THE ROYAL BOURNEMOUTH AND CHRISTCHURCH …...Over performance in cardiology is explained by the...

BoD/Agenda 14.10.2011 Page1 of 2

THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NHS FOUNDATION TRUST

A meeting of the Board of Directors will be held on Friday 14 October 2011 at 8.30am in the Committee Room, Trust Management Suite, Royal Bournemouth Hospital

If you are unable to attend on this occasion, please notify me as soon as possible on 01202 704777.

Rebecca Lawry TRUST SECRETARY

A G E N D A APPENDIX

1. APOLOGIES FOR ABSENCE Brian Ford (A/L) Paula Shobbrook (A/L Fiona Stephenson attending)

2. MINUTES OF THE PREVIOUS MEETING (a) To approve the minutes of the meeting held on 9 September 2011 A

(b) To provide updates to the Actions Log B

3. MATTERS ARISING (a) None 4. PERFORMANCE (a) Performance Report Helen Lingham C (b) Financial Overview Stuart Hunter D (c) Transformation Programme Update Stuart Hunter Verbal (d) Monitor Quarter 1 Overview Helen Lingham E

5. DECISION (a) Winter Plan 2011/12 Helen Lingham F 6. DISCUSSION (a) Closer Collaboration with Poole Hospital Update Tony Spotswood Verbal 7. INFORMATION (a) Core Brief (September) Tony Spotswood G (b) Update of Health and Social Care Bill Tony Spotswood H (c) Cancer Peer Review Helen Lingham I (d) 2011/12 Strategy Tracker Q2 Update Richard Renaut J (e) CQC Report – Christchurch Hospital Fiona Stephenson K

BoD/Agenda 14.10.2011 Page2 of 2

(f) Communications Update (inc RAAI September) Richard Renaut L (g) Board of Directors Forward Programme Rebecca Lawry M 8. NEXT MEETING

Friday 11 November 2011 at 8.30am in the Committee Room, Trust Management Suite, Royal Bournemouth Hospital

9. ANY OTHER BUSINESS Key Points for Communication

10. COMMENTS QUESTIONS FROM THE GOVERNORS

Board Members will be available for 10-15 minutes after the end of the Part I meeting to take comments or questions from the Governors.

11. EXCLUSION OF PRESS AND PUBLIC AND OTHERS To resolve that under the provision of Section 1, Sub-Section 2, of the Public Bodies

Admission to Meetings Act 1960, representatives of the press, members of the public and others not invited to attend be excluded on the grounds that publicity would prove prejudicial to the public interest by reason of the confidential nature of the business to be transacted.

_____________________________________________________________________________________ BOD/PT 1 MINS 09.09.11 PAGE 1 OF 6

THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NATIONAL HEALTH SERVICE FOUNDATION TRUST

Minutes of a Meeting of the Royal Bournemouth and Christchurch Hospitals National Health Service Foundation Trust Board of Directors held on Friday 9 September 2011 in the Committee Room, Royal Bournemouth Hospital Present: Mrs J Stichbury

Mr T Spotswood Mrs H Lingham Mrs K Allman Ms P Shobbrook Mr B Ford Mr S Hunter Mr S Peacock Mr R Renaut Ms B Atkinson Mr K Tullett Mr D Bennett Dr M Armitage

(JS) (TS) (HL) (KA) (PS) (BF) (SH) (SP) (RR) (BA) (KT) (DB) (MA)

Chairman (in the chair) Chief Executive Chief Operating Officer Director of Human Resources Director of Nursing and Midwifery Non-Executive Director Director of Finance and IT Non-Executive Director Director of Service Development Director of Nursing and Midwifery Non-Executive Director Non-Executive Director Medical Director

In attendance:

Mrs R Lawry Tracey Hall Lynsey Woodward Mike Desforges Glenys Brown Ken Hockey Lee Foord Margaret Neville Eric Fisher

(RL) (TH) (LW)(MD)(GB) (KH) (LF) (MN)(EF)

Trust Secretary Head of Communications Locum Anaesthetics Consultant Public Governor Public Governor Appointed Governor Appointed Governor Chair of Friends of the Eye Unit Member of the General Public

Apologies: Mrs Alex Pike, Non Executive Director Mr David Bennett, Non Executive Director

76/11 MINUTES OF MEETING 8 July 2011 (Appendix A)

The minutes of the meeting held on the 8 July 2011 were received and accepted as a true record.

77/11 Actions Log (Appendix B)

(a) 70/11 (a) Inpatient Survey Results The inpatient survey results have been deferred until October.

(b) 70/11 (b) Governor Scrutiny Report The Governors scrutiny report will be brought back to the BoD in due course.

78/11 MATTERS ARISING

(a) Letter to the PCT


TS advised that a letter was sent to the PCT to advise them of the increase in elective and emergency activity. TS reported a mixed response. The PCT did not recognise why the activity was ahead of plan even though there had been prior discussion and explanation on the increase in activity. TS advised that a meeting is booked to discuss this with the PCT, but confirmed that this will move to arbitration if it is not resolved. TS hoped that formal action will be avoided and an amicable agreement reached. TS noted that it is important not to agree to waive the payment if the Trust is to avoid being put into this position again. BF noted that the Finance Committee have reviewed this and offer its full support. The Board also fully endorsed this position.

79/11 PERFORMANCE

(a) Performance Report (Appendix C)

HL introduced the report and highlighted the following items:

Outpatient and elective inpatients figures are up, but non elective numbers are down.

ED activity was up on the year, but down on July’s figures. TS noted that these figures reflect conversion rate increases rather than the notion that clinicians are being asked to treat more patients in order to generate greater revenue. HL noted the importance of viewing this as appropriate clinical practice rather than number crunching. MA noted a relentless increase in emergency admissions.

Infection control. Clostridium Difficile numbers were marginally over trajectory and work is underway to prevent future linked cases. August shows a return to normal figures and this is being monitored closely.

MRSA cases still stand at zero Cancer standards indicated issues over meeting the 62 day

target for the bowel screening. This does not relate to a large number of patients, but HL confirmed that it is being taken very seriously. Bowel screening is an issue due in part to the temporary suspension of the service, but also as a result of demand outstripping capacity. For the first quarter, HL confirmed that the Monitor governance standard will change to amber green from green. HL predicted that the green rating will not return until the 3rd quarter and Monitor has been informed. .

ED indicators are slowly moving to a green position. It has been hugely challenging to get the Symphony system as the main feed. Out of hours is most vulnerable due to not having SPR cover overnight. HL commented that RBCH is doing very well in the national picture.

DToC was positive for August. Further staff have been


allocated by Bournemouth and Dorset local authorities. TS noted that the Dorset delays have reduced drastically, HL noted that this is due to improved staffing.

Sickness absence is heading in the right direction. Overall trend in referrals - GP referrals are up in specific

specialities and stable in others and HL believes this will remain consistent.

Ophthalmology - GP referrals from Dorset have shown a decline in the last year, and an increase from Bournemouth and Poole.

Over performance in cardiology is explained by the spike in referrals at the beginning of the financial year.

Orthopaedic referrals have seen a drop from Dorset but growth in Bournemouth and Poole and this is a concern. HL noted that further resource will be needed to deal with these cases in line with 18 week requirements. RR noted that the flux is very difficult to manage. HL agreed and noted that lists change month on month to deal with the erratic referrals.

Dermatology, Cardiology and Orthopaedics are key in terms of meeting the NHS Constitution and there needs to be an increase in capacity to achieve this. These requirements would be communicated to the PCT

RR

(b) Financial Overview (Appendix D)

SH introduced the report and noted that activity is impacting on expenditure budgets. This puts significant pressures into the system, offset with underspend in corporate areas. EBITDA remains high at 9.4% which is good news. The NET surplus of the Trust remains at £2.8m. SH reported that the Trust dipped into amber on the Monitor capital indicator but he confirmed that the capital will be spent by the end of the year and the position will recover.

(c) Transformation Programme Update (Verbal)

SH reported good performance on the transformation programme. He noted that the focus has been on 2012/13. It will continue to be a challenge, but the organisation is rising to this. TS noted this is outstanding performance and this distinguishes RBCH from other local partners.

80/11 DECISION

(a) Board Performance and Objectives (Appendix E)


TS introduced the report, he noted that this has been shared with the Governors and received very good feedback. TS noted that the Trust had the 2nd highest level of over performance in terms of savings against plan in England and patient experience is good. HL noted the importance of this and commended the transparency of sharing through the public session of the Board. She suggested that as a Trust RBCH should celebrate the huge successes but also acknowledge where there is more work to do. TS introduced the 2011/12 objectives. PD suggested expanding number 11 to mention staff BF commented that number 1 should say continue to provide. Subject to the suggested amendments, the Board approved the objectives. RL advised that these objectives will go to the Governors meeting in October.

(b) Categorisation of Board Papers (Appendix F)

PS recommended the report to the Board and noted that it will help in providing evidence in the future for NHSLA. The Board recognised that it is important to look at how this can be used at committee level. KA suggested looking at this at the Executive meeting. KT suggested allocating these outcomes to the individual committees that report to Board. PS to take this fwd. The Board supported this and agreed to use the format in the future.

Agenda item for Execs PS

81/11 DISCUSSION

(a) Extending Patient Choice of Provider (Appendix G)

TS noted that in general, there will be fewer providers going forward. This, he noted will be significant for any potential merger, consideration by the CCP. It was also noted that if you generate choice, you generate competition. He highlighted the significance to RBCH and noted that the PCT are still struggling with how to give effect to the policy, without it costing too much. RR noted that the concern is that the cost will increase for the tax payer.

(b) Closer Collaboration with Poole Hospital Update (Verbal)


TS gave an update and noted that locally RBCH has been ahead

of the curve in anticipating a need to react to future pressures and events, he explained there was now a need to take action to rationalise and centralise services to maintain viable services going forward. This is particularly relevant for some of the surgical specialities as national reductions in the number of junior doctors allocated means that RBCH will find it more difficult to maintain the current pattern of provision. . TS advised that there are various meetings next week to look at closer collaboration or merger between RBCH and Poole Hospital. TS advised that he aims to bring back a paper in November to both Boards that sets out a suggestion for the way forward. This will either suggest steps for closer collaboration or alternatively advise that the two trusts need to work together to develop the case for merger. JS noted that all discussions and decision must bear in mind the quality of service to patients. TS agreed that the Board should look at the service provided to the conurbation of East Dorset rather than what is right for RBCH.

82/11 INFORMATION

(a) QIPP Contract Schedule (Appendix H)

The report was noted for information.

(b) Core Brief (Appendix I)

TS highlighted the HSJ awards RBCH has been shortlisted for.

(c) Monitor Feedback on RBCH Annual Plan (Appendix J)


(d) Communications Update (inc RAAI July/August) (Appendix K)


(e) Board of Directors Forward Programme (Appendix L)


(f) Meeting Dates for 2012


83/11 DATE OF NEXT MEETING


Friday 14 October 2011 at 08.30am, Committee Room, Royal Bournemouth Hospital

84/11 ANY OTHER BUSINESS

JS thanked TS and TH for the Staff Awards.

3 Communications points for staff

1. Closer collaboration 2. Performance and financial 3. Board objectives.

85/11 QUESTIONS FROM GOVERNORS 1. LF raised concerns over RBCHs involvement in spinal surgery as it was raised on Radio Solent. TS noted that RBCH will tender again if it is possible to agree on some amendments to the specification. The tender will be made jointly with Poole Hospital with some reliance on Southampton Hospital. If the PCT takes the view that it wants a predominantly surgical service rather than the model that would be advocated by our physicians and surgeons, then RBCH would not tender for the service at this time.

_____________________________________________________________________________________ BOD/PT 1 Actions Log: 09.09.11 PAGE 1 OF 1

THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS NATIONAL HEALTH SERVICE FOUNDATION TRUST

Actions carried forward from a Meeting of the Royal Bournemouth and Christchurch Hospitals National Health Service Foundation Trust Board of Directors held on Friday 9 September 2011. 79/11 PERFORMANCE

(a) Performance Report (Appendix C)

Dermatology, Cardiology and Orthopaedics are key in terms of meeting the NHS Constitution and there needs to be an increase in capacity to achieve this. These requirements would be communicated to the PCT

RR

80/11 DECISION

(b) Categorisation of Board Papers (Appendix F)

PS recommended the report to the Board and noted that it will help in providing evidence in the future for NHSLA. The Board recognised that it is important to look at how this can be used at committee level. KA suggested looking at this at the Executive meeting. KT suggested allocating these outcomes to the individual committees that report to Board. PS to take this fwd. The Board supported this and agreed to use the format in the future.

