AGENDA - fhft.nhs.uk › media › 4635 › public-agenda-150121-diligent.pdfNomsa Gumunyu CQC...

Board of Directors Public Meeting Friday 15th January 2021, 08:30-11:00

Microsoft Teams

A G E N D A

Item Title Lead Action Paper Time

1. Welcome and Introduction Chairman - Oral 08:30

2. Apologies and Declarations of Interest Chairman - Oral 08:35

3. VIP Awards Chief Executive - Oral 08:40

4. Minutes of the previous meeting Chairman Approve Attached 08:55

5. Action Log from the previous meeting Chairman Note Attached 08:57

Chief Executive, Quality and Strategy Reports

6. Chief Executive’s Report including: a) Quality and Performance Reportb) Current Covid Status (oral update)

Chief Executive Assurance Attached 09:00

7. Quality Reports: a) Infection Prevention Control BAFb) Vaccination Programme Update

Chief of Nursing and Midwifery

Assurance Attached 09:15

Finance

8. Finance Report: Month 8 Director of Finance Assurance Attached 09:30

Short Break (09:45 -10:00)

Governance and Compliance

9. Ockenden Review of Maternity Services Chief of Nursing and Midwifery

Assurance Attached 10:00

10. Board Assurance Framework Chief Executive Assurance Attached 10:15

Committee Minutes and Recommendations

11. a) Audit: 25 November

b) Charitable Funds: 9 December

c) Finance Investment: 20 November

d) Performance and Remuneration:

1 December

e) Quality Assurance: 15 December

Committee Chairs Note Attached 10:25

Other Business and Public Questions

12. Any Other Business Chairman Oral 10:35

13. Public Questions Chairman Oral 10:40

14. Date of Next Meeting: Friday 5th March 2021, 08:30-11:00

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Report Title Minutes of the previous meeting

Meeting and Date Public Board of Directors, Friday 15th January 2020

Agenda Item 4.

Author and Executive Lead

Hannah Stubbs, Assistant Company Secretary Neil Dardis, Chief Executive

Executive Summary

The attached minutes records the items discussed at the Board of Directors meeting held in public on 6th November 2020.

Action

The Board is asked to approve the minutes as a correct of the meeting.

Compliance

NHS Provider Licence; Standing Order 14.1

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Tab 4 Minutes of the previous meeting


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BOARD OF DIRECTORS MEETING IN PUBLIC Friday 6th November 2020, 08:30-11:30

Microsoft Teams

MINUTES OF MEETING

Members Present: Pradip Patel Chairman Michael Baxter Non-Executive Director Bryan Ingleby Non-Executive Director Dawn Kenson Non-Executive Director Mike O’Donovan Non-Executive Director Rob Pike Non-Executive Director Thoreya Swage Non-Executive Director John Weaver Non-Executive Director Neil Dardis Chief Executive Nigel Foster Director of Finance Tim Ho Medical Director Caroline Hutton Interim Director of Transformation, Innovation & Digital Services John Seymour Acting Chief Operating Officer Eleanor Shingleton-Smith Acting Director of HR Lorna Wilkinson Chief of Nursing & Midwifery Apologies: Dan Bradbury Chief Operating Officer In Attendance: Tyrieana Long Company Secretary Hannah Stubbs Assistant Company Secretary James Taylor Assistant Director of Communications and Engagement Dorota Underwood Committee Administrator Emma Carroll CQC Inspector Nomsa Gumunyu CQC Inspector Priya Oomahdat NHS England and NHS Improvement VIP Awards: VIP Award Attendees are listed at Appendix 1 (item 3) Chemotherapy Team BMI Princess Margaret Hospital Covid-19 Swab Team Frimley Park and Wexham Park Hospitals Cystic Fibrosis Unit Frimley Park Hospital Dee Carter Heading of Nursing (item 4) Peter Clarkson Consultant Cardiologist (item 4) Robert Ham Cardiology Service Manager (item 4) Kirstin MacDonald Associate Director ED & Medicine Wexham Park (item 4) Heather Nicholson Clinical Matron (for item 4) Philomena Vallance Head of Nursing, Emergency and Cardiovascular Medicine (item 4) Michael Ellis Staff Governor: Heatherwood & Community Hospitals David Maudgil Staff Governor: Wexham Park Hospital Udesh Naidoo Staff Governor: Frimley Park Hospital Dale Birch Stakeholder Governor: Berkshire Council Rod Broad Public Governor: Windsor and Maidenhead

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Brian Hambleton Public Governor: Rushmoor John Lindsay Public Governor: Bracknell Forest and Wokingham Sarah Peacey Public Governor: Bracknell Forest and Wokingham Mary Probert Public Governor: Surrey Heath and Runnymede Jill Wakefield Public Governor: Rest of England Robin Wood Public Governor: Windsor and Maidenhead Bernadine Blease Head of Community Networks Dr Kate Brackenborough Darzi Fellow Gulrays Jamie Chief Registrar - Cardiology/General Medicine James Lawson HR Graduate Trainee Gladys Longwe Senior Sister Stroke Ward, WPH Jerry Andrews Member of the public Bob Bown Member of the public James Birdseye Member of the public Charlotte Jobson Member of the public Jan Burnett Member of the public John Ferns Member of the public Patrick O’Hagan BBC Radio Berkshire 1. Welcome and Apologies for Absence 1.1 The Chairman welcomed everyone to the November Board meeting in public. He introduced and

welcomed Nomsa Gumunyu the Trust’s CQC Relationship Manager & CQC Inspector and her colleague Emma Carroll a CQC Inspector.

1.2 The Chairman also introduced and welcomed Eleanor Shingleton-Smith, who was the acting Director

of HR. There was one apology for absence from Dan Bradbury. 1.3 The Chairman started the meeting by providing some context for the next period of time. He

acknowledged the ongoing pandemic and the recent increase in the number of Covid-19 cases. He advised that there were many challenges ahead for the Trust, including the usual winter pressures combined with a backlog of patients from the first peak of the pandemic, the forthcoming exit from the EU and the likelihood of a deep recession as a result of the impact on the economy of the ongoing pandemic. All of which, he recognised would require careful management by the Board of Directors, to ensure that we look after both of our people and our patients. He was sure that the board would rise to these challenges and provide the leadership to help the Trust navigate the next period of time.

2. Declarations of Interest 2.1 There were no declarations of interest. 3. VIP Awards 3.1 Neil Dardis welcomed the VIP nominees to the meeting and explained that each public Board

meeting began by recognising the outstanding contributions made by the Trust’s staff. The VIP award nominations were made by patients and colleagues. We had received a huge number of nominations and it was very difficult for the senior leadership committee to pick the three teams that had been chosen to receive an award.

3.2 The first award was for all the staff working within the Cystic Fibrosis Unit (CFU) at Frimley Park

Hospital. The CFU was recognised as a flagship and pioneering service. The Trust was one of the first in the country to roll out life-changing drugs and the CFU was well known nationally for its achievements. Neil Dardis congratulated the team on the award and for all their work which had made a tremendous difference to cystic fibrosis patients.

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3.3 The second award was for the Covid-19 Swab Teams at Frimley Park and Wexham Park Hospitals.

Neil Dardis explained that the Swab Teams had not existed before the pandemic and he praised the staff for coming together in such a positive way. He acknowledged the hugely important contribution that the Swab Teams had made in the Trust’s ability to tackle the pandemic.

3.4 The final award was for the Chemotherapy Team at BMI Princess Margaret Hospital. Neil Dardis said

that the Team had been recognised for working collaboratively during the peak of the pandemic, to ensure that no patients missed their chemotherapy appointments. He acknowledged the huge challenge and the sacrifices that the staff had made to deliver continuing patient care.

