PUBLIC TRUST BOARD MEETING TO BE HELD AT ON WEDNESDAY 29 JANUARY 2015 … Papers... · 2017. 9....

PUBLIC TRUST BOARD MEETING TO BE HELD AT ON WEDNESDAY 29 JANUARY 2015 AT 10.00 AM IN ROOM 10009/11, CLINICAL SCIENCES

BUILDING, UNIVERSITY HOSPITALS COVENTRY& WARWICKSHIRE, CV2 2DX

PUBLIC BOARD AGENDA

ITEM TITLE BOARD ACTION PAPER TIME 1 Apologies for Absence

Chairman

2 Declarations of Interest Chairman

Verbal

3 Minutes of Public Board Meeting Held on the 26 November 2014 Chairman

For Approval Enclosure 1

4 Trust Board Action Matrix Chairman

For Assurance Enclosure 2

5 Matters Arising Chairman

For Approval Verbal

6 Chairman’s Report Chairman

For Assurance Enclosure 3 5

7 Chief Executive’s Report Chief Executive Officer


Patient Quality and Safety 8 Patient Story – We Are Listening

– Feedback Making A Difference Chief Medical Officer


9 Parliamentary Health Service Ombudsmen Complaints Vision – Trust Response Chief Medical Officer


10 Quality Account 2014-15 and Quality Priorities 2015-16 Chief Medical Officer

For Approval Enclosure 7 5

11 Winter Plan and Emergency Care Pathway Update Chief Operating Officer


Performance 12 Integrated Quality Performance

and Finance Report Month – Month 9 Chief Finance Officer


13 Trust Development Agency (TDA) Oversight Monthly Self-Certification Requirements - January 2015 Chief Finance Officer


ITEM TITLE BOARD ACTION PAPER TIME

Feedback from Key Meetings 14 Private Trust Board Meeting

Session Report of 17 December 2015 Chairman


15 Quality Governance Committee Meeting Report from 1 December 2014 and 12 January 2015 Chair, Quality Governance Committee


16 Finance and Performance Committee Meeting Report 1 December 2014 Chair, Finance and Performance Committee


Regulatory, Compliance and Corporate Governance 17 Board Assurance Framework

Quarterly Update Chief Medical Officer


18 Fit and Proper Persons Test Declaration Chairman


19 Any Other Business For Assurance Verbal 20 Questions from Members of the Public Relating to Agenda Items 21 Date of Next Meeting:

The next meeting of the Trust Board will take place on Thursday 26 February 2015 at 10.00 am, University Hospitals Coventry and Warwickshire

22 Resolution of Items to be Heard in Private (Chairman) In accordance with the provisions of Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, and the Public Bodies (Admissions to Meetings) (NHS Trusts) Order 1997, it is resolved that the representatives of the press and other members of the public are excluded from the second part of the Trust Board meeting on the grounds that it is prejudicial to the public interest due to the confidential nature of the business about to be transacted. This section of the meeting will be held in private session.

UNIVERSITY HOSPITALS COVENTY & WARWICKSHIRE NHS TRUST

MINUTES OF A PUBLIC MEETING OF THE BOARD OF UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST HELD ON WEDNESDAY 26 NOVEMBER

2014 AT 1.00PM IN THE CLINICAL SCIENCES BUILDING, UNIVERSITY HOSPITALS COVENTRY & WARWICKSHIRE

HTB 14/686

PRESENT

Mr I Buckley Vice Chair (IB) Mr D Eltringham Chief Operations Officer (DE) Mr A Hardy Chief Executive Officer (AH) Mr K Hutchinson Interim Chief Human Resources Officer (KH) Mr E Macalister-Smith Non-Executive Director (EMS) Mr A Meehan Chairman (AM) Mr D Moon Chief Strategy Officer (DM) Mrs M Pandit Chief Medical Officer/Deputy Chief Executive Officer (MP) Professor M Radford Chief Nursing Officer (MR) Mrs B Sheils Non-Executive Director (BS) IN ATTENDANCE Ms G Arblaster Associate Director of Nursing – Research & Education (GA) Mrs K Beadling Head of Communications (KB) Ms Z Cox Executive Assistant/Note Taker (ZC) Miss S Conlon Patient Experience Manager (SC) Mrs C McCalmont Associate Director of Nursing – Women & Children (CMc) Mrs A Searle Ward Manager, Lucina Birth Centre (AS) Mrs R Southall Director of Corporate Affairs (RS) Mr R Youell Board Development Consultant (RY) HTB 14/687

APOLOGIES FOR ABSENCE

Mrs B Beal, Non-Executive Director (BB) Mrs G Nolan, Chief Finance Officer (GN) Mr T Robinson, Non-Executive Director (TR) Mr P Winstanley, Non-Executive Director (PW)

HTB 14/688

DECLARATIONS OF INTEREST

There were no declarations of interest. HTB 14/689

MINUTES OF TRUST BOARD MEETING HELD ON 29 OCTOBER 2014

The minutes were APPROVED by the Board as a true and accurate record of the meeting.

HTB 14/690

TRUST BOARD ACTION MATRIX The Trust Board NOTED the progress made and APPROVED the removal of those actions marked as complete.

HTB 14/691

MATTERS ARISING

There were no matters arising that were not on the action matrix or the agenda.

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HTB 14/692

CHAIRMANS REPORT

AM commented that he had been encouraged by the discussion around the need for system leadership at the FTN Conference. The Trust Board RECEIVED ASSURANCE from the report.

HTB 14/693

CHIEF EXECUTIVE OFFICER REPORT

AH advised that he had attended a Public Accounts Committee (PAC) at which system leadership had also featured. He went on to say that although CCG’s were relatively new, they were not fulfilling their system leadership role and the acute sector could not wait for this to happen. AH concluded that despite the challenges, UHCW was seen as a place that was ‘getting it right’ hence the invitation to attend the PAC. AH further advised that Dr. Foster Global Comparators of which the Trust was a founding member was growing globally. AH, MP and Dr Duncan Watson had attended a conference on 17-18 November 2014 as keynote speakers and MP had also presented on her research around complications following hysterectomy. Finally, AH advised that the Foundation Trust Network would be known as NHS Providers going forward, and that it has published its cross party programme for the next Parliament. The Trust Board RECEIVED ASSURANCE from the report.

HTB 14/694

PATIENT STORY

MP introduced AS and SC who took the Board through the patient story that detailed a positive experience at the Lucina Birth Centre. AS confirmed that the patient had given her consent for her story to be discussed at the public trust board meeting on an anonymous basis. The Board noted that the Lucina Birth Centre had received the All Party Parliamentary Award for improving patient experience and congratulated the team on this significant achievement. In response to a question from AM around the proximity of the centre to the labour ward in case of emergency, AS confirmed that the centre was next door, which allowed for any emergencies to be dealt with speedily. AS advised that only 24% of Mothers had gone onto require specialist assistance or medical intervention since the centre had been opened, which was below the national average. MP added that there was the ability to flex staff across both units. BS commented on the strong leadership within the Lucina Centre and asked what had created this and whether any good practice could be shared across the Trust. AS responded that there was a strong and stable team in place although rotation was still seen as an important and that accordingly, the midwives had grown in confidence throughout the year. DM asked whether it was feasible for a birthing centre to be located offsite and BS responded that as a Midwife her preference would be for standalone birth centres to be established.

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EMS asked whether community Midwives worked within the Lucina and BS advised that they do undertake Bank shifts, as Lucina does not use agency staff, but there are no formal rotation arrangements in place. MR confirmed that the Lucina brand was very strong within the area and advised that Worcester Acute Hospital NHS Trust had requested input from UHCW into their birthing centre which will open in 2015. EMS asked if the service is sought after by expectant Mothers outside of the local area and AS advised that there was a high uptake from the Leicester area. CMc summarised that the success of the centre was due to the strong leadership demonstrated by Claire Croxall, Matron and Alison Searle, Ward Manager and the Board thanked and congratulated them in this regard. The Trust Board NOTED the patient story.

HTB 14/695

NON-MEDICAL HEALTHCARE STAFF EDUCATION REPORT

MR introduced GA who presented the report and explained that it gave some insight into the work of the Practice Development Team, focusing on the 13 specific training areas that are linked to the Together Towards World Class (TTWC) programme. She went on to explain that the team would also be embedding the values and behaviours work that was being led by DE. GA advised that the in-house training that was provided represented a significant cost saving when compared to the cost of external training provision. IB asked whether staff came forward for the training of their own volition or as a direct result of an appraisal and GA confirmed both to be the case. DE asked if these courses are offered to external partners within the local health economy and GA advised that demand for these courses is extremely high internally and they are often fully subscribed. GA gave confirmation however that in the event that a course is attended by an external attendee, course fees are charged. EMS asked if there was a way in which the Trust could be reimbursed for the cost of training courses should an employee leave the Trust. AH suggested that the Trust would not want to put this measure into place as offering such a wide range of training courses was a key factor in attracting new recruits; KH also confirmed that this would not be possible from an HR perspective. EMS asked whether tracking was in place to determine whether individuals that have training that is funded or provided by the Trust then go on to leave, and it was suggested that this would be administratively difficult given that some individuals attend training in their own time. EMS asked if the Trust receives money from Health Education England (HEE) for training courses and GA confirmed this to be the case, although noted that this was in respect of more academic courses. BS asked whether training was evaluated against the Trust’s objectives and whether the Trust is training the right people with the right skills to fit current and future business needs. MR confirmed that some of the training courses have been linked in specific Key Performance Indicators (KPI’s) for example a Falls Summit which had resulted in a concurrent reduction in the number of falls across the Trust. BS emphasized that she was unable to determine whether training was based on ‘must do’ or linked to moving the Trust forward. IB supported this, commenting that it would be useful for this to be linked to TTWC and contained

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within a framework. The Trust Board NOTED the contents of the report.

HTB 14/696

WARD SAFER STAFFING

MR introduced the six monthly staffing report in accordance with the National Institute for Health and Care Excellence (NICE) safer staffing recommendations.

MR advised the Board that operational pressures have been significant and that shifts in acuity have also been seen. Whilst seasonal variation was expected during winter months, analysis had shown that this variation had been less over the last two-years, with the patterns formerly being seen in winter becoming more the norm. Turning to the national picture, MR explained that whilst NICE had undertaken work around the nurse to patient ratio, it had stopped short of actually prescribing this. Trusts are required to assess the ratio needed based on outcomes and on a ward by ward basis and MR went on to give assurance that most wards at UHCW were compliant with the ratios that had been determined and that whilst some were slightly outside of this, all were committed to bringing staffing levels in line with these. MR confirmed that the Trust benchmarked well against other organisations in respect of night time staffing and that the midwife to birth ratio had reduced following board investment in midwifery two-years previously. AM sought an explanation of the sections rated red within the report and MR confirmed that these were areas of focus for investment following the annual external benchmarking exercise that he undertook, and gave assurance that UHCW performed comparatively well in relation to nurse to patient ratios. IB asked MR about the relationship between the surge in agency costs and the sustainability of the current model. MR confirmed that resourcing is bundled into tariff which allows the Trust to fund the nursing establishment at appropriate levels; something that cannot be achieved by many organisations without external support. MR went on to say that staffing levels together with the training available makes the Trust an attractive employer in furtherance of the pursuit of ‘Employer of Choice’. MR then emphasised the national challenge that existed around recruiting Nurses and the 1,400 shortfall in nurses in the West Midlands, which created a buyer’s market. IB emphasized that a robust Workforce Plan was fundamental in terms of allowing the Trust to take decisions around where to deploy resources and what work it will stop doing if resource is not available. MR responded that acuity modelling does look at the needs of specific specialities but the challenge is affordability in terms of finance and numbers. BS asked whether agency spend was quantifiable within next year’s budgets and MR confirmed that budgetary control is delegated to Ward Managers. Where a vacancy exists, the budget against the vacant post is utilised to fund bank or agency costs, but MR emphasised that agency staff are at a premium cost. IB urged that the Board should tackle this issue aggressively and that a coherent plan should be drawn up around how the Trust is going to ensure that the required future workforce is available. MR advised that staffing levels are something that

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the CQC assesses trusts against and whilst the opportunity to re-design roles exists, care must be exercised as this could result in a reduction in the number of band 5 nurses, which would be a red flag for the CQC. EMS asked about ‘return to practice’ of former Nurses and MR confirmed that a Return to Practice Programme was being developed which would enable nurses with a lapsed registration to re-train and be re-instated as RGNs. This was currently being costed and will be considered at the Chief Officers Group. MP highlighted that there was a shortage of obstetric doctors some years back and the Royal College of Obstetrics and Gynaecologists had suggested training more support workers to undertake some of the work that was done by doctors. MP also suggested that there needed to be better use of ambulatory pathways and the conversion of day case procedures into treatment room procedures. AM brought the discussion to a close and summarised that the Trust was in a better position than many other Trusts with regards to staffing levels. The Trust Board NOTED and were ASSURED by the six monthly Nurse Staffing Report.

HTB 14/697

JOINT VISION UPDATE

AH gave a verbal update and advised that he and PW had attended a joint workshop on 7 November 2014 at which there had been good representation from both organisations. AH went on to say that 3-4 teams had been tasked with pulling together a strategy that would be launched in March 2015. AH advised that a further meeting was scheduled for January to check on progress, and that a board seminar would be held at Warwick University in the late spring. The Trust Board NOTED the progress in relation to the development of the Joint Vision.

RS

HTB 14/698

INTEGRATED QUALITY, PERFORMANCE & FINANCE REPORT – MONTH 7 2014/15

DM highlighted that 27 of the 69 KPIs for which data is available and reported against, are breaching the standard/target and a further 10 are Amber or ‘watching brief’ status. DM emphasised that the Trust is continuing to face significant operational pressures and is struggling to meet the 95% 4 Hour A&E Standard due to the increasing volume of patients. This, coupled with the significant increase in delayed transfers of care (DTOC) in the month had impacted on the Trust’s ability to bring in patients for elective surgery, which in turn had impacted on performance against the Referral to Treatment (RTT) target. DM went onto highlight that the number of nursing vacancies was resulting in high agency spend, and whilst the Trust was still forecasting an £1.8m surplus, as the new CFO it was incumbent upon him to undertake a review of the Trust’s financial position. He cautioned however, that there were existing significant risks to achieving the planned position and additional risks as a result of non-recurrent costs linked to the operational pressures that he had mentioned. AM asked why theatre utilisation targets were not being met given that there was the headroom and AH responded that bed availability was the issue in that patients could not be brought in for elective surgery if there were no beds available in the post-operative period. DM added that any planned surgery that is

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cancelled on the day impacts upon theatre utilisation, and DE went on to say that Getting Emergency Care Right and achieving the 4 hour standard was key to resolving access issues across the Trust. Clarification was given that theatre utilisation relates to how much of the 240 minute session is utilised, whereas efficiency relates to the ability to complete all operating lists without cancellation. Discussion followed in relation to the number of day case procedures that were now being carried out against the basket of 25 that was formerly used as a benchmark, and AH highlighted that this had moved on significantly in that some procedures that used to be day-case procedures are now carried out in a treatment room setting. EMS asked for a report against the original basket of 25 day cases and was advised that this was included within the papers for the Finance and Performance Committee meeting, which was taking place the following week. AM requested an update on the 4-hour standard and DE advised that pressure was being put onto external partners to reduce the number of patients subject to DTOC, which currently stood at 6%, or 79 patients that did not need to be in hospital. DE went on to say that he wanted to see the DTOC figure reduce to 1% and that discussions had taken place at the Urgent Care Board to try and agree a health economy-wide trajectory to reach this point. IB expressed concern in relation to performance in respect of pressure ulcers and MR expressed disappointment that there had been an increase. He went on to give assurance that the Root Cause Analysis (RCA) process that was undertaken into every occurrence was robust and that the outcome suggested that the cause of the grade 4 ulcer was multi-factorial. IB asked whether there were any linkages between the cases and MR confirmed that there were no links. MR also confirmed that a ‘Stop the Pressure’ campaign had been launched and that even tougher targets had been set. MR acknowledged the impact that pressure ulcers had on patients and reiterated that whilst there was always more that can be done; the Trust’s pressure ulcer rate was low compared to other teaching hospitals. The Board noted and congratulated the Frail Older People’s Team on their achievement. The Trust Board CONFIRMED its understanding of the October 2014 IPR and the associated actions.

HTB 14/699

NHS TRUST DEVELOPMENT AUTHORITY (TDA) OVERSIGHT – MONTHLY SELF-CERTIFICATION REQUIREMENTS NOVEMBER 2014

DM asked the Board to approve the submission to the NHS TDA for November and highlighted that there was no change from the previous month. The Trust Board APPROVED the November submission to the NHS TDA.

HTB 14/700

PRIVATE TRUST BOARD MEETING SESSION REPORT 29 OCTOBER 2014

AM advised that he had nothing further to add to his report and there were no questions raised by members of the Board. The Trust Board RECEIVED ASSURANCE from the report.

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HTB 14/701

QUALITY GOVERNANCE COMMITTEE MEETING REPORT FROM 3 NOVEMBER 2014

EMS presented the report and highlighted the key features. The Board had no questions around this. The Trust Board RECEIVED ASSURANCE of the meeting report.

HTB 14/702

FINANCE AND PERFORMANCE COMMITTEE MEETING REPORT FROM 3 NOVEMBER 2014

IB presented the report to the Board and no questions were raised. The Trust Board RECEIVED ASSURANCE from the report.

HTB 14/703

AUDIT COMMITTEE MEETING REPORT FROM 10 NOVEMBER 2014

RS presented the report to the Board and highlighted that the Committee had approved the proposal to remove the current requirement for Trust Board approval of any increase in the consultant headcount. RS confirmed that Trust Board approval was required given that it involved a change to the Scheme of Delegation. Members of the Board indicated that they were in agreement with this. The Trust Board RECEIVED ASSURANCE from the report and APPROVED the resolution to remove the requirement around Trust Board approval for increases in the consultant headcount from the Scheme of Delegation.

HTB 14/704

AUDIT COMMITTEE ANNUAL REPORT 2013/14

RS presented the annual report and highlighted that it related to the financial year 2013/14, and that there was now a full complement of NEDs on the Committee. The Trust Board NOTED and APPROVED the Audit Committee Annual Report 2013/14.

HTB 14/705

RAISING CONCERNS: A SAFER ALTERNATIVE TO SILENCE

AH presented the Policy, formerly known as the Whistleblowing Policy to the Trust Board for approval on the recommendation of the Audit Committee. It was noted approval was sought on the basis that the Policy would be reviewed and revisited following the publication of the Sir Robert Francis Report into Whistleblowing in the NHS. BS asked if there was a condensed version of the policy available on the website for staff. RS advised that the full policy document would be available and advised that when the Policy is next reviewed, as set out in the paper, a flow chart would be included for ease of reference. RS advised that the Policy had been presented to the Joint Negotiating Consultative Committee (JNCC) where it had been agreed that the next iteration would be subject to a fuller consultation. The Trust Board NOTED the move from the term ‘Whistleblowing’ to ‘Raising

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Concerns’ and APPROVED the Raising Concerns Policy subject to review within 3 months of the publication of Sir Robert Francis’ report into whistleblowing.

HTB 14/706

ANY OTHER BUSINESS

There was no other business raised. HTB 14/707

QUESTIONS FROM MEMBERS OF THE PUBLIC RELATING TO ITEMS ON THE AGENDA

Q. A member of the public asked what changes are being made to the A&E department as he had attended in an emergency and had found that he had to wait a long time to be seen. A. AH responded that there are tremendous pressures on the Trust’s A&E department as there is on A&E departments across the country, owing to a big increase in the number patients coming through the door, and went on to give assurances that the majority of those patients are treated within the 4 Hour Standard. AH went on to say that there were many patients that attended the A&E department that did not need to attend, and given that the Trust was one of the top 3 trauma centres in the UK, this did sometimes impact on patients with more minor ailments. He further stated that the Trust is working with external partners to try and address the provision of alterative options for the treatment of minor injuries but emphasised that this was a nationwide issue and not just specific to Coventry. Assurance was however given that this was a top priority for the Trust as the Chief Operating Officer had emphasised during the meeting. Q. A member of the public asked how long patients should be expected to wait for elective day case surgery. A. AH responded that it was 6-8 weeks depending on the speciality. The member of the public then clarified that she wanted to know how long after admission on the morning of the procedure the actual procedure takes place, and AH confirmed that at the present time all patients on the list for that day are asked to arrive at the same time to allow maximum list flexibility. It was accepted that this sometimes resulted in patients having to wait until late in day for surgery and as such, staggered starts were currently being considered. The patient then went on to ask why his friend had been waiting 6 months for a prostate procedure and MR advised that he could not comment on this specific case as he did not have the detail, but confirmed that there could be medical reasons as to why he may have to wait because there were different treatments and pathways.