Agenda item for Execs PS

THE ROYAL BOURNEMOUTH AND CHRISTCHURCH HOSPITALS

NHS FOUNDATION TRUST

BOARD OF DIRECTORS Meeting Date and Part:

14 October 2011 (Part 1)

Subject:

Performance Report

Section:

Performance

Executive Director with overall responsibility:

Helen Lingham, Chief Operating Officer

Author of Paper:

David Mills, Head of Information

Summary:

Monthly review of performance against DoH targets

Standards for Better Health domain:

Governance

Action required by Board of Directors:

Note for information

Board of Directors 14 October 2011 (Part 1)

Performance Monitoring Page 1 of 4 For Information

Performance Exception Report 2011/12 - October

1 Purpose of the Report

This report accompanies the Performance Indicator Matrix and outlines the Trust’s performance exceptions against key access and performance targets for the month of August 2011, as set out in the Monitor Compliance Framework and Operating Framework requirements.

2 Clostridium Difficile

In August there were 5 C. Difficile cases against a target of 8. For Quarter 2 we currently have 19 against a quarter trajectory of 25 and September incidence is being closely monitored.

3 Cancer Performance against Cancer Access Targets

The delays in the Bowel Cancer Screening Programme (BCSP) colonoscopies have continued to impact on the ‘62 day screening to treatment’ target. In July this has resulted in an achievement of 71.4%, below the target of 90%. This impact will continue to be seen in August and September and therefore, we do not expect to meet the target for Quarter 2. However, as a result of the BCSP’s recovery plan, the colonoscopies have now been restored to within two weeks and therefore, we currently expect to meet the target again from Quarter 3. We are also working with the PCT and the BCSP Lead Trust on plans for the anticipated increase in ‘take up’ when the national bowel cancer campaign commences in January 2012. This will also impact on fast-track referrals to our Gastroenterology, Colorectal and Endoscopy services and plans for additional capacity are underway. A comprehensive review of cancer target management has been undertaken and this is being backed up by an internal audit review as well.

4 Emergency Department Quality Indicators

With effect from Q.1 (DoH & Monitor)

Timeliness

Meeting the Clostridium Difficile objective



Total time in A&E (95%) – 4 hours In addition with effect from Q.2 (DoH only) Timeliness

Total time in A&E (95th percentile) – 4 hours Time to initial assessment (95th percentile) – 15 mins Time to treatment decision (median) – 60 mins Patient Impact Unplanned re-attendance rate - < 5% Left without being seen - < 5%

Reporting Requirement - tbc

Service experience – tbc Ambulatory care – tbc Consultant sign-off - tbc

The July performance against the quality indicators has been updated in the Matrix to reflect the final validated position. Total time in the department (95th percentile) and time to treatment decision (median) were amber in July. Overall the action plan is seeing improvements in a number of areas and together with the work on the validation process, we are continuing to see ongoing improvement in the performance. The August position is draft and this data continues to be validated prior to the final report being available in October. ED attendances and CDU admissions have increased compared to August 2010 and CDU admissions in particular are remaining high.

Admissions to RBCDU 2010/11 2011/12 % Change

April 1656 1952 17.9%

May 1747 1999 14.4%

June 1673 1901 13.6%

July 1873 1995 6.5%

Main ED Attendances 2010/11 2011/12 % Change

April 4238 4266 0.7%

May 4499 4705 4.6%

June 4360 4357 ‐0.1%

July 4863 4848 ‐0.3%

August 4551 4741 4.2%



August 1724 1939 12.5%

5 Stroke Indicators

Performance against Stroke Best Practice Tariff and Network indicators

Although 91% of patients were directly admitted to the Stroke Unit, admission within 4 hours has further reduced to 60% in August. This reduction is partly due to a change to reporting on discharge rather than admission. There is also evidence to suggest that the changeover of junior doctors in August, their awareness of as well as continued refinement of the internal stroke referral pathway contributed to this position, exacerbated by more than 50% of patients arriving out of hours. The low risk TIA measure has also now been included within the report, currently showing as amber with 80% (8) of patients being assessed within 7 days. One of these was due to a post 7 day GP referral and the other was a faxing error. This measure is included within the PCT contract although does not form part of the best practice tariff requirements. Ongoing month on month review and improvement work continues by the team on all of the Stroke measures, linked to the Stroke Network.

6 Bowel Cancer Screening

Patients with positive screening test undergo a colonoscopy within two weeks of the Specialist Nurse clinic appointment and GRS ratings meet JAG accreditation requirements

As stated above, the BCSP has now restored the colonoscopy waiting times to within 2 weeks, in line with the national standard. However, we continue to discuss with commissioners how the longer term action plan for capacity and managing demand can be implemented, particularly in the context of the national bowel cancer campaign which commences in January 2012.

7 Appraisals

90% of appraisals completed within one year

Compliance with the Trust’s annual appraisal target has improved in August to 88.6% from 85.5% in July.



8 Recommendation

HELEN LINGHAM CHIEF OPERATING OFFICER

The Board of Directors is requested to note the performance exceptions to the Trust’s compliance with the 2011/12 Monitor and Operating Framework requirements.

2011-2012 PERFORMANCE INDICATOR MATRIX for BOARD OF DIRECTORS

Indicator Measure Internal Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12

Referral to Treatment Waiting Times

Admitted (95th percentile) 18 weeks from GP referral to 1 st treatment – aggregate level 23 wks 17.4 17.1 17.7 17.8 17.9

Non Admitted (95th percentile) 18 weeks from GP referral to 1 st treatment – aggregate level 18.3 wks 13.2 13.4 13.9 13.8 13.0

Admitted (median) 18 weeks from GP referral to 1 st treatment – aggregate level 11.1 wks 5.4 5.8 5.4 5.3 5.2

Non Admitted (median) 18 weeks from GP referral to 1 st treatment – aggregate level 6.6 wks 3.6 4.6 3.9 3.6 3.3

Infection Control

MRSA Bacteraemias Number of hospital acquired MRSA cases (Target 6 with a stretch target of 2) 6 0 0

Clostridium difficile year on year reduction Number of hospital acquired C. Difficile cases (Target 87 with a stretch target of 44) 87 14 5

Cancer ¹

2 week wait 93% 93.02%

2 week wait for symptomatic breast 93% 98.70%

31 Day – 1st treatment 96% 96.20%

31 Day – subsequent treatment 98% 100.00%

62 Day – 1st treatment 85% 94.90%

62 day – Consultant upgradeAlthough this measure is no longer required by Monitor, it remains within the Operating Framework although the PCT target has yet to be confirmed. This will continue to be included in the Board report following confirmation of the agreed target .

90% 100.00%

62 day – screening patients 90% 71.40%

¹ Note: monthly performance data will be replaced with quarterly figures once signed off

E.D. Quality Indicators and 4 hour time to treatment target ²

Time to treatment 4 hour target (95%) Percentage of patients treated within 4 hours 95% 95.7%

Unplanned Reattendance Rate Percentage of patients reattending A&E within 7 days < 5 % 4.3%

Total Time in A&E (95th percentile) Total time spent in A&E Deprtment (hrs) < 4 hrs 05:11

Left Department Without Being Seen Percentage of patients who left department without being seen < 5 % 4.1%

Time to Initial Assessment (95th percentile) Time patients waited to be assessed (Ambulance Arrivals) < 15 mins 00:11

Time to Treatment Decision (median) Time patients waited to be treated (all) < 1 hr 01:02

Ambulatory Care tbc tbc tbc tbc tbc tbc

Service experience tbc tbc tbc tbc tbc tbc

Consultant Sign-off - Type 1 OnlyPercentage of patients presenting at A&E sites in certain high risk categories who are reviewed by an emergency medicine consultant before being discharged

tbc tbc tbc tbc tbc tbc

² Note: the ED quality Indicators (except the 4hr 95% target) are no longer reportable to Monitor in 2011/12 and the final validated position for August will be available in October

Stroke ³

TIA High Risk Patients High risk TIA cases investigated and treated within 24hrs 60% 62% 75% 61% 64% 63%

TIA Low Risk PatientsPercentage of low risk patients seen, assessed and treated by a stroke specialist within 7 days of contact

100% not avail not avail not avail not avail 80%

Brain Imaging – as per indications Patients with acute stroke meeting the indications receive brain imaging within 1 hr ⁴ tbc – 95% not avail not avail not avail not avail not avail

Brain Imaging – other stroke Other stroke patients receive brain imaging within 24 hrs ⁵ 100% 94% 100% 100% 95% 99%

Direct Admission to Stroke Unit Patients with suspected stroke are admitted to a specialist stroke unit within 4 hrs of arrival ⁶ tbc – 90% 63% 71% 71% 62% 60%

Alteplase (Thrombolysis) Percentage of appropriate patients receiving thrombolysis ⁷ 100% 13% 7% 6% 100% 100%

90% Time Spent on Stroke Ward%age of patients spending 90% or more of their time on the stroke ward during their inpatient stay ⁸

80%-inc in Q4 to 90% by Mar-

1285% 95% 98% 89% 89%

³ Stroke f igures are based on Vital Signs Monitoring Return guidance and not Payment by Results Best Practice guidance and as from July data is based on discharge⁴ The stroke best practice tariff requires imaging within 1hr. Network aspirations are for 30mins and therefore, the PCT target is under discussion.

⁵ The stroke best practice tariff requires imaging within 24 hrs. Network aspirations are for 12 hrs and therefore, the PCT target is under discussion.

⁶ The stroke best practice tariff requires direct admission within 4 hrs. Network aspirations are 45 mins linked to thrombolysis assessment and therefore, the PCT target is under discussion.

0

93.97%

99.45%

97.40%

100.00%

85.28%

95.65%

73.68%

11

vrbhinfo / performance management / board tmb / 2011-2012 / Oct 2011 Pt 1 Performance App 1 Page 1 of 3

Indicator Measure Internal Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12⁷ Quarter 1 figures are based on the % of total patients, from July onwards its based on % of appropriate patients.

⁸ The Monitor and Operating Framework stroke indicator is yet to be confirmed but it is anticipated that this measure is likely to feature.


Indicator Measure Internal Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12Other Quality & Performance Targets

Mixed Sex Accommodation Breaches No of patients affected by a breach of the mixed sex sleeping accommodation requirement 0 6 0 10 0 0

Bowel Cancer Screening To meet the current minimum standards set by the BCSP tbc

Workforce

Attendance Percentage of monthly sickness by directorate 4%-3% stretch 3.1% 3.3% 3.3% 3.4% 3.3%

Attendance Percentage of cumulative sickness by directorate (rolling 12 months) 4%-3% stretch 4.0% 3.9% 3.2% 3.8% 3.7%

Appraisals Percentage compliance with annual appraisals 90% 84.5% 87.3% 85.5% 88.6%

Delayed Transfers of Care

Delayed Transfers of Care Delayed transfer of care levels as per Heads of Terms (attributable) 10 6 14 16 14 7

Venous Thromboembolism

VTEThe number of adult hospital admissions who are being risk assessed for Venous Thromboembolism (VTE) to allow appropriate prophylaxis based on national guidance from NICE (Target 90%)

90% 94.6% 94.7% 94.1% 94.0% 93.0%

Cancelled Operations

<= 0.8% Canx Ops / Elec

Admissions0.58% 0.63% 0.52% 0.38% 0.72%

<= 5% Breaches /

Canx Ops 28 Day

Guarantee

0.0% 0.0% 0.0% 0.0% 2.6%

Cancelled OperationsAll patients cancelled on the day of admission or after admission for non-medical reason to be admitted for treatment within 28 days or have their treatment funded at the time and hospital of the patient’s choice




BOARD OF DIRECTORS Meeting Date:

14th October 2011, Part I

Subject:

Financial Performance

Sections:

Performance


Stuart Hunter, Director of Finance & IT

Author of Paper:

Pete Papworth, Deputy Director of Finance

Summary:

Review of the Financial Performance for Month 5 2011


Governance


Note for Information

Board of Directors October 2011

Financial Performance Page 1 of 2 For information

Financial Performance

1. Introduction

This report summarises the Trust’s top-level performance for August 2011. This includes patient activity, income and expenditure and key financial indicators.

2. Overview

The cumulative position for the Trust as a whole is a favourable one, with income above plan and expenditure variances being only marginally above plan at 0.26%. The Trusts positive position continues and demonstrates overall stability in the management of the budgets; however pressures are evident as a result of significantly increased activity over plan.

3. Activity

Whilst August has been a quieter month for the Trust, over activity has still been apparent. Year to date inpatient over-performance currently stands at 693 (2.8%). Non-elective spells and outpatient activity remain significantly above plan, with respective variances of 2,638 cases and 4,950 attendances to date. Emergency department attendances also remain above plan by 1,964 attendances (7.2%), which is consistent with previous months.

