0 trust board agenda 27 july 2016 final - amazon...

TRUST BOARD1

Wednesday 27 July 2016 at 1300Boardroom, Chief Executive’s Office, 2nd floor, Royal Free Hospital

ITEM LEAD PAPER

ADMINISTRATIVE ITEMS

2016/130 Apologies for absence D Dodd

2016/131 Declaration of interests D Dodd 1.

2016/132 Minutes of meeting held on 29 June 2016 D Dodd 2.

2016/133 Matters arising report D Dodd 3.

2016/134 Record of items discussed at the Part II board meeting on 29 June2016

D Dodd 4.

PATIENT SAFETY AND EXPERIENCE

2016/135 Quality improvement/patient safety

Young volunteers programme

D Sanders

2016/136 Patients’ voices E Kearney

ORGANISATIONAL AGENDA

2016/137 Nursing/midwifery staff - monthly report – May 2016 D Sanders 5.

2016/138 Director of infection prevention and control (DIPC) reports:

• Annual report 2015/16 (6.1)

• Quarterly report (6.2)

D Sanders 6.

2016/139 Complaints annual report 2015/16 D Sanders 7.

OPERATIONAL AGENDA

2016/140 Chair’s and chief executive’s report D Dodd /D Sloman

8.

2016/141 Trust performance dashboard K Slemeck 9.

2016/142 Financial performance report C Clarke 10.

Governance and regulation: reports from board committees

2016/143 Shadow group board (14 July 2016) D Dodd 11.

2016/144 Finance, investment and performance committee (21 July 2016 –verbal report) including quarter 1 Monitor quarterly self-certifications

D Dodd 12.

2016/145 Patient safety committee (4 July 2016) S Ainger 13.

2016/146 Clinical performance committee (18 July 2016) A Schapira Verbal

2016/147 Patient and staff experience committee (25 July 2016) J Owen Verbal

OTHER BUSINESS

2016/148 Questions from the public D Dodd

2016/149 Any other business D Dodd

2016/150 Date of next meeting – 28 September 2016 D Dodd

1 In accordance with the Health & Social Care Act 2012, all Trust Board meetings must be held in public. All decisions which require the board’scollective approval can only be made at a Trust Board (or a Part II meeting held in closed session to discuss confidential matters).

TRUST BOARD AGENDA(open to members of the public and the press)

DATE: Wednesday 27 July 2016

TIME: 1300 -1400 (approx.)

VENUE: Boardroom, executive offices, 2nd

floor, Royal Free Hospital

Distribution

CHAIR: Dominic Dodd Chairman of the trust board

TRUST BOARDMEMBERS:

Stephen Ainger Non-executive director

Deborah Oakley Non-executive directorJenny Owen Non-executive directorProf Anthony Schapira Non-executive directorVacant Non-executive directorDavid Sloman Chief executive

Caroline Clarke Chief finance officer and deputy chief executive

Prof Stephen Powis Medical director

Deborah Sanders Director of nursingKate Slemeck Chief operating officer

INVITED TO ATTENDDr Mike Greenberg Divisional director of women’s and children’s

servicesDavid Grantham Director of workforce and organisational

developmentProf George Hamilton Divisional director of surgery and associated

servicesDr Robin Woolfson Divisional director of transplant and specialist

servicesEmma Kearney Director of corporate affairs and communicationsAndrew Panniker Director of capital and estatesPeter Ridley Director of planningDr Steve Shaw Divisional director of urgent careWilliam Smart Chief information officerAlison Macdonald Board secretary (minutes)Desiree Benson andyoung volunteers

For item 2016/135 only

APOLOGIESCOPY FORINFORMATION:

Governors (agenda only)

Julie Dawes Interim trust secretary

Paper 1

Register of interests – trust board My 2016 1

REGISTER OF INTERESTS OF MEMBERS OF THE BOARD OF DIRECTORS

Executive summary

The trust constitution requires trust board members to declare interests which are relevant andmaterial to the NHS board of which they are a member.

The register of interests was ratified at the June board meeting, with some amendments. Theattached version has been updated with the amendments noted at the June meeting and with thedirector of planning’s declaration of interests (nil).

In future the register of interests will be presented to each board meeting.

Action required

Board members are asked to provide an update if they have any other changes in interests notnoted in the attached.

The board is asked to ratify the updated register, subject to any further changes made.

Public Patient andCarer involvement

The register will be made available to the public.