HTB 14/708

THE DATE AND TIME OF NEXT MEETING

AM advised that there will be no Public Trust Board meeting in December. The next meeting will therefore take place on 29 January 2015 at 10.00 am at University Hospital.

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HTB 14/709

These minutes are approved. SIGNED

…………………………………………............................

CHAIRMAN

DATE

…………………………………………............................

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UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST ACTIONS UPDATE: PUBLIC TRUST BOARD MEETINGS

29 JANUARY 2015

The Trust Board is asked to note the progress made with regards to matters arising and to approve the removal of those matters marked completed and recommended for removal.

AGENDA ITEM ACTION CHIEF OFFICER

DUE DATE

UPDATE REMOVAL

ACTIONS FROM JULY 2014 MEETING HTB14/613 Chief Executive Officer’s Report

Board seminar to be arranged around the AHSN agenda

RS TBC Agreed at the Board Development Session that seminar time in 2015 would be held for strategic discussion.

Yes

ACTIONS FROM SEPTEMBER 2014 MEETING HTB14/639 Duty of Candour

TL to attend Grand Round to present RS TBC Attended and gave presentation 23rd January

Yes

ACTIONS FROM OCTOBER 2014 MEETING HTB14/668 CEO report

5-Year Forward Look to be scheduled for discussion at a Seminar.

RS 26.11.14 Discussed at Board Seminar 7th January 2015

Yes

NO PUBLIC MEETING HELD IN DECEMBER 2014

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

REPORT TO THE TRUST BOARD: PUBLIC

29 January 2015

Subject: Chairman’s Report Report By: Andy Meehan, Chairman Author: Andy Meehan, Chairman Accountable Executive Director:

Andy Meehan, Chairman

PURPOSE OF THE REPORT:

To update the Trust Board of the key details of meetings and events attended by the Chairman.

SUMMARY OF KEY ISSUES:

Since the last Board meeting, the major meetings and areas of interest were as follows:

• HFMA Annual General Meeting – 4 December 2014 • Consultant Neonatal Interviews • Board Development Session • UHCW Carol Concert • Chief HR Officer Interviews • HFMA Chairs Meeting – 20 January 2015 • Corporate Trustees Board Meeting – 28 January 2015 • Board Safety & Quality Walk-Rounds

STRATEGIC PRIORITIES THIS PAPER RELATES TO (Please check one):

To Deliver Excellent Patient Care and Experience To Deliver Value for Money To be an Employer of Choice To be a Research Based Healthcare Organisation To be a Leading Training and Education Centre

RECOMMENDATION / DECISION REQUIRED:

The Trust Board are asked to RECEIVE ASSURANCE from the report.

IMPLICATIONS: Financial: None Highlighted HR/Equality & Diversity:

None Highlighted

Governance: None Highlighted Legal: None NHS Constitution: None Highlighted Risk: None Highlighted

COMMITTEES/MEETINGS WHERE THIS ITEMS HAS BEEN CONSIDERED: None –the report is for the Trust Board.



29th January 2015

Subject: Chief Executive Officers Report Report By: Andy Hardy, Chief Executive Officer Author: Andy Hardy, Chief Executive Officer Accountable Executive Director:

Andy Hardy, Chief Executive Officer

PURPOSE OF THE REPORT:

To update the Trust Board of the key details of meetings and events attended by the Chief Executive Officer and key policy issues.

SUMMARY OF KEY ISSUES:

Summary of Activity This month I have been involved in the following:

1. Sir Bruce Keogh visit 2. Chief Inspector of Hospitals Visit – the Trust will be inspected by the Care Quality

Commission as part of the Chief Inspector of Hospitals Inspection programme in the week commencing 9th March 2015 and a planning meeting between the Trust and the CQC took place on 7th January 2015.

3. Launch of Ophthalmology Room

Policy Issues and Publications: The following are key issues and reports that have been published that I would bring to the attention of the Trust Board

4. Following the publication of the 5-Year Forward view that the Trust Board discussed at the January Board seminar, NHS England has published The Forward View Into Action – Planning for 2015/16: http://www.england.nhs.uk/wp-content/uploads/2014/12/forward-view-plning.pdf

STRATEGIC PRIORITIES THIS PAPER RELATES TO (Please check one): To Deliver Excellent Patient Care and Experience To Deliver Value for Money To be an Employer of Choice To be a Research Based Healthcare Organisation To be a Leading Training and Education Centre

RECOMMENDATION / DECISION REQUIRED: The Trust Board are asked to RECEIVE ASSURANCE from the report.

IMPLICATIONS: Financial: None Highlighted HR/Equality & Diversity:

None Highlighted

Governance: None Highlighted Legal: None NHS Constitution: None Highlighted Risk: None Highlighted

COMMITTEES/MEETINGS WHERE THIS ITEMS HAS BEEN CONSIDERED: None - report is for the Trust Board

http://www.england.nhs.uk/wp-content/uploads/2014/12/forward-view-plning.pdf

Enclosure 5

PUBLIC TRUST BOARD PAPER

Title Patient Story Programme We are Listening - Feedback Making A Difference

Author Anita Kane, Associate Director of Quality Responsible Chief Officer

Meghana Pandit, Chief Medical and Quality Officer

Date 29 January 2015 1. Purpose This paper details a recent initiative the Patient Experience Team implemented at University Hospital and the Hospital of St Cross. As part of the ‘We are Listening’ campaign the team wanted to tell our patients, visitors, relatives and the public about action that had taken place as a result of feedback and compliments the Trust has received. Background and Links to Previous Papers The Trust Board receives a paper as part of the Patient Story Programme each month. The Trust Board received details of the ‘We are Listening’ campaign and ‘You Said We Did’ paper at the October 2014 Trust Board meeting. 2. Narrative It is important that the Trust puts listening into action. The team created a Reggie the Reindeer advent calendar, whereby each day from 1 December to the 24 December 2014, a window would be opened to display an action the Trust had taken as a result of feedback or a compliment. The Calendar was placed in the main Reception at University Hospitals Coventry & Warwickshire and in the Outpatients Department at the Hospital of St Cross. We believe this demonstrates our commitment to acting on our users’ feedback and changing or enhancing systems/processes or environments that will deliver a better patient experience. This aligns with our Organisational vision of being a national and international leader in healthcare and delivering a world class patient experience. 3. Areas of Risk There are no areas of risk highlighted as the advent calendar was successful. If the Trust does not openly receive, and take action following feedback however, this gives rise to the risk of a poor patient experience and consequent damage to the Trust’s reputation. 4. Governance NHS Constitution Section 3b - Please give feedback – both positive and negative – about your experiences and the treatment and care you have received, including any adverse reactions you may have had. You can often provide feedback anonymously and giving feedback will not affect adversely your care or how you are treated. If a family member or someone you are a carer for is a patient and unable to provide feedback, you are

encouraged to give feedback about their experiences on their behalf. Feedback will help to improve NHS services for all. Section 4b

• to contribute towards providing fair and equitable services for all and play your part, wherever possible, in helping to reduce inequalities in experience, access or outcomes between differing groups or sections of society requiring health care;

• to view the services you provide from the standpoint of a patient, and involve

patients, their families and carers in the services you provide, working with them, their communities and other organisations, and making it clear who is responsible for their care;

5. Responsibility Anita Kane, Associate Director of Quality Meghana Pandit, Chief Medical and Quality Officer 7. Recommendations The Board is invited to NOTE the campaign and actions staff have taken as a result of listening to user feedback and the compliments. Name and Title of Author: Anita Kane, Associate Director of Quality Date: 29 January 2015

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Patient Story Programme Patient Experience Advent Calendar “Reggie the Reindeer”

Background: As part of the Patient Experience Team’s ‘We are Listening’ campaign it was agreed that the Trust needed to share feedback received from the Friends and Family Test (FFT) and show to those using our hospitals that we act upon feedback. Description of concept: The Patient Experience Advent Calendar was a concept which was thought up by the Patient Experience Facilitator. This piece of work was part of a calendar of events which was devised to further promote the ‘We are Listening’ campaign (Agreed at Trust Board October 2014). Behind every window of this calendar was an initiative the Trust had introduced as a direct result of patient and visitor feedback or a compliment a department had received. This celebrated the hard work staff had done to act on feedback but was also used as a tool to promote the importance of completing the FFT. This advent calendar was situated in the main reception area of UHCW and one was placed in the Outpatients Department at the Hospital of St. Cross and both were sponsored by ISS. The picture on the front of the advent calendar was of a reindeer which the Patient Experience Team called Reggie. To create interest in this calendar the team introduced the hashtag #reggiethereindeer and worked collaboratively with the Trust’s Communications Department to tweet every day from the Trust’s account about what was behind each window. Content behind each window The attached appendix details what was behind each window of the calendar. Evaluation: The Patient Experience Advent Calendar was unveiled on 1st December 2014, with the Patient Experience Team handing out free mince pies which were sponsored by ISS. The opening of the final window on the 24th December 2014 was also celebrated with the handing out of mince pies and a picture opportunity with members of the Patient Experience Team with the Chief Executive Officer and the Chief Medical and Quality Officer/ Deputy Chief Executive Officer.

Throughout December the Communications tweeted about the content of this calendar and this generated a lot of re-tweets and other Twitter users marking the content as ‘favourites.’ The use of social media has also given the Patient Experience Team the insight into how they can make use of social media for future projects. The team also received many positive comments from staff, the Patient Advisors Team and visitors about the calendar which means the return of Reggie in 2015.

Window Text 1 You Said – You were unhappy with the lack of information

regarding waiting times in the Emergency Department. We Did – Triage Nurses are now informing patients of the waiting times and the digital displays are now being updated by the receptionists. Source: Impressions, Family & Friends Test

2 Compliment about Maternity Services: I felt overwhelmed with the care I received by the Maternity Services at University Hospitals Coventry and Warwickshire NHS Trust. I was a complex high risk pregnancy and saw many of the departments at work. Each midwife made me feel comfortable and a part of the decision making process … Thank you for all your care. Keep up the good work! Source: NHS Choices

3 Patient Experience Improvement Initiative for In-Patients With funding from UHCW Charity, an Art Cart, named Artie, has been purchased. Artie is taken to the wards by our volunteers and patients are invited to take painting, crayoning and embroidery materials for use during their stay in hospital. They are free to take their efforts home with them.

4 You Said – Maternity patients wanted quicker discharges. We Did – The department changed their way of working on the postnatal wards with a designated discharge midwife who facilitates all the aspects of discharge to ensure there are no delays.

5 Compliment about Cedar Ward: I was well looked after, the nurses kept checking me all night and asking me if I was in any pain, they were brilliant. Thanks to them and the whole team who looked after me on Cedar Ward. Source: Impressions

6 Patient Experience Improvement Initiative for new parents A trial scheme called ‘mum plus one’ has been running since October which enables a birthing partner to stay overnight in the Maternity Unit. The scheme is to be evaluated in the new year to assess its success with new parents.

Window Text 7 You Said – Walking frames were going missing even though

they were allocated to individual patients. We Did – Labels which include the patients details are now put on the walking frames so they are less likely to be lost. Source: Verbal feedback from patients, relatives, nursing & medical staff

8 Compliment about the Emergency Department I came into the Emergency Department with my husband by ambulance early this morning and while, thankfully, it turned out to be a minor issue, it was a very frightening experience, made better by the attentive staff and the feeling of calm efficiency across the ward. The nurses were very pleasant, extremely professional but cracking a few jokes with us, which we welcomed. They checked regularly on my husband and just seemed on top of things … thank you to everyone. Source: NHS Choices

9 You Said – You wanted longer visiting times in the Maternity Department. We Did – Visiting times for birth partners has been extended and visiting is now from 9.30 to 21.30. Source: Friends & Family Test

10 You Said – There was nowhere conducive for breaking bad news to patients undergoing surgery, their relatives and/or carers. We Did – A room was identified on the ward for this purpose and refurbished. Source: Verbal feedback to ward staff

11 Compliment about Surgical Care I have recently returned home from University Hospital Coventry and having spent 12 days there, I can’t praise the surgeons, doctors and nursing staff enough. The medical attention was excellent and the nursing staff were always good natured and extremely kind, showing great patience during

their long working hours. Source: NHS Choices

12 You said – The drop off point outside University Hospital was too small and traffic didn’t flow smoothly round the front of the hospital. We Did – Redevelopment of the University Hospital site has begun which involves a number of schemes all aimed at improving both access to the site, its car parks and to improve traffic flow. This has included the redesign of the drop off point outside the entrance to University Hospital. Source: Impressions, Healthwatch Coventry Survey

13 You Said – There was a lack of communication to patients around treatment, plans and progress within the Emergency Department. We Did – Staff were reminded of the importance of keeping patients and families informed. Notes were also placed in the Emergency Department’s communication folder so this would be passed on at each change of shift. Source: Friends & Family Test

14 Compliment about Rugby Day Surgery Unit All the staff were exceptional, professional and caring and made you feel relaxed. With such a happy atmosphere, recovery came quickly. Source: Impressions

15 You Said – New mothers said they wanted somewhere more comfortable to breastfeed. We Did – UHCW Charity funded a new breastfeeding lounge on Ward 25. Source: Friends & Family Test

16 You Said – you were unhappy with late cancellations of gynaecology procedures. We Did – Senior Trust Managers meet daily at 2.00pm to

assess the need for planned operations to be cancelled. This enables all patients to be informed by 4.00pm the day before their planned procedure of the need to regrettably cancel their admission. Source: Complaint

17 You Said – The Day Room on Ward 41 was dreary and uninviting. We Did – We carried out a refurbishment which saw the provision of comfortable seating and art work within the Day Room. Source: Impressions and verbal feedback to ward staff

18 You Said – We need more readily available wheelchairs throughout the Trust. We Did – Additional wheelchairs (50) have been purchased for the convenience of those patients and visitors with mobility/health conditions which make walking long distances difficult. Source: Impressions, Friends & Family Test, Complaints, Patient Advice & Liaison Service (PALS)

19 Compliment for Cedar Unit, St Cross Hospital My stay was excellent. Everybody was very helpful and kind and made you feel at home. I would recommend it to all my friends. It is a very friendly hospital. Thank you very much. Source: Impressions

20 You Said – There wasn’t enough arm warmers in the Arden Cancer Centre’s Chemotherapy Suite. (The arm warmers facilitate the easier infusion of drugs to patients). We Did – Additional arm warmers were purchased for use by patients undergoing chemotherapy. Source: Patient Story to Trust Board

21 You Said – There was no easily accessible parking meter point by the disabled parking at the Hospital of St Cross in Rugby. We Did – An additional meter was installed to enable easier

access for disabled patients and visitors. Source: Complaint

22 Compliment for Rugby Day Surgery Unit This is my third time at the hospital in the last 6 weeks of my treatment and the care has equalled, if not better, than when I have paid for private treatment. Source: Impressions

23 Compliment about the Maxillo Facial Department All the staff we met did an apparently effortless job of reassuring myself and my daughter, who was undergoing Maxillo Facial dental extractions. They were professional, knowledgeable, friendly and communicated brilliantly with us throughout the morning. They gave such a wonderful feeling of safety and competence. Source: Impressions

24 Season’s greetings to our patients, their friends and family from the Patient Experience Team!

Enclosure 6


Title Parliamentary and Health Service Ombudsman Complaints Vision

Author Anita Kane, Associate Director of Quality Responsible Chief Officer


Date 29 January 2015 1. Purpose To provide the Trust Board with a synopsis of two Parliamentary and Health Service Ombudsmen (PHSO) reports which were published in November 2014 and to set out the Trust’s response to these. 2. Background and Links to Previous Papers The Trust Board receives a quarterly Patient Experience Report and the Learning From Experiences Action Plan, which details the actions that the Trust is taking in relation to national reports into complaints handling published previously. 3. Narrative The PHSO provides a service to the public by undertaking independent investigations in complaints where the NHS has not acted properly or fairly or has provided a poor service. The first section of the report details the Trust’s performance in relation to a peer group of other NHS Trusts with regards to PHSO complaint investigations. The second section outlines the PHSO’s vision for complaint handling in the future as detailed in ‘My Expectations for raising concerns and complaints’ and the next steps that the Trust needs to take in meeting the recommendations for change. The PHSO vision will be utilised by the Care Quality Commission (CQC) within its new inspection regime and will also be used as a performance management tool by NHS England within the NHS Outcomes Framework. 4. Areas of Risk Failing to adopt and embed the PHSO vision gives rise to the following risks: Patient Experience; if we do not handle complaints appropriately and use them as opportunities for improvement there is the risk that patients will have a poor experience. Reputation; if patients have a poor experience of the Trust this will impact negatively on the Trust’s reputation and vision of becoming a World Class Organisation that provides World Class service. Regulatory; if the Trust does not comply with the CQC standards there is the risk that regulatory sanctions will be imposed, which at worst could mean that the Trust can no longer provide one or more services. This would be detrimental to the communities served and to the Trust’s staff.

5. Governance It is recommended that responsibility for monitoring progress against implementation of the vision be delegated to the Quality Governance Committee with an update report scheduled for 6-months’ time. NHS Constitution Section 3b - Please give feedback – both positive and negative – about your experiences and the treatment and care you have received, including any adverse reactions you may have had. You can often provide feedback anonymously and giving feedback will not affect adversely your care or how you are treated. If a family member or someone you are a carer for is a patient and unable to provide feedback, you are encouraged to give feedback about their experiences on their behalf. Feedback will help to improve NHS services for all. Health Service Complaints (England) Regulations 2009 NHS Outcomes Framework CQC Inspection Regime 6. Responsibility Anita Kane, Associate Director of Quality Meghana Pandit, Chief Medical and Quality Officer 7. Recommendations The Board is invited to:

• Note the content of the report. • Adopt the PHSO framework for complaints management. • Delegate monitoring of progress to QGC with a further report to be submitted in 6-

months’ time. Name and Title of Author: Anita Kane, Associate Director of Quality Date: 15 January 2015

Page 2 of 2

Part 1 - Parliamentary and Health Service Ombudsmen Report- Complaints about Acute Trusts 2013-14 and Q1,Q2 2014-15 The report published on 26 November 2014 details the information the Parliamentary and Health Service Ombudsmen (PHSO) collect about complaints involving acute trusts in England in 2013-14 and the first two quarters of 2014-15.

Before going to the PHSO with a complaint, an individual should give the Trust they are complaining about the opportunity to respond. As a result most complaints are resolved locally. The PHSO received 18,870 enquiries or complaints about NHS organisations, 3592 were accepted in 2013-14 for an investigation. Those enquiries not taken forward are usually because the complainant hasn’t given the organisations an opportunity to respond to the complaint itself or because an individual has not made the complaint in an appropriate way.

Over the first two quarters of 2014-15 diagnosis (including delay, failure to diagnose and misdiagnoses) was the single most common reason leading individuals to complain. The following four issues have remained in the top five list of the most mentioned reasons for complaining about trusts over the past 18 months.

• 3 out of 10 – clinical care and treatment • 3 out of 10 – communication • 3 out of 10 –diagnosis (including delay, failure to

diagnose and misdiagnoses) • 2 out of 10 - attitude of staff.

The report contains for each acute trust the number of written complaints, the number of complaints accepted for investigation alongside the number of clinical incidents.

On average, the PHSO investigated 2.2 complaints for every 100 written complaints. The ten trusts with the highest number of complaints investigated (average of 5.95 per 100) were 15 times more likely to have a complaint translate into an investigation by the PHSO.the lowest proportion was 0.41 investigations per 100 complaints.