4. Ward to Board Presentation – Cardiology 4.1 Pradip introduced and welcomed the Cardiology Team. He invited Peter Clarkson to highlight the

main points from the slide presentation and to answer questions from the Board. 4.2 Mike O’Donovan asked about the staffing to patient ratio at Wexham Park Hospital. Peter Clarkson

advised that there was an action plan in place to reduce the number of cardiac beds in line with demand and this will address the issue with staffing numbers. Kirstin MacDonald assured the Board that the service was being delivered with the right staffing levels.

4.3 Rob Pike commented on the outstanding progress that had been made to the primary

percutaneous coronary intervention (PPCI) service since he initially joined the Board 10 years ago. 4.4 Philomena Vallance stated that staff satisfaction rates within the cardiology service was high and

they were able to attract candidates to vacant roles. She added that there was a good rotational programme in place.

4.5 Michael Baxter asked about the risk of Covid to the service. Peter Clarkson advised that over 400

pacemaker patients had been taken care of remotely, to avoid them coming to our busy hospitals. There was a push for all pacemakers and complex devices patients to be subject to remote monitoring. It was possible to identify devices that had been activated and to analyse data online on a daily basis.

4.6 Neil Dardis queried whether the CQC Self-Assessment was modest or did it indicate that there were

challenges that should be highlighted. Philomena advised that the good rating across the five CQC domains was primarily modesty however, there were areas where improvements could be made to achieve the outstanding rating. Neil Dardis praised the team for the very good work that had already been achieved.

4.7 Mike O’Donovan queried whether there were any critical roles that the service was missing. Peter

Clarkson advised that consultants were required to work cross-site. There was some scope to strengthen the leadership and encourage excellence and some senior roles would be introduced as part of the redesign and upgrade improvement work.

4.8 The Chairman praised the team for making a difference to and saving patient lives, whilst

continuously making improvements to the service. He asked that the Board’s gratitude was passed on to the entire team.

5. Minutes of the previous meeting 5.1 The Chairman requested that any further amendments to the previous meeting minutes be

submitted to the Company Secretariat by Wednesday 11th November 2020. Subject to any subsequent amendments, the minutes would then be APPROVED by the Board.

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6. Actions Log from previous meeting 4th September 2020 – 8.6 Finance Report: Month 4 6.1 The action point had been completed and could be closed. 4th September 2020 – 12.5 Influenza Immunisation Programme 2020/21 6.2 The action point had been completed and could be closed. The Chairman thanked the Board for

receiving their vaccinations and leading by example. 5th June 2020 – 5.1.h COVID-19 General Update – Restoration 6.3 The Chairman requested that the action point remained open to provide an opportunity for John

Weaver to speak with Dan Bradbury. 4th September 2020 – 7.3 Chief Executive’s Report and Quality and Performance Report 6.4 The Quality Assurance Committee had received the patient experience results and the action point

could be closed. 7. Chief Executive’s Report and Quality and Performance Report 7.1 Neil Dardis presented the above report and acknowledged that the anticipated second Covid wave

combined with the winter pressures would present challenges for the Trust. However, he was confident that the Trust was better prepared because of the improved testing arrangements, the knowledge of treatment options gained through the first phase and the tried and testing operational and staffing plans. From the report he highlighted:

• The escalation plans that were in place in response to the increasing prevalence of Covid-19 in the region;

• The internal changes to the hospital sites that had been made to maintain patient flow, manage the Covid and non-Covid pathways and to increase capacity as required;

• The significant progress that had been made in addressing the backlog of patients requiring planned care and plans in place to use dedicated green elective pathways across the hospital sites and where possible to use same-day surgery care models;

• The national public campaigns that were focussed on a ‘Help Us Help You’ message and the 111-First service which would urge people to call ahead or go online for advice. Together with the planned ED booking system, the initiatives were designed to help patient flow and reduce the time spent in waiting areas where there was a high risk of infection;

• The strategy progress made and the enthusiasm from teams in putting the strategy into action. Recent examples were the introduction of the new Versius robot-assisted surgery to carry out colorectal surgery and a new state-of-the-art laser to treat bladder tumours;

• The special event held to mark the new five-year community contract with North East Hampshire, Farnham and Surrey Heath. The expansion and development of community services was a key part of the Trust’s future strategy; and

• The recent Trust achievements and developments which included the achievement of the prestigious ACSA accreditation by the Anaesthesia Department, a marker for safety and quality, the sustainability green wards initiatives and a variety of awards achieved by Frimley Health teams and individual staff.

7.2 Rob Pike highlighted that the Trust had reached over 1000 Covid-19 discharges which was a notable

achievement. Thoreya Swage pointed out that in spite of the pandemic, the Trust had continued to develop and achieve a number of its strategic goals.

7.3 Mike O’Donovan asked about the operational impact of NHSI/E taking greater control during the

second peak. Neil Dardis advised that previous arrangements were likely to be re-instated, however there had been learning at national, regional, and local levels from the first peak of the pandemic.

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Although the Trust would need to operate within the national and regional framework, as far as possible clinicians would be able to innovate and use their initiative in the interests of patient care.

7.4 Bryan Ingleby thanked Neil Dardis for including the community indicators in the performance

summary. Neil Dardis advised that further performance measures would be introduced. 7.5 In response to a question about the deteriorating SHMI performance from Michael Baxter, Tim Ho

confirmed that performance was being monitored and the Board would continue to receive SHMI and mortality updates.

7.6 The Board NOTED the Chief Executive’s and Performance Report. 8. Nurse and Midwifery Staffing Report 8.1 Lorna Wilkinson presented the Nurse and Midwifery Staffing Report which was due to be reported

earlier in the year but had been deferred due to the pandemic. The key highlights were: • Ward establishment reviews were ongoing, and it was clear in the short and medium term

that Covid-19 was presenting staffing challenges; • During the first peak of the pandemic there had been a mass redeployment of staff.

Preparatory work was being done to manage the response to the second peak and identify the staffing needs in terms of geography, acuity and capacity;

• The nursing and health care assistant vacancies had increased, however there were planned national and local recruitment activities to attract health care assistants, nursing trainees and trained nurses;

• Midwifery vacancies had reduced substantially following a targeted recruitment campaign; • Good staffing controls were in place, linked to the e-Rostering system, to monitor staffing

levels on a daily basis; • Health and wellbeing remained an important key area of focus, particularly the upgrade of

staff rest areas during the winter months; and • The Trust continued to benchmark positively on quality and the Care Hours per Patient Day

(CHPPD) performance measure. 8.2 Rob Pike highlighted that Salisbury NHS Foundation Trust, where Lorna Wilkinson was formerly the

Chief Nurse, had achieved the highest national ranking in relation to CHPPD performance. He asked if there were any improvement measures that the Trust could adopt from Salisbury. Lorna Wilkinson advised that since her appointment in June 2020, she was continuously reviewing processes and nursing practice to identify where improvements could be made. Some initial changes had been made to the clinical governance arrangements and staff meetings had been formalised. The greater use of technology had been identified as a way of accelerating the Trust’s efficiency and advancement in the quality of patient care.

8.3 Rob Pike also commented that it had been reported in the media, that there were record numbers

of people interested in HCA and nursing roles, and he queried whether the increase had been reflected locally. Lorna Wilkinson confirmed that there had been an increase in interest and the Trust was working to attract candidates and increase capacity, alongside the national campaign.

8.4 John Weaver praised the progress made by the Midwifery Service and asked whether there were

any learning points that could be applied to other services. Lorna Wilkinson advised that some of the learning could be implemented elsewhere, some of which could be implemented quickly.