Report From Dominic DoddAuthor(s) Alison MacdonaldDate 19 July 2016

Report to Date of meeting Attachment number

Trust Board 27 July 2016 Paper 1

Version 8Updated 19/7/16

Declaration of interests – board members are requested to highlight any changes to the register of interests at each board meeting held in public.

REGISTER OF THE INTERESTS OF MEMBERS OF THE TRUST BOARD

Board Member andpositionDate of latestamendment/confirmedcorrect

Directorships,including non-executive directorshipsheld in privatecompanies or PLCs(with the exception ofthose of dormantcompanies)

State whendirectorshipcommenced

Ownership or part-ownership of privatecompanies, businessor consultancies likelyor possibly seeking todo business with theNHSState when interestacquired

Majority orcontrolling shareholdings inorganisations likelyor possibly seekingto do business withthe NHSState when interestacquired

A position ofauthority in a charityor voluntaryorganisation in thefield of health andsocial care

State when positionaccepted

Any connection with avoluntary or otherorganisationcontracting for NHSservices


Researchfunding/grants thatmay be received byan individual or theirdepartment

State whenfunding/grantcommenced

Interests in pooled funds that are underseparate management (any relevantcompany included in this fund that has apotential relationship with the Trust mustbe declared)

State when interest acquired

Non-executive directors

Dominic Dodd,Chair8/4/16

UCLPartners1

Director of ownconsultancy firm

Nil Nil Nil Nil Nil

Stephen AingerNon-executivedirector5/1/16

Chair DownshireHill Residents’Association.

Nil Nil Nil Nil Nil

1The Company’s constitutional documents have been drafted in accordance with charity law and Charity Commission guidance, so that the Company can apply for charitable status in the

future as and when its Board of Directors considers this appropriate.
















Deborah Oakley,non-executivedirector13/5/16

Medicines andHealthcareProductsRegulatoryAgency Non-ExecDirector

Nil Nil Nil Medicines andHealthcareProductsRegulatoryAgency Non-Exec Director

Nil I work for Veritas InvestmentManagement. The firm investsmoney on behalf of clients. Clientportfolios are invested in varioushealthcare companies whichmay do business with the trustand with the NHS more broadly.These investments include butare not limited to: SonicHealthcare; Roche; Novartis;GlaxoSmithKline, United Health,Alphabet, Oracle and others.Clients also invest in pooledfunds which are managedexternally and invest in a broadrange of healthcare companieswhich may do business with thetrust and the NHS.I and my family have personalholdings in pooled funds whichare managed externally andinvest in a broad range ofhealthcare companies whichmay do business with the trustand the NHS.I do not have any directinvestments in companies whichmay do business with the trust orwith the NHS.
















Jenny Owen,non-executivedirector6/4/16

Nil Nil Nil Board memberof Housing andCare 21

Trustee ofAlzheimer’sSociety

Housing 21 andCare 21

Alzheimer’sSociety

Nil Nil

ProfessorAnthony SchapiraNon-executivedirector13/5/16

Upper HampsteadWalk Residents’Association.AHV Schapira Ltd

Non-executivedirector, Ministryof Justice

Nil Nil Parkinson’sDisease SocietyResearchStrategy Group

Nil MedicalResearchCouncil,Wellcome Trust,Parkinson’sDisease Societyand othercharitablesources ofresearch funding

Nil

Executive directors

Caroline ClarkeDeputy chiefexecutive &director offinance11/4/16

Member, AdvisoryBoard to TheLearning Clinic

Nil Nil Trustee

Royal FreeCharity (1/4/16)

Nil Nil Nil
















Professor

Stephen Powis,

medical director

16/5/16

Director of HSL

(appointed by

RFL)

Nil Nil Employee of

UCL

Trustee

Peter Samuel

Trust

Trustee

Healthcare

Management

Trust

Trustee

Moorhead Renal

Trust

Trustee

Royal Free

Charity (1/4/16)

Member ofgoverning body,Merton NHSClinicalCommissioningGroup

Trustee

Healthcare

Management

Trust

Moorhead RenalTrust and variousother sources ofcharitable fundingheld bycolleagues withinthe academicrenal department

No individualfunding butcollaborate onresearch withinacademicresearchdepartmentfunded by avariety of sourceseg MRC, KidneyResearch UK.

Nil

Deborah SandersDirector ofnursing16/1/13

Nil Nil Nil Board member,The Royal FreeHospital Nurses’Home of RestTrust

Nil Nil Nil
















Kate Slemeck,executive directorof operations7/4/16

Nil Nil Nil Nil Husband worksfor Canon whoprovide thetrust’s managedprint service.