Report Headlines & Quick Statistics

• • •

This report is the first in a series of regular publications and its purpose it to provide statistical insight not a measure of quality

It is not possible to make direct comparisons and the report is not designed to rank trusts on the basis of their complaints or assess the performance of individual Trusts when it comes to handling complaints.

Provides a useful insight into trends and poses some interesting questions on why some organisations appear to have a significantly higher, or lower level of complaints that translate into investigations.

The NHS received 174, 872 written complaints 2013-14

In the last 18 months the PHSO has upheld 44% of investigations into complaints.

Reasons for complaints in 2013-14:

Poor communication including quality and accuracy of information accounts for three in ten complaints

Staff attitude accounts for two in ten complaints

14% of all complaints were regarding inadequate apologies from the NHS

• • •

On average the PHSO investigated 6.0 complaints for every 100.000 clinical incidents during 2013-14. The 10 acute trusts with the highest proportion of complaints accepted for investigation were on average 11 times more likely to have a complaint investigated than the 10 trusts with the lowest proportion of investigation per 100,00 clinical incidents (an average of 1.72 per 100,000 investigations compared to 14.73 per 100,000 investigations).

Data considerations and caveats

The data needs to be interpreted with the following caveats taken into account.

A number of complaints involve multiple trusts

A number of complaints the PHSO investigate will relate to more than one acute trust. In these cases, the PHSO have counted the complaint more than once. For instance, if an investigation relates to three separate trusts, this would be counted against each trust. This differs from how the PHSO has reported on complaints in other reports and in their Annual report.

Written complaints information

Comparing the number of complaints the PHSO investigate with the number of written complaints received only gives a broad indication of the proportion of the total complaints that go to the PHSO. A trust that is very open about giving complainants information on how to escalate their complaint if they are not happy about how it has been dealt with locally might expect a higher proportion of complainants to contact the PHSO, in turn leading the ombudsmen to investigate a greater number.

Hospital activity data

The number of clinical incidents provides only a broad indicator of the size of each trust. In this contact a clinical incident relates to any elective general and acute admission (inpatient) ad all first outpatient attendances in general and acute specialties.

For 2014-15 Q1 and Q2 both Whittington Hospital NHs trust and Heart of England NHs Foundation Trust have been excluded from the hospital activity analysis as a result of multiple incomplete submissions of monthly activity data.

Time lag

Care should be taken when making direct comparisons between PHSO statistics and NHS written complaints information as there is a time lag between when a complaint is made to a trust and when it is received by the PHSO.

Variability in uphold rates

Caution must be used when comparing upheld rates across trusts. For most organisation the PHO only investigate a small number of complaints this means the rate varies significantly.

UHCW’s published complaints data for 2013-14

Peer Comparison (Trusts are the same trusts chosen for mortality peer group comparison)

Trust Complaints made to Trust

Enq's to PHSO

Enq's accepted

Investigations fully or partly upheld

Enq's per 100 complaints

Investigations per 100 complaints

Enq's per 10,000 clinical incidents

Investigations per 100,000 clinical incidents

Total number of clinical incidents

UHCW 490 48 14 8 9.8 2.9 1.74 5.09 275261 Cambridge UH NHS FT

465 68 19 2 14.6 4.1 2.65 7.40 256771

Heart of England NHS FT

958 113 15 4 11.8 1.6 2.79 3.71 404697

Nottingham UH NHST

693 73 17 1 10.5 2.5 2.48 5.77 294493

Oxford UH NHST 890 67 13 2 7.5 1.5 1.76 3.41 381294 Sandwell & West B’ham NHST

663 90 12 2 13.6 1.8 3.36 4.48 267644

University College London NHSFT

788 108 19 2 13.7 2.4 3.12 5.48 346409

University Hospital of North Staffordshire

809 82 15 6 10.1 1.9 3.17 5.80 258597

• • •

Trust Complaints made to Trust

Enq's to PHSO

Enq's accepted


Enq's per 100 complaints

Investigations per 100 complaints




NHST

University Hospitals Birmingham NHSFT

664 70 14 2 10.5 2.1 3.21 6.43 217769

University Hospitals Bristol NHSFT

775 69 16 1 8.9 2.1 2.84 6.59 242729

University Hospitals Leicester NHST

2034 101 19 2 5 0.9 2.51 4.73 401821

Worcester Acute Hospitals NHST

600 46 6 3 7.7 1 1.81 2.36 253900

From the above peer comparison UHCW is:

• Slightly above the average for investigations per 100 complaints 2.9 versus a 2.2 average • Below the average for investigations per 100,00 clinical incidents 5.09 versus a 6.43 average • An outlier for those investigations full or partly upheld with the most (8) out of the peer group. (All of the 8 were partially

upheld) • Second lowest acute trust in terms of number of written complaints.

On further examination of these 8 for the reasons by the PHSO upheld or partially upheld the complaint the following themes emerge.

Five were partially upheld due to service failures (discharge arrangements, delays and clinical assessments).

Two were partially upheld due to insufficient complaint handling/thoroughness of investigation

One was partially upheld due to failure to comply with the PHSO recommendations. (UHCW disagreed with the PHSO report)

• • •

In 2013 The PHSO asked the trust to pay £1000 in compensation for ‘injustice’.

Quarters 1&2 2014-15

Trust Enq's to PHSO

Enq's accepted


Investigations not upheld




UHCW 31 5 2 3 2.56 4.13 121210 Cambridge UH NHS FT

29 10 5 3 2.65 9.15 109304

Heart of England NHS FT

65 20 3 6 - - 107558

Nottingham UH NHST 35 9 5 8 2.55 6.56 137289 Oxford UH NHST 44 8 4 1 2.64 4.79 166941 Sandwell & West B’ham NHST

37 9 2 4 3.45 8.39 107267

University College London NHSFT

56 6 2 6 3.68 3.94 152310

University Hospital of North Staffordshire NHST

38 8 4 4 3.34 7.03 113855

University Hospitals Birmingham NHSFT

47 15 5 3 4.98 15.89 94373

University Hospitals Bristol NHSFT

19 5 5 5 1.82 4.78 104574

University Hospitals Leicester NHST

41 10 1 9 2.18 5.31 188334

Worcester Acute Hospitals NHST

29 3 1 2 2.64 2.73 109876

This data illustrates that UHCW is below the average for the number of investigations per 100,000 clinical incidents 4.13, versus the average.7.4

Actions taken with regards to UHCW complaints service since April 2014

• Revised the complaints information that is presented to Trust Board, Quality Governance Committee and Clinical Quarterly review Group to include further information regarding Ombudsmen cases, learning and brief synopsis of 5 complaints.

• Anonymous complaints now presented to Trust Board as part of the patient story programme. • Restructure of the Complaints and PALS team to form better strategic alignment and to

enhance staffing and skill levels. • Introduction of Datix Web module for complaints and PALS • Complaints officers now aligned to specialty groups to enhance relationships and case handling • Complaints Officers now instigate a complaints management plan with each complainant to

ascertain the key issues and specifics, this is agreed with the complainant along with keeping in touch points and what outcome they are expecting.

• Complaints and PALS leaflets updated, along with the webpages on our internet site. Due for release in January 15

• Complaints and PALS policies revised, due to be approved January 2015 • Sample complaints letter developed to allow complainants to follow a format. • Complaints handling questionnaire designed and to be sent out with all final responses to begin

in January • Training and education for nursing staff on statement writing will now be included as part of

Band 5, 6 and 7 training programmes. Medical staff to be further explored

The PHSO statistics will now form part of regular reporting to Patient Experience and Engagement Committee and feature within complaints reports to Committees and Trust Board.

• • •

PART 2 - Parliamentary and Health Service Ombudsmen, Healthwatch England and Local Government Ombudsmen Report – My Expectations for raising concerns and complaints Published November 2014

As part of the Complaints Programme Board (a board set up in 2013 by the DH following the inquiry into the failings at Mid Staffordshire NHS Foundation Trust) the Parliamentary and health service Ombudsmen (PHSO) was invited to lead the development of a vision for good complaint handling across health and social care sectors, in partnership with Healthwatch England (HWE) and Local Government Ombudsmen (LGO).

The vision lays out a guide to what good outcomes for patients and service users look like if complaints are handled well. It does this by presenting a series of ‘ I statements’ laid out across a complaint journey. The ‘ I statements’ are expressions of what patients and service users might say if their experience of making a complaint was a good one.

The vision for complaint handling aims to respond to these needs;

1) The need to ensure that patient and service user expectations lies at the heart of any system or approach to complaint handling. And;

2) The need for a framework of good practice in complaints handling that is relevant to health and social care providers.

Ambitions:

1) Vision is of practical use to all involved 2) Give patients and service users a set of questions they

can ask themselves 3) Gives frontline staff a guide on how to be dealing with

complaints 4) Gives organisational leaders a way of measuring the

performance of the complaint handling system 5) Gives regulators a means of identifying good practice

across different organisations.

The full report which details the background to the research , how the vision was created can be found on the PHSO website,

Report Headlines • • •

Post publication of Hard Truths, the PHSO, LGO and Healthwatch England committed to developing a user led ‘vision’ of the complaints system.

Vision aims to align the health and social care sector on what good looks like from the user perspective when raising concerns and complaints.

CQC will use the framework in its new inspection regime

NHSE will use it as a performance management tool to be built into the NHS outcomes framework

PHSO and LGO will use it to improve the way they work by integrating the vision into the principles of good complaint handling.

• • •

Accompanying each of the five stages there is a simple overarching ‘I statement’ that embodies the values of the more detailed statements outlined below. When put together these five statements describe, in simple terms, what a good complaint journey looks like from the perspective of the complainant.

‘I felt confident to speak up and making my complaint was simple. I felt listened to and understood. I feel like my complaint made a difference. I would feel confident making a

complaint in the future.’

For each stage in the complaint journey there are a number of ‘I statements’ considered to be essential as opposed to be desirable. The essential statements are detailed below for the full list please refers to the full report available on the PHSO website.

Stage in the Complaint Journey

Essential ‘I’ Statements

1. Considering making a complaint ‘I felt confident to speak up’

• I knew I had a right to complain • I was made aware of how to complain (when I first started to receive

the service) • I knew that I could be supported to make a complaint • I knew for certain that my care would not be compromised by

making a complaint

2. Making a complaint

‘I felt that making my complaint was simple’

• I felt that I could have raised my concerns with any of the

members of staff I dealt with • I was offered support to help me make my complaint • I was able to communicate my concerns in the way that I wanted • I knew my concerns were taken seriously the very first time I

raised them

• • •

• I was able to make a complaint at a time that suited me

3. Staying informed

‘I felt listened to and understood’

• I always knew what was happening in my case • I felt that responses were personal to me and the specific nature

of my complaint • I was offered the choice to keep the details of my complaint

anonymous and confidential • I felt that the staff handling my complaint were also empowered

to resolve it

4. Receiving outcomes

‘I feel that my complaint made a difference’

• I received a resolution in a time period that was relevant to my

particular case and complaint • I was told the outcome of my complaint in an appropriate

manner, in an appropriate place, by an appropriate person • I felt that the outcomes I received directly addressed my

complaint(s) • I feel that my views on the appropriate outcome had been taken

into account

5. Reflecting on the experience

‘I would feel confident making a complaint in the future’

• I would complain again, if I felt I needed to • I felt that my complaint had been handled fairly • I would happily advise and encourage others to make a

complaint if they felt they needed to • I understand how complaints help to improve services

Consideration and Implementation of the framework

The vision framework presents a number of practical opportunities for improvement that will work alongside the good practice that already exists within UHCW. These opportunities are;

• Incorporate the statements into the new complaints training for staff, helping to empower them further to be able to deal with patient expectations.

• UHCW could create a set of ‘we promise’ statements against each of the ‘I’ statements these in turn could help to further the work already started with reviewing complaints handling processes.

• Helping to provide a mechanism by which the Trust can measure whether or not it has the ability to deliver against each of the patient statements.

The report details a number of considerations with regards to Environment, culture, process and emotion. The below is where UHCW is presently in answering those questions.

• • •

Facet Considerations UHCW position Environment

• Is our complaints literature visible and accessible to all of our service users?

• Are our complaints communications available in a number of formats?

• Do we make clear how we use complaints to improve services?

• Do we communicate our openness to receiving complaints from the moment we first receive a patient/service user?

• Are our complaint handling and support services highly visible? For example, is PALS highly visible? Is our complaints service easily accessible from service user waiting areas and public entrances?

New PALS and complaints literature is live on the website. New leaflets have been finalised and will be distributed to all wards and areas. A process has been agreed with Voluntary services to ensure replenishment takes place. The aforementioned leaflets will be translated into Audio and the top two languages by February 2015. The literature talks about the how we actively encourage feedback and use it to improve services. PALS will be relocating to the main entrance in early 2015. Complaints service is accessible via 24 hour telephone and email.

Culture • Can we ensure that those who want to

make a complaint can do so privately and anonymously if they wish to?

• Do our staff all encourage people to complain, without fear for themselves?

• Are our frontline staff sufficiently empowered and sufficiently knowledgeable to deal with a patient or service user who wants to make a complaint?

• How well do we communicate the importance of receiving complaints?

• Are we transparent about the outcomes of complaints?

• Are all complaints handled equally and treated with equal respect and dignity?

• How do we reassure patients and service users that making a complaint won’t have a negative effect on their care?

• Do we rely on one person to handle complaints or can all staff be part of the

The mock CIH inspection found that some staff were not sufficiently knowledgeable about the complaints process. Training programme has been agreed for Band 5,6 and 7 Nursing staff in April 2015. Still to explore Medical staff. Literature communicates how important receiving feedback/complaints are to the Trust. Outcomes of complaints are presented as part of a Trust Board patient experience report on a quarterly basis. This information could be made public on the website. Complaints are coordinated by the central complaints team members in conjunction with clinical staff members. Complaints is reported to Patient Experience & Engagement Committee

• • •

complaint system? • Do those charged with governance have

proper oversight of complaint handling?

and in turn Quality Governance Committee and Board. From January 2015 a complaint handling questionnaire will be given to all complainants.

Process • Are we transparent about the way we are handling a specific complaint, or only about our processes in general?

• Do we acknowledge and address ‘attrition’ in complaints not taken to conclusion?

• Are our responses identifiably personal to the complainant and the specifics of their complaint?

• Do our staff have sufficient understanding of how complaints relate to safeguarding and protection systems?

• Do we place too much burden on a complainant to produce evidence, fill in forms, or write extensive amounts of detail?

• Are our staff able to go beyond process guidelines in order to solve specific problems?

Since November 2014 a complaints management plan process has been put in place whereby the complaint handling is discussed with the complainant, as well as the detail around specific concerns and questions, expectations and outcomes are agreed. The only forms a complainant may need to complete are consent forms. The complaints and PALS team strongly encourage staff to try and resolve queries and concerns as they arise, and can be in support of staff if required.

Emotion • Do we always take account of the specific needs and conditions of the patient or service user? For example, when they are feeling unwell, or have mental health issues or physical disabilities.

• Do our complaints processes take account of the emotional impact of the perception of something having gone wrong in service delivery? For example, the death of a patient or the mistreatment of a loved one?

• Are the tone and setting of our communications in keeping with the nature of the complaints being made?

• Do we avoid exacerbating possible trauma by labelling complainants and complaints with stigmatising labels such as ‘vexatious’ or ‘complex’?

The complaints and PALS teams will always take each complaint case by case and use their expertise to ensure sensitivity at all times.

• • •

Conclusion

Both reports give UHCW a clearer insight into the opportunities available to become a national leader in complaint handling in line with our vision and the aims and objectives of the together Towards World Class Experience Programme. Much work has taken place already over the last 12 months and the addition of this information is recognised as a helpful contribution to this continual cycle of improvement

Enclosure 7


Title Quality Account 2014-15 and Quality Priorities 2015-2016 Author Anita Kane, Associate Director of Quality Responsible Chief Officer


Date 29th January 2015 1. Purpose To provide the Board with a brief overview of the structure of the 2014-2015 Quality Account, high level timeline for production and suggested options for Quality Priorities for 2015-2016. 2. Background and Links to Previous Papers The Trust Board approves the Quality Priorities for the forthcoming year on an annual basis. As in previous years, the suggested priorities for 2015-16 were discussed at the Chief Officers’ Group (COG) on 12th January 2015 and the Quality Governance Committee (QGC) on 14th January 2015 before presentation to the Trust Board. 3. Narrative

The previous DH Quality Account Toolkit 2010/11 is still valid and no changes have been made to the information required in the account, which is split into four sections: 1) Statement on Quality 2) Priorities for Improvement & Statements of assurance 3) Overview of performance indicators and national priorities 4) Commentaries from Commissioners and stakeholders. A meeting of the Quality Account Task and Finish Group (a Group initiated and co-ordinated by Warwickshire County Council, which includes membership from Healthwatch Coventry and Warwickshire, Coventry City Council & Rugby Borough Council) was held on the 17 December 2014, the aim of which was to allow these stakeholders to put forward suggestions for the information that should be included. Intelligence gathered from staff following the Listening Events held as part of the Together Towards World Class programme and information obtained from complaints, incidents and other qualitative information has also been used to shape the suggested Quality Priorities for 2015/16. Following discussion at COG and QGC the following Quality Priorities for 2015/16 are recommended to the Trust Board for approval: Safety Ensuring Effective Handover Effectiveness Ensuring appropriate End of Life Care including Do Not Attempt

CPR (DNACPR) Experience Implementing ‘Always Events’

4. Areas of Risk The Trust is required to produce a Quality Account that is compliant with Department of Health guidance, part of which is the identification and inclusion of the Trust’s quality priorities for the following year. Failure to approve the priorities will delay the production of the document which could ultimately result in deadlines not being met. This will impact negatively on the Trust’s reputation and could result in breach of the Trust’s statutory duty. 5. Governance Quality Account Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011 and the National Health Service (Quality Accounts) Amendment Regulations 2012). The final Quality Account will be presented to the Trust Board for approval prior to submission and publication. 6. Responsibility Anita Kane, Associate Director of Quality Meghana Pandit, Chief Medical and Quality Officer 7. Recommendations The Board is invited to note the timeline for the production of the Quality Account 2014/15 and to agree and approve the three quality priorities for 2015/16. Name and Title of Author: Anita Kane, Associate Director of Quality Date: 15 January 2015

Page 2 of 2

Agreeing the 2015-16 Quality Account Priorities for the 2014-15 Quality Account

Purpose of a Quality Account

The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011 and the National Health Service (Quality Accounts) Amendment Regulations 2012)).

In preparing the Quality Account, directors are required to take steps to satisfy themselves that:

• the Quality Account presents a balanced picture of the Trust’s performance over the period covered;

• the performance information reported in the Quality Account is reliable and accurate;

• there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice;

• the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and

• the Quality Account has been prepared in accordance with Department of Health guidance.

The QA must include at least three priorities for quality improvement and should demonstrate how patients, staff and partner agencies have been involved in its production.

The QA is required to demonstrate how patients, staff and partner agencies have been fully engaged in the preparation process.

Structure of the Quality Account 2014/15 The Account will be structured in the following way: Part 1 Foreword from our Chief Executive Officer 2 Introduction to Quality

Overview of progress against our 2014-2015 priorities Quality Improvement Priorities for 2015-2016 Statements of Assurance from the Board (Mandatory) Performance against NHS Outcomes Framework 2014-2015 3 Overview of Organisational Quality Safety Effectiveness Experience Performance against national and local priorities 4

An invitation to comment

Page 1 of 4

Annexes Statements from Partner Agencies Director’s Statement of Responsibility External Auditor’s Limited assurance Statement Invitation to comment and offer feedback Appendices Glossary Appendix A details a high level project plan.

Publication and Audit We are required to publish the Quality Account on the NHS Choices website by 30 June, send an email version to the Secretary of State, publish on our internet site and have hard copies available. Statement of Directors Responsibilities – External Auditor requirement

As part of this process Directors are required under the Health Act 2009 to confirm to the best of their knowledge and belief that they have complied with the requirements in preparing a Quality Account. This requires a statement of Directors Responsibilities to be signed by the Chairman and CEO, to reach our External Auditors (PWC) by 30th June.