8.5 Regarding the EU exit, Thoreya Swage asked whether the Trust had established a method to track

how many of its staff had applied for settlement status. Eleanor Shingleton-Smith advised that the

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HR Team was supporting staff with the settlement application process in line with the official guidance that had been issued.

8.6 The Board NOTED the Nursing and Midwifery Staffing Report and the Chairman thanked Lorna

Wilkinson for the comprehensive update. 9. Finance Report: Month 6 9.1 Nigel Foster presented the month 6 Finance Report and highlighted:

• The Trust delivered a break-even position for the first half of the financial year; • The Covid-related spend was expected to increase from October, given the second wave of

infections; • The total year-to-date capital spend was £39.1m; • It was anticipated that the Trust would be subject to an audit of Covid costings. Nigel Foster

stated that benchmarking information revealed that the Trust’s Covid spend was at the lower end of the national scale and the audit did not present a major risk for the Trust; and

• The Trust was awaiting formal approval of £3m additional central capital allocated for diagnostics and emergency care. The Executive Team had discussed the implications for the capital budget if the additional capital was not approved.

9.2 From the Finance Investment Committee perspective, Rob Pike said that he was conscious that the

Trust needed to be prudent with its spending, to minimise any financial shortfalls that would need to be rectified post-Covid. He highlighted that the £10m in lost income and underspends of £14.2m as a direct result of the pandemic.

9.3 The Board NOTED the month 6 Finance Report. 10. Elective Recovery and Winter Planning 10.1 John Seymour presented the Elective Recovery and Winter Planning report. He assured the Board

that overall, the phase 3 recovery of normal services was going well. From the report he highlighted that:

• Elective activity had increased since September and had been maintained during October at around 95%;

• Surgical recovery had exceeded expectations which was attributed to a new theatres timetable implemented in September;

• There was a focus on patient waiting lists. The 52 week waits had been prioritised and were reducing;

• Cancer performance treatment times remained excellent; • Diagnostics and outpatient’s activity remained below historical levels; and • Recovery during the winter months would be supported by the national expansion of the

111 service to manage the access to urgent care. 10.2 Tim Ho confirmed that the Trust’s cancer performance had been the best in the country in October

and the news was welcomed by the Board. 10.3 Thoreya Swage asked about the Trust’s 111 communications strategy. John Seymour advised that

the Trust would follow the national lead to ensure communications were aligned. 10.4 Michael Baxter queried whether it was anticipated that the Trust could face circumstances where

elective services would need to cease. John Seymour advised that there were measures in place which would tell us when clinicians would need to be re-deployed, however the Trust did not intend to use them except as a last resort. He added that each week the Trust was able to continue offering elective surgeries meant that hundreds of patients were receiving the care they required.

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10.5 Rob Pike asked how the staff to patient ratio would differ from the first peak of the pandemic. John

Seymour informed the Board that the main change was in the use of ventilators because of the learning from the first wave of infections. Together with the use of different drug treatments it was anticipated that the staff to patient ratio could be reduced.

10.6 Neil Dardis thanked John Seymour for his work during the pandemic and for taking on the Chief

Operating Officer role whilst Dan was recovering from Covid 19. 10.7 The Board NOTED the Elective Recovery and Winter Planning Report. 11. 2019/2020 Safeguarding Report 11.1 The Board received the 2019/2020 Safeguarding Report which had been presented at the

September meeting of the Quality Assurance Committee. 11.2 Lorna Wilkinson advised that the 2019/2020 report provided a wider view of the Trust’s

safeguarding activity than the previous annual report. Lorna Wilkinson confirmed that the expected changes to DOLS legislation had been deferred until April 2022. Increasing numbers of young people were being affected by youth violence in the Slough area and there were rising numbers of young people presenting in mental and social health crisis.

11.3 Mike O’Donovan advised that the Quality Assurance Committee had received assurance from Deidre

Race, the Trust’s Safeguarding Lead, on specific implementation activity, such as sharing data with ICS partners. He acknowledged that the demand for safeguarding would continue to grow with the ongoing pandemic, and he advised that the Trust’s safeguarding performance was improving.

11.4 Dawn Kenson asked about the level of ICS involvement. Lorna Wilkinson confirmed that the Trust

was receiving a good level of support from the wider system, although because of the varied approach from the local authorities it could sometimes complicate the safeguarding work. Conversations were ongoing to encourage a consistent approach from local authorities and other external partners. The Chairman said that it was in everyone’s interest for all organisations to work collaboratively and to share resources. Pradip commended the team for the great work they do to protect vulnerable adults and children, as sadly we live in difficult times and the number of cases just keep rising. He asked Lorna to pass on the thanks on behalf of the board to the whole team.

11.5 The Board NOTED the 2019/20 Safeguarding Report. 12. Frimley Health 2019/2020 Quality Report 12.1 The Board was presented with the 2019/2020 Quality Report, which had also been presented to the

September meeting of the Quality Assurance Committee. Mike O’Donovan advised that when the report had initially been presented to the Committee, they had requested the document be amended to make it more user-friendly. The amendments had been made and the Committee was comfortable that the document was easier to read. The few other requested minor amendments since the QAC meeting had also been completed.

12.2 Lorna Wilkinson added that the drafting of the report had involved a huge team effort and the

feedback received had been positive. 12.3 Dawn Kenson asked whether there was a process in place to review the accuracy of data within the

report. Lorna Wilkinson advised that there were leads in each team that reviewed the data quality, to ensure good compliance. The Chairman reminded the Board that KPMG were responsible for auditing the mandatory quality indicators, although owing to the pandemic the requirement had

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been withdrawn for foundation trusts earlier in the year. He said that the CCGs also review the whole report and comment on it, and this was included in the appendix

12.4 Nigel Foster highlighted the quality elements of the internal audit plan and it was agreed that

Lorna Wilkinson, Nigel Foster and Dawn Kenson would discuss whether there were any areas that the internal auditors should examine. Action: LW, NF and DK

12.5 Rob Pike noted that there was no mention of Heatherwood or the community hospitals within the

document. It was agreed that the Quality Report would be amended before it was published to include Heatherwood and the community hospitals. Action: LW

12.6 Subject to the above amendments the Board APPROVED the 2019/20 Quality Report. 13. Infection Prevention Control Board Assurance Framework (IPC BAF) 13.1 Lorna Wilkinson introduced a new version of the IPC BAF which had been released on 15th October

2020 and confirmed that it would be presented to the Quality Assurance Committee. Lorna Wilkinson explained that the virus was very difficult to control, we have continued to learn more about it through the year, and the IPC BAF was a dynamic document which required continuous assessment.

13.2 Additional infection prevention control improvements had been implemented:

• Mask wearing in all Trust premises; • Improved signage on all sites; • Testing on all sites; and • A risk assessment process to facilitate workforce safety.

13.3 The Trust also planned to improve/encourage ventilation in offices and clinical areas. The Hospital

Infection Control Committee was monitoring the infection control measures. 13.4 The Board NOTED the Infection Prevention Control Board Assurance Framework and requested

that the IPC BAF was presented at the next Quality Assurance Committee meeting for formal monitoring and Board reporting. Action: LW

14. Committee Minutes and Recommendations Audit Committee: 9th September 2020 14.1 The Chair of the Audit Committee did not have any highlights to report. Finance Investment Committee: 21st September 2020 14.2 Rob Pike highlighted the development of the Business Case Tracker, which would prove useful for

the Board and Senior Leadership Committee. It was agreed that the Business Case Tracker be shared with the Council of Governors in 2021/2022. Action: NF

Quality Assurance Committee: 22nd September 2020 14.3 Mike O’Donovan advised the Board that there had been improvements in the number of serious

incidents involving deteriorating patient and falls. People Committee: 1st October 2020 14.4 Thoreya Swage advised that the Committee had been presented with the NHS People Plan and there

was a requirement to meet some short-term objectives by the end of March 2021. Although the Trust had already met a lot of the objectives, there would be some challenges in achieving other objectives.