4. Income

Income overall was ahead of plan in August by £141k, bringing the year to date income over achievement to £2.2 million. A significant proportion of this (£1.1 million) relates to cardiology, continuing the trend seen in previous months.

5. Expenditure

Expenditure in August was maintained within budget, recording a modest favourable variance of £113k. This is reflective of a quieter month, and brings the year to date expenditure variance to £247k adverse.

6. Summary Financials

Key Performance Indicators (KPI’s)

Earnings Before Interest, Taxation, Depreciation and Amortisation (EBITDA)

The EBITDA ratio is one of the key KPI’s the Foundation Trust is monitored against and shows a 9.8% return YTD against the quarterly target of 5.8%. The Trust remains on target to deliver a full year forecast of 5.9%. In terms of the Monitor financial risk rating; this performance combined with other indicators in the matrix translates to a financial rating of 5 and compares with a planned rating of 3. The highest rating is 5.

Board of Directors October 2011

Financial Performance Page 2 of 2 For information

Net Surplus

The net surplus in August is recorded at £1,149k against the planned surplus of £895k. This brings the year to date position to a net surplus of £3,967k. This is reflective of the significant levels of over activity seen year to date.

Transformation Programme (TP)

The recorded savings to date total £3,166k against a target of £3,208k. The Project Management Office continues to work with Directorates to embed the identified schemes.

Capital expenditure

Expenditure is currently under target, standing at £2,171k against a year to date plan of £3,145k. The significant under spend to date is expected to correct itself in September due to current progress against a number of ongoing schemes, however progress will need to be monitored closely to avoid further slippage.

7. Workforce

Staffing numbers continue the previous year’s trend and are currently below establishment by 145 WTE’s (3.96%). Sickness levels were 3.7% in month, being on trajectory for the year.

8. Monitor Risk Indicators The majority of indicators are green, however the following indicators are rated as amber: Capital expenditure: this is currently less than 75% of plan, however as noted

above, this position is expected to be corrected during September. Debtors: the current significant outstanding balance with Poole Hospital is the

main driver, meaning that this indicator is currently rated amber. However, a productive meeting was recently held with Poole Hospital, which is expected to improve this position during Month Six.

9. Recommendation The Board is invited to consider and note this report.

Pete Papworth Head of Management Accounting September 2011

ACTIVITY 2011/12YTD

2010/11 Actual YTD Plan YTD Actual

YTD Variance

Full year plan

Full year forecast

Forecast vs plan

variance

Planned same day / day cases 19,560 19,692 20,482 790 47,747 47,747 0Elective spells 4,922 4,870 4,773 -97 11,808 11,808 0Non elective spells 11,845 10,607 13,245 2,638 25,373 25,373 0Outpatient attendances 103,730 110,280 115,230 4,950 267,394 267,394 0Outpatient Pre assessment 0 8,114 9,736 1,622 19,675 19,675 0ED attendances 29,126 27,342 29,306 1,964 65,406 65,406 0

INCOME 2011/12YTD

2010/11 Actual YTD budget YTD actual Variance

Full year budget

Full year forecast

Forecast vs budget

variance

£000 £000 £000 £000 £000 £000 £000Planned same day / day cases 14,338 13,588 14,302 714 32,946 32,946 0Elective spells 14,731 14,379 14,087 -292 34,864 34,864 0Non elective spells 21,934 21,451 21,886 436 51,313 51,313 0Outpatient attendances 13,122 14,096 14,337 241 34,177 34,177 0ED attendances 2,182 2,093 2,138 45 5,006 5,006 0Cost and volume 7,358 8,530 9,507 978 20,869 20,869 0Block 8,255 8,172 8,172 -0 19,613 19,613 0MFF 3,338 4,245 4,278 34 10,242 10,242 0Interest receivable 161 167 177 10 400 400 0Non contracted 10,524 9,337 9,328 -10 21,486 21,486 0Total 95,943 96,056 98,212 2,156 230,916 230,916 0

EXPENDITURE 2011/12YTD

2010/11 Actual YTD budget YTD actual Variance

Full year budget

Full year forecast

Forecast vs budget

variance

£000 £000 £000 £000 £000 £000 £000Pay 57,247 58,069 57,153 917 138,549 138,549 0Drugs 8,812 8,641 9,394 -752 20,799 20,799 0Clinical supplies 14,166 12,919 13,414 -495 30,854 30,854 0Other costs 7,682 8,559 8,462 97 26,273 26,273 0Depreciation 3,494 3,739 3,697 42 8,973 8,973 0Dividends payable 2,035 2,070 2,125 -55 4,968 4,968 0Total 93,436 93,997 94,245 -247 230,415 230,415 0

OTHER FINANCIALS 2011/12YTD

2010/11 Actual YTD plan YTD actual Variance

Full year plan

Full year forecast

Forecast vs plan

variance

£000 £000 £000 £000 £000 £000 £000EBITDA 7,875 7,701 9,613 1,912 14,042 14,042 0EBITDA margin 8.2% 5.8% for Q2 9.8% 4.0% 5.9% 5.9% 0Net surplus / (deficit) 2,507 2,058 3,967 1,908 501 501 0Transformation Programme 2,650 3,208 3,166 -42 7,879 8,714 835Capital expenditure 1,559 3,145 2,171 974 9,611 9,611 0

STATEMENT OF FINANCIAL POSITION 2011/12YTD

2010/11 Actual YTD actual

Full year plan

Full year forecast

Forecast vs plan

variance

£000 £000 £000 £000 £000Non Current Assets 144,648 148,226 150,399 150,399 0Current assets 49,165 59,125 45,267 45,267 0Current and Non Current liabilities -25,558 -26,280 -18,485 -18,485 0Total assets employed 168,255 181,071 177,181 177,181 0Public dividend capital 78,674 78,674 78,674 78,674 0Income and expenditure reserve 17,652 26,295 22,829 22,829 0Revaluation reserve 65,957 69,326 69,325 69,325 0Donated asset reserve 5,972 6,777 6,353 6,353 0Total funds employed 168,255 181,071 177,181 177,181 0

WORKFORCE 2011/12YTD

2010/11 Actual Establish ment Actual Variance

Full year plan

Full year forecast

Forecast vs plan

variance

Staff (whole time equivalents) 3,515 3,660 3,515 145 3,678 3,678 0Sickness rate 3.8% 3.7% 3.7% 0.0% 3.0% 3.0% 0.0%Turnover rate 10.3%

The Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust - Summary Performance Report as at 31 August 2011

Proposed indicator

Potential financial weakness

Q1 2011/12

Plan

Q2 2011/12

Plan

Q3 2011/12

Plan

Q4 2011/12

Plan

2011/12 Month 5 Actual

Unplanned decrease in Earnings before Interest, Tax, Depreciation & Amortisation (EBITDA) margin in two consecutive quarters

Deteriorating trend in operating performance and cash flow generation

Quarterly self-certification by trust that the Financial Risk Rating (FRR) may be less than 3 in the next 12 months

Identified risk of potential financial breach within the next year

FRR 2 for any one quarter In year deterioration in financial performance

Working capital facility (WCF) agreement includes default clause. This will require all trusts to review their WCF agreements.

Risk that WCF, whilst included in calculation of liquidity days for the purpose of FRR, may not be available if and when required e.g. FRR 1 or 2.

Debtors more than 90 days past due account for more than 5% of total debtor balances

Potential for payment / debtor collection concerns

Creditors more than 90 days past due account for more than 5% of total creditor balances

Potential for build up in creditors, resulting in future liquidity concerns

Capital expenditure is less than 75% of plan for the year to date

Capital expenditure plans are delayed to conserve cash

Quarter end cash balance less than 10 days of operating expenses or less than £4 million.

Potential liquidity concerns and ability to meet liabilities as they fall due

Interim Finance Director in place over more than one quarter end

Absence of permanent / substantive appointment to key position

Two or more changes in Finance Director in a twelve month period

Multiple changes in a short period of lead financial officer





Subject:

Monitor Quarter 1 Report 2011/12

Section:

Performance



Author of Paper:


Summary:

To present the results of the Monitor Quarter 1 report


Governance


For information


Monitor Quarter 1 2011/12 Results Page 1 of 1 For Information

Monitor Quarter 1 Results 2011/12

1 Summary I am pleased to confirm we have received formal notification from Monitor regarding Q1 performance as follows: Financial risk rating - 5 Governance risk rating – Amber/Green

2 Recommendation


The Board of Directotors is asked to note the above for information.





Subject:

Winter Plan 2011/12

Section:

Decision



Author of Paper:

BJ Waltho, Associate Director of Operations

Summary:

To seek approval of the plans the Trust proposes to put in place to cope with winter pressure 2011/12


Clinical and cost effectiveness Patient focus Accessible and responsive care


For decision


Winter Plan 2011/12 Page 1 of 4 For decision

Winter Plan 2011/12

1 Introduction The Trust’s Plan sets out the actions being put in place to ensure that essential services are maintained including the delivery of elective workload and achievement of performance targets over the winter period. The Trust has been building on the lessons learnt each year to ensure that the Winter Plan is progressive and current. Our experience demonstrates that emergency activity increases, patients are sicker and our partner organisations are not always able to respond to the demands made upon them during this period.

2 Winter Plan 2010/11

The Trust coped well with the additional demands experienced last winter despite the background threat of Pandemic Flu and a reduced bed base due to reconfiguration and relocation of services. The progress made by the Trust’s Length of Stay Steering Board and the actions undertaken also complimented the way the Trust managed the additional pressures. The main action for the Winter Plan was the opening of twenty-eight additional beds on the Christchurch site. This was predominantly for patients with delayed transfers of care or awaiting further assessment. Other measures introduced last year were: A Rapid Response Therapy Team Increase into Clinical Site Team Triage Bay on Surgical Admissions Unit Improved discharge planning Improved length of stay Additional portering staff Enhanced REDS service

Measureable improvements were made around Infection Control across the Trust. Data clearly demonstrated that the number of closed beds was significantly reduced from previous years. The number of cancelled operations due to lack of beds was negligible and an improvement on previous years. In addition, regular meetings with the Trust, PCT and Social Services (SPRIG) had also developed a better understanding of the issues. The Trust has been fully engaged in the development and use of the county’s Capacity Management System (CMS). Unfortunately the full benefits of the system have not yet been realised due to insufficient partnership working and co-ordination of response to bed pressures in Acute Trusts.



3 Winter Plan 2011/12

The key focus of this year’s plan, as developed by the Trust’s Service Delivery Group, is to cohort eighteen unfunded beds currently available in Surgery. Presently there are three six bedded bays across three wards that are used infrequently to cope with peaks in admissions. Surgery will be reconfiguring their bed base to release this capacity which will result in Ward 8 being available for medical patients during winter pressures. Having the beds in one area has advantages both for patient flow and patient care. The ward will be made available for medical patients for a period of three months starting on the 1st January 2012. This is a reduction in the number of beds made available last year but is a reflection in improvements in length of stay across the Trust.

4 Other Initiatives

4.1 Enhanced OPAL service The aim is to provide an enhanced 7 day service in ED and AAU as well as enabling wider coverage outside of these areas if required.

4.2 Increase support into Clinical Site Team An additional fulltime Band 6 Nurse will be incorporated into the Clinical Site Team over the winter period. This is a specific post to enhance the resilience of the Clinical Site Team and to ensure the availability of H@N Bleep over the entire weekend. This will also support junior doctors with their workload.

4.3 Ward based Discharge Planners

The plan is that there will be a designated Discharge Planner identified on each of the medical wards throughout the winter period. This will improve communication with outside organisations, patients, and families thereby improving patient flow.

4.4 Additional Porter This porter will work specifically between ED and X-ray to ensure efficient flow of patients between the two departments. This porter can also be designated to support AAU when the new emergency patient pathways come to fruition.

4.5 Frequent Attender Project Funds will be made available from October to support this project initially piloted by Dr James Stallard and the Gastro team. The early results showed significantly reduced admissions by this specific client group with associated cost savings

4.6 Gastroenterology Nurse Project The aim of this project is to provide an urgent investigative GI service to specific groups of patients. The pilot will provide next working day access



to a nurse led clinic supported by a Consultant Gastroenterologist. The objective being to reduce admissions and lengths of stay.

4.7 Directorate based projects

Initiatives being carried out by various directorates will further support the Trust’s ability to manage over the forthcoming winter period. These include: The new Emergency Care Pathways Rapid Assessment Clinics at Christchurch Enhanced Recovery Project Transfer team for patients using the Discharge Lounge Early Supported Discharge Team for Stroke patients Early Supported Discharge Team for Orthopaedic patients Investigations Unit for one day and short stay investigation patients Alcohol Nurse Specialist to reduce re/admissions and LoS 7 day ward therapy Directorates have been asked to identify specific plans they have within their own wards and departments to deal with the increased activity over the winter period.