Choosing Quality Priorities for this year’s Quality Account The priorities for improvement section of the Account form the forward looking section of the report and is the Trust’s opportunity to show clearly our plans for quality improvement within the organisation and why they have been chosen. The options below have been formed from various sources, namely the focus UHCW has had around the Getting Emergency Care Right Programme as well as complaints, incidents, audits, Healthwatch, the Patients Advisor Team (formerly the patients council) , and national and regional drivers. Following presentation at Quality Governance Committee on the 12 January and the Chief Officers Group on the 14th January the recommended options are highlighted in Green Patient Safety Rationale Improving the process around DNACPR

Highlighted in the CQC Mock Inspection, Grand Round with clinical staff, increasing number of CAES, appearing more frequently in Complaints.

Improving the reporting of Medicines Incidents

Medicines Management Committee, and through the QPS dashboards, highlight Medication errors as an issue in the Trust. Impacts on Safety for patients. Healthwatch priority stated in a meeting of the QA Task and finish Group 17/12/14

Ensuring Effective Handover A 2014-15 Priority this is currently behind schedule. Effective handover still cited in CAEs, mortality reviews and PALS queries.

Clinical Effectiveness Rationale Care Bundle Compliance Improving Care bundle compliance as a means of

identifying quality of care by demonstrating evidence of the use of interventions which prevent avoidable mortality and morbidity, and as a systematic method of measuring and improving clinical care processes.

Page 2 of 4

End of life care and the implementation of the Amber Care Bundle

The Trust recognises this important area and the contribution of the supportive care team. Since the introduction of Transform there have been identified QA Task and Finish group proposed priority 17/12/14

7 day working across UHCW Patients need the NHS every day. Evidence shows that the limited availability of some hospital services at weekends can have a detrimental impact on outcomes for patients, including raising the risk of mortality QA Task and Finish group proposed priority 17/12/14

Patient/Staff Experience Rationale Support for Carers UHCW are implementing a Carers pass with further work

ongoing to support carers in the hospital setting Healthwatch priority stated in a meeting of the QA Task and finish Group 17/12/14

Introducing Always Events Always events are events that should always happen for patients. The concept is from the Picker Institute and the IHI adopted it as good practice for healthcare organisations. Aligns with the aspirations of TTWC

Enhancing PALS and the complaints services

Numerous recommendations and reports concerning complaints handling and culture since Oct 2013. Opportunity to publicise the enhancements. Healthwatch priority stated in a meeting of the QA Task and finish Group 17/12/14

Page 3 of 4

Appendix A - Project Plan to deliver the QA by the required timescale Activity Person

Responsible Oct Nov Dec Jan Feb Mar Apr May Jun

Review and prepare 2014-15 Template and implementation plan for QGC

A Kane

Prepare progress against 14-15 priorities Priority Leads Gather intelligence to develop long list of priorities for 14-15 QA

Quality Team

Agree tentative timetable with Partners A Kane Finalise list of Quality priorities to go to COG prior to January QGC and Board.

A Kane

COG and QGC receive priority paper A Kane Board agree Quality priorities Board Agree Annexes and Supplements if required Quality 1st Draft of the QA prepared A Kane Approved QGC Draft circulated to partners for comment Quality Dept Rep Deadline for all comments to be included in QA Quality Dept Rep Send all documents to the printers Quality Dept Rep Board Approval of QA Director of

Corporate Affairs

Publication of QA Communications

Page 4 of 4

Enclosure 8


Title Winter Plan and Emergency Care Pathway Update Authors David Eltringham, Chief Operating Officer

Alan Cranfield, Deputy Chief Operating Officer – Medicine Mark Kemp, Deputy Chief Operating Officer - Surgery

Responsible Chief Officer

David Eltringham, Chief Operating Officer

Date 29 January 2015 1. Purpose The purpose of this paper is to provide an overview of the Trusts performance against the 95% Emergency Department (ED) standard, set out the trajectory going forward and outline those activities within the Winter Plan that are being pursued to improve the Trust’s position. The National Waiting Time Standard for ED is set by the Department of Health (DH) and features in the Trust Development Authority (TDA) and NHS England Accountability Framework. It measures the percentage of A&E attendances where the patient spends four hours or less in A&E from arrival to transfer, admission or discharge, for which the target is 95%.

2. Background • The Trust’s ED Performance is presently below the 95% national standard. • The Trust last achieved the standard in April 2014 (95.6%) and has gradually

deteriorated in its position since then. Table 1

Month % April 2014 95.6 May 2014 94.2 June 2014 93 July 2014 92.9

August 2014 93.1 September 2014 91.5

October 2014 91.5 November 2014 90.5 December 2014 87

• Year to date performance stands at 91.59% and it is not mathematically possible

to hit the target for the full year. • The Trust takes its performance very seriously and has agreed actions to improve

its performance with the Coventry & Rugby Clinical Commissioning Group (CCG) and the TDA. These include:

Table 2

Improved management of patients outlying on wards not directly related to their condition (so called ‘outliers’) Review and revision of the Acute Assessment processes. Improved access to discharge medications (TTO’s). Increased use of the discharge lounge to release beds earlier in the day. Improved clinical processes & standards (access to imaging etc.) Community partnership engagement (e.g. Home First). Clinical leadership and engagement. Admissions avoidance where ever it is practicable to do so through use of alternative pathways and Ambulatory/Hot Clinic provision. Bed reconfiguration (gerontology and acute frailty unit). Improved access to patient transport. • These actions have been set against a recovery trajectory and after a significantly

difficult performance period, the Trust remains committed to the agreed actions and is constantly reviewing its approach to improvements in this regard.

• Getting Emergency Care Right focussed Trust staff, on internal ownership of the Emergency Care Pathway through the creation of 25 safety standards, a set of principles to apply to each patient (FREED metrics), and a campaign to make sure that every member of staff understands the importance of timely, effective emergency care.

3. What does the data tell us? A suite of data is provided at Appendix 1 and sets out • Attendance patterns to ED (all types and Type 1) for the last 24 months • Conversion to admission from ED ( all types and Type 1) for the last 24 months • Ambulance conveyances to ED (last 24 months) • Discharge profile – last 24 months • Delayed Transfers of Care – last 24 months • Age profile – attendances/admissions >65 years – last 24 months • Outliers from base ward Our analysis of the data shows • An increase in attendances to ED in March 2014, sustained to this point in time

but no longer rising. • An associated rise in admissions, with the percentage conversion rate broadly

holding stable. • An increase in ambulance conveyances and an increase (in recent weeks) of >65

year old attendances/admissions which would imply an increase in frailty dependency, complexity and acuity.

• A steady decline in discharges over time (both simple and complex) although year on year comparisons indicate higher levels of discharge this year than last.

• A significant rise in Delayed Transfers of Care (DTOC).

Page 2 of 12

• A significant rise in patients outlying their base-ward. The table below provides a direct year on year comparison Table 3

Whilst the focus of this paper is Emergency Care Pathway performance, the Trust Board will be aware of the impact that a struggling Emergency Care Pathway has on:

• Admitted Referral To Treatment (RTT) performance • 62 Day Cancer Indicators • Cancelled Operations

The RTT position is summarised in table 4 below Table 4 December 2014 fast track report

The Trust position is such that the size of the elective backlog will now require a prolonged period of admitted target failure to reduce the backlog to an acceptable level ahead of next winter.

Internal analysis of the problem can be summarised as:

• An increase in attendances to ED • Resulting in an increase in admissions to the hospital • Particularly in the over 65 years age group and suggesting a greater

complexity, frailty, dependency and activity of patients. • A reduction in the number of discharges being made from the hospital • A rise in Delayed Transfers of Care

4. Actions to deal with the problem

The over-arching strategy required to manage this situation is three fold:

1. Reduce emergency admissions

Page 3 of 12

2. Improve flow within the capacity available to the hospital 3. Increase discharges

A number of examples of specific projects/continuing workstreams which focus on the delivery of this strategy follow =

Creation of an extended Acute Medical Unit footprint incorporating a

Frail Elderly Assessment Unit, GP Assessment Unit and Ambulatory Care Facilities(Phase 1 by 01.02.2015 and the remaining phases by April 2015.

This will:

- Reduce the number of admissions to the hospital by improving the efficiency of the assessment process

- Direct elderly patients away from admission - Improve access and utilisation of Ambulation Emergency Care/Hot Clinics - Reduce congestion in ED

This model requires significant support from partners across the health economy as pathways out of the hospital are required to prevent admission.

Introduction of Primary Care into or adjacent to ED by 31.03.2015 This will:

- Reduce the number of patients with primary care issues in ED. - Reduce total congestion in ED. - Improve relationships/intraoperative waiting between GP’s ED and the hospital at

large. - Create a platform for further work to improve Urgent and Emergency care in

Coventry and Warwickshire. This may not have a dramatic effect on 4-hour performance as patients on this pathway are likely to be those currently seen on the high performing minors pathway. Different models need to be tested to assess maximum effect.

Improve simple discharge planning and delivery

- Continuing with GECR initiatives and campaign - the Chief Nursing Officer (CNO) and Chief Medical Officer (CMO) have been leading roadshows and conversations across the organisation to do this

- Promoting Board Rounds and Ward Rounds and testing consistency and quality through Peer Review

- Daily case management of delays - Developing “Home First” which is an initiative that seeks to provide community

support in the home or normal place of residence to those patients who require it, rather than transferring them to another care provider (e.g. nursing home, or home with care) as an interim or permanent solution. It relies on more intensive therapy and nursing support during the period of hospital admission.

Page 4 of 12

Continued pursuit of tactical solutions for example

- Command and Control arrangements - Utilisation of contingency capacity - Daily review of cancellations - Visible leadership and communications - Patient stories and staff stories - Simple discharge planning and early TTO’s - Matching staffing to demand

Dealing with Delayed Transfers of Care – The Trust has attended

regional escalation meetings associated in particular with Delayed Transfers of Care.

A recovery trajectory has been agreed by the System Resilience Group (SRG) on behalf of the Health Economy and is set out in Appendix 2. Performance against the trajectory is currently off track and is the subject of weekly review by the SRG. The summary position with delays as of Friday 16th January 2015 was:

• Total number of patients fit to go and awaiting package = 123 • Total number of patients in formal DTOC = 77

A real time update will be available at the Board meeting. Partner organisations are unable to provide the capacity to meet this need. This is the primary focus of the SRG and escalation meetings with regulators. 5. Winter Monies

Historically, Trusts have created winter plans against a known increase in activity over that period, in actual fact; this level of activity is now a year round phenomenon. In April 2014 the Trust approved a proposal to invest £8.4m substantively to manage emergency pressures on the basis that £3.2m would be available through winter funding allocations later in the year. In fact, £5.8m of winter resilience funding has been made available across the local health economy in 2 tranches, of which, UHCW received £4.65m. This funding against the UHCW Winter Plan has funded enhanced staffing across the emergency pathways as follows:

• Increased staffing across the ED with specific emphasis on known times of peak activity.

• Increase of clinicians across the busy area of Acute Medicine, with particular emphasis on evening and night times.

Page 5 of 12

• Improved nursing presence within the major assessment areas to cope with the increased demand.

• Provision of additional nursing support to the base wards areas. • Provision of an increase in doctors to support those patients who were not

accommodated in the specialist ward commensurate with their condition. • To accommodate the additional workload it was necessary to bolster the

clinical support areas such as Imaging, Therapy and REACT. • The use of Medihome as a ‘virtual ward’ to allow patients to go home and

continue their treatment whilst remaining under the care of the hospital consultant has provided an increase in capacity to the hospital of 30 beds.

The breakdown of that staffing expenditure by department is reflected in Table 5 below: Table 5

Area of Expenditure Actual

Expenditure

External Winter

Funding

1 - Emergency Department 1,893,736

363,237

2 - Acute Medicine 2,636,805

232,695

2 - Acute Assessment Areas 517,373

384,102

3 - Base Wards 1,919,179

868,167

4 - Outliers Teams 4,206,215

640,758

5 - Clinical Support 725,020

270,975

6 – Medihome/Premium Costs 1,784,093

1,890,066

Grand Total 13,682,421

4,650,000 There is a clear increase of £5.3M to (£13,682,421) against the original planned expenditure of £8.4M and this is driven by:

• Creation of additional beds (Medihome), which was not in the original plan - £1.9m

• Premium costs incurred in staffing the above posts whilst they are substantively recruited to - £3.4m.

In summary, the total cost was £13,682,421 of which £4,650,000 was provided through winter resilience funding. 6. Risks

1. Clinical risk to patients – Patients waiting for extended periods of time may have a poor care experience.

Page 6 of 12

This risk is mitigated by constant surveillance of patients waiting in the Emergency Department and the provision of additional staff to ensure that this surveillance can be provided.

2. Reputation – Regulations, staff, patients and communities may form a poor view of the service offered by UHCW. This risk is mitigated by constant efforts to manage pressure, rapid response to specific feedback/complaints, communication strategies which keep all stakeholders informed of waiting times, actions to address issues, and through regular briefings to regulators and staff.

3. Performance – Poor performance is currently being reported against the ED/Four Hour standard, RTT Standards and Cancer Standards. This is an active risk at this time. This paper sets out actions to mitigate the performance risks in the Emergency Care Pathway which will then result in improvements against other core standards.

6. Recommendations The Trust Board is asked to NOTE:

1. The current performance and the revised recovery trajectory. 2. The impact upon other standards e.g. RTT. 3. The underlying causes as demonstrated by the analysis and the necessary

multifactorial response. 4. The range of measures in place aimed at reducing admissions, improving

flow and increasing elective admissions. And 5. Discuss and agree upon further reporting arrangements and/or additional

action that can be taken.

Page 7 of 12

Appendix 1

Page 8 of 12

15/01/2015

Area Scheme(s) Action Rationale Lead Clinical Lead Start dates End date Progress RAG Key Performance indicator Evaluation Recovery

Trajectory Identified risks & Mitigation

Prescribing Hub

Implementation of a prescribing hub with 2 practices with a roll out if successful

Empower patients to take responsibility of ordering their own repeat prescriptions in a timely manner reducing the need to A&E for repeats Altaz Dhanani (CCG) Mark Galloway

(CCG) 01/02/15 ongoing Green Reduction in A&E Attendances Review monthly Attendances

Poor patient uptake, equipment and IT link not working correctly with practices , managing peak and toughs of demand, staffing. Better promotion , IT on site during implementation , back up staff available from MM team

Extra GP slotsProvide additional appointments for frequent flyers to A&E

Reduction in number of frequent flyers to A&E Michelle Horn (CCG) Surinder Chaggar (CCG) 08/01/15 ongoing Amber Reduction in

frequent flyers Monthly Attendances GP practices do not carry out the reviews with the FF patients.GP practice to produce reports on patients seen monthly

Implement falls pathway across Coventry & Rugby

999/NHS111 receive 700 calls per month relating to Falls, of which 350 patients are conveyed to ED per month, this equates to on average 12 patients per day of which between 5/6 patients have been identified that could follow a different pathway in the community.

Gary Empsall (CCG) Ed Hartley (UHCW) 01/12/14 ongoing AmberReduction of 5

ambulance conveyances/day

Initially daily (until 10/12/14) then

weeklyAttendances WMAS not following the pathway when the correct patients are identified.

Escalated to WMAS management team to promote service with the teams

Implementation of abnormal blood tests

Introduction of Ambulatory Care pathway to prevent up to 10 A&E attendances/day for those with abnormal blood tests

Veronica Ford (CWPT) Ed Hartley (UHCW) 05/01/15 ongoing Amber Reduction in 5

attendances/day weekly Attendances

Pathway not sign off by CWPT panel and access to ambulatory care slots OOH's and process to confirm patient attendance. Policy to be presented to the next panel by member of the team and appointment process to be developed for sign off by end of January

Implement UTI pathway across Coventry & Rugby Reduction of 2/3 attendances/admissions per day Gary Empsall (CCG) Ed Hartley (UHCW) 05/01/15 ongoing Amber Reduction of 2 amb

conveyances/dayTbc (as a result of first pathway) Attendances

Implement respiratory pathway across Coventry & Rugby

Reduction of 2/3 attendances/admissions per day Gary Empsall (CCG) Ed Hartley (UHCW) 02/02/15 ongoing Amber Reduction of 2 amb conveyances/day

Tbc (as a result of first pathway) Attendances

Developing service specification for up scaling the primary care assessment model

Maximise opportunities for genuine alternatives to A&E through improved use of ambulatory care, hot clinics and technology Sue Davies (CCG) Surinder Chaggar

(CCG) 13/01/15 tbc (dependent on procurement route) Amber Reduction in NE

admissions tbc Workshop carried out 13/1/15 , next steps meeting planned 23/1/15

HH2 (Communication)

Cascade of key messages via all providers, LA, GP practices using a variety of methods to raise awareness of alternatives to A&E i.e. use of NHS111

Prioritise, profile & plan communications & behavioural interventions for quick wins & key patient groups to help manage demand for A&E in terms of mild cases Rob Fontane (CCG) Peter O'Brien

(CCG) 01/12/14 ongoing Green Reduction in 2 attendances/day Monthly Attendances Campaign on going

Mental Health Street Triage

Implementation of service in partnership with CWPT & Police

Reduction in number of A&E Attendances for people with mental health issues - 1 attendance/day

Josie Spencer (CWPT)

Vicky Hancock (CWPT 01/12/14 ongoing Green Reduction in 1

attendance/day Monthly Attendances Triage service not called to the correct incidents.Regular reviews carried out and feedback to front line given

Been in place since March 14 - recently visited all homes to ensure maximise the care home usage of the service

Providing clinical advise & support to 15 care homes in Coventry & Rugby to help reduce avoidable hospital admissions Rob Fontane (CCG) Gerry Horn (CCG) 01/03/14 ongoing Amber Reduction in

admissions Monthly

Care homes not using the equipment for advice before calling the emergency services. Promotion visits carried out to care homes to promote the benefits - clinical audit on admissions from those homes using service to assess whether could have been avoided

To extend to the Local Authority first responder service

Provide immediate clinical support to responder services to avoid 999 call out Rob Fontane (CCG) Gerry Horn (CCG) 01/02/15 ongoing AmberReduction in A&E Attendances/amb

conveyancesMonthly Admission Training of responders not carried out to timescales.

Provider given deadlines for delivery of training.

Hydration Strategy

Additional education & support to care homes to prevent infection related admissions to hospital i.e. Norovirus

Provision of education & support in relation to hydration & infection control to avoid Noro Virus/D&V hospital admission & early supportive discharge for those requiring admission Sharon Stuart (CCG) Sharon Stuart

(CCG) 01/12/14 ongoing GreenReduction 2/week infection related

admissionsMonthly Admission

AMU reconfiguration strategy implementation*

Reconfigure bed base for acute medicineRedesign pathway for GP referrals out of EDImprove patient care and reduce overcrowding in EDIntroduce Frail Elderly Assessment Unit

Jon Barnes(UHCW)

Dr Tim Peterson Helen Pickard

(UHCW)11/12/14 Phase 1

01/02/2015 Amber Reduction in 2 NE Admissions/day weekly Admission

The key risks to this development are around the relocation of the discharge lounge and the gym and the introduction of a dedicated frail elderly unit into the acute medicine footprint.

Simple Discharge

Improve known delays:TTO's prescriptionTransportuse of discharge facility etc.

Alan Cranfield(Lorraine Owen) Dr Murthy 27/11/14

will be ongoing, but good progress by 31-

1-15Amber Improved flow weekly

* Engagement and acceptance of the principles are key.* Link with Project 21 below.

Internal standardsImprove and document processes and standards for:Referral responsesDiagnostics etc.