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14.5 Dawn Kenson asked about the support available to staff that had been working remotely for a long period of time. Neil Dardis assured the Board that such staff were able to join remote drop in sessions and there was a wellbeing and employee support programme in place. The Trust had also encouraged all people managers to check in with their staff weekly and continue with one on one and team meetings.

15. Any Other Business 15.1 The Chairman confirmed that the next Board of Directors meeting would be held in January 2021

and he reminded attendees of the Annual Members Meeting that was due to be held virtually on Tuesday 17 November 2020. In the meantime, the Chairman acknowledged the challenging period ahead. He emphasised that the Trust’s value of working together and he was confident that Frimley Health would work with the ICS and all its partners in the coming months to look after our people and patients.

16. Public Questions 16.1 Bob Bown asked how the Trust would implement urgent care services, given the constraints on the

Frimley Park site, and whether temporary units had been considered. Neil Dardis advised that the Estates Department was considering a range of options, however it was very difficult find adequate space to build temporary accommodation at Frimley Park.

16.2 In relation to the safeguarding report, Brian Hambleton, said that he was surprised that there was

little reference to education and schooling. Lorna Wilkinson advised that the Trust had established links in place with educational providers through partnership boards.

16.3 Sarah Peacey noted that the Chief Executive of NHS Professionals had referred to the role of

integrated care systems in the implementation of health care legislation and queried whether the Trust would be able to take a holistic approach. Lorna Wilkinson acknowledged the challenges in accessing mental health services as an example and advised that there was a national and system wide approach to address the shortfalls.

16.4 Jan Burnett commented on the disparity of challenges nationally, caused by the pandemic. She

queried whether there would be an increase in sharing resources across the system, and if so, whether there would be an impact on the Trust’s performance, particularly if the Nightingale Hospital were to re-open. Neil Dardis advised that the Trust was building on the learning points from the first peak and working collaboratively with its partners. He added that there was a possibility to expand at the Wexham Park site to provide additional capacity. He acknowledged that during the first peak the opening of the Nightingale Hospital was a concern, as the Trust could not afford to operate with a reduced workforce. However, he was assured from conversations with regional and national teams that there would be a collaborative approach.

16.5 Jerry Andrews queried the progress of the Heatherwood Hospital new build. Nigel Foster advised

that he had taken part in a recent walk around on the site and was assured that the plans were on track. Kier had started work on the internal fittings and it was anticipated that the hospital would be handed over to the Trust in summer 2021. It would then take another 6 months before the hospital was fully operational. The opening date had not yet been formalised. Rob Pike echoed Nigel’s comments and added that the biggest challenge would be any change requests from us, as they were likely to cause delays and further expense.

16.6 Mary Probert said that the meeting had been very good and welcomed the presentations that had

been delivered. She asked that the Patient Experience and Involvement Group were given the opportunity to review the Quality Report later after the drafting stages so that better quality feedback could be provided.

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16.7 Rod Broad asked for clarification around the introduction of the 111 first initiative. John Seymour

advised that relevant staff receive training, especially in relation to patient pathways. 17. Date of the Next Meeting Friday 15th January 2021, 08:30-11:00

Microsoft Teams

These minutes were duly approved by the Board:

Name: Pradip Patel, Chairman

Signature:

Date:

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BOARD OF DIRECTORS MEETING IN PUBLIC Friday 6th November 2020, 08:30-11:30

Appendix 1

VIP Award Attendees Mary Hayes BMI Princess Margaret Hospital, Chemotherapy Lucy Scott BMI Princess Margaret Hospital, Chemotherapy Claire James BMI Princess Margaret Hospital, Chemotherapy Gibi Biju BMI Princess Margaret Hospital, Chemotherapy Mariana Da Silva BMI Princess Margaret Hospital, Chemotherapy Julie Kerr Covid-19 Swab Team Thereasa Baxter Covid-19 Swab Team Claire Lloyd Covid-19 Swab Team Louise McArthur Covid-19 Swab Team Theresa Parker Covid-19 Swab Team Joanne Brown Covid-19 Swab Team Patricia Samushonga Covid-19 Swab Team Janice King Covid-19 Swab Team Ishwar Gurung Covid-19 Swab Team Lynne Innes Covid-19 Swab Team Josh Miller Covid-19 Swab Team Elizabeth Morton Covid-19 Swab Team Carlo Alcober Covid-19 Swab Team Brenda Saunders Covid-19 Swab Team Karen Emerton Covid-19 Swab Team Jackie Barlow Covid-19 Swab Team Emilie Cudiamet Cystic Fibrosis Unit Lani Santos Cystic Fibrosis Unit Judith Duguid Cystic Fibrosis Unit

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BOARD OF DIRECTORS MEETING – PUBLIC Friday 15th January 2021

ACTION LOG

AGREED ACTION LEAD END DATE

CLOSED ACTIONS 6th November 2020 – 12.4 Frimley Health 2019/2020 Quality Report It was agreed that Lorna Wilkinson, Nigel Foster and Dawn Kenson would discuss whether there were any areas that the internal auditors should examine.

Lorna Wilkinson/ Nigel Foster/ Dawn Kenson

15th January 2021

6th November 2020 – 12.5 Frimley Health 2019/2020 Quality Report It was agreed that the Quality Report would be amended before it was published to include Heatherwood and the community hospitals.

Lorna Wilkinson 15th January 2021

ACTIONS IN PROGRESS 5th June 2020 – 5.1.h COVID-19 General Update – Restoration JW asked that the action point from the minutes of the meeting on 5th June 2020, regarding a demand and capacity report to be prepared by DB and JW, be added to the action log. He added that the action point was ongoing. The Chairman requested that the action point remained open to provide an opportunity for John Weaver to speak with Dan Bradbury.

John Weaver/ Dan Bradbury 15th January 2021

6th November 2020 – 14.2 Finance Investment Committee: 21st September 2020 It was agreed that the Business Case Tracker be shared with the Council of Governors in 2021/2022.

Nigel Foster 31 March 2021

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Report Title Chief Executive’s Report including the Quality and Performance Report

Meeting and Date Public Board of Directors, Friday 15th January 2021

Agenda Item 6.

Author and Executive Lead

Neil Dardis, Chief Executive

Executive Summary

The Chief Executive’s Report provides a bi-monthly update on key activities and events in the Trust. The report highlights the national context, the Trust’s developments and achievements and the areas for focused Board discussion.

Attached to the report at Appendix 1 is a copy of our updated strategy which the Board approved in December 2020.

Action The Board is asked to note the report and receive assurance on the Trust’s quality and performance achievements.

Compliance CQC quality standards and NHS performance standards

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Tab 6 Chief Executive’s Report including the Quality and Performance Report


Chief Executive’s report including Quality & Performance update

November 20206

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Chief Executive’s report – November 2020Frimley Health NHS Foundation Trust – Board of Directors Page 2

ContentsSafe Effective Caring Responsive Efficiency / FinanceWell-led Activity

This report covers the period from November 2019 to allow comparison with historic performance.

However, the targets and exception reports relate to November 2020 for the financial year 2020/2021

Page Page

Contents 2

Chief executive’s overview 3

Performance Summary 10

Statistical Process Control 12

SPC Performance Summary 13

SPC Leading Indicators 20

Improving Quality for Patients 25

Exception reports 27

Benchmarking

Selected measures 31

Historical performance 35

RAG key

Achieving target

Between target and threshold (where applicable)

Worse than target or threshold (where applicable)

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Chief executive’s overview (1)

Safe Effective Caring Responsive Efficiency / FinanceWell-led Activity

INTRODUCTION

This report aims to highlight to Board members those areas that will benefit from focused discussion in today’s meeting, note the national context we

are currently operating in, and recognise the developments and achievements of the Trust since we last met.