Nil Nil

David SlomanChief executive15/4/16

Director,

UCLPartners2

Trustee/Non-executive director,Skills for Health

Chair of North

Central London

Sustainability and

Transformation

Plan

Nil Nil LondonProcurementPartnershipboard member.

Relative whoworks for Ernst &Young

Member of HSJ’sProduct AdvisoryBoard

Member of NHSImprovementCEO AdvisoryGroup (January2016)

Nil Nil

2The Company’s constitutional documents have been drafted in accordance with charity law and Charity Commission guidance, so that the Company can apply for charitable status in the

future as and when its Board of Directors considers this appropriate.
















Non-voting directors

David Grantham

Director of

Workforce and

OD

7/4/16

Nil Nil Nil Board Member

and Treasurer

London

Healthcare

People

Management

Academy –

March 2013

Chair of NHS

Employers

Medical

Workforce

Forum – August

2010

Board MemberHealth EducationNorth and EastLondon(HENCEL) – July2014Board Memberand TreasurerLondonStreamliningProgramme(s) –March 2014

Nil Nil
















Mike Greenberg

Divisional director

women’s,

children’s and

imaging services

7/4/16

Nil Nil Nil Nil Relative of COOof Optum Labs, asubsidiary ofOptum

Nil Partner with HCA in Wellington

Diagnostic and Outpatient

Centre LLP since 2007

George Hamilton

Divisional director

surgery and

associated

services

Nil Nil Nil Nil Consultantshares in W.Docwhich is affiliatedwith theWellingtonHospital.

Nil Nil

Emma Kearney

Director of

corporate affairs

and

communications

Director, EK

Consulting Ltd

Nil Nil Nil Nil Nil Nil

Andrew Panniker

Director of capital

and estates

Nil Nil Nil Nil Director, Royal

Free Charity

Development Co

Nil Nil

Peter Ridley

Director of

Planning

Nil Nil Nil Nil Nil Nil Nil
















Steve Shaw

Divisional director

urgent care

7/4/16


Will Smart

Chief information

officer

8/4/16


Robin Woolfson,

Divisional director

transplant and

specialist

services


Paper 2

Matters arising – trust board 27 July 2016

Trust BoardMatters Arising report as at 27 July 2016

Actions completed since last meeting of the Trust Board

MinuteNo

Action Lead Complete Board date/agenda item

Outstanding

FROM TRUST BOARD HELD ON 29 JUNE 20162016/115 Nursing and midwifery staffing monthly report

Board to receive report on potential impact of Brexit

Include performance against the £29m agencycontrol target

C Clarke

D Sanders

Programme for September/October meeting

FROM TRUST BOARD HELD ON 25 May 20162016/94 Annual safeguarding report

Director of planning to pursue commissioning ofperinatal mental health services

P Ridley Meeting has taken place with the RF team toreview the current position (includingsafeguarding, maternity and mental healthrepresentatives). A request for commissioningguidance, and funding flows, is being followedup with Haringey CCG as leaders of thenetwork for NCL.

FROM TRUST BOARD HELD ON 27 APRIL 20162016/77 Patient safety committee report

Board to receive training on corporatemanslaughter

S Powis To be arranged as part of a future boardmeeting – tentatively booked for September2016.

FROM TRUST BOARD HELD ON 6 APRIL 20162016/54 Chairman and chief executive’s report

Progress reports on pathology joint venture to theshadow group board and finance and performancecommittee.

M Dinan Agreed at May shadow group board that thisshould be programmed for July, following acustomer/investor annual review. Deferred toSeptember as HSL annual accounts notreceived.

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MINUTES OF THE TRUST BOARD

HELD ON 29 JUNE 2016

Present

Mr D DoddMr S AingerMs C ClarkeMs D OakleyMs J OwenProf S PowisMs D SandersMr D SlomanMs K Slemeck

ChairmanNon-executive directorChief finance officer and deputy chief executiveNon-executive directorNon-executive directorMedical directorDirector of nursingChief executiveChief operating officer

Invited to attendMrs K FisherMr D GranthamDr M GreenbergProf G HamiltonMs E KearneyMr A PannikerDr S ShawMr W SmartDr R WoolfsonMs A Macdonald

Director of service transformationDirector of workforce and organisational developmentDivisional director for women’s, children’s and imaging servicesDivisional director for surgery and associated servicesDirector of corporate affairs and communicationsDirector of capital and estatesDivisional director – urgent careChief information officerDivisional director, transplant and specialist servicesBoard secretary (minutes)