5 PCT Initiatives

The PCT have been developing their Integrated Seasonal Escalation Pandemic Influenza Plan. This has been done in conjunction with the three acute Trusts, NHS Dorset, SWAST and the local authorities. The approved plan should be available by the end of September. The use and reliance of CMS is expected to be a key focus, thereby achieving its key objective which was the escalation of all services across the local health community in times of bed crisis. The Trust is working with the SPRIG and the Unscheduled Care Services Delivery Group to progress a number of initiatives. These include:

Spot purchase of beds at Broadwaters Increased capacity within Intermediate Care Increasing capacity within community hospitals 7 day working from Intermediate Care teams and Social Services Closer integration of Dorset and Bournemouth Social Service teams Optimising care closer to Home by upskilling staff within community

services Enhancing out of hours service provision Supporting South West Ambulance Service with its project to reduce

conveyances to hospital by 10%



6 Social Services Initiatives

Social Services continue to be a concern in the planning for winter. The Trust has worked hard to try to seek their engagement in finding solutions to their response times and delays in progressing patients. Discussions continue with both Dorset and Bournemouth about increased provision of packages of care and access to Nursing Home placements, especially EMI.

7 Finance

A total of £350,000 has been identified to support winter planning. This is the same amount as last year. The majority of the budget will be used to support the opening of the eighteen additional beds with the remaining being used to support the initiatives as detailed above.

8 Conclusion

Winter always brings challenges to the Trust. These include managing more acutely ill medical patients, the potential of a Norovirus and pandemic flu and the limited ability of Social Services and Community Services to cope with increased demand. The location of the entire Trust’s bed base on one site is seen as a very positive step and will significantly improve patient flow and length of stay during the forthcoming winter.

This proposed plan builds on previous years’ experience and actions. In addition it incorporates lessons learnt and, in so doing, provides the Trust the best opportunity to manage winter pressures effectively and protect elective activity. This plan will be regularly reviewed and modified if required as we progress through the winter period.

9 Recommendation


The Board of Directors is asked to approve the plan for winter 2011/12.




14 October 2011 Part I

Subject:

Core Brief

Section:

Information


Tony Spotswood, Chief Executive

Author of Paper:

Tracey Hall, Head of Communications

Summary:

The Core Brief distributed within the Trust in September 2011


N/A

Action required by Board of Directors

Note for information

Core BriefSeptember 2011 From: Tony Spotswood, Chief Executive

winners announced

This month we are joined by Paula Shobbrook, Director of Nursing. Paula brings with her a wealth of knowledge from working in various positions in the NHS, most recently as the Director of Nursing at Winchester Hospital where she worked for ten years.In this role, Paula is the professional lead for nurses, midwives and allied health professions and her executive portfolio includes infection prevention and control, safeguarding adults and children and patient experience. Hampshire-born Paula qualified from Southampton in 1991 and went on to work as a ward sister in acute medicine, cardiac and respiratory specialties. She also spent some time working as a manager in a Primary Care Group before moving back to into a hospital setting.Paula said: “I’m interested in leading patient safety and ensuring high quality patient care. I can’t do that from the office so I will be out and about as much as I can be, speaking to staff and patients. This will be a key part of my role as I will be leading on patient experience.“This was a great move for me, to a large, successful Foundation Trust, and I’m really looking forward to working with everyone.”.

New director of nursing20 1 1 Staff

Excellence AwardsThere were more than 100 nominations for the awards this year, so congratulations to everyone who was nominated and shortlisted.

The winners for each of the award categories were:

Award for Putting Patients First: Sara Graham, Rehabilitation Assistant, Christchurch Day Hospital

Award for Patient Safety: Critical Care Outreach Team

Customer Care Award: Chris Bailey, Acute Admissions Unit

Award for Leadership: Sister Gibson, Clinical Leader, Ward 17

Award for Transformation or Innovation: Rachel Richardson with Andrew Duncan and Jacqui Bowden, Pharmacy

Team of the Year Award: Stroke Team for Stroke Thrombolysis

Award for Going the Extra Mile: Endoscopy Decontamination Team

Unsung Hero Award: John Warren, Volunteer Stroke Rehabilitation Unit

Chairman’s Award: Sarah Graham

Mentor Awards 2011: Fiona Campbell, Day Hospital and Margaret Mangles, Ward 11

The full list of winners and pictures of the evening can be seen in the September/October edition of Buzzword.

Environmental SurveyWant to know how you can make your area, department or ward more sustainable? Why not request an environmental survey? The survey will take about 40 minutes to one hour, and a report will then be produced to record the findings. A copy of the report will then be returned to your department, a copy will be kept by the Sustainability Manager, and all maintenance issues reported to the docket line. To request an Environmental survey please email laura.skinner @rbch.nhs.uk Laura Skinner, Sustainability Manager

As you will know, work is taking place to explore closer collaboration with Poole Hospital NHS Foundation Trust, including the option of a merger. During this week (week commencing 12th September), a series of meetings are taking place with representatives from both organisations board of directors, clinicians and governors. Following these meetings a further update will

be issued. Further joint meetings will take place in October, with a report due from our independent consultants exploring this work with us, McKinsey, in November. Should the report recommend that further work is carried out leading to a potential merger, both Trusts will carry out staff, public and stakeholder consultation.

Update on joint working

The Trust’s Annual Report, Quality Report and Annual Accounts are now available to view on the Trust’s website.www.rbch.nhs.uk/index.php?id=78

Annual report online

Implementation of the Short Stay Unit ProjectFollowing the successful pilot of the Medical Investigations Unit, the Short Stay Unit project started in July 2011 to provide a dedicated short stay investigation/treatments area that would be accessed by all directorates based on the requirements of the different services.Michelle Dixon, General Manager Surgical Directorate and Maternity Services, has led the project with engagement and support from key personnel from the areas involved. The project, which started on Monday 5th September, will see:• A large cohort of patients

requiring medical investigation procedures being cared for on the Derwent facility from Monday to Wednesday, when orthopaedic demand is reduced

• The hepatology nurse specialist-led day treatments transferring to the Derwent facility on a Tuesday and

Wednesday, along with the nurse specialist team

• The remaining cohort of medical patients requiring short stay investigations/treatments cared for within Day Surgery Services accommodation, such as the Sandbourne Suite and/or Short Stay Unit (Ward 12)

• The current service provided by the Short Stay Unit team (Ward 12) for elective day case, surgical and orthopaedic patients will continue with gradualincreasedflexibilityofadmission criteria, in association with revised protocols and improved staff training

• The Short Stay Unit (Ward 12) will open from 7am Monday through to 1pm Saturday (except bank holidays), to provide additional capacity and flexibilityforelectivesurgical/orthopaedic services

• The recovery area on Sandbourne Suite will increase itsflexibility/utilisation particularly for surgical elective patients who are undergoing procedures in main theatres and require day case care

A detailed information pack will be distributed to the Clinical Directors and General Managers for each directorate involved, to disseminate.A review of the project implementation will take place in October 2011.I would like to take this opportunity to thank all of the teams involved for their continued enthusiasm for the project to improve the patient pathway and experience.Michelle Dixon, General Manager, Surgical Directorate and Maternity Services

Staff are celebrating success after the year-to-date results of the Real Time Patient Feedback showed steady improvement in several areas across the Trust.In August 2010, the Trust started an innovative scheme, Real Time Patient Feedback, which sees a team of highly committed volunteers carry out interviews with patients using Personal Digital Assistant (PDA) technology across 14 pilot areas. This feedback, taken monthly, measures how inpatients rate their experiences at the Trust, and improvements are put in place according to what the patients tell us.The Trust does this in order to ensure our patients’ experiences are the best they can be, so we can pick up on any areas that may need improvement as soon as possible. This is just one of the 15 ways for patients to provide feedback to the trust. In the last year, our volunteers have managed to speak with morethan2,500inpatientstofindout more about their experiences whilst under the care of the Trust, to establish what we do well and what we can improve.The questionnaire covers topics such as cleanliness, staff attitude and communication, respect and dignity and pain management, as well as standard demographics.Previously, the Trust was marked down because patients were not receiving copies of letters sent from hospital doctors to their GPs. Changes were made to the discharge process and staff have

been trained to ensure that patients on discharge, wherever possible, receive a copy of the letter.Patients said that they were not given enough opportunities to give feedback - the Trust reviewed this and we now have more than 15 ways for patients to give feedback. Patients are provided with a bookmark which tells them about the variety of ways they can provide feedback. Consequently, in the last year, the number of patients saying they were not given enough opportunities to give feedback has fallen from 19 to 9%.Some of the other improvements shown in the year-to-date feedback were:• Continued high levels of respect

and dignity - 94% of patients agreed this ‘always’ happened

• Continued levels of cleanliness - 99% of patients rated ward / room cleanliness as ‘very’ or ‘fairly’ clean

• Patients continue to feel safe on wards - 95% agreed that they felt ‘very safe’ on wards

• 94% rated care as ‘excellent’ or ‘very good’

• 89%ofpatientswould‘definitely’recommend the hospital to family and friends

Areasidentifiedwithroomfor improvement were:• Disturbanceatnight-twofifths

of patients still report being disturbed by noise at night, with 78% saying the cause was other patients and 39% saying staff as well

• Compassionate care - 15% of patients reported that they could notfindsomeoneonthe hospital staff to discuss their worries and fears with. The year-to-date results show that more than 240 patients who had worries and fears reported notbeingabletofindamemberof staff to discuss them with, so this will become a focus for improvement going forward.

This technology enables the Trust to capture patient feedback on a continuous basis, quickly highlighting areas of need as well as feeding back positive news to the Trust.We have a great team of volunteers who give up their time to carry out these surveys, which isahugebenefittotheTrustasitallows us to shape our services according to what patients tell us.Credit needs to go to the clinical leads and teams who have embraced the feedback, and actively made changes in response this patient experience.The year-on-year results show a fantastic improvement and I truly believe that staff should be very proud of the high quality of care they provide on a day-to-day basis, and I know we can continue to offer our patients an excellent experience.Staff can see the full results on the intranet: http://rbhintranet/ppi/2011pdf/annual_report_0711.pdfSue Mellor, Head of Patient Engagement

Inpatient feedback shows steady improvement

Last chance to have your say on pension proposal Are you part of the NHS Pension Scheme? Do you know about the proposed changes to employee contributions the scheme? Take the chance to have your say on the proposals and take part in the Department of Health’s consultation. The exercise runs until Friday 21st October 2011.

To view the table of proposed increases, please go to the pensions department intranet page.Take part in the live consultation by visiting www.dh.gov.uk/en/Consultations/Liveconsultations/DH_128710 Hazel Bolton, Pensions Lead

Ask the Execs

?Askth

e Execs

You can also email your questions in advance to the

Communications Department at [email protected]

Have you got any questions about the joint working taking place with Poole Hospital or

questions about the Trust that you would like to ask our Chief Executive? If so, come along

and ask - this is your chance to ask the questions you would like answers to.

Joint Working Update

?Deborah Matthews, Special Projects Lead. ?Tony Spotswood, Chief Executive.

21st Septemberat 12.30pm

RBH Lecture Theatrewith lunch in the Oasis afterwards

21st October at 12pm

Howard Centre, XCHWith lunch provided.

Consultant changes in the surgical directorateTwo consultants retired from the Surgical Directorate in September. John Rundle, Consultant Urologist and Simon Parvin, Consultant Vascular Surgeon, made continuous major contributions to surgical development throughout the Trust.

The directorate will welcome Consultant Urologist, Josh Phillips, and Vascular Surgeon Christopher Lee in the autumn.

We wish to thank both consultants for their considerable contribution and wish them a happy retirement. Both of the new candidates are new to Dorset and we look forward to them developing specialist services within the Trust going forward.