COVID-19 AND OPERATIONAL DELIVERY

With the rapidly rising numbers of Covid-19 patients threatening to overwhelm the NHS, the Government last week enforced a new national

lockdown. The surging numbers of Covid infections across London and the south east of England has been reflected in the high numbers of

inpatients at our hospitals, which during the first week of the year were running at double the peak of the first wave last spring, with 609 patients

across our Trust.

Staff have been phenomenal with many of them working throughout the Christmas period to help manage the most challenging situation and ensure

that all our patients have received the care they urgently need, whether they are Covid patients or needing our services for other reasons. While we

hoped that the surge would not reach recent levels, we have prepared for the worst and implemented our surge plans effectively. This has meant

utilising elective and theatre space to significantly expand our Covid bed capacity, expanding community provision of services, postponing all but the

most urgent elective and diagnostic procedures and providing alternative pathways and services to keep our patients safe. Many of our non-clinical

staff have volunteered for our FHFT Ward Ambassadors programme to directly support clinical colleagues on the front line and staff who have had to

shield have been redeployed for work that they can carry out in their homes.

We have had tremendous support from colleagues across the health and care community, for example in helping to safely discharge patients as

soon as they are well enough, caring for patients to avoid hospital admissions and sharing emergency care between neighbouring hospitals at peak

times to manage capacity regionally.

We have further plans to manage an expected increase in demand, including expanding support from health and care colleagues and the private

sector, redeploying further staff and creating alternative care pathways. However, we expect to have to make some difficult decisions at what has

been the most challenging period we have encountered.

The roll out of the Covid vaccine offers the hope of an end in sight and so we were delighted to have been involved at the start of the national Covid-

19 vaccination programme in early December. The Postgraduate Medical Centre at Wexham Park Hospital was one of 50 vaccination hubs across

the country to operate in the first day of the biggest ever vaccination programme embarked upon by the NHS. We were among the first to vaccinate

with our first recipient Dr Prem Premachandran being inoculated by Tracey Coulson, our vaccination lead, just an hour after the first in the country.

The Wexham hub featured prominently on national and regional news as we hosted TV and radio broadcasts during the day, including interviews

with key staff and some of the older residents who had their vaccination. It was a fantastic effort from the team to mobilise so quickly and we have

now vaccinated significant numbers of patients over the age of 80, care home staff and other healthcare staff and we expect to be able to increase

our rate of vaccination further. We have also continued to work with vaccination sites run by partners in our system as we seek to mobilise mass

vaccination of our communities.

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COVID-19 AND OPERATIONAL DELIVERY (CONTINUED)

It would be hard to overstate the phenomenal efforts of our teams and the pressure this is placing upon them is significant. We continue to support

our staff in every way possible and recently published a further set of measures to support their health and wellbeing and to show our gratitude for

their amazing efforts. Sadly, there will be tougher weeks ahead but with the vaccine we can be confident of a way through this difficult period and a

return to normality. The result of the amazing effort from our teams is the number of lives they have saved, with more than 2,000 Covid-19 patients

recovered from our hospitals to be home with their families and loved ones, and for that we can never thank them enough.

STRATEGY AND NATIONAL POLICY

NHS England and NHS Improvement (NHSE/I) has published ‘Integrating Care: Next steps to building strong and effective integrated care systems

across England’. It sets out NHSE/I’s view of the strategic direction of system working, including a consultation on two new proposals to put

Integrated Care Systems (ICSs) on a statutory footing in the NHS Bill expected in late spring 2021. Key proposals for NHS trust and foundation trust

boards include the expanded role and functions of ICSs, the new emphasis on at-scale provider collaboratives and place-based partnerships, and

legislative changes to facilitate the changes that NHSE/I is aspiring to. The proposals are in line with ‘Our Future FHFT’ strategy and our ICS plans

and the Board will consider the opportunities from any proposed changes further over the coming months.

We have worked with our colleagues in Frimley Health and Care ICS to develop a roadmap to define what we need to do to ensure the future

success of the ICS and making sure we are working together to deliver the system’s strategic objectives and vision to create healthier communities.

The roadmap is in line with the national direction of travel and includes provision for provider collaboratives - with acute, primary care, mental health,

ambulance and social care providers working more closely together and aligning tactical functions. There is also recognition of a need for greater

strategic alignment with providers from neighbouring systems. Another function of the road map is a provision for place-based working to retain a

local focus where it is needed and to address health inequalities across the system. The road map also identified the need for closer financial

arrangements and a clearer overall governance structure for the system.

Uncertainty over the financial impact of Covid-19 means we will not know the financial settlement for the NHS until much nearer the beginning of the

financial year, and we expect fuller guidance soon. However, we will need to start planning with our system to lay the foundation for recovery

including how Covid-19 costs can be reduced and eliminated as we start to exit the pandemic and calculating our baseline contract values.

Following the publication of the Ockenden Report into the review of maternity services at Shrewsbury and Telford Hospitals NHS Trust, NHSE/I has

written to trusts with a series of required actions and assurances relating to enhanced safety, listening to women and their families, staff training,

managing complex pregnancy, monitoring foetal wellbeing, risk assessment and informed consent.

NHSE/I published a consultation document on transformation of urgent and emergency care models and measurement last month. This was linked to

the clinically led review of access standards in which Frimley Health has been one of 14 trusts across the country chosen to pilot new measures of

urgent care performance. The proposed standards are more comprehensive and aimed at supporting the role of NHS 111, optimising ambulance

services and reducing wider pressures, improving access and flow through hospitals and to manage hospital occupancy better. The proposals are

based on outcomes from the pilot studies and reflect a wider focus on the whole patient journey to improve experience and outcomes. The

consultation will close on 12 February 2021.

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STRATEGY AND NATIONAL POLICY (CONTINUED)

Last month we held a strategy refresh week to focus on Our Future FHFT five-year strategy, which was reviewed in the autumn as part of our annual

process and to reflect the impact of the pandemic. The week also provided the opportunity to launch our Frimley Excellence programme of

continuous quality improvement that will enable us to deliver our strategic ambitions and achieve our vision. Senior leaders used the opportunity to

distribute chocolates to staff across our sites to say thank you for all they have done and to discuss how the strategy is being implemented at every

level, how it has changed through the year as a result of Covid, and how we will maintain momentum to deliver our ambitions and vision. As part of

the refresh, a programme of communications for the six strategic ambitions was announced on a rolling monthly basis, with a focus on improving

quality through December and January and advancing our digital capability from January to February. These themed months will be backed up by

webinars, forums and discussions so we have more proactive and systematic communication of our plans and progress.

Our Board seminar last month again included presentations on how we are putting Our Future FHFT strategy into action. These included: how we

are developing the paediatric respiratory service in the south of our catchment to replicate the model in the north and ensure a consistent and

excellent service across the system; the work of musculoskeletal practitioners in providing a first contact physiotherapist service in GP surgeries to

help standardise MSK pathways; and adopting a quality improvement process to reduce patient falls.

Following the appointment of Epic Systems as our supplied for out new electronic patient record (EPR) we have now appointed a team of 80

analysts who have come together as a team for the first time this month. The analysts, most of whom are already associated with the Trust, are

undergoing training and induction during January and will begin deployment to design, configure and build the system from next month. We have

also agreed a go live date for our EPR in late March 2022, which means we have a challenging but exciting timetable for delivery.