Mark Kemp(UHCW)

Dr Lydia Fresco (UHCW) 27/11/14

will be ongoing, but good progress by 31-

1-15Amber Improved flow weekly

Escalation policyReview and re-write the Trust escalation policyInclude mutual aid from partners

TBC(Fiona Wade)

(UHCW)

Dr Duncan Watson (UHCW) 27/11/14 31 January 2015 Amber Improved response

to poor flow weekly

Re-invigorate GECR including 'Perfect Week'

Plan for a 'Perfect Week' with support from ECISTRe-launch GECRIntroduce Peer review process to support continues improvement TBC TBC 15/12/14

GECR ongoingaim for 'Perfect

Week' beginning February 15

Greenreset system and

form platform to re-invigorate GECR

weekly

* Keeping the principles of GECR in focus and profile is key.

Urgent Care Centre on UHCW site / GP in ED

Evaluate cost benefit of UCC on UHCW site

Alan Cranfield(TBC)

Dr Jim Davidson (UHCW) 15/12/14 TBC Green Reduce ED

attendances weekly

* Identify funding provision* Take up of/transfer to the Service - Communication plan* GP take up to provide - Statistically identify patient population to determine throughput.* GP taking advantage of easy access to 'testing'.* Identification of appropriate accommodation for phase 2.* Identification of support and equipment resource for phase 2. Additional funding requirement?

Introduce Frail Elderly Assessment model *(linked to AMU)

as above

Alan Cranfield (UHCW)

Dr Nick Balcombe (UHCW)

Steve Allen (CRCCG)

15/12/14 TBC Amber Improve flow through ED weekly Discharge

* Delay of introduction through competing priorities with AMU reconfiguration.* Delayed introduction because of nurse staffing deficiencies associated with inability to recruit gerontology nurses in a timely manner.* Ability of community to cope with additional demand of patients being turned-around/discharged more quickly.

Gerontology Bed reconfiguratIncrease Gerontology bed baseImprove patient careReduce outliers


Nick Balcombe (UHCW) 31 January 2015 Green

reduction in Outliers/ improved

patient careweekly Discharge

* Risk surrounds the nursing establishment to properly configure and man wards.* Risk around the permanent temporary staff mix to allow project to go live.

Improving Patient Flow, ED 4-hour Performance & DTOC

Ownership: David Eltringham; UHCW

Josie Spensor; CWPTDavid Watts; CCC

Sue Davies; CRCCG

Prim

ary

Car

ePr

e-H

ospi

tal

Hothouse 2 (pathways)

Car

e H

omes

Immedicare (video link to clinical hub)

ospi

tal F

low

A&E Recovery Plan

Integration of hospital health & social care discharge teams, introduction of single notification for complex discharges

Increase in simple discharges & reduction in DTOC through integration of discharge teams

Sue Davies (CCG)Alan Cranfield

(UHCW)David Watts (CCC)

Dr Nick Balcombe (UHCW)

Steve Allen (CRCCG)

17/11/14 Ongoing Green Increase no. of simple discharges Weekly Discharge

Single Brokerage to improve access to community services

Increase in number of simple & complex discharges by 7/week Sue Davies (CCG)David Watts (CCC) n/a 05/01/15 Amber

Increase in discharges by

2/dayDischarge

Engagement with ward staff and clinicians to promote Home First

Improved discharge planning from point of admissions to help increase number of daily discharges

Alan Cranfield (Lynn Thomas)

(UHCW)

Kerrie Manning(UHCW) 17/11/14 Amber Increase in simple

daily discharges Discharge

Provide detail on funding requirements for increased capacity for Home First to cover weekends

Increase in simple discharges & reduction in DTOC through integration of discharge teamsDavid Watts (CCC)


n/a 28/11/14 15 December 2014 Amber Reduction in DTOC of 2/week weekly DTOC

First Choice Process to be developed and Implemented

Improve the process for those individuals waiting for first choice to ensure they are discharged appropriately to alternative accommodation and not delayed in hospital Sarah Hall (UHCW) n/a 05/01/15 Amber Reduction in

DTOC of 2 /week weekly DTOC

Improve links with SWFT Community services to ensure timely discharges for Warwickshire Residents

Increase in simple discharges & reduction in DTOC through integration of discharge teams Bie Grobet (SWFT) Bie Grobet (SWFT) 01/12/14 tba Amber Additional 5 discharges/week Discharge

Poor uptake of the scheme by the hospital Better communication channels developed to ensure closer working from GPs and health and care professionals in the community.

Increase in Home care hours by 100hrs/week (Sevacare & Care UK)

Reduce number of DTOC waiting for short term support David Watts (CCC) 15/12/14 31 March 2015 Amber Reduction in DTOC by 2/week DTOC

Care Agencies having difficulty recruiting staff to maintain level of capacity. To share applicants from CWPT recruitment (project 31) who suitable but not successful with care agencies

Early Supportive Discharge

Increased capacity of the Community Neuro-rehabilitation Team (CNRT)

Increase no. of discharges from hospital by 7/week Tina Hennessy (CWPT) Gavin Farrell 01/12/14 31st March 3015 Green additional 7

discharges/week Weekly Discharge

Revision of current pathways Improved flow through short community capacity to improve access to short term support & maximise capacity

Sue Davies (CCG)David Watts (CCC) 24/11/14 Amber Reduction in

DTOC DTOC

Use of resilience money to increase social worker input - relook at whether need additional monies over & above current allocation (including therapy/nursing etc. & Age UK Practically Home service))

Ensure flow & reduce delays within short term services/CWPT DTOC, moving people on to longer term support.

Josie Spencer (CWPT)

David Watts (CCC)n/a 28/11/14 On going review Amber Reduction in

DTOC by 2/week DTOC

Additional fund may well be needed above the current allocation to ensure the correct manpower is allocated to the scheme once the recruitment process has been completed. (including therapy/nursing etc. & Age UK ) Recruitment day on 15th Jan to recruit HCA's then a review of numbers will be carried out.

CWPT to recruit support workers to increase short term support packages

Increase no. of discharges from hospital by 5/week Veronica Ford (CWPT) N/A 01/03/15 Amber Reduction in

DTOC weekly inability to recruit sufficient Support Workers with the flexibility required to cover 24/7Recruitment day planned

DTOC Audit Complete clinical audit of current DTOC

Better understand what is driving the increase in DTOC and assess need to retarget resources if necessary

Steve Allen (CRCCG)

Steve Allen (CRCCG) 03/12/14 05 December 2014 green

Recovery Plan Escalation

Senior weekly teleconference/face to face meetings in place (inc UHCW/CCG/CWPT/CCC/WCC/SWFT)

To monitor performance and resolve issues & blockages to ensure recovery plan is implemented to deliver improved performance

David Eltringham (UHCW)

Steve Allen (CRCCG) 04/12/14 green All Weekly

RAG key Green Action On Track

Amber Action On Track but some risk

Mon

itorin

gH

o

Home First, Supportive Discharge (Phase 1)

Com

mun

ity F

low

Home First (phase 2) short term support

DTOC Target Trajectory: 2014/15

Predicted weekly values are calculated using a mean average of Discharges in the rolling 6 weeks prior to the week in question.

Action List 06/0

4/20

14

13/0

4/20

14

20/0

4/20

14

27/0

4/20

14

04/0

5/20

14

11/0

5/20

14

18/0

5/20

14

25/0

5/20

14

01/0

6/20

14

08/0

6/20

14

15/0

6/20

14

22/0

6/20

14

29/0

6/20

14

06/0

7/20

14

13/0

7/20

14

20/0

7/20

14

27/0

7/20

14

03/0

8/20

14

10/0

8/20

14

17/0

8/20

14

24/0

8/20

14

31/0

8/20

14

07/0

9/20

14

14/0

9/20

14

21/0

9/20

14

28/0

9/20

14

05/1

0/20

14

12/1

0/20

14

19/1

0/20

14

26/1

0/20

14

02/1

1/20

14

09/1

1/20

14

16/1

1/20

14

23/1

1/20

14

30/1

1/20

14

07/1

2/20

14

14/1

2/20

14

21/1

2/20

14

28/1

2/20

14

04/0

1/20

15

11/0

1/20

15

18/0

1/20

15

25/0

1/20

15

01/0

2/20

15

08/0

2/20

15

15/0

2/20

15

22/0

2/20

15

01/0

3/20

15

08/0

3/20

15

15/0

3/20

15

22/0

3/20

15

29/0

3/20

15

Increased SW & OT capacity to improve community flow 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 5 5 5 5 5 5 5 5 5 5 5 5Single Brokerage to improve access to community services 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 7 7 7 7 7 7 7 7 7 7 7 7Increase in home care hours by 100hr/week 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2Addiitonal SW and OT capacity in community 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 8 8 8 8 8 8 8 8 8 8 8 8CWPT Recruitment of support workers to increase short term support packages

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Action 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -22 -22 -22 -22 -22 -22 -22 -22 -22 -22 -22 -22 -22% Of which affect DTOC 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 50% 75% 75% 50% 25% 25% 13% 13% 10% 5% 5% 5% 5%Total Action Impact 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -11 -16.5 -16.5 -11 -5.5 -5.5 -2.75 -2.75 -2.2 -1.1 -1.1 -1.1 -1.1

Target 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35Total Predicted 44 35 43 33 56 41 40 33 35 51 48 55 59 66 61 54 52 62 52 64 68 52 47 67 66 79 74 60 80 75 76 86 74 80 90 76 86 83 78 77 72 94 101 96 106 104 127 106 117 104 97 102

Total Predicted Trajectory (After Actions) 44 35 43 33 56 41 40 33 35 51 48 55 59 66 61 54 52 62 52 64 68 52 47 67 66 79 74 60 80 75 76 86 74 80 90 76 86 83 78 66 45 43 35 27 25 22 24 18 18 15 13 13Total DTOC Actual 44 35 43 33 56 41 40 33 35 51 48 55 59 66 61 54 52 62 52 64 68 52 47 67 66 79 74 60 80 75 76 86 74 80 90 76 #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/AUH Predicted 44 43 43 43 41 41 34 34 34 34 33 35 36 38 40 44 45 48 42 43 40 42 40 40 39 39 43 45 48 49 49 49 50 49 54 52 55 45 46 45 44 45 44 43 42 41 44 43 43 40 41 39UH Actual 33 24 36 29 40 31 33 25 28 43 40 46 48 58 51 42 31 42 37 44 48 36 34 52 48 60 60 49 57 56 67 66 66 65 71 64 #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/ASt Cross Predicted 10 10 11 10 10 11 11 9 9 9 10 10 8 9 10 9 9 10 11 13 14 17 16 17 17 17 15 14 13 15 15 15 15 15 15 13 14 14 12 12 12 12 12 11 12 12 12 10 11 13 11 13St Cross Actual 11 11 7 4 16 10 7 8 7 8 8 9 11 8 10 12 21 20 15 20 20 16 13 15 18 19 14 11 23 19 9 20 8 15 19 12 #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A2 year average (Trust) 42 44 55 55 46 45 51 48 47 48 50 57 51 53 50 47 45 54 42 49 49 62 48 53 54 50 53 51 50 49 43 41 47 36 44 35 40 38 36 36 33 44 47 44 49 48 59 49 54 48 45 47

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Actio

n Zo

neD

TOCs

0

20

40

60

80

100

120

140

06/0

4/20

14

13/0

4/20

14

20/0

4/20

14

27/0

4/20

14

04/0

5/20

14

11/0

5/20

14

18/0

5/20

14

25/0

5/20

14

01/0

6/20

14

08/0

6/20

14

15/0

6/20

14

22/0

6/20

14

29/0

6/20

14

06/0

7/20

14

13/0

7/20

14

20/0

7/20

14

27/0

7/20

14

03/0

8/20

14

10/0

8/20

14

17/0

8/20

14

24/0

8/20

14

31/0

8/20

14

07/0

9/20

14

14/0

9/20

14

21/0

9/20

14

28/0

9/20

14

05/1

0/20

14

12/1

0/20

14

19/1

0/20

14

26/1

0/20

14

02/1

1/20

14

09/1

1/20

14

16/1

1/20

14

23/1

1/20

14

30/1

1/20

14

07/1

2/20

14

14/1

2/20

14

21/1

2/20

14

28/1

2/20

14

04/0

1/20

15

11/0

1/20

15

18/0

1/20

15

25/0

1/20

15

01/0

2/20

15

08/0

2/20

15

15/0

2/20

15

22/0

2/20

15

01/0

3/20

15

08/0

3/20

15

15/0

3/20

15

22/0

3/20

15

29/0

3/20

15

Num

ber o

f DTO

Cs

Week

Weekly DTOC Performance Trajectory

Trajectory (With Actions) Predicted (No Actions) Actual Target 2 year average

A&E 4hr Performance Target Trajectory: 2014/15

Predicted weekly values for type 1 facilities are calculated using a mean average of breaches and attendances in the same week in 12/13, the same week in 13/14 and the rolling 6 weeks predictions prior to the week in question. This means it is weighted 6/8th's to current year and 2/8th to previous performance.

Action List 06/0

4/20

14

13/0

4/20

14

20/0

4/20

14

27/0

4/20

14

04/0

5/20

14

11/0

5/20

14

18/0

5/20

14

25/0

5/20

14

01/0

6/20

14

08/0

6/20

14

15/0

6/20

14

22/0

6/20

14

29/0

6/20

14

06/0

7/20

14

13/0

7/20

14

20/0

7/20

14

27/0

7/20

14

03/0

8/20

14

10/0

8/20

14

17/0

8/20

14

24/0

8/20

14

31/0

8/20

14

07/0

9/20

14

14/0

9/20

14

21/0

9/20

14

28/0

9/20

14

05/1

0/20

14

12/1

0/20

14

19/1

0/20

14

26/1

0/20

14

02/1

1/20

14

09/1

1/20

14

16/1

1/20

14

23/1

1/20

14

30/1

1/20

14

07/1

2/20

14

14/1

2/20

14

21/1

2/20

14

28/1

2/20

14

04/0

1/20

15

11/0

1/20

15

18/0

1/20

15

25/0

1/20

15

01/0

2/20

15

08/0

2/20

15

15/0

2/20

15

22/0

2/20

15

01/0

3/20

15

08/0

3/20

15

15/0

3/20

15

22/0

3/20

15

29/0

3/20

15

Improved management of Outliers 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.00% 0.10% 0.10% 0.20% 0.30% 0.40% 0.50% 0.50% 0.50% 0.60% 0.60% 0.60% 0.60% 0.60% 0.60% 0.60% 0.60% 0.60%Review and revision of Acute Assessment processes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.00% 0.00% 0.00% 0.00% 0.05% 0.10% 0.10% 0.20% 0.20% 0.25% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20% 0.20%Improved access to TTO’s 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.10% 0.20% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30%Increased use of discharge lounge (timely access to beds) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.10% 0.10% 0.20% 0.30% 0.40% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50%Improved clinical processes & standards (access to imaging etc) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.10% 0.20% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30% 0.30%Partnership engagement (e.g.Home First) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.10% 0.20% 0.30% 0.40% 0.50% 0.60% 0.70% 0.80% 0.90% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00%Clinical leadership and engagement 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.10% 0.20% 0.30% 0.40% 0.50% 0.60% 0.70% 0.80% 0.90% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00%Admissions avoidance 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.10% 0.20% 0.30% 0.40% 0.50% 0.60% 0.70% 0.80% 0.90% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00%Bed reconfiguration (Gerentology and acute frailty unit) 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.10% 0.10% 0.20% 0.30% 0.40% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50% 0.50%Improved access to internal patient transport 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.05% 0.10% 0.15% 0.20% 0.20% 0.20% 0.25% 0.30% 0.35% 0.35% 0.35% 0.35% 0.35% 0.35% 0.35% 0.35% 0.35% 0.35%Total Action Impact 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.7% 1.2% 1.9% 2.5% 3.2% 3.8% 4.4% 4.9% 5.4% 5.8% 5.8% 5.8% 5.8% 5.8% 5.8% 5.8% 5.8% 5.8%

Type 1 95% Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%Type 1 Predicted 94.3% 92.7% 96.6% 93.6% 91.3% 94.0% 93.2% 91.3% 91.7% 90.1% 88.7% 89.7% 94.3% 87.8% 94.2% 90.9% 88.9% 91.1% 93.8% 94.4% 94.9% 80.4% 87.5% 98.5% 87.7% 81.9% 86.7% 87.2% 83.4% 92.3% 94.6% 90.4% 90.6% 87.4% 82.2% 89.9% 88.5% 88.3% 88.6% 87.2% 87.7% 88.5% 88.4% 87.3% 87.2% 87.8% 89.0% 87.2% 87.1% 86.2% 86.5% 87.8%Type 1 Trajectory (After Actions) 94.3% 92.7% 96.6% 93.6% 91.3% 94.0% 93.2% 91.3% 91.7% 90.1% 88.7% 89.7% 94.3% 87.8% 94.2% 90.9% 88.9% 91.1% 93.8% 94.4% 94.9% 80.4% 87.5% 98.5% 87.7% 81.9% 86.7% 87.2% 83.4% 92.3% 94.6% 90.4% 90.6% 87.4% 82.8% 91.1% 90.3% 90.8% 91.7% 91.0% 92.1% 93.4% 93.7% 93.1% 93.0% 93.5% 94.8% 92.9% 92.8% 91.9% 92.3% 93.6%Type 1 Actual 94.3% 92.7% 96.6% 93.6% 91.3% 94.0% 93.2% 91.3% 91.7% 90.1% 88.7% 89.7% 94.3% 87.8% 94.2% 90.9% 88.9% 91.1% 93.8% 94.4% 94.9% 80.4% 87.5% 98.5% 87.7% 81.9% 86.7% 87.2% 83.4% 92.3% 94.6% 90.4% 90.6% 87.4% 82.2% 83.5% 84.9% 78.6% 86.4% 75.3% 74.3% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/AType 2/3 Predicted 99.3% 99.4% 99.6% 99.6% 99.8% 99.4% 99.6% 100.0% 99.9% 99.9% 98.7% 99.5% 99.8% 99.6% 99.7% 99.4% 99.7% 99.2% 99.2% 99.9% 99.9% 99.7% 100.0% 99.9% 99.6% 99.6% 99.7% 99.6% 99.6% 99.6% 99.6% 99.6% 99.4% 99.6% 99.6% 99.6% 99.6% 99.4% 99.6% 99.5% 99.6% 99.5% 99.6% 99.5% 99.5% 99.5% 99.4% 99.3% 99.1% 99.2% 99.0% 99.1%Type 2/3 Actual 99.3% 99.4% 99.6% 99.6% 99.8% 99.4% 99.6% 100.0% 99.9% 99.9% 98.7% 99.5% 99.8% 99.6% 99.7% 99.4% 99.7% 99.2% 99.2% 99.9% 99.9% 99.7% 100.0% 99.9% 99.6% 99.6% 99.8% 99.9% 99.9% 99.5% 99.7% 99.5% 99.9% 100.0% 100.0% 99.8% 99.3% 99.8% 99.9% 99.3% 99.9% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/ATotal A&E 95% Target 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%Total A&E Predicted 95.6% 94.5% 97.4% 95.1% 93.4% 95.4% 94.8% 93.5% 93.8% 92.7% 91.4% 92.3% 95.7% 90.8% 95.7% 93.1% 91.6% 93.3% 95.2% 95.9% 96.2% 85.0% 90.5% 98.9% 90.8% 85.9% 89.9% 90.3% 87.4% 94.2% 95.8% 92.7% 92.8% 90.3% 86.3% 92.3% 91.2% 91.1% 91.3% 90.3% 90.7% 91.3% 91.2% 90.4% 90.4% 90.8% 91.7% 90.3% 90.2% 89.6% 89.8% 90.8%Total A&E Trajectory (After Actions) 95.6% 94.5% 97.4% 95.1% 93.4% 95.4% 94.8% 93.5% 93.8% 92.7% 91.4% 92.3% 95.7% 90.8% 95.7% 93.1% 91.6% 93.3% 95.2% 95.9% 96.2% 85.0% 90.5% 98.9% 90.8% 85.9% 89.9% 90.3% 87.4% 94.2% 95.8% 92.7% 92.8% 90.3% 86.8% 93.2% 92.6% 93.0% 93.7% 93.2% 94.0% 95.0% 95.2% 94.7% 94.6% 95.1% 96.0% 94.6% 94.4% 93.8% 94.0% 95.0%Total A&E Actual 95.6% 94.5% 97.4% 95.1% 93.4% 95.4% 94.8% 93.5% 93.8% 92.7% 91.4% 92.3% 95.7% 90.8% 95.7% 93.1% 91.6% 93.3% 95.2% 95.9% 96.2% 85.0% 90.5% 98.9% 90.8% 85.9% 90.0% 90.3% 87.4% 94.0% 95.9% 92.6% 92.9% 90.3% 86.1% 87.2% 88.1% 83.6% 89.3% 80.7% 80.4% #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