Others in attendance

Dr J RunnaclesMs Y Coghill OBEMs Y Oluyede

Consultant paediatrician (for item 2016/113)Director WRES- Implementation, NHS England (for item 2016/119)Head of Workforce Health, Diversity and Equality (for item 2016/119)

2016/108 APOLOGIES FOR ABSENCE AND WELCOME Action

Apologies for absence were received from:

Mr P Ridley Director of planningProf A Schapira Non-executive director

2016/109 DECLARATION OF INTERESTS

The report on the register of interests was noted and entries confirmed to becorrect, subject to the following changes:

• Stephen Ainger was no longer CEO of Partnership for Renewables orInfrared Capital Partners Ltd

• Chair of the North Central London Sustainability and Transformation Planto be added to David Sloman’s declaration

• Consultant shares in W.Doc to be removed from Emma Kearney’sdeclaration and added to George Hamilton’s

AM

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2016/110 MINUTES OF MEETING HELD ON 25 MAY 2016

The minutes were accepted as an accurate record of the meeting.

2016/111 MATTERS ARISING REPORT

The matters arising report was noted.

2016/112 RECORD OF ITEMS DISCUSSED AT PART II BOARD MEETING ON 25 MAY2016

The report was noted.

2016/113 QUALITY IMPROVEMENT – PAEDIATRICS ‘SAFETY HUDDLE’

Dr Jane Runnacles, consultant paediatrician was in attendance for this item. Shetold the board about the ‘safety huddles’ which were taking place in paediatrics.Children in the UK experienced higher morbidity and mortality than those incomparable health systems and it was against this background that the HealthFoundation had funded the ‘safety huddles’ project. ‘Safety huddles’ took place atthe beginning of the day and night shifts and involved the multidisciplinary wardteam. A series of questions were asked to identify patients who might be at riskor required additional supervision. The ‘huddles’ flattened the ward hierarchy andimproved communications on the ward and with families.

Ms Owen, non-executive director, asked how progress was measured. DrRunnacles responded that safety indicators included the number of transfers tointensive care, cardio-respiratory arrests.

The chairman thanked Dr Runnacles for attending the meeting.

2016/114 PATIENTS’ VOICES

The director of nursing read out a complaint and a compliment.

The complaint was about a cancelled operation. The patient had been due tohave an operation on their hand at the Royal Free Hospital. They arrived at thehospital at 7.30am to be told that their operation had been cancelled, with noexplanation offered. They had not received a letter informing them of thecancellation and had been put to inconvenience and expense as they had lost aweek’s pay. This had happened before for a previous operation.

The compliment was from a family about the end of life care their mother hadreceived on Rowan ward at Barnet Hospital. The palliative care team had spent alot of time communicating with the family and ensuring excellent end of life care.It had not been possible to organise hospice care but the family were notconcerned about this as the care their mother had received was as good as if shehad been in a hospice. The doctor made them feel like their mother was the onlypatient and she died peacefully and well cared for.

The director of corporate affairs and communications would present this item nexttime.

EK

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2016/115 NURSING AND MIDWIFERY STAFFING MONTHLY REPORT

The director of nursing presented the report, and reported that during April 2016,there had been 2% fewer actual than planned hours.

She drew attention to ward 7 East A at the Royal Free which had a high vacancyrate. This was a trauma and orthopaedics ward and all the current vacancies hadbeen recruited to but not all staff were yet in post. Some beds had been closedand staff had been transferred from other wards in the meantime. FFT resultsfrom the ward did not suggest major concerns.

The peak time for recruitment was approaching with approximately 600 studentshaving expressed an interest in working at the trust.

The director of nursing reported that the trust was seeing a reduction in spend onagency staff of circa £100K a week compared with last year. She added that therehad been a particular focus on urgent care as that was the main area of agencyspend. This had been so successful that some wards were close to having noagency staff other than in exceptional circumstances. NHS Improvement had notissued a requirement for a further percentage reduction in agency pay, rather thetrust had been set on overall control total of £29m on agency pay for all staffgroups.

Ms Oakley, non-executive director, asked about the variations on Spruce ward.The director of nursing responded that this was the stroke ward at Barnet Hospitaland a skill mix and establishment review was currently underway. Howeverbecause there was a small number of HCAs on the establishment, even one ortwo additional HCAs to meet a particular need would show as a high percentageof actual in excess of planned staffing.