I was delighted to have a further tour of the new Heatherwood Hospital in December and it was fantastic to see the progress in the facility, which

remains on schedule. We are expecting to see our first patients there at the end of 2021, with full opening of services in the first or second quarter of

2022. Plans are ongoing to engage staff and patients over the coming year ready to transfer services from the existing hospital site, including

contingencies for virtual tours if full access remains problematic.

Thank you to everyone who attended our Annual Members Meeting, which had been postponed from September, via Microsoft Teams Live. This

was an important event to engage with our members and we have also reviewed our foundation trust membership communications, much of which

has been changed or suspended since March. In December we published and distributed to members our first InTouch members’ magazine in 10

months, including individual letters of introduction to their governors and how to contact them. As public meetings are not likely to be possible for

many months yet, we are exploring the option of delivering our Health Events for members via Teams from this month.

Preparations are on track for the new BSPS Lighthouse Laboratory at Brants Bridge to start testing this month (January 2021). New staff are being

inducted and trained with support from The Pirbright Institute. State of the art technology has been installed at the laboratory to deliver high

throughput accurate testing for Pillar 2, testing tens of thousands of samples each day when fully operational.

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PERFORMANCE OVERVIEW

Performance data for November reflects the recovery and return to normal levels of activity that prevailed before the current surge in Covid infection

began to spike from mid-December onwards. Diagnostic services showed an improvement in waiting times, although not at pre-Covid waits, and our

cancer performance was strong. Referral to treatment times and waiting lists for treatment continue to be impacted with an increase in patients

waiting over 52 weeks for treatment. Overall, our benchmarked metrics mostly remained among the upper quartile of acute trusts nationally,

reflecting the excellent efforts of our staff to treat as many patients as possible ahead of winter. Workforce metrics are generally above target,

although staff sickness is a challenge reflecting the prevalence of Covid infection, and ongoing work pressures make it harder for staff and managers

to set aside time for appraisals. However, I am pleased to say that mandatory and statutory training rates remain above target.

Progress against our key quality objectives following completion of the second quarter (April to October 2020) show a reduction in the number of

reported serious incidents related to suboptimal care of deteriorating patients from 11 in the previous year to eight and a 4% reduction in patient falls.

Infection control measures also improved, with hand hygiene performance at 94% compliance (compared with 85%), a 48% reduction in hospital-

acquired Clostridium difficile infection and a 46% reduction in E. Coli. We have made progress on our priority to improve the safe transfer of care

from hospital to home and we were surveying patients post discharge to identify where we need to focus further work.

For the second half of the year trusts have been issued guaranteed block allocation contracts and we have to manage our finances to break-even

within these fixed allocations. Top up arrangements for Covid-19 activity have ceased and Covid spend is now held at ICS level, again within a fixed

envelope.

The forecast is for the Trust to break even by the end of the year provided that NHSE/I adjust identified errors in their allocation to the Trust

amounting to £25m. Despite the current unprecedented operational pressure, we remain focused on efficiency and realising the financial benefits of

factors such as reduced agency costs and virtual clinics.

In the summer all trusts were asked to collaborative with primary care partners to deliver 111 First by December 2020. This encourages the public to

contact 111 via phone or online for non-serious or life-threatening conditions before they access services. Anyone needing to attend the emergency

department (ED) will be booked a timeslot.

As part of our winter planning with health and care partners across the Frimley system, we went live with phase 1 of 111 First on 24 November. This

involved direct booking into the EDs at Frimley Park and Wexham Park adults from 10am to 8pm daily. Referrals and bookings to our EDs from 111

have been steadily increasing with about 34 a day at Frimley Park (nine booked) on average and 30 a day (eight booked) at Wexham Park. Access

to same day emergency care (SDEC) services in medical and surgical ambulatory care and in gynaecology/ early pregnancy care have also been

made available through 111 First, following a virtual assessment by a qualified clinician. Subsequent phases in January and April will introduce

further innovation with the expectation that the system will be embedded nationally. Work is underway across the Trust to upgrade and install

necessary IT systems, create suitable SDEC space including vascular and early pregnancy units, and to install 111 First multi-media booths in ED

triage areas. This work has enabled us to reduce the proportion of hospital admissions by 5% and provide safer and better alternatives to hospital

care. By encouraging patients to call 111 in most instances instead of attending ED the hope is to reduce pressure on emergency care and inpatient

beds in the long term.

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PERFORMANCE OVERVIEW - CONTINUED

We are continuing with our annual flu vaccination campaign for staff, which began successfully in October. To date 71% of staff have taken up the

offer of a free inoculation. After an initial surge of interest, the challenge has been to maintain attention on the flu vaccine and we have been urging

staff to get theirs in good time for the Covid-19 vaccination, which cannot be given less than seven days after the flu inoculation.

The Trust has been involved in several inquests in recent weeks due to the number that were postponed over spring and summer because of Covid-

19. This has involved a lot of work by our legal and patient safety teams to ensure that all issues and potential lessons have been covered in respect

of the care that was provided.

You may have seen the recent news about the publication of the report by Dr Bill Kirkup into the circumstances surrounding the tragic death in 2001

of baby Elizabeth Dixon. Dr Kirkup’s comprehensive report concluded that every organisation that looked after Elizabeth had let her down and he

criticised the initial responses and investigations in the report. Following a meeting with the family in 2013, the Trust apologised to Elizabeth’s family

after commissioning an independent review of Elizabeth’s neonatal care which identified failings. The Chairman and I have written to Mr and Mrs

Dixon again since the publication of the report to apologise again and to offer to meet to provide this apology in person. Our care for neonatal infants,

support for bereaved parents and how we investigate concerns have changed beyond recognition since Elizabeth’s death, but we are carefully

considering the recommendations within the report and remain committed to taking any action that is needed.

I am pleased to report that the microbiology lab at Frimley Park successful passed its United Kingdom Accreditation Service inspection last month

thanks to the hard work and dedication of our biomedical scientists, laboratory assistants, pathology quality team and clinical support staff. This is a

special achievement given the pressure that Covid-19 have put on the service and the switch to a new automation system. The department

processes around a million samples every year for several hospitals in the region.

A recently pre-announced visit by Health and Safety Executive inspectors to the Frimley Park Hospital site found no major issues with our workplace

practices relating to Covid-19 safety. The overall feedback was very good with good practice in training highlighted and only verbal recommendations

in some areas, such as better ventilation in some indoor spaces, importance of reviewing vulnerable people’s risk assessments, and cleaning of high

contact points.

I want to bring more visibility to decisions made by the Senior Leadership Committee, and in the last month, as well as overseeing operational

delivery of our services and strategic objectives, we have approved funding for a number of projects, including almost £3m to upgrade Frimley

Health’s wireless infrastructure to enable a seamless WiFi service across our sites, £408,000 for a secure radiology reporting solution to enable

radiologists to send images and diagnostic reports from home, £3m to upgrade and expand endoscopy at Wexham Park (including £1.8m from NHS

England), £309,000 to increase nurse staffing in Frimley Park ED and a review of non-emergency patient transport to greatly reduce reliance on

external contractors and create a ‘one Frimley’ approach to the service. These developments progress our strategic ambitions and provide return on

investment to support our overall position.