Tony Skene, Clinical Director for the Surgical Directorate and Maternity Services

Third Thursday for Medical ManagersTo remind you that the program for the rest of the year is:

22 September 2011 Mr Andrew Morris, Consultant Ophthalmologist: Retinal Disease.

19 October 2011 (Wednesday) Mr Dexter Perry, Consultant Surgeon: Update on Breast/Skin Cancer.

8 December 2011 Mr Robert Middleton, Consultant Orthopaedic Surgeon: Hip Surgery.

A buffet lunch will be available in the Oasis Dining Room from 12.30pm with the lecture starting at 1pm in the Lecture Theatre, Postgraduate Centre (the lectures last 40-45 mins).Dr Mary Armitage, Medical Director





Subject:

Update on Health & Social Care Bill

Sections:

Information



Author of Paper:


Summary:

Confirmation of key changes to the Health and Social Care Bill

Standards for better Health Domain:

Governance Clinical and Cost-effectiveness Accessible and responsive care


For Information

Board of Directors Part I 14 October 2011

Update on Social Health and Care Bill Page 1 of 2 For Information

THE ROYAL BOURNEMOUTH & CHRISTCHURCH HOSPITALS


Update on the Health & Social Care Bill

The Health and Social Care Bill has cleared its House of Commons stage and is now passing through the House of Lords with its second reading scheduled for 11 October 2011. The Department of Health recently published its latest amendments to the Bill which include details on the continuity of services and what will happen to Foundation Trusts or other providers that become unsustainable. The essence of these amendments is that there should be a pre-failure/distress regime which seeks to secure the turnaround of poorly performing or troubled Trusts before they reach the point of failure. The proposed new regime allows clinical and financial problems to be addressed at a local level in order to ensure service continuity in the long term. Commissioners will have the primary responsibility here, but Monitor will have an important role in supporting them and ensuring that this is delivered. The proposed amendments would mean that failing Foundation Trusts could no longer be de-authorised and that Monitor could appoint a suitably qualified person (an Administrator to take control of the providers’ affairs) in the event of previous interventions having been unsuccessful. The key changes in revising the Bill are as follows:-

- Those providers with services which are considered unsustainable under the National Tariff but continue to be required by population and commissioners can be subject to a price modification which will be agreed by Monitor and the National Commissioning Board to support the ongoing sustainability of services. In other words some Trusts will be able to secure an additional payment above the Tariff to maintain uneconomic services where there is no alternative choice in terms of the provision of these services to the population.

- The revised Bill makes clear that Commissioners have a duty to meet patients’ reasonable requirements for NHS healthcare services if a provider becomes unsustainable. In such circumstances Monitor would work with the Trust or Trusts in question through its established intervention processes and retains the facility to introduce an administrator to run the Trust where previous interventions have failed.

- The amendments to the Bill extend the transitional period where Monitor retains specific intervention powers over Foundation Trusts until March

Board of Directors Part I 14 October 2011

Update on Social Health and Care Bill Page 2 of 2 For Information

2016. They also make all Foundation Trusts subject to these powers. It is considered that extending this time period will allow Governors time to build the capability in holding the Board to account.

- There are a total of 715 technical amendments which support the change in name of the Commissioning Consortia to the Clinical Commissioning Group.

A further update on the passage of the Bill will be given as it progresses through the Lords.

Tony Spotswood Chief Executive 7 October 2011





Subject:

National Cancer Peer Review Programme 2011

Section:

Information



Author of Paper:

Sue Higgins, Lead Cancer Manager/Lead Cancer Nurse

Summary:

This report provides information on the following areas: The National Cancer Peer Review

Programme. The local process and how it

works


Governance Patient focus Accessible and responsive care


To note for information


National Cancer Peer Review Programme Page 1 of 3 For Information

National Cancer Peer Review Programme 2011

1 Background The Manual for Cancer Services is an integral part of Improving Outcomes: A Strategy for Cancer (2011) and aligns with the aims of the Government: to deliver health outcomes that are comparable to other countries in terms of better outcomes and improved survival rates. The Manual supports the National Cancer Peer Review quality assurance programme for cancer services and enables quality improvement both in terms of clinical and patient outcomes. Substantial progress has been made in cancer during the last decade, particularly since the publication of the NHS Cancer Plan in 2000. However, major challenges remain and in January 2011 Improving Outcomes: A Strategy for Cancer was published. The strategy sets out how the future direction for cancer will be aligned with Equity and Excellence: Liberating the NHS in addition to meeting its stated aim to save an additional 5,000 lives every year by 2014/15, aiming to narrow the inequalities gap at the same time.

2 The National Cancer Peer Review Programme At a national level the programme is directed by a National Cancer Peer Review Steering Group. Four “zonal” co-ordinating teams have been established; Dorset Cancer Network (of which RBCH is part) falls within the South Zone.

3 The Scope for Peer Review and reducing the burden of Peer Review The National Cancer Peer Review (NCPR) Programme will cover all cancer types and all stages of the patient’s journey. The Programme will review compliance with measures (formally Standards) contained within the Manual of Cancer Services. In order to adopt a more collaborative approach the national team will be working closely with the Care Quality Commission (CQC) which should reduce the burden of inspection. In line with all NHS organisations, the NCPR programme has been asked to respond to the difficult financial climate. A key change is reducing Internal Validation to every other year on the assumption that teams can be trusted to be honest and accountable when undertaking the annual Self Assessment process.

4 The Peer Review Programme The key stages of the Peer Review Programme are:-

Self Assessment.

Internal Validation.

External Validation.

Targeted Peer Review visits. There are no Peer Review visits for RBCH this year.



5 Self Assessments (SA) All Multi-Disciplinary Team (MDTs) / Services covered by the Manual of Cancer Services will be required to complete a bi-annual self-assessment. The only exception this year is Breast and Colorectal who have been given an “amnesty”. However they will be reviewed next year so an internal self-assessment will take place in the Autumn. Peer review is now based on self-assessment to ensure better use of resources but will be supported by a “targeted visit” programmed. National evidence guides have been produced which will help teams to structure their supporting evidence in a way which demonstrates compliance against the measures using key questions. The self-assessment documents will need to be uploaded on to CQuINS (The Cancer Quality Improvement Network System) by the end of September in the same year. CQuINS is a secure web-based database which provides the functionality for system users to attach evidence documents.

6 Internal Validation (IV) Internal Validation is in place to reassure the public that Self Assessment is robust and reliable and to encourage internal quality assurance processes. The national team envisage that if the IV process is robust the need for Peer Review visits will be reduced.

7 External Validation (EV) This is an external check of selected validated self-assessments led by the zonal cancer Peer Review team. This will take place for each team at least once every five years.

8 2011 Peer Review Programme for RBCH, to be completed by 30 September 2011 with the exception of Chemotherapy

Lung Self-assessment Urology Internal Validation, 15 July, RBH, Chaired by Dr Laws Skin Self-assessment UGI Self-assessment Gynae

(diagnostics) Internal Validation, 9 August, RBH, Chaired by Mr Perry

Chemotherapy Internal Validation, 13 October, RBH, Chaired by Mr Skene. (Delay in National Team updating measures, timescale therefore extended to 30 November 2011 for Internal Validation and upload completion).

Acute Oncology Team (AOT)

New Measures, Internal Validation will take place at the Dorset Cancer Network, date to be confirmed.

9 Process Each MDT Lead Clinician (or a nominated team member) will need to collate evidence against the cancer measures for each tumour site. The evidence is produced within three key documents: MDT Operational Policy, MDT Work



Programme and MDT Annual Report. When these documents are completed and agreed by the Lead Cancer Manager and the MDT they will need to be uploaded to the CQuINS data base as PDF files. Once uploaded they are accessible to all cancer networks and once validated and reported on by the National Team they are accessible to the public. This process will continue on an annual basis with targeted peer review visits being identified at national level. More detailed information is available on www.cquins.nhs.uk or from Sue Higgins, Lead Cancer Manager Ext 4325.

10 Next Year’s programme All tumour sites will follow the IV / SA cycle set this year with any new measures being included. Targeted Peer Review visits have not yet been announced.

11 Recommendation

The Board of Directors is asked to note this report for information.





14th October 2011 Part 1

Subject:

2011/12 Strategy Tracker Q2 Update

Section:

Information


Richard Renaut, Director of Service Development

Author of Paper:

Steve Thomas, Project Consultant

Summary:

Tracking progress of our strategy


Patient focus Governance


To note the report for information

Board of Directors – Part I 14th October 2011

2011/12 Strategy Tracker Q2 Update Page 1 of 1 For Information

2011/12 Strategy Tracker Q2 Update 1. Introduction The report is the new Strategy Tracker overview report which gives a top line overview of progress against each of the seven Trust strategic goals and the assurance & reporting mechanisms in place in order that the board can be assured the Trust is working towards achievement of those strategic goals. Under each strategic goal, the report lists the initiative, the monitoring mechanism, the RAG rating and details the current status. The RAG status indicates whether we are assured, partially assured or not assured regarding achievement of the initiative for the current year. 2. 2011/12 Q2 Update The 2011/12 Strategy Tracker Q2 update report is attached at Annex A. The report covers 15 top line initiatives of which two are rated amber and one is rated ‘amber – green’. There are no red ratings. The amber green rating reflects the Q1 Monitor Governance Risk Rating due to the failure to meet 62 day cancer standards on bowel cancer screening (as separately reported to the Board). An action plan is in place. The amber ratings include: Investors in People “retained recognition” status, for which reassessment is due in November and Pan Dorset QIPP which has been separately reported upon to the Board. 3. Recommendation

The Board is asked to note this report.

2011/12 Strategy Tracker Overview - Q2: Oct 11 Annex 1

Key to bullets:P Assured? Partially assured - action planning in placeX Not fully assured - action planning required / in place

Goal 1:

Initiative Monitoring mechanism RAG rating Current StatusPerformance Measures: ·Governance Risk Rating - this is the overarching measure - comprising detail on:·Cancer standards·Aggregate admitted pathways: (90% target)·Aggregate non admitted: (95% target)·4 Hour emergency target: (95% target)·Cardiac indicators·Stroke indicators·Cancelled Operations·VTE: Risk assessment target: (target 90%)

·Weekly PMG meetings·Monthly Performance Report to TMB & BoD·Forms part of Monitor Governance ratings, self score on quarterly basis.

On track

?Indicative Governance Risk Rating: Q1 rating of "Amber-Green" - All targets achieved except 62 day screening target. See Board Performance Report for further information. ? Cancer standards: Q1 not achieved for 62 Day screening patients which failed based on a v small number of patients. (due to Bowel Cancer Screening capacity issue for 1st seen appt) Full action plan in place and being monitored on a daily / weekly basis Prediction that Q2 screening target will not be met, but Q3 will be met.PAggregate admitted pathways: achieved - July 11PAggregate non admitted: achieved - July 11 P4 hour emergency target: achieved - July 11 P Stroke: Monitor stroke target still to be clarified - see Performance Report. PCancelled Operations (<= 0.8%) and 28 day guarantee (<=5%): targets achieved - July 11PVTE: Risk assessment target achieved: July 11

Infection Control Measures:Part of Governance Risk Rating:·MRSA (hospital acquired) ·C.DifficileOther:·MRSA screening target for elective patients·MSSA & E-Coli (hospital acquired) - National Mandatory Reporting (expected to be part of Governance rating in future)

Governance Risk Rating measures:·Monthly report to Infection Control Sub Committee, TMB & BoD·Forms part of Monitor Governance ratings, self score on quarterly basis.Other:·MRSA screening target for elective patients - internally monitored via PMG& BOD·MSSA (hospital acquired) - National Mandatory Reporting

On track

PMRSA: No hospital acquired MRSA - July 11.PC.Difficile: July 11 was above target (red) although YTD performance is within trajectory.PMSSA: Mandatory reporting commenced.PE-Coli: Mandatory reporting commenced.

“To offer patient centred services through the provision of high quality, responsive, accessible, safe, effective and timely care”.



Goal 2: “To promote and improve the quality of life of our patients”

Initiative Monitoring mechanism RAG rating Current StatusPatient Outcomes·Mortality HMSR·Note: HMSR is a key measure by which the Trust monitors its performance. This is a risk adjusted measure of death rate within the hospital, across a basket of the 56 most common groups of diagnoses. Each year this national comparator is reset by Dr Foster and therefore to keep below this figure the Trust has to continually review both its clinical processes and the information capture derived from these. It is likely that in 2011 a new measure will emerge to measure hospital death rates with a different methodology of risk adjustment.

·The NHS Outcomes Framework is expected to provide additional indicators, but these are yet to be confirmed

·Quarterly Mortality Group·Mortality HMSR

On track

POur adjusted HSMR figures for the last 3 years (07/08, 08/09, 09/10) are as follows: 105, 107, 96 (09/10 figure published Nov 10). National benchmark of 100, with better performance indicated as scoring below 100.

P The Trust “raw” HSMR for 2010/11 was 95 but this has now been rebased (allowing for improved performance across the country). A change to the Dr Foster methodology has also been instituted and the combination of these has been to raise the score to 99 . The Mortality group regularly monitor the implications of the change in HSMR with a view to further reducing our score.