Mr Ainger, non-executive director, asked about the potential impact of thereferendum result. The director of nursing responded that it was still very early topredict the impact but a reassuring message had been sent out to staff. Theoverseas recruitment agency had been advised that the trust still wanted toemploy the nurses that had been recruited. The chief executive added that thetrust had 2,700 non-UK staff but it was not known how many of these were fromthe UK. All the trust’s staff were cherished, wanted and respected.

It was agreed that the board should receive a report on the potential impact ofBritain’s exit from the EU in September/October, with a wider perspective than justrecruitment.

The report noted that there had been four shifts when the nurse: patient ratio fellbelow 1:11 on a night shift and no occasions where the 1:8 day shift ratio had notbeen met. There had been no associated patient safety issues with any of theshifts.

Ms Owen, non-executive director, suggested that it would be helpful to see howthe trust was doing against the £29m control total. The director of nursing wouldinclude this in the next report, but it was important to note that this related to totalagency spend of which nursing agency only accounted for 50%.

The board agreed that the report provided sufficient assurance that the nursestaffing levels were meeting the needs of patients and providing safe care.

CC

DSa

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2016/116 RETENTION OF STAFF UPDATE

The director of workforce and OD presented this report. He referred to theoverarching staff experience retention plan alongside the Vision 2020workstreams which would also impact on staff retention.

The retention work was clinically led, with the director of nursing leading nurseretention and the divisional director for women’s, children’s and imaging servicestaking the lead for medical workforce.

Ms Oakley, non-executive director, noted that the corporate departments had thehighest number of unfilled posts and asked whether these vacancies were ‘real’ orwould be removed as part of the financial improvement plan. The chief financeofficer responded that there had been a number of changes in the corporatedepartments, with relocation of staff and restructuring. A number of vacancieswere being filled by contractors and efforts were being made to move tosubstantive appointments. There had been reductions in some departmentsresulting from bringing different teams together, but increases in others makingthe overall headcount about the same.

Ms Owen, non-executive director, asked whether the trust’s corporatedepartments could be benchmarked.

There was discussion of appraisal rates and the need to improve these. Thedirector of workforce commented that there were limited sanctions, for examplewithholding incremental progression and the answer probably laid in emphasisingthe benefits of appraisal, for example improving morale and better staff surveyrates. It was also important that appraisal was good quality.

The board noted the report.

2016/117 NHS IMPROVEMENT LICENCE CONDITION – CORPORATE GOVERNANCESTATEMENT

The director of corporate affairs and communications introduced this report. Shenoted that in future years this would be presented to the audit committee first.

Mr Ainger, non-executive director, suggested that it needed to be made clear thatboard training on corporate manslaughter was planned, rather than completed.

The chief executive suggested that it would be important to keep the documentunder review given the complex environment in which the trust was operating.

The board:

a) Reviewed and approved each statement; andb) Authorised the chairman and chief executive to sign the certification in the

prescribed format on behalf of the board for submission to NHSImprovement to meet the specified 30 June 2016 deadline.

2016/118 CQC NATIONAL INPATIENTS’ SURVEY 2015

The director of nursing introduced this item, which related to the results from theCQC inpatients survey which had been undertaken in 2015. Overall the resultswere about the same as the previous year. Results from peer organisations had

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been reviewed and the 2015 inpatient survey results had been compared with thelocal survey and FFT results. All were consistent with each other. The surveyresults would be used to inform the patient experience plans.

It was suggested that it would be worthwhile to contact other trusts who had donewell in the survey, for example Northumbria Healthcare NHS Foundation Trust.

The board noted the report.2016/119 WORKFORCE RACE EQUALITY STANDARDS (WRES) REVIEW

The chairman welcomed Ms Coghill and Ms Oluyede to the meeting.

The director of workforce and OD explained that NHS England required eachNHS organisation to publish the WRES data in order to raise the profile of equalityand diversity and reduce the unequal treatment and experience of black andminority ethnic (BME) staff. He corrected one of the figures in the report; therehad been a decrease not an increase of 75 in the number of management posts.

The chairman and chief executive had attended a national WRES conference todescribe the action that RFL was taking. This was gathering pace but it wouldtake many years to achieve equal treatment. In order to achieve BMErepresentation at senior levels, it would be necessary to appoint at least 50 a yearat band 8a and above for 5 years.

Ms Owen, non-executive director, asked about progress in training BME staff tosit on recruitment panels. The director of workforce and OD responded thatsufficient staff had been trained to cover panels for band 8a and above, althoughthe intention was to extend this to other levels.