Q1

Q2

Q3

Q4

14/1

5 Ye

ar E

nd

Type 1 Predicted 94.3% 92.3% 90.7% 90.6% 90.9% 88.8% 88.8% 87.6% 88.8% 87.8% 87.8% 86.9% 92.4% 90.1% 88.4% 87.5% 89.6%Type 1 Trajectory (After Actions) 94.3% 92.3% 90.7% 90.6% 90.9% 88.8% 88.8% 87.8% 91.0% 92.7% 93.5% 92.6% 92.4% 90.1% 89.1% 92.9% 91.1%Type 1 Actual 94.3% 92.3% 90.7% 90.6% 90.9% 88.8% 88.8% 87.6% 83.3% 92.4% 90.1% 86.7% 89.1%Type 2/3 Predicted 99.5% 99.7% 99.5% 99.5% 99.7% 99.8% 99.6% 99.5% 99.5% 99.5% 99.4% 99.1% 99.6% 99.6% 99.6% 99.4% 99.5%Type 2/3 Actual 99.5% 99.7% 99.5% 99.5% 99.7% 99.8% 99.7% 99.9% 99.7% 99.6% 99.6% 99.8% 99.5%Total A&E Predicted 95.6% 94.2% 93.0% 92.9% 93.1% 91.5% 91.5% 90.5% 91.5% 90.8% 90.8% 90.1% 94.3% 92.5% 91.2% 90.6% 92.2%Total A&E Trajectory (After Actions) 95.6% 94.2% 93.0% 92.9% 93.1% 91.5% 91.5% 90.6% 93.1% 94.4% 95.1% 94.3% 94.3% 92.5% 91.7% 94.6% 93.3%Total A&E Actual 95.6% 94.2% 93.0% 92.9% 93.1% 91.5% 91.5% 90.5% 87.0% 94.3% 92.5% 89.8% 91.7%

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Actio

n Zo

neM

onth

, Qtr

and

Yea

r En

d Re

port

ing

Wee

kly

Repo

rtin

g

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

06/0

4/20

14

13/0

4/20

14

20/0

4/20

14

27/0

4/20

14

04/0

5/20

14

11/0

5/20

14

18/0

5/20

14

25/0

5/20

14

01/0

6/20

14

08/0

6/20

14

15/0

6/20

14

22/0

6/20

14

29/0

6/20

14

06/0

7/20

14

13/0

7/20

14

20/0

7/20

14

27/0

7/20

14

03/0

8/20

14

10/0

8/20

14

17/0

8/20

14

24/0

8/20

14

31/0

8/20

14

07/0

9/20

14

14/0

9/20

14

21/0

9/20

14

28/0

9/20

14

05/1

0/20

14

12/1

0/20

14

19/1

0/20

14

26/1

0/20

14

02/1

1/20

14

09/1

1/20

14

16/1

1/20

14

23/1

1/20

14

30/1

1/20

14

07/1

2/20

14

14/1

2/20

14

21/1

2/20

14

28/1

2/20

14

04/0

1/20

15

11/0

1/20

15

18/0

1/20

15

25/0

1/20

15

01/0

2/20

15

08/0

2/20

15

15/0

2/20

15

22/0

2/20

15

01/0

3/20

15

08/0

3/20

15

15/0

3/20

15

22/0

3/20

15

29/0

3/20

15

%

Week

Weekly Type 1 A&E 4Hr Performance Trajectory Predicted (No Actions) Trajectory (With Actions) Actual Target

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

06/0

4/20

14

13/0

4/20

14

20/0

4/20

14

27/0

4/20

14

04/0

5/20

14

11/0

5/20

14

18/0

5/20

14

25/0

5/20

14

01/0

6/20

14

08/0

6/20

14

15/0

6/20

14

22/0

6/20

14

29/0

6/20

14

06/0

7/20

14

13/0

7/20

14

20/0

7/20

14

27/0

7/20

14

03/0

8/20

14

10/0

8/20

14

17/0

8/20

14

24/0

8/20

14

31/0

8/20

14

07/0

9/20

14

14/0

9/20

14

21/0

9/20

14

28/0

9/20

14

05/1

0/20

14

12/1

0/20

14

19/1

0/20

14

26/1

0/20

14

02/1

1/20

14

09/1

1/20

14

16/1

1/20

14

23/1

1/20

14

30/1

1/20

14

07/1

2/20

14

14/1

2/20

14

21/1

2/20

14

28/1

2/20

14

04/0

1/20

15

11/0

1/20

15

18/0

1/20

15

25/0

1/20

15

01/0

2/20

15

08/0

2/20

15

15/0

2/20

15

22/0

2/20

15

01/0

3/20

15

08/0

3/20

15

15/0

3/20

15

22/0

3/20

15

29/0

3/20

15

%

Week

Weekly All Type A&E 4Hr Performance Trajectory

Predicted (No Actions) Trajectory (With Actions) Actual Target

94.3

%

92.3

%

90.7

%

90.6

%

90.9

%

88.8

%

88.8

%

87.6

%

88.8

%

87.8

%

87.8

%

86.9

%

94.3

%

92.3

%

90.7

%

90.6

%

90.9

%

88.8

%

88.8

%

87.8

%

91.0

%

92.7

%

93.5

%

92.6

%

94.3

%

92.3

%

90.7

%

90.6

%

90.9

%

88.8

%

88.8

%

87.6

%

83.3

%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

%

Month

Monthly Type 1 A&E 4Hr Performance Trajectory Predicted (No Actions) Trajectory (With Actions) Actual Target

4

95.6

%

94.2

%

93.0

%

92.9

%

93.1

%

91.5

%

91.5

%

90.5

%

91.5

%

90.8

%

90.8

%

90.1

%

95.6

%

94.2

%

93.0

%

92.9

%

93.1

%

91.5

%

91.5

%

90.6

% 93

.1%

94.4

%

95.1

%

94.3

%

95.6

%

94.2

%

93.0

%

92.9

%

93.1

%

91.5

%

91.5

%

90.5

%

87.0

%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

Apr-

14

May

-14

Jun-

14

Jul-1

4

Aug-

14

Sep-

14

Oct

-14

Nov

-14

Dec-

14

Jan-

15

Feb-

15

Mar

-15

%

Month

Monthly All Type A&E 4Hr Performance Trajectory Predicted (No Actions) Trajectory (With Actions) Actual Target

92.4

%

90.1

%

88.4

%

87.5

%

92.4

%

90.1

%

89.1

% 92

.9%

92.4%

90.1%

86.7%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

Q1

Q2

Q3

Q4

%

Qtr

Quarterly Type 1 A&E 4Hr Performance Trajectory

Predicted (No Actions) Trajectory (With Actions)

Actual Target

94.3

%

92.5

%

91.2

%

90.6

% 94

.3%

92.5

%

91.7

% 94

.6%

94.3%

92.5%

89.8%

95%

95%

95%

95%

80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%98.0%

100.0%

Q1

Q2

Q3

Q4

%

Qtr

Quarterly All Type A&E 4Hr Performance Trajectory

Predicted (No Actions) Trajectory (With Actions)

Actual Target

89.6%

91.1%

89.1%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

14/15 Year End

%

Year End Type 1 A&E 4Hr Performance Trajectory

Predicted (No Actions) Trajectory (With Actions) Actual

92.2% 93.3%

91.7%

80.0%

82.0%

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

14/15 Year End

%

Year End All Type A&E 4Hr Performance Trajectory

Predicted (No Actions) Trajectory (With Actions) Actual

DTOC Target Trajectory: 2014/15

Predicted weekly values are calculated using a mean average of Discharges in the rolling 6 weeks prior to the week in question.

Action List 06/0

4/20

14

13/0

4/20

14

20/0

4/20

14

27/0

4/20

14

04/0

5/20

14

11/0

5/20

14

18/0

5/20

14

25/0

5/20

14

01/0

6/20

14

08/0

6/20

14

15/0

6/20

14

22/0

6/20

14

29/0

6/20

14

06/0

7/20

14

13/0

7/20

14

20/0

7/20

14

27/0

7/20

14

03/0

8/20

14

10/0

8/20

14

17/0

8/20

14

24/0

8/20

14

31/0

8/20

14

07/0

9/20

14

14/0

9/20

14

21/0

9/20

14

28/0

9/20

14

05/1

0/20

14

12/1

0/20

14

19/1

0/20

14

26/1

0/20

14

02/1

1/20

14

09/1

1/20

14

16/1

1/20

14

23/1

1/20

14

30/1

1/20

14

07/1

2/20

14

14/1

2/20

14

21/1

2/20

14

28/1

2/20

14

04/0

1/20

15

11/0

1/20

15

18/0

1/20

15

25/0

1/20

15

01/0

2/20

15

08/0

2/20

15

15/0

2/20

15

22/0

2/20

15

01/0

3/20

15

08/0

3/20

15

15/0

3/20

15

22/0

3/20

15

29/0

3/20

15

Increased SW & OT capacity to improve community flow 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 8 8 8 8 8 8 8 8 8 8 8 8Single Brokerage to improve access to community services 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 6 6 7 7 7 7 7 7 7 7 7 7Increase in home care hours by 100hr/week 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 2 2 2 2 2 2 2 2CWPT Recruitment of support workers to increase short term support packages

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total Action 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -5 -5 -20 -21 -21 -22 -22 -22 -22 -22 -22 -22 -22 -22 -22% Of which affect DTOC 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 50% 75% 75% 50% 25% 25% 13% 13% 10% 5% 5% 5% 5%Total Action Impact 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -10 -15.75 -15.75 -11 -5.5 -5.5 -2.75 -2.75 -2.2 -1.1 -1.1 -1.1 -1.1

Target 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35Total Predicted 44 35 43 33 56 41 40 33 35 51 48 55 59 66 61 54 52 62 52 64 68 52 47 67 66 79 74 60 80 75 76 86 74 80 90 76 86 83 78 77 72 94 101 96 106 104 127 106 117 104 97 102

Total Predicted Trajectory (After Actions) 44 35 43 33 56 41 40 33 35 51 48 55 59 66 61 54 52 62 52 64 68 52 47 67 66 79 74 60 80 75 76 86 74 80 90 76 86 83 78 67 47 46 38 30 28 25 28 21 22 18 16 16Total DTOC Actual 44 35 43 33 56 41 40 33 35 51 48 55 59 66 61 54 52 62 52 64 68 52 47 67 66 79 74 60 80 75 76 86 74 80 90 76 84 68 56 63 87 77 #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/AUH Predicted 44 43 43 43 41 41 34 34 34 34 33 35 36 38 40 44 45 48 42 43 40 42 40 40 39 39 43 45 48 49 49 49 50 49 54 52 55 55 58 56 52 52 50 49 49 47 49 48 47 44 44 43UH Actual 33 24 36 29 40 31 33 25 28 43 40 46 48 58 51 42 31 42 37 44 48 36 34 52 48 60 60 49 57 56 67 66 66 65 71 64 76 58 47 48 60 #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/ASt Cross Predicted 10 10 11 10 10 11 11 9 9 9 10 10 8 9 10 9 9 10 11 13 14 17 16 17 17 17 15 14 13 15 15 15 15 15 15 13 14 14 10 11 11 10 11 10 11 12 11 10 11 12 10 12St Cross Actual 11 11 7 4 16 10 7 8 7 8 8 9 11 8 10 12 21 20 15 20 20 16 13 15 18 19 14 11 23 19 9 20 8 15 19 12 8 10 9 15 23 #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A2 year average (Trust) 42 44 55 55 46 45 51 48 47 48 50 57 51 53 50 47 45 54 42 49 49 62 48 53 54 50 53 51 50 49 43 41 47 36 44 35 40 38 36 36 33 44 47 44 49 48 59 49 54 48 45 47

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Actio

n Zo

neD

TOCs

0

20

40

60

80

100

120

140

06/0

4/20

14

13/0

4/20

14

20/0

4/20

14

27/0

4/20

14

04/0

5/20

14

11/0

5/20

14

18/0

5/20

14

25/0

5/20

14

01/0

6/20

14

08/0

6/20

14

15/0

6/20

14

22/0

6/20

14

29/0

6/20

14

06/0

7/20

14

13/0

7/20

14

20/0

7/20

14

27/0

7/20

14

03/0

8/20

14

10/0

8/20

14

17/0

8/20

14

24/0

8/20

14

31/0

8/20

14

07/0

9/20

14

14/0

9/20

14

21/0

9/20

14

28/0

9/20

14

05/1

0/20

14

12/1

0/20

14

19/1

0/20

14

26/1

0/20

14

02/1

1/20

14

09/1

1/20

14

16/1

1/20

14

23/1

1/20

14

30/1

1/20

14

07/1

2/20

14

14/1

2/20

14

21/1

2/20

14

28/1

2/20

14

04/0

1/20

15

11/0

1/20

15

18/0

1/20

15

25/0

1/20

15

01/0

2/20

15

08/0

2/20

15

15/0

2/20

15

22/0

2/20

15

01/0

3/20

15

08/0

3/20

15

15/0

3/20

15

22/0

3/20

15

29/0

3/20

15

Num

ber o

f DTO

Cs

Week

Weekly DTOC Performance Trajectory

Trajectory (With Actions) Predicted (No Actions) Actual Target 2 year average

Enclosure 10


Title Trust Development Authority (TDA) Oversight – Monthly Self Certification Requirements January 2015

Author Lynda Cockrill, Head of Performance & Programme Analytics Responsible Chief Officer

David Moon, Chief Finance Officer

Date 29th January 2015 1. Purpose This paper presents the proposed self-certification against the Board Statements and the Monitor Provider License Compliance statements for the month of December and seeks approval of these prior to submission to the NHS Trust Development Authority (TDA). 2. Background and Links to Previous Papers It is a requirement of the TDA regulatory regime that a Trust Board approved submission against these statements is made on the last working day of each month. The regime was introduced as a forerunner to NHS Trusts becoming licensed as Foundation Trusts (FT) because Monitor requires that the Board of Directors of each Foundation Trust considers compliance against these on a monthly basis as a core component of the FT governance framework. In the event that compliance is declared and subsequent events suggests this not to have been the case, Monitor will intervene in the Trust and as such, the TDA mirrored the Monitor arrangements in order that Trusts are accustomed to making declarations and confident in their processes for declaring compliance in readiness for when their FT license is granted. It is important therefore that Board members are satisfied that the Trust is compliant where compliance is being declared, and members are therefore encouraged to consider each statement and to seek further assurances where this is felt necessary. 3. Narrative Appendix A details the Trust’s assessment against each of the Board Statements and as in previous months the Trust is declaring compliance against all but statement 11 which relates to having achieved level 2 against the requirements of the Information Governance Toolkit. Board members will be aware that level 2 could not be achieved owing to the Trust not meeting the required standard with regards to mandatory Information Governance Training, and because the Trust is only assessed against the tool kit annually, this will remain until the next assessment is completed. Appendix B details the Trust’s assessment against the Monitor license conditions and the Trust is declaring full compliance.

4. Areas of Risk Reputation; clearly the fact that the Trust is not compliant with statement 11 is a reputational risk but as highlighted above, this will remain the case until re-assessment against the tool-kit takes place. Work is however underway to ensure that the Trust is in a position to comply with level 2 at the next assessment. 5. Governance Self-assessment and submission against the Board and License conditions is a regulatory requirement of the TDA. 6. Responsibility David Moon, Chief Finance Officer 7. Recommendations [A] The Board is invited to note:

1. The proposed January submission against the Board and License requirements.

and [B] approve:

1. Submission of the document to the TDA. .

Page 2 of 2

APPENDIX A

OVERSIGHT: Monthly self-certification requirements - Board Statements Compliance

CLINICAL QUALITY

1. The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight model (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to

adopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

YES

2. The Board is satisfied that plans in place are sufficient to ensure on-going compliance with the Care Quality Commission’s registration requirements. YES

3. The Board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements. YES

FINANCE

4. The Board is satisfied that the trust shall at all times remain a going concern, as defined by the most up to date accounting standards in force from time to time. YES

GOVERNANCE

5. The Board will ensure that the trust remains at all times compliant with the NTDA accountability framework and shows regard to the NHS Constitution at

all times. YES

6. All current key risks to compliance with the NTDA's Accountability Framework have been identified (raised either internally or by external audit and assessment bodies) and addressed – or there are appropriate action plans in place to address the issues in a timely manner.

YES

7. The Board has considered all likely future risks to compliance with the NTDA Accountability Framework and has reviewed appropriate evidence regarding the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued compliance. YES

8. The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliver the annual operating plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily. YES

9. An Annual Governance Statement is in place, and the trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk).

YES

10. The Board is satisfied that plans in place are sufficient to ensure on-going compliance with all existing targets as set out in the NTDA oversight model; and a commitment to comply with all known targets going forward. YES

11. The trust has achieved a minimum of Level 2 performance against the requirements of the Information Governance Toolkit. NO

12. The Board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests, ensuring that there are no material conflicts of interest in the board of directors; and that all board positions are filled, or plans are in place to fill any vacancies.

YES

13. The Board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.

YES

14. The Board is satisfied that: the management team has the capacity, capability and experience necessary to deliver the annual operating plan; and the management structure in place is adequate to deliver the annual operating plan.

YES

http://www.hm-treasury.gov.uk/

APPENDIX B

OVERSIGHT: Monthly self-certification requirements - Compliance Monitor Page

Reference (PDF document) †

Annex Page

Number ‡ Compliance

1. Condition G4 – Fit and proper persons as Governors and Directors (also applicable to those performing equivalent or similar functions).

64 5 YES

2. Condition G5 – Having regard to monitor Guidance. 66 7 YES

3. Condition G7 – Registration with the Care Quality Commission. 68 9 YES

4. Condition G8 – Patient eligibility and selection criteria. 69 10 YES

5. Condition P1 – Recording of information. 74 15 YES

6. Condition P2 – Provision of information. 76 17 YES

7. Condition P3 – Assurance report on submissions to Monitor. 77 18 YES

8. Condition P4 – Compliance with the National Tariff. 78 19 YES

9. Condition P5 – Constructive engagement concerning local tariff modifications. 79 20 YES

10. Condition C1 – The right of patients to make choices. 80 21 YES

11. Condition C2 – Competition oversight. 81 22 YES

12. Condition IC1 – Provision of integrated care. 82 23 YES

† https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/285008/ToPublishLicenceDoc14February.pdf

‡ https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/285009/Annex_NHS_provider_licence_conditions_-_20120207.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/285008/ToPublishLicenceDoc14February.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/285009/Annex_NHS_provider_licence_conditions_-_20120207.pdf



29 JANUARY 2015

Subject: Private Trust Board Meeting Session Report of 17th December 2014

Report By: Andrew Meehan, Chairman Author: Rebecca Southall, Director of Corporate Affairs Accountable Executive Director: Andrew Meehan, Chairman

PURPOSE OF THE REPORT: To report in public the substantive agenda items discussed at the private section of the Trust Board meeting held on 17th December 2014

SUMMARY OF KEY ISSUES: The Board met in private as there was no public board meeting scheduled for the month of December. Items discussed included:

• EPR Business Case; the Trust Board gave approval to entering into the next phase of the procurement process for an Electronic Patient Record system.

• Pathology Tender; the Trust Board was advised that the Trust had been selected as preferred bidder for a contract to supply Pathology Services.

STRATEGIC PRIORITIES THIS PAPER RELATES TO (Please check one): To Deliver Excellent Patient Care and Experience To Deliver Value for Money To be an Employer of Choice To be a Research Based Healthcare Organisation To be a Leading Training and Education Centre

RECOMMENDATION / DECISION REQUIRED:

The Board is asked to RECEIVE the report.