Goal 3: “To strive towards excellence in the services and care we provide”Initiative Monitoring mechanism RAG rating Current StatusClinical Quality·Compliance with CQC registration; achieve Green rating

·Compliance with CQC registration·QRP report issued monthly by CQC·Reviewed monthly by Director of Nursing·Report bi monthly to HAC

On track

P Rated by Monitor as 'Green Low' (highest rating)P CQC unannounced inspection of Christchurch Hospital undertaken August 2011 demonstrated the hospital was meeting all the essential standards of quality and safety

Goal 4: “To be the provider of choice for local patients and GPs”Initiative Monitoring mechanism RAG rating Current StatusPatient engagement ·Bi monthly reporting to Marketing Committee

·National Patient Survey·Real time (RTM) patient feedback

On track

P Increase in Patient experience cards to over 500 received in July.PRTPF underway, over 3,000 surveys to date across outpatients, emergency dept and inpatients.P2010 Picker National survey results widely shared in organisation.? Picker Annual Survey for 2011 delayed by CQC & DH. This delay may impact on respondents perceptions and overall response.



Goal 5: “To listen to, support, motivate and develop our staff”Initiative Monitoring mechanism RAG rating Current StatusStaff satisfaction ·Staff survey 2010

·BoD

On track

PThe 2010 Staff Survey is now closed with actions completed. PThe annual Staff Survey is due to be repeated, with questionnaires being sent out in September 2011 and the initial data available December 2011. The final report will arrive at the Trust February/ March 2012

Investors in People ·Investors in people accreditation·Valuing Staff Group·Workforce Board Sub Committee

Amber

?The Investors in People assessors are due to return to the Trust w/c 21 November 2011, to re-assess the two standards previously failed by the Trust. The mina actions from the previous assessment are around improving appraisal rates, which has been addressed by the appraisal task and finish group and to improve management and leadership skills through training.PThe IIP action plan is well under way, with a marked increase in completed appraisals. Level 3 and 4 management training has been arranged, with both courses starting September/October 2011. In-house training for managers is also being arranged for disciplinary, capability and grievance training.

Health & Wellbeing Strategy ·Workforce Board Sub Committee

On track

P The Trust’s Health and Wellbeing strategy has been agreed and the First Friday Fitness programme has been re-launched in September 2011, as a quarterly event on a larger scale. The topic for September was Physical Activity and promoted local leisure centres, gyms, cricket and tennis. Also, healthy eating advice and blood pressure monitoring was available to staff.P The Employee Assistance Programme trial, which was initially for six months, has been extended for a further six months and will now run until the end of April 2012.



Staff Awards ·Marketing Committee

On track

P2011 Staff Excellence Awards took place on Wednesday 7th September PA review of the awards process will now take place and a date for the 2012 awards will be announced shortly.



Goal 6: “To work collaboratively with partner organisations to improve the health of local people”Initiative Monitoring mechanism RAG rating Current StatusContracting ·PbR Committee

·Finance Committee·BoD On track

PPerformance against 11/12 contract: above plan. QIPP expected to pull back to deliver on track performance via "taskforce" projects.PContract agreed for NHS Bmth & Poole and Dorset.P NHS Hants contract still to be agreed for financial values & reporting.

Pan Dorset QIPP ·TMB

Amber

P Plan agreed as part of contract, with PCT leading on majority of actions. Remains amber as performance on specific actions against five priority areas led by PCT is mixed.

Acute Services Review ·TMBOn track

P Joint working on opportunity scoping with Poole Hospital; project agreed and underway.

Delayed Transfers of Care ·Monthly report to TMB & BoD·Forms part of Monitor Governance ratings, self score on quarterly basis.

On track

No more than two DToC per organisation agreed as part of contract setting with PCTs (total 10). P Overall significant improvement on previous years, with minor fluctuations above threshold.

Goal 7: “To maintain financial stability enabling the Trust to invest in and develop services for patients”Initiative Monitoring mechanism RAG rating Current StatusFinancial Risk Rating·Monitor Quarterly Financial Risk Rating: Aim to score either 4 or 5 (highest). Self score on quarterly basis.

·Monitor Quarterly Financial Risk Rating·Monthly report to TMB & BoD

On track

P Achieved rating of 4 for Q1 11/12 against a target of 3. P Planned for rating of 3 for 11/12, on track for rating of 4 for Q2.

Delivery of Trust Transformation Plan ·Transformation Steering Board·Finance Committee·TMB On track

POn track for delivery of Year 3 of three year plan. PYear 4 and 5 plans currently in development. Paper covering Year 4 in detail and Year 5 in outline will go to the Board in November 2011.



BOARD OF DIRECTORS Meeting Date:


Subject:

Feedback from CQC Visit to Christchurch Hospital

Section:

Information


Paula Shobbrook Director of Nursing and Midwifery

Author of Paper:

The Care Quality Commission

Summary:

The CQC made an unannounced visit to inspect Christchurch Hospital on 11th August 2011. Their feedback report is attached.

Core Standards domain:

Safety; Governance; Patient focus; Public Health; Accessible and Responsive Care; Care, environment and amenities; Public health

Action required by the Board

The report is provided for information.

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Review ofcompliance

The Royal Bournemouth and Christchurch Hospitals NHS Foundation TrustChristchurch Hospital

Region: South West

Location address: Christchurch HospitalFairmile RoadChristchurchDorsetBH23 2JX

Type of service: Acute services with overnight beds

Hospice services

Rehabilitation services

Community healthcare service

Date of Publication: September 2011

Overview of the service: The Hospital has 218 beds and a 45 place Day Hospital. Its main focus is as an all-age rehabilitation service, though most patients are elderly. There are

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physiotherapy and occupational therapy services to support rehabilitation as well as Macmillan Unit for palliative care.

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Our current overall judgement

Christchurch Hospital was meeting all the essential standards of quality and safety.

The summary below describes why we carried out this review, what we found and any action required.

Why we carried out this review

We carried out this review as part of our routine schedule of planned reviews.

How we carried out this review

We reviewed all the information we hold about this provider and carried out a visit on 11 August 2011.

What people told us

We spoke with at least four people on each ward who were able to communicate with us and a number of visitors. As some people who were staying on one of the wards were not able to communicate with us as they have dementia or were very physically frail, we used a formal way to observe people during this visit to help us understand their experiences. This involved our observing four people for a 40 minute period, and recording their experiences at five minute intervals. We observed their mood state, how they engaged in activities, and interacted with staff members, other people, and the environment.

We observed four people for a period of 40 minutes on Ward K lounge in the morning before lunch.

Staff had good relationships with the people and were patient and encouraging. Staff gavepeople appropriate reassurance when they seemed unsure, distressed or anxious.

We spoke with a number of people who had started their care in other local hospitals and had transferred to Christchurch Hospital as a final stage before returning home. All said that they felt that had received the best care and attention whilst at Christchurch. Other people told us things such as

"they are like my second family, they are wonderful""I cannot fault the Day hospital""nothing is too much trouble""the staff are respectful, kind and on-the-ball"

What we found about the standards we reviewed and how well

for the essential standards of quality and safetySummary of our findings

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Christchurch Hospital was meeting them

Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run

People, and/or their representatives, are involved in making decisions and choices about their care and support they need. Staff promote people's privacy, dignity and independence.

Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights

People receive effective care and support in accordance with their assessed needs and preferences.

Outcome 07: People should be protected from abuse and staff should respect their human rights

Suitable policies and procedures are in place to ensure that people are protected from the risk of harm or abuse.

Outcome 14: Staff should be properly trained and supervised, and have the chance to develop and improve their skills

Staff are well-supported, and receive appropriate training, supervision and appraisals.

Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care

The hospital has systems in place to ensure quality monitoring and learning from experience, including adverse events, and we saw many examples where this had resulted in improvements to patient care. Risks to the health, welfare and safety of patients are managed effectively.

Other information

Please see previous reports for more information about previous reviews.

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What we foundfor each essential standard of qualityand safety we reviewed

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The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate.

We will have reached one of the following judgements for each essential standard.

Compliant means that people who use services are experiencing the outcomes relating tothe essential standard.

A minor concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard.

A moderate concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard and there is an impact on their health and wellbeing because of this.

A major concern means that people who use services are not experiencing the outcomesrelating to this essential standard and are not protected from unsafe or inappropriate care, treatment and support.

Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary improvements are made. Where there are a number of concerns, we may look at them together to decide the level of action to take.

More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety

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Outcome 01:Respecting and involving people who use services

What the outcome saysThis is what people who use services should expect.

People who use services:* Understand the care, treatment and support choices available to them.* Can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support.* Have their privacy, dignity and independence respected.* Have their views and experiences taken into account in the way the service is provided and delivered.

What we found

Our judgement

The provider is compliant with Outcome 01: Respecting and involving people who use services

Our findings

What people who use the service experienced and told usPeople told us that staff treated them kindly and were sensitive when providing any personal care.

All of the people we spoke with told us that they had been involved and consulted in decisions about their care and treatment.

We observed staff supporting people in a respectful and dignified way: staff automatically drew curtains or closed doors when giving any care or treatment and knocked on doors where appropriate.

We observed that, as much as possible, depending on their medical needs, people chose where to spend their time. All wards had lounge/dining areas and some had gardens attached too. People were either in bed, in chairs by their beds or sitting in theother areas of the wards.

Other evidencePrior to our visit, we assessed the information that we hold regarding Christchurch Hospital. This showed that there was a very low risk that they were not meeting this outcome.

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During the visit we tracked the care of at least three people on each ward. This involvedmeeting the person, observing staff interactions and looking at the individual's plan of care.

We saw that people were involved in the assessments of their needs and the creation of a plan of action to meet their needs and enable them to be discharged from hospital.We saw that for people who didn't have the capacity to be involved in decision-making because of their mental frailty, appropriate assessments were in place and other relevant parties had been consulted about best interest decisions on their behalf.

Each person had also been consulted about their preferences with regard to things such as form of address, social and cultural needs, dietary needs and any other lifestylepreferences which were important to them.

Our judgementPeople, and/or their representatives, are involved in making decisions and choices about their care and support they need. Staff promote people's privacy, dignity and independence.

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Outcome 04:Care and welfare of people who use services


People who use services:* Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

What we found

Our judgement

The provider is compliant with Outcome 04: Care and welfare of people who use services

Our findings

What people who use the service experienced and told usOne person we spoke with said that 'It's first class here, the best hospital I have been in. The care is very good'.

One relative told us that 'I'm very pleased with everything; they look after her really well here'

Other evidencePrior to our visit, we assessed the information that we hold regarding Christchurch Hospital. This showed that there was a very low risk that they were not meeting this outcome.

Each person had an individual plan of care and support. These plans were person centred and included good easy to follow descriptions of how staff were to support individuals.

The plans included the individual's assessed needs, risk assessments and a plan of care and support. There were falls, moving and handling, nutritional and pressure area risk assessments and plans in place. These had all been reviewed monthly or as and when peoples' needs changed.

During our visit we spoke with a number of the staff on duty on each of the wards. They were knowledgeable about the people that they care for and had a good understanding of their needs as well as any goals that people were trying to reach with

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regard to their rehabilitation.

We observed that staff supported people in the ways described in their care plans.

Our judgementPeople receive effective care and support in accordance with their assessed needs andpreferences.

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Outcome 07:Safeguarding people who use services from abuse


People who use services:* Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld.

What we found

Our judgement

The provider is compliant with Outcome 07: Safeguarding people who use services from abuse

Our findings

What people who use the service experienced and told usPeople we spoke to told us that they feel safe and have confidence in the staff.

We spoke with one of the visitors who told us that they feel able to relax knowing that their relative is safe and looked after by staff who are kind and caring.

Other evidencePrior to our visit, we assessed the information that we hold regarding Christchurch Hospital. This did not contain a sufficient range or level of data for us to assess the level of risk regarding the Trust meeting this outcome.

During our visits to the wards we spent time with a number of staff discussing various aspects of their work. Many of these meetings were held in the privacy of private offices.

As part of our discussions we asked staff about how they would recognise and report any abuse, whether they had received training in this area as well as the Mental Capacity Act 2005 Code of Practice and the Deprivation of Liberty Safeguards. All of the staff had a basic understanding of policies and procedures and were able to reassure us that they would be able to take appropriate action should the need arise. Many staff had undertaken training or had training sessions planned.

The Trust has recently introduced a new procedure for reporting of concerns about patients in the hospital. All staff were aware of it and those that had used it were full of

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praise for the new system which was clearly seen as more effective and efficient.

We spoke with the Safeguarding Adults Co-coordinator for the hospital and looked at the training matrix for staff. The use of Safeguarding alerts and investigations is relatively new to the hospital and a large training programme has had to be created. The co-ordinator confirmed that all clinical and non-clinical staff, with the exception of Doctors and Consultants, have either received or will soon be receiving training and that a refresher programme for staff is also being developed to run in conjunction with other mandatory training and updates.

We were aware, prior to our visit, that a number of alerts had been made over the last few months, many of which were substantiated after investigations were undertaken. The Trust has taken these seriously and were able to demonstrate that they had taken robust action and developed detailed action plans to try to ensure that lessons are learnt and events are not repeated.