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PERFORMANCE OVERVIEW - CONTINUED

Our Team Brief cascade initiative to deliver key staff messages continued in December. The feedback from the first set of briefings was that it was

well received and reinforced our ability to ensure feedback from all of our staff to Board as well as communication of key corporate messages. The

main feedback from this round was more rest areas, which is already being addressed. A large-scale programme to transform 38 staff rest rooms is

underway. Over the next few weeks, they will be given new décor and furniture and kitted out with kitchens, fridges and other additions. This was part

of our programme of thanks for our staff that we agreed after the initial Covid surge – based on feedback from staff made possible by funds from

NHS Charities Together and Frimley Health Charity from public donations in honour of NHS staff’s hard work during the first surge of Covid-19. We

are also exploring other potential projects at community sites, where we do not own the real estate, outdoor areas during warmer weather and a

‘Project Wingman’- style facility for staff. Some of the donated funds were also put towards robust and sustained psychological support, which staff

also said they valued.

FURTHER DEVELOPMENTS AND ACHIEVEMENTS

We are immensely proud of our Medical Director Dr Tim Ho and Di Dodsworth, Head of Nursing for Critical Care, who were both made MBEs in the

New Year Honours list for their contribution to the response to Covid-19 since last year. They both demonstrated exceptional leadership, Tim in

helping to mobilise support from senior colleagues and stepping into emergency command roles, and Di in her key role in doubling our critical care

capacity to ensure very sick patients could get the care they needed and continuing to support her teams. It is a tremendous honour for them and the

Trust and is also a reflection of the phenomenal work of all our staff at Frimley Health. Four military personnel at Frimley Park were also honoured in

the Military Division of the New Year Honours – Lt Col Emma Hutley (microbiologist, OBE), Lt Jenny Dyson (Senior Sister – Parkside, MBE), Maj Ami

Newburn-Johnson (Parkside, AARC) and Maj Steph Lea (ED, 4* UKStratcom Commendation) have all been recognised. We are very proud of our

partnership with Joint Hospital Group (SE) - what we have achieved this year wouldn’t have been possible without their commitment and support.

Three fantastic teams were chosen for our last ViP Awards, which are announced as part of our public Board meetings. The cystic fibrosis team at

Frimley ensured their patients were among the first to get life changing new drugs on the NHS. Within days of the Trikafta drug, the latest in a new

generation that treats the cause of the disease rather than the symptoms, being approved by National Institute of Health and Care they had offered

and prescribed it to all suitable patients – one of the first units in England to do so. The Covid-19 swabbing teams at Frimley and Wexham were

nominated by a patient for their tremendous work providing a vital service in all weathers and for always being positive and cheerful. The Trust’s

chemotherapy team did an amazing job of reconfiguring and bringing together FPH’s chemo day unit and WPH’s Eden Day Unit to BMI Princess

Margaret Hospital, Windsor to ensure that all patients could safely continue their vital chemo sessions.

Congratulations again to Lt Jenny Dyson from Parkside, who in addition to her MBE last month was named the Nursing Times Nurse Leader of the

Year. Jenny, who was commended for her drive, determination and compassionate leadership, introduced a new safe staffing model into the unit

based on her experience from military deployment. Congratulations too to Frimley nurses Sgt Lucy Laughton and WO2 Robbie Beech who were all

nominated in the Nursing Times Awards for Rising Star and Florence Nightingale Nurse respectively.

The business and retail community in Slough honoured our staff at Wexham Park Hospital by dedicating 12 illuminated angels, a key feature of this

year’s town centre Christmas decorations, to individuals and teams for their contribution in fighting Covid. Each of the 12 people and teams was

photographed and described alongside their angel. The angels formed a town centre trail for Christmas shoppers to follow.

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FURTHER DEVELOPMENTS AND ACHIEVEMENTS - CONTINUED

I was privileged to be able to say a few words at this year’s Trust Christmas service, organised by our chaplaincy teams. Due to limited space in our

chapels the service was this year broadcast via Facebook Live for the first time. The service is always very popular and provides a message of hope,

especially for this who have suffered bereavement over the year, and I was able to reflect on colleagues we had lost during 2020. To date more than

10,000 people have watched the service on Facebook Live.

We have begun treating bladder tumours with a new state-of-the-art laser system. The mini unit at our Heatherwood urology department, enables

urologists to treat appropriate cases quickly and efficiently on an outpatient basis. Such procedures would previously have taken 90 minutes in

surgery, but tumours can now be blasted through a laser fibre inserted into the bladder via a flexible cystoscope. This project was made possible by

funding from the CEO Change Challenge from early 2020. This Dragon’s Den style format where staff bid for funding for their improvement ideas

proved really popular, although many of the projects have been delayed due to Covid. Shortlisting for the 2021 CEO Change Challenge, which was

to take place this month, has been suspended because of current pressures.

Finally, congratulations to vascular surgeon Keith Jones, who has been nominated for the Association of Surgeons in Training’s prestigious Silver

Scalpel Award. Nominations come from trainees and are judged by the ASiT in March.6

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Performance Summary – key indicators at a glanceNote – these indicators are for the current month only (November 2020) and the variation and assurance are based on 24 months data where available

SPC icon interpretation

▪ Pay particular attention to this – unless there is a change in

process, the current target will not be met

▪ Need consideration – indicate cause for concern or higher

pressure

▪ Indicates that although there has been sustained

improvement, this is not sufficient to achieve the target

▪ Indicates that although the target will consistently be

passed, there has been an increase of concerning nature

Statistical Process Control (SPC)

SPC helps to understand what is the norm and what is different by looking at the performance of

a KPI over time. SPC analysis highlights significant improvement or deterioration in performance.

It also provides indication of whether targets are likely to be met

Variation Assurance

Common

cause – no

significant

change

Special cause of

concerning nature or

higher pressure due

to (H)igher or

(L)ower values

Special cause of

improving nature or

lower pressure due

to (H)igher or

(L)ower values

Variation

indicates

inconsistently

hitting, passing

and falling short

of the target

Variation

indicates

consistently

(P)assing the

target

Variation

indicates

consistently

(F)alling short of

the target

Caring

Metric Performance Target Variation Assurance

Inpatient FFT Reporting suspended

MSA Breaches Reporting suspended

Safe

MetricCurrent

monthYTD Target Variation Assurance

MRSA 2 3 0

C-Diff 3 24 5

E-Coli 12 52 TBC

Never Events 2 6 0

Effective – SHMI

Metric Performance Normal Variation Assurance

Overall 99.8 100

Non-elective 100.2 100

Elective 72.1 100

Well Led

Metric Performance Target Variation Assurance

Vacancy rate % 8.7% =85%

Staff FFT Reporting suspended

Projected variance

vs. financial plan-£0.3m No target

CIP delivery £1.9m No target

Agency Spend

(% of pay bill)3.9% 4 hours Not reporting data (pilot scheme)

RTT < 18 weeks 78.9% >=92.0%

RTT waiting list

(total incomplete)38151 =85%

Diagnostics

(< 6 weeks)6.6% =85%

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Performance Summary (2) – activity at a glance

Metric Month Variation SPC chart Comment

GP Referrals 14292 Activity is within expected limits

OP Atts 73573 Activity is within expected limits

Day cases 4828Activity is lower than expected with a

sustained increase in activity

Elective admissions(includes Day cases)

7299Activity is lower than expected with a

sustained increase in activity

ED Atts 16397 Activity is within expected limits

Non elective

admissions6958 Activity is lower than expected

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Statistical Process Control (SPC)

Statistical Process Control helps to understand what is the norm and what is different. Performance of a KPI is looked at over time and statistical

analysis is used to calculate an “upper control limit” and a “lower control limit”. Where there has been a significant improvement or deterioration in

performance and a real process change has been identified and the change has been sustained over a number of data points, the process limits are

reset.