The following points were made in discussion:

It was important to publish information about the impact of inequality – this madethe most compelling case for taking action

How staff could be protected from racist patients and visitors

The director of nursing noted that not all BME staff necessarily agreed that theyneeded special treatment and care needed to be taken not to unintentionallyalienate staff.

There was discussion of acting up, which could provide staff with a valuableopportunity to demonstrate their ability to progress but staff were not alwaysoffered these opportunities in an equitable way. The director of workforce and ODcommented that there was little data about acting up but there were guidelinesabout advertising opportunities and providing fair access.

Summarising the discussion, the chairman made the following points:The listening events had generated some very powerful stories of individuals“suffering in dignified silence” – he suggested using these in induction and training

More focus was needed on management capability and the need to developexcellent managers who could make their staff feel they belonged

It was important to feed back to staff about action taken in response to what was

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said at the listening events.

Ms Coghill applauded the board for taking this so seriously. Race inequality as ahuge problem in the NHS and the board was showing a strong lead. It was doingthe right things, for example listening, having BME representation on recruitmentpanels and mentoring. Momentum, energy and communications were vital andthe trust was making good progress, albeit that it would take years to show realprogress.


2016/120 CHAIR AND CHIEF EXECUTIVE’S REPORT

The chairman highlighted the following points from the report:

• He was pleased to announce the appointment of Judy Dewinter as leadgovernor and Frances Blunden as deputy lead governor

• He congratulated Judy Dewinter for receiving a British Empire Medal in theQueen’s Birthday Honours

It was noted that a review of the Pathology joint venture would be presented to theboard in July and that this would be before any decision was made about theBarnet Hospital and Chase Farm Hospital pathology services. The chiefexecutive added that the North Central London Sustainability and TransformationPlan was also looking at Pathology and back office functions.

The chief executive noted that a judicial review application regarding the PearsBuilding had been lodged and would be heard in July.

Ms Owen, non-executive director, asked if the trust was working with BartsHealthcare regarding a new non-emergency patient transport contract and thedirector of nursing responded not at present.

2016/121 TRUST PERFORMANCE DASHBOARD

The chief operating officer presented the performance report, noting that theparticular performance challenges were A&E, RTT and cancer. RTT was close tothe required trajectory but A&E and cancer both presented difficulties andrecovery trajectories were in place.

Although the trust continued to score green overall against the NHS Improvementgovernance regime, it was important for the board to note the areas of non-compliance.


2016/122 FINANCIAL PERFORMANCE REPORT

The chief finance officer reported the trust had delivered an actual deficit of£12.8m and an adverse variance from plan of £3.4m at end of May. The year todate adverse performance had been driven by under performance in clinicalincome due the junior doctors’ strike (£1.7m), slippage against savings target

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phased until end of month 2 (£3.3m) and pay overspends relating to agencypremium. There had been some improvement on agency spend but notsufficient. NHS Improvement had issued the trust with a new control total takingaccount of land sales.


2016/123 PATIENT SAFETY COMMITTEE REPORT

The committee chair reported that there had been one new never event, relatingto a misplaced nasogastric tube. The board noted the report.

2016/124 SHADOW GROUP BOARD REPORTThe board noted the report from the committee.

2016/125 AUDIT COMMITTEE REPORT

The board noted the report from the committee.

2016/126 FINANCE INVESTMENT AND PERFORMANCE COMMITTEE REPORT

The board noted the report from the committee.

2016/127 QUESTIONS FROM THE PUBLIC

There were no questions from the public.

2016/128 ANY OTHER BUSINESS

There was no other business.2016/129 DATE OF NEXT MEETING

The next trust board meeting would be on 27 July 2016 at 1300 in the Atrium,ground floor, Royal Free Hospital.

Agreed as a correct record

Signature …………………………………..date 27 July 2016…………………………….Dominic Dodd, chairman

Paper 4

Confidential trust board meeting update – trust board 27 July 2016

ITEMS DISCUSSED AT THE CONFIDENTIAL BOARD MEETING HELD ON 29 JUNE 2016

Executive summary

Decisions taken at a confidential trust board are reported where appropriate at the next trustboard held in public. Those issues of note and decisions taken at the trust board’s confidentialmeeting held on 29 June 2016 are outlined below.

• Stocktake of the workforce race equality standards, building on the discussion which tookplace in the public part of the meeting

• Financial improvement plan

• NCL sustainability and transformation plan (STP) – a summary of the June submission isincluded elsewhere on the agenda

• Non-emergency patient transport contract – an update is provided in the chairman’s and chiefexecutive’s report.