Our judgementSuitable policies and procedures are in place to ensure that people are protected from the risk of harm or abuse.

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Outcome 14:Supporting staff


People who use services:* Are safe and their health and welfare needs are met by competent staff.

What we found

Our judgement

The provider is compliant with Outcome 14: Supporting staff

Our findings

What people who use the service experienced and told usPeople being cared for in the hospital and their visitors told us that they felt their needs were met by the staff team. They said that the staff always knew what needed to be done and were confident that they were properly trained to do it. Some people did say that they felt staff were always very busy and it might be good to have more staff.

Other evidencePrior to our visit, we assessed the information we hold regarding Christchurch Hospital.This showed that there was a medium risk that they were not meeting this outcome.

Staff confirmed with us during our meetings with them, that they had completed an induction period when they were first appointed and that this period had included training in mandatory areas such as moving and handling, infection prevention and control, health and safety and fire prevention. They also confirmed that they receive regular refresher training in these topics.

Managers were also able to provide us with training plans and records which confirmed that regular training was planned and provided to ensure staff are kept up to date.

Staff also told us that they have a formal annual appraisal, regular one to one meetings with their manager and that there are regular staff meetings.

Staff told us that they felt well supported and that they received good training. We observed staff appeared to be happy in their work and were seen requesting help from each other and working well together.

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Our judgementStaff are well-supported, and receive appropriate training, supervision and appraisals.

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Outcome 16:Assessing and monitoring the quality of service provision


People who use services:* Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

What we found

Our judgement

The provider is compliant with Outcome 16: Assessing and monitoring the quality of service provision

Our findings

What people who use the service experienced and told usPeople who use the service did not tell us anything specifically about this outcome.

Other evidencePrior to our visit, we assessed the information that we hold regarding Christchurch Hospital. This showed that there was a low risk that they were not meeting this outcome.

We saw that the Trust has systems in place to assess and monitor the quality of serviceand manage risks. We spoke with staff at all levels and a representative from the Council of Governors. Everyone was aware of the Trust's priority to provide the best quality healthcare and this was part of the working culture. Risk management was seen by staff as part of this.

Discussion with managers showed that they had a current knowledge of the performance requirements in their areas. We saw that there is a systematic approach to the analysis of incidents, alerts and complaints to ensure that safety and experience lessons are learned and shared, and lead to embedded improvements in practice. There was also a detailed programme of audits and surveys which were also used to inform the Trust of how well the service is operating and to alert managers to possible areas of concern. We discussed examples where such systems had lead to direct actions and improvements being taken.

Our judgement

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The hospital has systems in place to ensure quality monitoring and learning from experience, including adverse events, and we saw many examples where this had resulted in improvements to patient care. Risks to the health, welfare and safety of patients are managed effectively.

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What is a review of compliance?

By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care.

The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety.

CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care.

When making our judgements about whether services are meeting essential standards, we decide whether we need to take further regulatory action. This might include discussions with the provider about how they could improve. We only use this approach where issues can be resolved quickly, easily and where there is no immediate risk of serious harm to people.

Where we have concerns that providers are not meeting essential standards, or where we judge that they are not going to keep meeting them, we may also set improvement actionsor compliance actions, or take enforcement action:

Improvement actions: These are actions a provider should take so that they maintain continuous compliance with essential standards. Where a provider is complying with essential standards, but we are concerned that they will not be able to maintain this, we ask them to send us a report describing the improvements they will make to enable them to do so.

Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. Where a provider is not meeting the essential standards but people are not at immediate risk of serious harm, we ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met.

Enforcement action: These are actions we take using the criminal and/or civil proceduresin the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people.

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Information for the reader

Document purpose Review of compliance report

Author Care Quality Commission

Audience The general public

Further copies from 03000 616161 / www.cqc.org.uk

Copyright Copyright © (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified.

Care Quality Commission

Website www.cqc.org.uk

Telephone 03000 616161

Email address [email protected]

Postal address Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA



BOARD OF DIRECTORS

Meeting Date and Part: 14th October, 2011 – Part 1

Subject: Communications Update

Section: Information



Author of Paper: Tracey Hall Head of Communications and Fundraising

Summary:

An overview of communications and fundraising activity. The update also includes Read All About (media coverage September).


Patient focus Accessible and responsive care Public Health

Action required by the Board of Directors:

For Information

Board of Directors – Part I 14th October, 2011

Communications activity – October 2011 Page 1 of 3 For information

Communications activity October 2011

1. Introduction

The October Communications Report provides a summary of key communication and fundraising activities over the past month – with a focus on e-communications - as well as highlighting key areas for the coming quarter.

2. Recent activities 2.1 Communications

The main focus for the Communications Team has been: Delivering a successful Staff Excellence Awards ceremony Communications around joint working with Poole Hospital Ongoing publications and events; Buzzword, Core Brief, Medical

Director columns, FT Focus and Understanding Health E-communications; developing web pages and focusing on search

optimisation to ensure the Trust features high in search engines when users search generic terms

2.1.2 E-communications - search optimisation Search optimisation within the Trust’s website refers to how high the hospitals’ services are ranked when users search for key words. These key words can be specific to our Trust or general medical terms, for example, ‘blood test Bournemouth hospital’ or ‘hospital charity’ The Trust is ranked very highly for a number of areas:

Non RBCH Specific Key words Ranked in Google Orthopaedic outpatients 1st Biochemistry bone profile 2nd Patient needs 2nd Hospital charities 5th Hospital cars 5th Haematology tests 6th What tests are conducted in haematology 7th Anticoagulation clinic 10th Staff Charter 11th Thoracic Medicine 11th NHS pension scheme 11th Advice on contraception 13th Hospital 17th Blood infusion 18th Bone profile 21st



Work is continuing to optimise the above keywords (ranking them higher when searched in Google) but will also focus on search optimisation for the Trust’s key services. Other opportunities for search optimisation and increasing traffic to rbch.nhs.uk: Utilise popular pages

The vacancies page has consistently been one of the most visited pages on our website this year. This page, and other popular pages, will be used for campaign promotion to prompt visitors to view other pages of the site.

Partner participation

A link has been developed to share with partner agencies to help encourage/signpost members to our website. This link will be shared with local organisation to be put onto their websites.

GP web promotion

A desktop icon has been developed which will be linked to the new GP web pages when launched.

This icon can be emailed to all Practice contacts to upload onto their

desktops. This in turn will encourage regular visits to our GP pages. A similar icon will be developed for the Jigsaw Appeal and circulated to

key contacts.

2.2 Fundraising For fundraising the focus has been on developing a:

Fundraising Legacy Strategy Corporate relationship activities – developing the corporate brochure and

a corporate evening (Monday 14 November) Sourcing a Customer Relationship Management database

3. Forward plan

The focus for the Communications and Fundraising teams for the remainder of the year is: Communications:

Supporting Transforming Corporate Services and efficiency work streams including joint working, pharmacy and medication project.

E-Communications. Stakeholder communication. Seasonal communications (winter planning and infection control

education). Supporting fundraising communications. Maintaining publications and events. Proactive media relations including, Supporting the opening of the new

Stroke Unit



Fundraising:

Christmas activities Events Programme 2012. Legacy Plan, including promotion and training Fundraising Strategy 2012/13. Developing staff and corporate relationships/opportunities.

Tracey Hall Head of Communications and Fundraising October, 2011




14 October, 2011 (part 1)

Subject:

Read All About It

Section:

Information



Author of Paper:

Melanie Croydon, Communications Officer

Summary:

A summary of the Trust’s media coverage for September.


N/A


For Information

September 2011 l 1

Dr Mary Armitage, Medical Director.

[email protected]

Innovative service sees stroke patients

return home sooner

At the beginning of August the Trust launched

an innovative new pilot service to help

rehabilitate stroke patients in their own homes.

The Stroke Early Supported Discharge Service

(ESD), jointly funded by the Trust and NHS

Bournemouth and Poole, allows patients who

have experienced a mild to moderate stroke

to leave hospital earlier by having their stroke

specialist rehabilitation at home.

The service, which is made up of staff

members from a variety of disciplines, is on

hand seven days a week.Supported by a Stroke Consultant, the stroke

specialist physiotherapists, occupational

therapists, nurses, speech and language

therapists and rehabilitation assistants work

together to offer patients rehabilitation at

home, for around two weeks after they are

discharged from hospital.After that, they are referred to appropriate

community services for on-going support and

rehabilitation if it is needed.This will benefit patients from:

• A smooth and seamless transfer from

hospital to home - patients are seen at home

within 24 hours of discharge from hospital.

• Rehabilitation centred around patients’ goals

and delivered in a setting meaningful to their

lives.• More independence and a reduction in

long-term dependency.• Improved outcomes - evidence indicates

that patients benefit physically and

psychologically as a result of being cared

for at home. Claire Stalley, ESD Lead, said: “This exciting

new service will be a real benefit to patients

as it will help them get back on their feet

earlier, and increase their confidence in their

everyday surroundings.“The new approach allows patients and carers

to be involved in all stages of discharge

planning so that they can leave hospital

sooner.”This service, a six-month pilot, has been

developed using research evidence and

national clinical guidance. For the course

of the pilot the team will monitor the

impact of the service on patients,

carers, the inpatient stroke

service and the wider health

and social care community.

www.rbch.nhs.uk www.rbch.nhs.ukDr Mary Armitage, Medical Director.

[email protected]

Emergency phone

line for patients

with urgent eye

problems

The Eye Unit at the Royal Bournemouth

Hospital treats more than 34,000 patients

and carries out around 10,000 procedures

a year.

The Unit is getting busier, with an

increasing number of people needing

emergency eye treatment or advice.

Although an appointment-based system for

urgent eye appointments has been running

for the last eight years, around ten people

a day turn up without an appointment.

Members of the public who have an urgent

eye problem are being asked to phone

first, on 01202 704181. This will ensure

you receive instant and appropriate advice

as well as access to treatment fast.

Julie Tillotson, Nurse Consultant at

the unit, said: “Having instant medical

advice over the phone could be crucial.

It also helps us assess where the patient

should go to receive the most appropriate

treatment.”

Those phoning the emergency helpline

will speak to an experienced ophthalmic

nurse who will then make a decision about

the most appropriate form of care. This

could mean seeing a GP or an optometrist

or it may mean dropping everything and

coming into the Eye Unit’s Acute Referral

Unit straight away.

New patient film

A new patient film especially designed

for cataract patients will be available to

view at the end of October on our website,

at www.rbch.nhs.uk/

The three minute film covers the whole

patient pathway, starting with the referral

from a GP or optician, through to the

consultation with the eye unit consultant

and finally the procedure. It was designed

to show patients exactly what

to expect when they start

treatment in the eye unit,

and answer any questions

they may have.

Read All About It... September / September 2011

Summary of media coverage:

*This does not include Mary Armitage’s Echo column or Notice of Election

Articles are published with the kind permission of the Daily Echo, Advertiser, the New Milton Advertiser and the Stour and Avon Magazine.

The September media report includes positive coverage about the results of the PEAT annual assessment in which the Trust achieved good scores, and also the promotion of some Jigsaw events.

There was a negative article about ambulance delays at ED and a positive article promoting the remaining Jigsaw places for the Great South Run.

2011 Coverage*Positive 9Negative 1OK 1 September 2010 Positive 15 Negative 0 OK 8

September 2011 Print 13 Radio 0 Television 0

September 2011 l 2

DatePublicationInformation

TitlePage numberArticle size

2 September 2011Daily EchoArticle about the results of the PEAT annual assessment.Great scores for hospital quality6Eighth of a page

DatePublicationInformationTitlePage numberArticle size

1 September 2011 Daily EchoArticle promoting a Jigsaw cricket event.Got Gatting12Sixteenth of a page

September 2011 l 3


2 September 2011Daily EchoArticle about ambulance delays at ED.Hospitals fined £91k over ambulance delays10Half page

September 2011 l 4


3 September 2011 Daily EchoArticle publicising the Board meeting.Hospital plans board meeting7Sixteenth of a page

September 2011 l 5


6 September 2011Daily EchoArticle about the Jigsaw cricket event.Cricket day is a big hit for charity5Quarter page



7 September 2011 Daily EchoArticle promoting the remaining Jigsaw places at the Great South Run.Still places for charity race25Eighth of a page

September 2011 l 6



9 September 2011 Stour and Avon MagazineArticle about the results of the PEAT annual assessment.Top scores for patient environment23Eighth of a page



12 September 2011 Daily EchoArticle promoting a 007 themed event at AFC Bournemouth in November.Charity event has 007 theme20Eighth of a page

September 2011 l 7


TitleArticle size

13 September 2011Daily EchoArticle about an experience that a new mum had at another hospital. The Mum was then transferred to RBH.First time Ringwood mum ‘left alone for five hours’Three quarters of a page

September 2011 l 8

DatePublicationInformationTitle

14 September 2011 Daily EchoMedical column.Innovative service sees stoke patients return home sooner

Dr Mary Armitage, Medical Director. [email protected]

Innovative service sees stroke patients return home sooner At the beginning of August the Trust launched an innovative new pilot service to help rehabilitate stroke patients in their own homes.The Stroke Early Supported Discharge Service (ESD), jointly funded by the Trust and NHS Bournemouth and Poole, allows patients who have experienced a mild to moderate stroke to leave hospital earlier by having their stroke specialist rehabilitation at home.The service, which is made up of staff members from a variety of disciplines, is on hand seven days a week.Supported by a Stroke Consultant, the stroke specialist physiotherapists, occupational therapists, nurses, speech and language therapists and rehabilitation assistants work together to offer patients rehabilitation at home, for around two weeks after they are discharged from hospital.After that, they are referred to appropriate community services for on-going support and rehabilitation if it is needed.This will benefit patients from:• A smooth and seamless transfer from

hospital to home - patients are seen at home within 24 hours of discharge from hospital.

