Specialist Nurse

0

2


Month

0


Month

0


Month

Page 6 of 28


Patient Safety

Commentary: Analysis: Clostridium Difficile infections against national target

Clostridium difficile

There were no Healthcare Acquired Clostridium Difficile (C Diff) cases in February

(YTD = 6) and we remain within our planned control total for the national threshold

of 12 for the year.

We are currently working towards a locally stretched target of 8. This threshold is

weighted across the year to take account of the historically expected winter

increase. We have entered this winter period and remain within our stretched

trajectory.

Methicillin-resistant Staphylococcus Aureus (MRSA)

There have been no cases of Healthcare Acquired MRSA bacteraemia in the Acute

hospital during February.

The Action Plan for MRSA is progressing and work continues on the Healthcare

Associated Infection agenda.

All cases continue to be subject to root cause analysis to identify actions necessary to ensure the

trajectory remains achieved.

Executive

Director of Nursing &

Workforce

Mar-14 Ongoing

An external Healthcare Acquired Infection expert (currently working with the Trust Development

Authority) visited during February to oversee our current policies & procedures to offer advice on

improvement. The report has yet to be received.

Executive


Workforce

Mar-14 Report expected

A risk register entry for this target is under development by the Director of Infection Prevention &

Control (DIPC) in conjunction with the Infection Prevention & Control Team.

Executive


Workforce

Mar-14 In progress

Status:

Associated Infection agenda.

Action Plan: Person Responsible: Date:

Page 7 of 28Page 7 of 28


Formal Complaints

Analysis: Complaints Commentary:

There were 17 formal Trust complaints received in February

2014 (24 previous month) with 256 compliments recieved by

letters and cards of thanks across the same period. There were

over 21,400 consultant led contacts during February.

Across all complaints and concerns in February 2014:

Top areas complained about were:

- Orthopaedics (8)

- Medical services (7 )

- Ambulance services (6)

Across all complaints and concerns in February 2014:

Top subjects complained about were:

- Clinical care (28)

- Out-patient appointment delay/cancellation (27)

- Communication (10)

80

29

69

4

20

7

9

0

20

40

60

80

100

120

Acute Community Planned Corporate

Complaints received April 13 to date

including those returning

dissatisfied

Original Number received Returners

Clinical Care 4 12 11 -1 �Nursing Care 3 2 1 -1 �Staff Attitude 1 1 0 -1 ��Communication 1 3 2 -1 �Outpatient Appointment Delay/ Cancellation 0 2 1 -1 �Inpatient Appointment Delay / Cancellation 0 0 1 1 �Admission / Discharge / Transfer Arrangements 0 0 0 0 ��Aids and appliances, equipment and premises 0 1 0 -1 ��Transport 0 0 1 1 �Consent to treatment 0 0 0 0 ��Failure to follow agreed procedure 0 0 0 0 ��Hotel services (including food) 0 0 0 0 ��Patients status/discrimination (e.g. racial, gender) 0 0 0 0 ��Privacy & Dignity 0 0 0 0 ��Other 1 3 0 -3 ��

RAG

rating

Primary Subject December 2013

January

14

February

14CHANGE

Quality Account Priority 3 - Improving communications

Date:

- Communication (10)

Quality Account Priority 3 - Improving Communication

The target of a 20% reduction in both complaints & concerns

across the year regarding communication is being monitored.

This is currently achieved for Year to Date complaints although

concerns continue to exceed the planned trajectory. This could

be due to increased awareness and accessibility addressing

concerns before reaching conversion to formal complaint level. Individual months are colour rated for their achievement of the target for that month. The Year to Date figure for 2013/14 shows the cumulative position against the equivalent YTD position for 2012/13

Status:Action Plan: Person Responsible:

Following the review of complaints, recommendations have been made

relating to complaints management. Resources will be allocated to Clinical

Directorates to assist them in owning their complaints and managing them

closer to the point of care. Resource to be identified through organisational

change.

Executive Director of Nursing & Workforce / Business Manager -

Patient Safety; Experience & Clinical EffectivenessApr-14 Planned

Other 1 3 0 -3 ��

Links to The NHS Outcomes Framework Domain 4 – Ensuring That People Have A Positive Experience Of Care

KPI Description Target

(cumulative)

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

YTD

Reduction in complaints relating to

communication �20%

2012/13 3 4 6 3 4 6 8 7 1 7 5 2 56

2013/14 4 1 3 5 2 2 3 2 4 5 5 36

Reduction in concerns relating to

communication �20%

2012/13 20 19 12 14 8 10 11 6 6 10 8 8 132

2013/14 17 12 8 8 7 5 18 10 11 9 10 115

Page 8 of 28Page 8 of 28


Litigations

NPSA Category

Q4 12/13 Q3 13/14 Q4 13/14 Change RAG

Access, Appointment, Admission, Transfer, Discharge 1 3 0 -3 ��

Accident that may result in personal injury 0 0 0 0 ��

Consent, Confidentiality or Communication 0 0 0 0 ��

Infrastructure or resources (staffing, facilities, environment) 0 0 0 0 ��

Medication 0 0 2 2 ��

Implementation of care or ongoing monitoring/review 2 4 1 -3 ��

Q4 Isle of Wight NHS Trust Claims Dashboard

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