If performance falls within the control limits, then it is seen as “normal statistical fluctuation” and does not need special attention. However, if

performance has either risen above the “upper control limit” or fallen below the “lower control limit” then this needs special attention

The notation used in the SPC charts is

Variation icons: orange indicates concerning special

cause variation requiring action; blue indicates

where improvement appears to lie, and grey indicates

no significant change (common cause variation)

Assurance icons: Blue indicates that the trust should

consistently expect to achieve a target. Orange

indicates that the trust should consistently expect to

miss a target. A grey icon tells you that sometimes the

target will be met and sometimes missed due to

random variation

Produced with thanks to NHS Improvement resources (Making data count – getting started and Making data count – strengthening decisions)

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Performance Summary – Responsive

Diagnostics

RTT total incomplete (waiting list)

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Performance Summary – Well Led

Sickness absence rate

Vacancy rate - total

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Non-medical appraisal

MAST

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Net surplus / deficit – variance to plan

The increasing figures between March

and September 2020 represent all COVID

reimbursements above deficit plan

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Performance Summary – Community Services (1)

In order to demonstrate an element of community activity and performance a number of metrics demonstrating the performance

of Community Services activity have been included in this month's report.

We are working on the CSDS 2 hour urgent response and 2 day response standards data with intention that they are included in

future reports.

Community Referrals

Community Services Supported Discharges

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Number of referrals to Community Services

Number of New patient contacts

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Number of Follow-up patient contacts

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Leading indicators – Well Led (Efficiency)

Leading Indicators is a new section designed to provide early warning of potential performance issues.

1. Length of stay (non-elective) is a leading indicator to track potential issues impacting on:

▪ Capacity pressures, patient flow, waiting list management

Length of stay (non-elective)

4.31 (November 2020)

Latest statistical analysis

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

4.98 4.11 3.95 4.17 4.21 5.25 4.11 3.22 3.97 3.87 3.98 4.11 4.09 4.31

Target & Threshold

LOS Non-elective

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Leading indicators – Effective

Total in-hospital

deaths

59 (week ending 12/12/20)


Weekly numbers

COVID Deaths

14 (week ending 12/12/20)


Weekly numbers

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Effective – Mortality and morbidity – SHMI charts and table

Safe Effective Caring Responsive Efficiency / Finance

In-hospital mortality and summary hospital-level mortality indicator (SHMI) (SOF)

KEY: Higher than expectedWithin expected range : 90 - 110 (overall and non-elective)

70 - 130 (elective)Lower than expected

Range (confidence intervals) Deaths

Well-led Activity

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Effective – Mortality and morbidity – HSMR charts and table


Hospital Standardized Mortality Ratio (HSMR)

KEY: Higher than expected Within expected range Lower than expected insufficient data

Range (confidence intervals) Deaths6

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Effective – Mortality and morbidity table and key messages


18/19 19/20 Nov-19 Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov-20 YTD

Number of inpatient deaths 2688 2820 227 254 289 223 316 379 217 193 138 148 184 181 223 1663

Total deaths screened (including 50% likely to be

due to problems with care10 9 1 0 0 1 1 1 0 0 0 0 0 0 0 1

Number of deaths of patients with a Learning

Disability22 26 2 2 4 0 3 4 0 2 1 0 1 1 0 9

Total number of deaths of patients with LD judged >

50% likely to be due to problems with care0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

*The number of completed reviews updates monthly and may increase as there is a 12 week review time

Area Key messages

Mortality Case Record

Review and Feedback from

Medical Examiner Service

Feedback from Medical Examiner :

Mortality Review: Next Mortality Review Group - 16th December 2020

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Improving Quality for Patients – Key measures (1)

IndicatorTarget

(Monthly)FHFT SPC Chart – trust performance Comments

Total number of falls


IndicatorTarget

(Monthly)FHFT SPC Chart – trust performance Comments

Number of serious incidents

– deteriorating patient


Never events update


Background / Issues Action Plan Date and named person

Situation: A total of 6 never events have been reported by

Trust from April 2020 to Nov 2020. A thematic analysis of

the root causes of the never events has been undertaken

and identified that human error under pressurised

conditions led to a failure to follow standard process and in

several cases there was a hand off involved mid way

through the procedure.

Definition: Never Events are serious incidents that are

considered preventable because guidance or safety

recommendations providing strong systemic protective

barriers are available at a national level, and should have

been implemented by all healthcare providers.

• Combat human factors risk - Urgent clinical safety

messages have been globally communicated regarding

staff breaks, assertiveness, training and effective

communication whilst in PPE

• New patient safety warnings developed for urgent

distribution and display

• Planned action for increased staff engagement and

vigilance – implement hot topics handover

• Visible clinical leadership safety walkabouts

• Never events to be captured on the Trust platinum Covid

dashboard

January 2021

Head of Patient Safety -

Cepta Hamm

Context:

Executive Lead

Lorna Wilkinson

Apr 2020 Urology – Wrong site surgery, rectified at the time

Jun 2020 Surgery – Air /Oxygen

Aug 2020Dermatology – Wrong site surgery, rectified in

follow up

Oct 2020Anaesthetics – Wrong site block process, rectified

immediately

Nov 2020 Maternity – Retained foreign object

Nov 2020 ITU – Misplaced NG tubeNov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20

Never Events 1 0 0 1 0 1 0 1 0 1 0 1 2

6

Tab 6 C



erformance R

eport

43 of 136B

oard of Directors M



Pressure Ulcers – exception report



Standard: The Trust is currently aiming to reduce the

number of hospital acquired grade 2 pressure ulcers in line

with the previously agreed trajectory.

Definition: A patient who develops a grade 2 pressure ulcer

(as per national definition) whilst in our care

Comments / context: The current trajectory was set prior to

a change in the categorisation of hospital acquired pressure

ulcers. Hospital acquired pressure ulcers are now declared

earlier during the hospital inpatient stay i.e. at anytime after

initial assessment, in line with new national guidance. This is

likely to be responsible for the increased number of reported

pressure injuries.

The target trajectory will be reviewed at the outset of the

new continuous quality improvement approach which was

due to commence in January 2021 – this is postponed due

to Covid to be reviewed February 2021.

▪ Continue to promote the accurate reporting of pressure ulcers and provide

ongoing education to clinical teams regarding the correct categorisation of

pressure ulcers and correctly identifying them on admission to hospital to

avoid data entry discrepancies

▪ Commence continuous Quality Improvement methodology (Now Feb 2021)

approach to reduction in pressure ulcers initially with a targeted approach in

areas of increased concern.

▪ Pressure ulcers are now included as a standard agenda item on the patient

safety meeting.

▪ Successful introduction and ongoing multidisciplinary cross site rapid review

approach to Category 3 and 4 pressure ulcers to share learning and embed

changes in practice

▪ Increased presence of TVT in clinical areas of concern with improved

feedback to the patient safety team

▪ Team approach and increased scrutiny of the potential hospital acquired

pressure ulcers. Improving understanding of clinical areas of concern.

▪ Planned work to improve the potential of the RL system to improve local

investigation and data collection.

December 2020 Head of

Patient Safety - Cepta Hamm

Trajectory for improvement

Executive Lead (s)

Lorna Wilkinson

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

Pressure Ulcer - Grade 2 47 74 57 60 62 46 60 48 49 49 47 56

Pressure Ulcer - Grade 3 4 5 7 5 2 1 2 3 2 3 7 3

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erformance R

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oard of Directors M



Stroke Unit – 4hr direct admission – exception report



National standard:

“People with suspected acute stroke should be admitted directly

to a hyper acute stroke unit (HASU) within 4 hours.”

Local QI standard:

“Not all patients with new suspected stroke receive the required

assessment, intervention and admission to the HASU within 4

hours. This can impact on the quality of their care, their

outcomes and the experience of others within the system.”

Comments / context:

Although 35th best performance from 170 HASUs, our

performance is far below expectation. Challenges to achieving

this measure include bed availability on the ward, having

sufficient individuals

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