ENCLOSURE NO: 12

QUALITY GOVERNANCE COMMITTEE INTERIM REPORT TO BOARD

Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted, are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Quality Governance Committee Committee Meeting Date: 1 December 2014 Quorate: Yes Apologies: Barbara Beal Chair: Ed Macalister-Smith Report submitted by: Ed Macalister-Smith, Non-Executive Director 1. Minutes of the 3 November 2014 meeting were approved and actions were noted as

completed or updated. 2. National Cancer Patient Survey - The purpose of this survey is to monitor the experience of

cancer patients from their first visit to their local GP through to discharge from hospital. The majority of answers in the survey are ‘amber’ and the meeting was advised that the scores are low due to a number of minor actions on a small number of wards, the priority issues being the attitude of staff, and privacy afforded to patients. Ward Managers and Matrons have been asked to develop remedial action plans and a meeting has been planned to look at options for improving public perception of ward nurses. The scoring methodology was explained and details given of the improvements that have already taken place.

3. Serious Incidents – There was one Never Event reported during the month of October 2014 which related to Urology/Theatres and concerned a retained foreign body. The Committee was assured that national guidelines are followed regarding reporting serious incidents and the meeting was advised that the Trust appears to be more transparent than most other Trusts. According to FTN, only 15% of other Trusts report in the same depth as UHCW, e.g. with regard to falls and fractures, and to recording all (not just more severe) pressure ulcers. Thus UHCW may appear to benchmark against comparable Trusts as having a high number of incidents, when in fact it is the reporting rate that is high. This is a strength, not a weakness and the Committee felt that staff needed to be made more aware of this, and encouraged to continue to report.

4. Information Governance Toolkit – the Trust needs to achieve the IG training target set out in the IG Toolkit and a plan is in place to try and achieve this. All available resource is being deployed but this still remains a risk. The Committee was advised that the threshold will have been crossed in the early New Year.

5. Coventry & Rugby CCG Vision for Quality - Jacqueline Barnes and Adrian Canale-Parola, Chair of Rugby CCG, joined the meeting for the purpose of exploring opportunities to share processes and practices within the Quality Improvement Schedule. There was a good discussion and meeting of minds on how to measure and to improve quality. It was agreed that everyone owns the quality process and working collectively was recognised as the best way forward towards improvement. Care should be all encompassing from when a patient sees their GP to when they leave hospital and any subsequent aftercare, which is why shared ownership is so important and territorial issues should be left behind. It was agreed that contractual issues and clarity of timelines need focus and agreed that this coming year the Quality Schedule should be considered prior to contract signing. The CCG welcomed the strong reporting culture in the Trust.

6. HR Strategy & Workforce Report - The key issues in the report related to increasing concerns regarding agency expenditure and the shortfall in workforce whole time equivalent (WTE) against plans. There has been improvement in areas such as sickness, appraisals, job planning and mandatory training compliance, although further improvement is still needed

in some areas. Active recruitment is taking place within the next few months and it is hoped this will improve the situation. Revalidation is showing improvement and action is being taken to consolidate this.

7. Robot Users Group - The Patient Safety Committee advised the Committee of a new Robot User Group which will meet monthly and be in charge of co-ordination of training and utilisation of the robot across specialities. The Committee was advised that many procedures had already been completed: 34 robotic prostatectomies; 12 renal procedures; 10 colorectal procedures; 2 head and neck procedures.

The Board is asked to NOTE the business discussed at the meeting and to RAISE any questions in relation to the same.

Page 1 of 2 Interim Report to Board

ENCLOSURE NO 12

QUALITY GOVERNANCE COMMITTEE 12 Jan 2015 - Interim Report to Board

Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted, are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Quality Governance Committee Committee Meeting Date: 12 January 2015 Quorate: Yes Apologies: Barbara Beal Chair: Ed Macalister-Smith Report submitted by: Ed Macalister-Smith, Non-Executive Director 1. Minutes of the 1 December 2014 meeting were approved and actions were noted as

completed or updated. 2. WMQRS Theatres and Anaesthetics Peer Review- This is the first peer review that theatres have had in recent years; the review took place over

two-days and involved 450 staff, 2 sites and 33 theatres. There were a number of serious concerns raised as well as immediate concerns and an action plan was developed in response. The Committee was assured by the actions that were generated and the team commented that it was a fair reflection. There were a number of areas of positive practice identified including the team briefing process, auditing in the area, the openness of and anaesthetic guidelines. The Committee discussed the progress made against the actions and were satisfied with these; the team were also commended for inviting a Peer Review and embracing the recommendations arising from the exercise.

3. Safeguarding Children and Vulnerable Adults – The Committee was informed of the increasing activity in respect of both children and adults

for which there was variable explanation. There continues to be an internal focus on mandatory training and level 3 training will be delivered as part of a Trust Grand Round in January 2015. A recent Ofsted report generated 8 actions for the Trust which have all been completed. The PREVENT strategy has been reviewed and there are no further returns for the Trust.

4. Maternity Never Event RCA – Following the incident, a Root Cause Analysis (RCA) was undertaken and presented to the

Chief Executive Officer. No single cause identified but a number of actions and recommendations were made and the Committee was assured that these are being progressed and that a reporting mechanism was in place.

5. Quality Account Priorities – The Committee discussed the Quality Priorities for 2015/16 with a view to making a recommendation to the January Trust Board. The Committee suggested the following priorities for the relevant period: • Ensuring effective handover • End of life care (including Do Not Attempt CPR) • Introducing ‘Always Events’

6 Hospital Standardised Mortality Rate (HSMR) Summary Hospital Mortality Indicator (SHMI) HSMR for August 2014 was 104.83 which was within expected ranges. This is a recently remodelled figure based on remodelled risks to maintain a national expected mortality benchmark of 100. When remodelling, the national average is reset to 100. The Committee discussed and asked questions on the new data and in particular the impact of palliative care coding on the Trust’s HSMR.

The Trust Board is asked to NOTE the business discussed at the meeting and to RAISE any questions in relation to the same.

ENCLOSURE NO 13

INTERIM COMMITTEE REPORT TO BOARD Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted, are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Finance and Performance Committee Committee Meeting Date: 1 December 2014 Quoracy: Yes Apologies: Mrs. B Beal, Non-Executive Director, Mrs S Rollason, Deputy Chief Finance Officer Chair: Ian Buckley Report submitted by: Ian Buckley, Non-Executive Director & Vice Chair 1. Minutes; the minutes of the November meeting were approved as an accurate record. 2. CQUIN; Concerns were raised with the poor level of dialogue and uncertainty surrounding

intentions as well as the generally immature relationship with commissioners in relation to this.

3. Deep Dive: Operational Planning and CIPs for 2015/16; a comprehensive deep dive into operational planning and CIPs for 2015-16 was presented to the Committee. Plans are progressing well with good levels of engagement. Past non- recurrent savings have steadily accumulated to present a challenging target going forward.

4. Timing of the meeting; coming after the Board meeting seems to inhibit debate around Integrated Performance Report (IPR) and this process needs to be reviewed at a future date if issues continue.

5. Emergency Department; the knock-on consequences of the pressure in the department remains a serious issue and significant efforts are being made to tackle the factors undermining performance, particularly engagement with partner organisations.

The Board is asked to NOTE the business discussed at the meeting and to RAISE any questions in relation to the same.

Enclosure 14


Title Board Assurance Framework Quarterly Update Author Rebecca Southall, Director of Corporate Affairs Responsible Chief Officer

Meghana Pandit, Chief Medical Officer

Date 29th January 2014 1. Purpose The paper is intended to update the board in relation to the progress that is being made in relation to managing and mitigating against the risks set out in the Board Assurance Framework (BAF) 2014/15. 2. Background and Links to Previous Papers The BAF for 2014/15 was approved at the May Trust Board meeting following the risk mapping session that took place on 2nd April 2014, at which the risks to achieving the Corporate Objectives were identified by Board members. This report represents the second quarterly progress update that the board has received; the first having been received and debated at the September Trust Board meeting. 3. Narrative Good progress has been made in relation to managing and mitigating the risks to the corporate objectives since the BAF was approved. A number of recommendations will therefore follow and the Trust Board is asked to consider, discuss and approve these: New Risks: No new risks from the Corporate Risk Register are currently recommended for inclusion on the Board Assurance Framework. Risks Recommended for an increase in score: Given the discussion that took place at the December Trust Board meeting around the financial position it is recommended that the score in respect of the following risk increases as outlined below: Risk ID

Risk Description Current Score

Recommended score

2088 Failure to achieve annual financial targets

12 (moderate)

16 (high)

Risks Recommended for a decrease in score: The following risks have been partially mitigated and a reduction in the current score is recommended as outlined below:

Risk ID

Risk Description Current Score

Recommended score

1467 Failure to implement the TTWC Organisational Development Programme

12 (moderate)

4 (low) – demonstrable progress has been made during 2014/15 in terms of implementation of the programme and the risks of it not being implemented as identified at the start of the year are significantly decreased as a result.

2091 Failure to implement an effective strategy with Warwick Medical School

8 (moderate)

4 (low) – progress has been made as has been reported to the Trust Board. The final strategy is expected to be launched in April 215 at a seminar. The risk is therefore considerably reduced from that identified at the start of 2014/15.

Risks recommended for closure: The following risks are recommended for closure with the rationale outlined below: Risk ID Risk Description Current

Score Recommendation

2987 Failure to identify and describe adequately investment case for prioritised capital schemes

8 (moderate)

The Trust has received external financing by way of a loan; this risk therefore no longer exists.

2086 Failure to plan for the impact of potential service changes within the local health economy

12 (moderate)

There will be no changes within the local health economy until after the general election in May 2015, so this risk will not arise during the current financial year.

1908 Failure to engage with and provide leadership to the AHSN and CLRN

8 (moderate)

AHSN South Spoke is now established; programme of meetings for 2015 in place with UHCW CEO continuing to chair meetings.

Remaining Risks: Given the overall responsibility of the Trust Board for ensuring that there are appropriate mechanisms in place for the identification and management of risk, members are asked to note the controls and assurances and actions that are in place with regard to each of the BAF risks as set out in the attached report and assess whether these are:

1. Are appropriate and sufficient, and; 2. Whether the current risk assessment (risk level) for each risk is appropriate

Page 2 of 3

4. Areas of Risk The Board Assurance Framework comprises the risks to achieving the Trust’s objectives and full details against each risk are therefore set out within the attached report. 5. Governance

The Trust Board is required to adopt a Board Assurance Framework as a key component of the overall system of internal control in order to ensure that risks to the achievement of the overall objectives are identified, managed and mitigated effectively. The BAF is assessed by Internal Audit each year and is an integral part of the Head of Internal Audit Opinion and also contributes to the Annual Governance Statement. 6. Responsibility

Meghana Pandit, Chief Medical Officer has overall executive responsibility for risk and is supported by the Director of Corporate Affairs in respect of the BAF element. 7. Recommendations The Trust Board is asked to:

1. Consider and approve the proposed recommendations outlined in section 3. 2. Note the current controls ,assurances and actions that are in place in relation to

each risk and ensure that the risk score is appropriate; and 3. Seek further information and assurances as necessary.

Winter Plan and Emergency Care Pathway Update

Page 3 of 3

BAF Report16.01.15

ID

Dat

e Id

entif

ied

Clo

sed

date Title Description Principal objectives Risk Subtype

Ris

k O

wne

r

Han

dler

Exec

utiv

e Le

adLi

kelih

ood

(initi

al)

Con

sequ

enc

e (in

itial

)R

isk

leve

l (in

itial

) Current controls Gaps in controls

Like

lihoo

d (c

urre

nt)

Con

sequ

enc

e (c

urre

nt)

Ris

k le

vel

(cur

rent

) Assurance Gaps in assurance

Like

lihoo

d (T

arge

t)C

onse

quen

ce

(Tar

get)

Ris

k le

vel

(Tar

get) Action Plan Summary

Nex

t rev

iew

da

te

378

2-Ap

r-20

14 (BAF) Poor patient experience, reputational and financial impact of failing key national performance indicators and inspections

If the Trust does not meet all applicable national targets and inspection standards there will be a negative impact on the patient experience and quality, on the Trusts reputation and potentially on the financial position.

To deliver excellent Patient Care and Experience

Operational

Mr J

on B

arne

s

Mr J

on B

arne

s

Dav

id E

ltrin

gham

ALC

ERT

MAJ

OR

HIG

H (1) Scrutiny in relation to all levels of performance at the Group Quarterly Performance Review meetings. (2) Scrutiny at Board through Integrated Performance Report and additional challenge at the Finance and Performance Committee. (3) High level action plan in place covering 5-domains including 4-Hour ED standard, pre-hospital, DTOC/Capacity, Discharge/External Discharge. (4) Robust process to manage patient access to 18 week RTT and 2 week wait/cancer pathways. (5) Getting Emergency Care Right Campaign with associated investment to work towards implementing 7-day services. 19.08.2014 - Monitor delivery of recovery plans for 4 hours and 18 week RTT through performance management structure

Capacity across the Trust needs to be reviewed in the context of ever increasing demandBed Reconfiguration exercise needs to be undertaken

LIKE

LY

MAJ

OR

HIG

H Monthly IPRReal time "speedo"Extramed breach trackingEscalation and response systemsFace to Face Executive leadership and scrutinyDCOO/ADN/AMD supervisionPatient Experience ReportInternal Audit Report around Data Quality in cancer services - significant assuranceCQC Action Plan developed following mock visit

Possibility of Speciality Groups non-adherence to agreed standards/procedures resulting in targets and/or standards not being met

RAR

E

MO

D

VLO

W Establishment of discharge hub to manage DTOC patients (completed)Mock CIH inspection and CIH Programme Board established to prepare for inspection in March (in progress)Strategy around the increased use of Rugby Hospital in development.Reconfiguration of Acute Medical Unit (in progress)Reinvigoration of Getting Emergency Care Right (continuing)

5-Ja

n-20

15

1067

2-Ap

r-20

14 (BAF) Insufficient controls and adherence to safety procedures may lead system failures and Never events

If staff do not follow policies and procedures there is a risk that patients will come to avoidable harm through the occurence of a never-event or other clinical incident.

To deliver excellent Patient Care and Experience

Safety - Clinical

Dr A

ndre

w P

hillip

s

Mrs

Kar

en B

ond

Meg

hana

Pan

dit

LIKE

LY

MAJ

OR

HIG

H Following a review on mechanisms that are in place and have been applied following previous incidents and are now incorporated into ongoing training, an intention to apply innovative techniques and processes was agreed.This has resulted in the following actions being completed and techniques and principles being developed; further actions are planned as detailed in the action plan summary:Audit of process for counting & checking equipment Feedback to manufacturer re packaging of different types of prosthesisReview of storage of prostheses Theatre list planning

Actions to be undertaken arising out of Internal Audit WHO Checklist report issued in September 2014 in relation to areas of limited assurance; detailed action plan in placeNon-compliance may not be identified until an event occurs.

POSS

MAJ

OR

MO

D on-line incident reporting to ensure that all incidents are captured and followed upInternal Audit WHO check-list report demonstrates full and significant assurance in relation to 2Surgical Safety Checklist weekly compliance reports

We cannot be assured that all staff are adhering to all policies and procedures aimed at preventing avoidable harm to patients and can only put plans in place to mitigate this

POSS

MAJ

OR

MO

D Review of current practice/mechanisms (completed). Global awareness strategy to be rolled out in theatres (in progress) Further root cause analysis training to be rolled out (in progress) Training and swab check competencies and implant training competencies (completed) Audio Surgical Safety Checklist/promots in theatre to be implemented Human factors training to be undertaken as part of Sign up to Safety pledges (in-progress)

31-M

ar-2

015

1467

2-Ap

r-20

14 (BAF) Failure to implement the TTWC Organisational Development Programme

If the Trust does not successfully implement the TTWC Organisational Development Strategy then there is the risk that the Trust's overall 'world-class' ambitions and strategic objectives will not be achieved.

To be a Research based Healthcare organisation To be a leading Training and Education Centre To be an Employer of choice To deliver Value for Money To deliver excellent Patient Care and Experience

Human ResourcesM

r Ken

Hut

chin

son

Mr A

ndre

w M

cMen

emy

Ken

Hut

chin

son

POSS

MAJ

OR

MO

D (1) TTWC Programme Board established (2) Each work-stream is led by a Chief Officer (3)sub-Programme Board structure in place to monitor and manage programme for each work-stream alongside work-stream leads (3) quarterly progress reports to Trust Board.

No gaps have been identified PO

SS

MAJ

OR

MO

D TTWC Programme Board in place which reports to COG and Trust Board. Leadership Event to report progress to top 100 leaders took place 16/01/15

None

RAR

E

MAJ

OR

LOW NED to be identified to attend TTWC Board to strengthen

governance (replacinging S Tubb) (completed)

30-J

an-2

015

1909

2-Ap

r-20

14 (BAF) Failure to develop leadership, managerial & financial awareness & competence of managers

If the competence of managers in terms of leadership, management and financial awareness is not developed there is the risk that there will be lack of delivery and accountability for delivery which will result in poor performance.

To deliver Value for Money

Operational

Mrs

Don

na G

riffit

hs

Mrs

Raj

ni M

artin

Dav

id E

ltrin

gham

POSS

MAJ

OR

MO

D (1) Formal Leadership Programme being developed as part of TTWC (2)Group Performance Review Process (3)existing managment programmes in place as part of the PDR/PDP process (4)managerial responsibility for the identification and provision of support and personal development.

Absence of a values based leadership programme

POSS

MO

D

MO

D Development and delivery of financial awareness training Development and implementation of leadership behavioural framework and competency frameworkEstablishment of a leadership development group focussed on development requirements for leadership development programme

Delivery and estalishment of a programme which cuts across the organisation and has a strong leadership focus.

UN

LIKE

MIN

OR

LOW Leadership Development Programme to be developed as part of the

TTWC Programme (completed). Programme to be rolled out across the Trust (on-going over next 5-years).

31-D

ec-2

014

1911

2-Ap

r-20

14 (BAF) Poor organisational reputation hinders recruitment and retention

As a result of any reputational issues it may be the case that in some instances the Trust cannot attract the best candidates to vacant positions which has a detrimental impact on the ability to provide services, the patient experience and potentially the Trust's financial position.

To be a leading Training and Education Centre To be an Employer of choice To deliver Value for Money To deliver excellent Patient Care and Experience

Human Resources

Mr K

en H

utch

inso

n

Mr A

ndre

w M

cMen

emy

Ken

Hut

chin

son

POSS

MAJ

OR

MO

D Communications & Engagement Strategy being developed alongside World Class Conversations area of work that is within the unbrella of Together Towards World Class OD Programme. The overall aim of the OD programme is to achieve world class reputation.

No strategy around recruitment and retention

UN

LIKE

MAJ

OR

MO

D Reports to Committee in relation to workforceScrutiny of workforce plans by TDA

Strategy around recruitment and retention requires development

POSS

MIN

OR

LOW Recruitment and Retention Strategy in development (in progress) -

completion date 31st March 2015.

30-J

an-2

015

BAF Report16.01.15

ID

Dat

e Id

entif

ied

Clo

sed


Ris

k O

wne

r

Han

dler

Exec

utiv

e Le

adLi

kelih

ood

(initi

al)

Con

sequ

enc

e (in

itial

)R

isk

leve

l (in

itial


Like

lihoo

d (c

urre

nt)

Con

sequ

enc

e (c

urre

nt)

Ris

k le

vel

(cur

rent


Like

lihoo

d (T

arge

t)C

onse

quen

ce

(Tar

get)

Ris

k le

vel

(Tar


Nex

t rev

iew

da

te

1912

2-Ap

r-20

14 (BAF) Regulatory and/or funding bodies withdrawal of training accreditation and funding

If the Trust cannot demonstrate that progress has been made with regards to improving training & experience in Acute Medicine HEWM may consider withdrawing further training posts (2 ST3+ already withdrawn) with further risk that this may attract criticism of other training posts within the Trust.