• DeepMind update

The board also discussed the trust performance and financial performance reports.

Action required

For the board to note.

Report From D Dodd, chairmanAuthor(s) A Macdonald, board secretaryDate July 2016



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Monthly report of Nursing staffing levels May 2016

Executive summary – including resource implications

In January 2014 the Royal Free London NHS Foundation Trust board considered the Government response to the Mid-Staffordshire NHS Foundation Trust Public Inquiry, Hard Truths – The Journey to Putting Patients First and the guidance published by the National Quality Board and the Chief Nursing Officer, How to ensure the right people with the right skills are in the right place at the right time Hard Truths set out the Government’s requirement that from April 2014 and by June 2014 at the latest, NHS trusts will publish ward level information on whether they are meeting their staffing requirements. This guidance has been replaced by the updated document from the National Quality Board, Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time – Safe, sustainable and productive staffing The overall trust summary of planned versus actual hours for May was that actual hours met planned:

Barnet hospital actual hours met planned hours Chase Farm hospital 0.5% more actual hours met planned hours

Royal Free hospital 0.5% less actual hours than planned

In May out of a minimum of 3,100 shifts there were 4 shifts (where the nurse:patient ratio dropped below 1:8 on a day shift or 1:11 on a night shift. There were no reported patient safety incidents on these occasions.

Action required

The board is requested to consider if the report provides sufficient assurance that the nurse staffing levels are

meeting the needs of patients and providing safe care consider the new National Quality Board requirements

Trust strategic priorities and business planning objectives supported by this paper

Board assurance risk number(s)

1. Excellent outcomes – to be in the top 10% of our peers on outcomes

2. Excellent user experience – to be in the top 10% of relevant peers on patient, GP and staff experience

3. Excellent financial performance – to be in the top 10% of

Report to

Date of meeting Attachment number


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relevant peers on financial performance 4. Excellent compliance with our external duties – to meet our

external obligations effectively and efficiently

5. A strong organisation for the future – to strengthen the organisation for the future

CQC outcomes supported by this paper

1 Respecting and involving people who use services 4 Care and welfare of people who use services 5 Meeting nutritional needs 7 Safeguarding people who use services from abuse 8 Cleanliness and infection control 9 Management of medicines 13 Staffing 14 Supporting staff

Risks attached to this project/initiative and how these will be managed (assurance)

Equality analysis

No identified negative impact on equality and diversity

Report from Deborah Sanders, Director of Nursing Author(s) Deborah Sanders, Director of Nursing Date 20 July 2016 References: Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time – Safe, sustainable and productive staffing, July 2016, https://www.england.nhs.uk/ourwork/part-rel/nqb/

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Introduction In January 2014 the Royal Free London NHS Foundation Trust board considered the Government response to the Mid-Staffordshire NHS Foundation Trust Public Inquiry, Hard Truths – The Journey to Putting Patients First and the guidance published by the National Quality Board and the Chief Nursing Officer, How to ensure the right people with the right skills are in the right place at the right time. Hard Truths sets out the Government’s requirement that from April 2014 and by June 2014 at the latest, NHS trusts will publish ward level information on whether they are meeting their staffing requirements and board’s should receive a monthly report concerning the same. This report provides information on planned versus actual nurse staffing for May 2016 and an update on progress with the reduction in use of agency nursing and midwifery staff.

National Quality Board Guidance July 2016

The document, Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time – Safe, sustainable and productive staffing provides an updated set of National Quality Board expectations for nursing and midwifery staff. This replaces the 2013 guidance. The guidance has been brought together with the Carter report findings setting out key principles and tools that provider boards should use to ensure safe, sustainable and productive services. The updated guidance sets out the expectation that there should be a triangulated approach to staffing decisions as shown:

Under the previous guidance the Board received a 6 monthly review of nurse staffing levels determined using the Safer Nursing Care tool and professional judgement. The updated guidance requires an annual strategic staffing review, using a triangulated approach, with

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takes account of all healthcare professional groups and that is in line with financial plans. This should be followed by a comprehensive review after 6 months to ensure that workforce plans are still appropriate.