• Rehabilitation centred around patients’ goals and delivered in a setting meaningful to their lives.

• More independence and a reduction in long-term dependency.

• Improved outcomes - evidence indicates that patients benefit physically and psychologically as a result of being cared for at home.

Claire Stalley, ESD Lead, said: “This exciting new service will be a real benefit to patients as it will help them get back on their feet earlier, and increase their confidence in their everyday surroundings.“The new approach allows patients and carers to be involved in all stages of discharge planning so that they can leave hospital sooner.”This service, a six-month pilot, has been developed using research evidence and national clinical guidance. For the course of the pilot the team will monitor the impact of the service on patients, carers, the inpatient stroke service and the wider health and social care community.

www.rbch.nhs.uk

September 2011 l 9


Title

24 September 2011 Daily EchoArticle about a former RBCH patient fundraising by selling a red arrows painting. The proceeds go to charity.Red Arrows painting on charity sale


Title

25 September 2011The TelegraphArticle about the results of an early trial of a new drug for breast cancer. RBCH was part of one of these trials.Breast cancer drug could add five months

September 2011 l 10

DatePublicationInformationTitle

28 September 2011Daily EchoMedical column.Emergency phone line for patients with urgent eye problems

www.rbch.nhs.uk

Dr Mary Armitage, Medical Director. [email protected]

Emergency phone line for patients with urgent eye problems The Eye Unit at the Royal Bournemouth Hospital treats more than 34,000 patients and carries out around 10,000 procedures a year. The Unit is getting busier, with an increasing number of people needing emergency eye treatment or advice. Although an appointment-based system for urgent eye appointments has been running for the last eight years, around ten people a day turn up without an appointment.Members of the public who have an urgent eye problem are being asked to phone first, on 01202 704181. This will ensure you receive instant and appropriate advice as well as access to treatment fast.Julie Tillotson, Nurse Consultant at the unit, said: “Having instant medical advice over the phone could be crucial. It also helps us assess where the patient should go to receive the most appropriate treatment.” Those phoning the emergency helpline will speak to an experienced ophthalmic nurse who will then make a decision about the most appropriate form of care. This could mean seeing a GP or an optometrist or it may mean dropping everything and coming into the Eye Unit’s Acute Referral Unit straight away.New patient filmA new patient film especially designed for cataract patients will be available to view at the end of October on our website, at www.rbch.nhs.uk/ The three minute film covers the whole patient pathway, starting with the referral from a GP or optician, through to the consultation with the eye unit consultant and finally the procedure. It was designed to show patients exactly what to expect when they start treatment in the eye unit, and answer any questions they may have.





Subject:

Board of Directors Forward Programme

Section:

Information



Author of Paper:

Rebecca Lawry, Trust Secretary

Summary:

Copy of the Board of Directors Forward Programme


Governance


For Information

Board of Directors - Meeting Map 1Board of Directors Business Programme 2011

What Who Where Before Jan Feb Mar Apr May Jun Jul Sep Oct Nov Dec Where After

Annual PlanBoard Objectives TS Chief Executive N/AAnnual Plan - BoD approve Draft for Public Consultation RR TMB BoDAnnual Plan - Feedback from Consultation to BoD RR CoG BoDAnnual Plan - Final Draft for BoD Approval RR TMB BoD PublicationStrategy Tracker - Quarterly RR Service Development N/A

BudgetBudget for next financial year SH Finance N/ACapital Plan for next financial year SH CMG & Finance N/ACode of Conduct for Payment by Results RR Service Development N/APCT Contract Sign Off RR Service Development PCT

Annual reportAnnual Report & Accounts First Draft SH Finance N/AAnnual Report - Audit Committee SP Audit N/AAnnual Report - Finance Committee BF Finance N/AAnnual Report - Healthcare Assurance Committee PS HAC N/AAnnual Report & Accounts - Final draft for approval SH Finance & Audit Cttees MonitorAnnual Report & Accounts - Going Concern Statement SH Finance & Audit Report & A/Cs

CQC RegistrationQuality and Risk Profile Update PS HAC CQC

Charitable FundsAnnual Report & Accounts SH Charity Cmtte Charities Commission?

HealthcareAssurance Framework PS HAC N/AChild Protection & Safeguarding Annual Report PS HAC N/AClinical Governance - Quarterly Report PS HAC N/AClinical Governance - Annual Report PS HAC N/ADr Foster Quarterly Report MA Medical Director ?Quality Accounts - First Draft PS Clinical Governance N/AQuality Accounts - Final Draft for Approval PS Clinical Governance Publication

Infection ControlBoard Statement of Commitment to prevention of Healthcare Associated Infection PS Infection Control ?Infection Control - Annual Report PS Infection Control N/AInfection Control - Quarterly Update PS Infection Control N/A

MonitorMonitor Quarter 1 Report HL Director of Ops MonitorMonitor Quarter 2 Report HL Director of Ops MonitorMonitor Quarter 3 Report HL Director of Ops MonitorMonitor Quarter 4 Results HL Director of Ops MonitorMonitor Annual Risk Assessment TS External Monitor?Monitor's FT Sector Overview - Annual Risk Assessment TS Chief Executive N/AMonitor Self Certification - Board Statements RL Trust Secretary Monitor

Staff

Board of Directors - Meeting Map 2What Who Where Before Jan Feb Mar Apr May Jun Jul Sep Oct Nov Dec Where After

Staff Excellence Awards - Chairman's Prize RR Awards Panel Staff AwardsStaff Excellence Awards - Process for current year RR Service Development N/AStaff Survey - Results KA Workforce ?Workforce Committee - Quarterly Report KA Workforce N/ALocal Clinical Excellence Awards MA Remuneration ?Local Clinical Excellence Awards - Annual Report MA Remuneration N/A

GovernanceRegister of Interests RL Trust Secretary FileConstitutional Documents - Annual Review RL Trust Secretary CoGCode of Governance Disclosure Statement RL Trust Secretary MonitorMeeting Dates for Next Year RL Trust Secretary N/AForward Programme RL Trust Secretary N/A

Minutes of Subordinate groupsAudit Committee Cttee Audit N/ACharity Committee Cttee Charitable Funds N/ACouncil of Governors RL CoG N/AFinance Committee Cttee Finance N/AHealthcare Assurance Cttee HAC N/AInfection Control Cttee Infection Control N/AMarketing Committee Cttee Marketing N/ARemuneration Committee Cttee Remuneration N/ATrust Management Board Cttee TMB N/AWorkforce Committee Cttee Workforce N/A

Review Performance & Terms of Reference subordinate Groups Audit Committee SP Audit File - RL Charities Committee KT Charitable Funds File - RL Finance Committee SH Finance File - RL Healthcare Assurance Committee PS HAC File - RL Infection Control Committee PS Infection Control File - RL Marketing Committee RR Marketing File - RL Remuneration Committee SC Remuneration File - RL Trust Management Board TS TMB File - RL Workforce Committee KA Workforce File - RL

CommunicationsCommunications Audit Action Plan RR Marketing ?Inpatient Annual Survey Results RR Marketing Publication?Marketing & Communications Report RR Service Development N/APutting Patients First - Quarterly Progress Report RR Marketing N/ARead All About It RR Service Development N/AService Guide RR Service Development ?

Board of Directors - Meeting Map 2012 1Board of Directors Business Programme 2012

What Who Where Before Jan Feb Mar Apr May Jun Jul Sep Oct Nov Dec Where After

Annual PlanBoard Objectives TS Chief Executive N/AAnnual Plan - BoD approve Draft for Public Consultation RR TMB BoDAnnual Plan - Feedback from Consultation to BoD RR CoG BoDAnnual Plan - Final Draft for BoD Approval RR TMB BoD PublicationStrategy Tracker - Quarterly RR Service Development N/A

BudgetBudget for next financial year SH Finance N/ACapital Plan for next financial year SH CMG & Finance N/ACode of Conduct for Payment by Results RR Service Development N/APCT Contract Sign Off RR Service Development PCT

Annual reportAnnual Report & Accounts First Draft SH Finance N/AAnnual Report - Audit Committee SP Audit N/AAnnual Report - Finance Committee BF Finance N/AAnnual Report - Healthcare Assurance Committee PS HAC N/AAnnual Report & Accounts - Final draft for approval SH Finance & Audit Cttees MonitorAnnual Report & Accounts - Going Concern Statement SH Finance & Audit Report & A/Cs

CQC RegistrationQuality and Risk Profile Update PS HAC CQC

Charitable FundsAnnual Report & Accounts SH Charity Cmtte Charities Commission?

HealthcareAssurance Framework PS HAC N/AChild Protection & Safeguarding Annual Report PS HAC N/AClinical Governance - Quarterly Report PS HAC N/AClinical Governance - Annual Report PS HAC N/ADr Foster Quarterly Report MA Medical Director ?Quality Accounts - First Draft PS Clinical Governance N/AQuality Accounts - Final Draft for Approval PS Clinical Governance Publication

Infection ControlBoard Statement of Commitment to prevention of Healthcare Associated Infection PS Infection Control ?Infection Control - Annual Report PS Infection Control N/AInfection Control - Quarterly Update PS Infection Control N/A

MonitorMonitor Quarter 1 Report HL Director of Ops MonitorMonitor Quarter 2 Report HL Director of Ops MonitorMonitor Quarter 3 Report HL Director of Ops MonitorMonitor Quarter 4 Results HL Director of Ops MonitorMonitor Annual Risk Assessment TS External Monitor?Monitor's FT Sector Overview - Annual Risk Assessment TS Chief Executive N/AMonitor Self Certification - Board Statements RL Trust Secretary Monitor

Staff

Board of Directors - Meeting Map 2012 2What Who Where Before Jan Feb Mar Apr May Jun Jul Sep Oct Nov Dec Where After

Staff Excellence Awards - Chairman's Prize RR Awards Panel Staff AwardsStaff Excellence Awards - Process for current year RR Service Development N/AStaff Survey - Results KA Workforce ?Workforce Committee - Quarterly Report KA Workforce N/ALocal Clinical Excellence Awards MA Remuneration ?Local Clinical Excellence Awards - Annual Report MA Remuneration N/A

GovernanceRegister of Interests RL Trust Secretary FileConstitutional Documents - Annual Review RL Trust Secretary CoGCode of Governance Disclosure Statement RL Trust Secretary MonitorMeeting Dates for Next Year RL Trust Secretary N/AForward Programme RL Trust Secretary N/AAnnual Members Meeting 9th

Minutes of Subordinate groupsAudit Committee Cttee Audit N/ACharity Committee Cttee Charitable Funds N/ACouncil of Governors RL CoG N/AFinance Committee Cttee Finance N/AHealthcare Assurance Cttee HAC N/AInfection Control Cttee Infection Control N/AMarketing Committee Cttee Marketing N/ARemuneration Committee Cttee Remuneration N/ATrust Management Board Cttee TMB N/AWorkforce Committee Cttee Workforce N/A

Review Performance & Terms of Reference subordinate Groups Audit Committee SP Audit File - RL Charities Committee KT Charitable Funds File - RL Finance Committee SH Finance File - RL Healthcare Assurance Committee PS HAC File - RL Infection Control Committee PS Infection Control File - RL Marketing Committee RR Marketing File - RL Remuneration Committee SC Remuneration File - RL Trust Management Board TS TMB File - RL Workforce Committee KA Workforce File - RL

CommunicationsCommunications Audit Action Plan RR Marketing ?Inpatient Annual Survey Results RR Marketing Publication?Marketing & Communications Report RR Service Development N/APutting Patients First - Quarterly Progress Report RR Marketing N/ARead All About It RR Service Development N/AService Guide RR Service Development ?

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