To be a leading Training and Education Centre

Strategic

Dr M

Alle

n

Mar

ie M

idgl

ey

Meg

hana

Pan

dit

POSS

MAJ

OR

MO

D (1) CMO leading a project: Postgraduate Medical Training, 'raising the bar'. (2) Regular submissions to QGC including reports following the 2 recent successful visits (3) Specialty junior doctor forums taking place, (4) Surveys taken and identified actions followed. (5) Progress both related specifically to actions in Acute Medicine and on all other training related matters is being closely monitored by Trust management including PMEC. 21/08/14 Update to Patient Safety Committee: There has been fundamental change at all levels (with trainee input), resulting in improved staffing at all levels. Recent changes; Medical Rota Co-Ordinator continue to focus on medical rota.Improved senior workforce with the appointment of new consultants, 6 Advanced Nurse Practitioners & senior/ junior clinical fellows will support the service, patient safety & education & training 26/11/14 The Action group continues to meet and work on the Action plan. Significant improvements have been achieved on a number of the issues e.g. staffing, rotas, induction information. Another Level 4 (HEWM/ GMC)inspection is due 27th February 2015

Since many concerns and pressures are operational, rather than educational, sustained input and effort is needed at Directorate and Group level

UN

LIKE

MAJ

OR

MO

D HEWM QA require updates on UHCW's progress against the Action Plan from the Level 4 visit. This has been returned with detailed evidence on our progressJEST and GMC surveys are collated for all areas, but those related to areas Acute Medicine are looked at by the AM Action Group and follwed through in detail. There have been some improvements in scores in both surveys and a major drop in reporting of pateinst safeyy issues via these surveys PSC - monthlyQGC - QuarterlyTrust Board - annuallyTERC- quarterlyPG Medical Education Committee (reports to TERC)1:1 meetings with CMO

Acute Medicine had a targetted Level 4 multi-professional and GMC review on 30th June 2014. Training and operational issues were rated as improved in many areas but there with sufficient ongoing concern to warrant a second Regulatory body (GMC) visit

RAR

E

MO

D

VLO

W Education metrics to be included on IPR and Group DashboardsTraining Programme

1-Fe

b-20

15

2084

2-Ap

r-20

14 (BAF) Failure to embed a culture of planning and delivery of activities required in the current year

If the Trust does not embed a culture of planning and delivery then there is the risk that the required operational,quality and financial targets will not be delivered within the current year.

To deliver Value for Money To deliver excellent Patient Care and Experience

Operational

Mr J

ohn

Amph

lett

Cra

ig R

adfo

rd

Dav

id M

oon

POSS

MO

D

MO

D (1) Planning process and ODPs in place for each group (2) Quarterly Performance Review Process led by COG (3) Integrated Performance Report to Trust Board (4) Monthly ODM meetings occur with each of the Groups. 31.07.14. - Regular meetings set up with lead CCG around future planning rounds to ensure integrated approach.

There are no gaps in controls identified PO

SS

MO

D

MO

D ODP in place for each groupQuarterly performance reviewsIntegrated Performance Report submitted to Trust Board each month

No programme in place aimed a developing planning and delivery skills

RAR

E

MO

D

VLO

W Development of Leadership Development Programme aimed at developing these competencies through TTWC programme (completed) Review of business case process (completed)

31-J

an-2

015

2085

2-Ap

r-20

14 (BAF) Inability to deliver a workforce plan sufficient to deliver excellent, safe,effective patient care and experience

If the Trust does not have sufficient skills or resources to develop robust workforce plans then the workforce may not be able to deliver excellent, safe and effective patient care and experience.

To be an Employer of choice To deliver Value for Money To deliver excellent Patient Care and Experience

Human Resources

Mr A

ndre

w M

cMen

emy

Mr A

ndre

w M

cMen

emy

Ken

Hut

chin

son

POSS

MAJ

OR

MO

D (1)regular reports on Workforce are submitted to HRED/QGC and COG (2)scrutiny and support from TDA around workforce planning (3)access to and use of TDA Workforce Assurance Tool (4) regular assessment against NQB guidance on Safer Staffing and reports to Trust Board. In addition the ODP process has commenced,and this will consider workforce plans against assumed activity levels for 2015/16.

No current report directly to Trust Board around work-force metrics/data but plans in place to introduce this.

POSS

MAJ

OR

MO

D NQB Safer Staffing Assessment

No formal strategy around recruiment and retention of nursing staff U

NLI

KE

MAJ

OR

MO

D Workforce Reporting; report detailing key workforce metrics to be developed and submitted to the Trust Board (completed - January 2015 board)Recruitment processes; changes to the recruitment process to be made to speed up recruitment of substantive staff; this in turn will reduce reliance on bank and agency staffing and will ensure that staff are not lost to other organisations as a result of slow recruitment processes (in-progress) - deadline 31st March 2015Nursing Recruitment and Retention Stragegy; recruitment and retention strategy for nursing to be developed to ensure that UCHW has the nursing workforce that it requires going forward and that staff remain with the Trust once employed (in-progress)

30-J

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14 (BAF) Failure to plan for the impact of potential service changes within the local health economy

If the Trust does not consider and plan for the potential impact(s) of decisions within the local health economy then there is the risk that it will not be in a position to respond to any changes that this might bring about

To deliver Value for Money To deliver excellent Patient Care and Experience

Strategic

Mr J

ohn

Amph

lett

Cra

ig R

adfo

rd

Dav

id M

oon

POSS

MAJ

OR

MO

D Ongoing dialogue and engagement with the Trust Development Agency (TDA)and Local Area Teams (LAT)around future service configurations. 31.07.14- Recent discussions around the future of the health economy at a 360 degree event with the LAT. Presentation planned for a board seminar in October 2014 around the impact of any possible changes with GEH.

General election makes any service changes in the remainder of 2014/15 unlikelyDecision making process is outside of the control of the Trust

POSS

MAJ

OR

MO

D Update to board via CEO and Chair's report each monthOn-going dialogue at Chief Officer level Discussion around Strategy at the January Board Development session

None; the Trust is taking the action that it can through engagement with partner organisations

UN

LIKE

MO

D

LOW No actions have been identified as the Trust is undertaking all of the

preparation that it can.

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14 (BAF) Failure to identify and describe adequately investment case for prioritised capital schemes

If the case investment case for capital schemes is not adequately described then there is the risk that the necessary funding will not be forthcoming resulting in inability to proceed with schemes. This may impact negatively on the staff and patient experience, on the Trust's reputation and financial position


Strategic

Ms

Susa

n R

olla

son

Mr A

lan

Jone

s

Dav

id M

oon

LIKE

LY

MAJ

OR

HIG

H (1)Capital priotisation principles identified and published (2) Capital Plan approved by Trust Board and submitted to TDA for scrutiny (3)assessment included in integrated planning process for all areas of the Trust (4) Capital Planning Group in place which co-ordinates the collation of all capital bids which are mapped to Board approved priorities (5) LTFM refreshed routinely which underpins planning assumptions (6) Finalised application for capital financing submitted to ITFF (via the TDA) on 3rd September 2014 (case will be considered at the ITFF meeting scheduled for 19th September 2014). (7) Confirmation from TDA received in early November 2014 that funding has been approved in the form of a capital investment loan (CIL) rather than PDC - this will require formal Trust Board approval at the end of November 2014.

Backlog demand masked due to long standing use of fully depreciated assets

UN

LIKE

MAJ

OR

MO

D Approved Financial Strategy which includes capital prioritisation principles in placeApproved Integrated Plan in place which includes Capital Investment for 2014/15 and the next 3-yearsTDA scrutiny applied and feedback given to the Trust BoardLTFM in place which underpins planning assumptions

No gaps in control identified now that loan has been approved. U

NLI

KE

MAJ

OR

MO

D Bids will be written based on experience from previous year given the lack of formal guidance (competed)

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BAF Report16.01.15

ID

Dat

e Id

entif

ied

Clo

sed


Ris

k O

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r

Han

dler

Exec

utiv

e Le

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ood

(initi

al)

Con

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enc

e (in

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)R

isk

leve

l (in

itial


Like

lihoo

d (c

urre

nt)

Con

sequ

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e (c

urre

nt)

Ris

k le

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(cur

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lihoo

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Ris

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Nex

t rev

iew

da

te

2088

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14 (BAF) Failure to achieve annual financial targets

If the Trust does not meet statutory financial targets then there is the risk of scrutiny, potential sanctions and damage to reputation.


Financial

Mr D

avid

Moo

n

Ms

Susa

n R

olla

son

Dav

id M

oon

POSS

MAJ

OR

MO

D (1)Integrated Planning Process in place with clearly defined in-year priorities and outcomes. (2)Clear accountability at Group level with monthly reporting via ODMs (3)Scrutiny and challenge at Performance Review meetings (4)Scrutiny at Trust Board level through monthly Integrated Performance Report(5)Standing Financial instructions in place.

Dynamics of activity, workforce, infrastructure and finance not fully evidenced within planning process/accountability frameworkLack of precise definition of strategic objectives and associated KPIs to understand and test progress towards strategy which may mean focus is on short term decisions that do not take adequate account of future financial consequences.

POSS

MAJ

OR

MO

D Integrated Plan developed with contribution from departments, groups and Trust BoardTwo-Year Plan approved by the Trust BoardGroup Operational Delivery Plans describe activity, workforce, infrastructure, capacity finance and quality standards signed for all groupsAnalytical review of 2013/14 outturn provides insight into forecasting and deliveryOn track to deliver full CIP for 2014/15

TDA assessment of plan is graded as medium riskCIP target of 5.4% deemed high risk by TDAForecast slippage in CIP programmeCommissioner affordability has not been confirmed for both income CIP and anticipated overperformance levels

RAR

E

MAJ

OR

LOW Bids submitted to ITFF to support Capital Programme (completed)

Priortisation of Capital Schemes once outcome of bid known (completed) Negotiations with commissoners (on-going)

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14 (BAF) Failure to safeguard income by not planning for changing commissioner intentions

If commissioner intentions with regards to services are not understood then there is the risk that the Trust will not be in a position to respond to service tenders and may lose out on business opportunities.

To be a leading Training and Education Centre To be an Employer of choice To deliver Value for Money To deliver excellent Patient Care and Experience

Strategic

Mrs

Jan

et W

hite

Mrs

Jan

et W

hite

Dav

id M

oon

POSS

MAJ

OR

MO

D (1)Planning Unit acting as Strategic Programme Board and receiving monthly updates and approving tendering priorities (2) weekly monitoring of opportunities via NHS Procurement websites (3)on-going dialogue with Coventry & Rugby CCG (4) building on exising relationships to fully understand commissioning intentions (5) log and library of previous responses in place to support and enable swift responses to tender opportunities (6) training/communication on successfully responding to tenders planned - for appropriate delivery during 2015(7) OCSO support for services responding to tenders.

Tenders are expanding geographically and the Trust will need to invest in partnership working in order to be in a position to respond to opportunitiesNumber of appropriate market opportunities being advertised is expanding, putting significant pressure at times on OCSO teamTimescales for responding to market opportunities and deadlines for various submissions/actions are becoming increasingly challenging and organisation is experiencing some difficulties in respondingLength taken for Commissioner evaluation of tender responses is increasing and timescales for notification of outcomes slip, resulting in ad hoc contract extensions, posing opperational and financial risks to services

POSS

MO

D

MO

D Reports and updates from CSO to Chief Officers GroupReports and updates from CSO to Trust BoardPlanning Unit

Capacity of Planning Unit to provide appropriate level of attention to Strategic ProgrameCapacity of OCSO team to cope with number of market opportunities and amount of support services require. Discussion at January Board seminar around Dalton Review and 5-Year Forward View.

UN

LIKE

MIN

OR

LOW Review of team capacity (on-going)

COG review of recent policy publicationsRefreshed Market Assessment and Strategy chapter of IBP to be submitted to February Trust Board

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14 (BAF) Failure to implement an effective strategy with Warwick Medical School

If the Trust does not further develop and implement an effective strategy with Warwick Medical School then there is the risk that the Trust's standing as a teaching hospital could be jeopardised.

To be a leading Training and Education Centre

Strategic

Reb

ecca

Sou

thal

l

Mrs

Vic

toria

Dem

ery

Andy

Har

dy

UN

LIKE

MAJ

OR

MO

D Dean of Warwick Medical School is a NED on the Trust Board. Board Seminar has taken place and Joint Vision between the Trust and the wider University is under development. Strategies for Research and Education are also under development Strategy development is high on the list of priorities for the Trust Board.

Joint Vision needs to be implemented following approval U

NLI

KE

MAJ

OR

MO

D Regular progress updates provided to Trust BoardDirect involvement/influence of Chairman, CEO and NED appointed by Warwick UniversityDevelopment of the strategy is a high priority for the Trust Board

Strategy not yet produced and signed off although regular updates to the board and good progress being made

RAR

E

MAJ

OR

LOW Strategy in development; to be presented at seminar on 2nd April

2015.

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Enclosure 15


Title Fit and Proper Persons Test Declaration Author Rebecca Southall, Director of Corporate Affairs Responsible Chief Officer

Andy Meehan, Chairman

Date 29th January 2015 1. Purpose This paper seeks to provide assurance that all members of the Trust Board meet the requirements set out in Regulation 5 of the Care Quality Commission fundamental standards, which came into force on 27th November 2014. 2. Background and Links to Previous Papers The Trust Board received a presentation on the Fit and Proper Persons Test (FPPT) at the September 2014 meeting and it was agreed at that time that any measures over and above those already taken by the Trust would be put into place to meet the required standard when the detailed guidance was published. This guidance was published in late November 2014. 3. Narrative The Chairman is responsible for ensuring that all members of the Trust Board and those that are regularly in attendance at meetings meet the requirements of the FPPT. The Trust already undertakes a range of pre-employment checks to ensure that all staff have the qualifications and capability to undertake them and that they are generally of sound character. Although the suite of checks that are already in place as part of the Trust’s recruitment processes will continue to be undertaken, all new members of the Board or individuals to whom the regulations apply will be asked to sign the attached declaration on appointment and to commit to informing the Chair of any changes in circumstance that mean that they no longer comply. A register will be held by the Director of Corporate Affairs and Board members will make a signed declaration each year, which will be formally reported to the Trust Board. Each member of the Board has confirmed their compliance with the regulations on an individual basis and the signed forms will be retained by the Director of Corporate Affairs as evidence of this. 4. Areas of Risk If the Trust does not comply with the FPPT regulations then the following risks arise: Regulatory risks; the Trust will not be compliant with the CQC standards which could lead to regulatory action, consequent damage to the Trust’s reputation and undermining of public confidence. The measures described above and the written declaration and reporting proposal are aimed at mitigating this risk.

Clinical Risks/Patient Experience risks; the regulations are aimed at ensuring that Boards of Board of providers of NHS are capable of governing the organisation to a high standard and ensuring that decisions that it takes are in the interests of patients and the wider community. If the Trust does not implement these regulations then there is the risk that these objectives may not be met and the best interests of patients will not be served. The process outlined in this paper mitigates against this risk. 5. Governance The Fit and Proper Persons test is part of the CQC essential standards which are a core component of the Trust’s governance framework. An annual declaration of compliance will therefore be made at the Public Trust Board meeting as outlined in section 3. 6. Responsibility Andy Meehan, Chairman supported by Rebecca Southall, Director of Corporate Affairs 7. Recommendations The Trust Board is asked to NOTE that declarations of compliance with the requirements of the Fit and Proper Persons Test have been received from all members of the Trust Board. Board members are also asked to COMMIT to informing the Chair of any change in individual circumstances that might affect compliance on an on-going basis and to making a written declaration on an annual basis.

Page 2 of 2

Changes to CQC Regulations – Fit and Proper Person Test

Regulation 5 of the Care Quality Commission (CQC) fundamental standards; the fit and proper persons requirement came into force on 27th November 2014 and will become law as of 1st April 2015. This stipulates that the Chair of all NHS Trusts is responsible for ensuring that members of the Trust Board meet the requirements of the ‘Fit and Proper Person Test’ (“the test”) and for establishing processes to underpin this. UCHW is committed to ensuring the highest standards of safety, quality and governance and to this end, in addition to making the usual pre-employment checks, members of the Trust Board will be asked to make a declaration upon appointment and an annual declaration thereafter around their fitness to execute these roles, in order that there is assurance on an on-going basis. Members are also expected to notify the Chair of the Trust in the event of any change of circumstances.

Applicability

Staff required to complete this self-declaration are;

• Members of the Trust Board and senior staff in attendance with significant influence in reporting information for decision making. For the purpose of UHCW this is defined as Chief Officers, Non-Executive Directors (NEDs) and those regularly in attendance at the Trust Board

A central register will be held by the Director of Corporate Affairs and will be made available for inspection by the CQC.

Recruitment Processes

As part of the recruitment process for the defined staff group appointed by the Trust a number of checks will take place;

• Checks on the individuals o Qualifications o Competence, skills required, relevant experience and ability o Good character

• Consider physical and mental health in line with the role and good occupational health practice

• Ensure, as far as possible the individual has not been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether lawful of not) in the course of carrying on a regulated a service; this includes any allegations of such

• Disclosure and Barring Service (DBS) checks will be carried out on all individuals to whom the test applies as part of the pre-employment check process. Only individuals

who will be acting in a role that falls within the definition of a ‘regulated activity’ as defined by the Safeguarding Vulnerable Groups Act 2006 will be eligible for an enhanced DBS check.

Chair and Non-Executive Directors

As UHCW is an NHS Trust, the Chair and NEDs are at the present time appointed by the Trust Development Authority (TDA). TDA has confirmed that it is responsible for providing assurance to the CQC that the Chairs and NEDs that it appoints meet the requirements of the test. Notwithstanding this, in recognition of the responsibility of the Chair as set out in the regulations and as a reflection of the seriousness with which the Trust treats this matter, all UCHW NEDs will be required to complete a declaration upon appointment and an annual declaration in the same way that Chief Officers and other individuals to which the test applies are.

Appraisal

Through the annual appraisal process, persons subject to the test will be monitored to ensure that they meet the requirements to hold the office of their appointment in terms of competence and skills; in the event that they do not, action will be taken by the Chief Executive and/or Trust Chair or relevant Chief Officer (and where appropriate in consultation with the Remuneration Committee). The TDA is responsible for undertaking the annual appraisal of the Chair and any issues identified during NED appraisals will be discussed with the TDA who will take appropriate action in conjunction with the Chair.

In addition to the above checks and on-going monitoring, staff subject to the test are required to make the annual declaration set out below in relation to their eligibility to carry out their role and meet requirements as defined by the Fit and Proper Person Test.

……………………………………………………………………………………………………………

Self-Certification

I declare that I am a Fit and Proper Person to carry out my role, I am of good character, I have the qualifications, competence, skills and experience which are necessary for me to carry out my duties, I am capable by reason of health of properly performing tasks which are intrinsic to the position, I am not prohibited from holding office (e.g. directors disqualification order), within the last 5 years I have not been convicted of a criminal offence and sentenced to imprisonment of 3 months or more, been undischarged bankrupt nor have been subject to bankruptcy restrictions, or have made arrangement/compositions with creditors and has not discharged it, nor is on any ‘barred’ list.

The legislation states, for those required to hold a registration with a relevant professional body to carry out their role, they must hold such registration and must have the entitlement to use any professional titles associated with this registration. Where the person no longer meets the requirement to hold the registration, and if they are a health care professional,

social worker or other professional registered with a health care or social care regulator, they must inform the regulator in question.

Should my circumstances change, and I can no longer comply with the Fit and Proper Person Test (as described above), I acknowledge that it is my duty to inform the Chair of University Hospitals Coventry & Warwickshire NHS Trust.

Name and job title/role……….…………………………………………………………………….

Professional registrations held…………………………………………………………………….

………………………………………………………………………………………………………..

Signature …………………………………………………………………………………………….

Date ………………………………………………………………………………………………….

Please return to Rebecca Southall, Director of Corporate Affairs [email protected]

mailto:[email protected]

PUBLIC TRUST BOARD MEETING TO BE HELD AT ON WEDNESDAY 29 JANUARY 2015 … Papers... · 2017. 9....

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