Planned versus actual staffing The overall trust summary of planned versus actual hours for May 2016 was that actual met planned (planned = 282,364 hours, actual 282,617 hours) Site specific data is as follows:

Barnet hospital actual hours met planned hours Chase Farm hospital 0.5% more actual hours met planned hours Royal Free hospital 0.5% less actual hours than planned

Planned versus actual staffing

The tables below shows the planned versus actual hours for May 2016

Ward Beds

Registered nurse to

patient ratio

Day Shift

Percent of actual vs

total planned shifts

(RN days)



(RN nights)



(HCA days)



(HCA nights)

Falls Attributable

Cdiff FFT Score

9 West 26 1:4 105% 106% 122% 71% 0 0 87%

9 North 33 1:4.7 96% 100% 115% 108% 2 0 93%

11 West 22 1:4.8 99% 105% 171% 254% 2 0 88%

11 South 19 1:3.8 95% 100% 101% n/a 5 0 90%

11 East 24 1:4.8 92% 100% 98% 155% 0 1 98%

10 East 24 1:3.4 93% 99% 94% 98% 1 0 88%

10 South 25 1:6.25 92% 101% 101% 100% 5 0 88%

5 East B 10 1:5 97% 100% 103% 106% 0 0 86%

Mulberry 13 1:5 107% 100% 92% n/a 1 0 90%

Transplantation and Specialist Services May 2016

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

Falls Attributable

Cdiff FFT Score

10 North 32 1:5.3 94% 101% 97% 101% 4 0 100%

8 West 36 1:5.1 98% 100% 94% 98% 5 0 79%

8 North 32 1:4 98% 99% 98% 100% 3 0 92%

10 West 27 1:5 98% 116% 128% 167% 2 0 100%

8 East 26 1:4.3 92% 98% 96% 100% 4 0 89%

6 South 28 1:4 98% 100% 100% 100% 2 0 87%

ITU (RF) vary 1:1/1:2 96% 97% 84% 76% 1 0 n/a

ED (RF) n/a n/a 103% 107% 109% 100% 0 0 86%

ED(BH) n/a n/a 110% 104% 153% 124% 2 0 81%

UCC (CF) n/a n/a 112% n/a 56% n/a 0 n/a

Adelaide 25 1:6.25 75% 100% 100% 206% 4 0 80%

Capetown 36 1:5.1 96% 124% 151% 204% 5 0 67%

CCU 8 1:2 100% 100% n/a n/a 0 0 100%

CDU 24 1:4.8 114% 118% 113% 225% 2 0 87%

ITU (BH) vary 1:1/1:2 100% 95% 100% 95% 0 0 n/a

Juniper 24 1:4.8 100% 100% 99% 72% 5 1 82%

Larch 22 1:5.5 102% 102% 101% 85% 2 0 94%

Olive 22 1:5.5 101% 105% 96% 66% 0 0 92%

Palm 22 1:5.5 94% 100% 99% 82% 2 0 83%

Quince 24 1:4.8 98% 106% 96% 206% 2 0 86%

Rowan 24 1:4.8 87% 99% 88% 145% 6 0 96%

Spruce 24 1:6 118% 132% 97% 105% 5 0 67%

NRC 15 1:7.5 107% 104% 128% 248% 3 0 n/a

Walnut 24 1:6 96% 100% 92% 116% 1 0 91%

Urgent Care May 2016

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Safe staffing

In May out of a minimum of 3,100 shifts there were 4 shifts where the nurse: patient ratio dropped below 1:8 on a day shift or 1:11 on a night shift. The 4 occasions were on Capetown, the rehabilitation ward at Chase Farm where there was a 1:9 ratio. There were between 5 – 7 nursing assistants on each shift and no reported patient safety incidents related to this.

Registered nurse agency staff On 1 September 2015 Monitor wrote to the trust advising of the rules for nursing agency spending and setting out the spending ceiling for the trust. The rules are an annual ceiling for total nursing agency spending for each trust and a mandatory use of approved frameworks for procuring agency staff. The rules apply to all NHS trusts, NHS foundation trusts receiving interim support from the Department of Health and NHS foundation trusts in breach of their licence for financial reasons. All other NHS foundations trusts have been strongly encouraged to comply.

On 19 October 2015 Monitor wrote to the trust confirming that the agreed ceiling of nurse agency pay as a % of total nurse pay for the Royal Free London was 9.8% by March 2016 with a further reduction in April 2016. The further reduction % of nursing pay by agency has not yet been issued rather the trust has been sent an overall control total of £29 million on agency pay (all staff groups). In quarter one the trust met its trajectory for agency reduction however the trajectory becomes steeper in the coming quarters.

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

Falls Attributable

Cdiff FFT Score

5 north A 18 1:4.5 96% 100% 98% 100% 1 0 92%

7East A 20 1:5 101% 100% 106% 132% 3 0 67%

7 East B 13 1:4.3 94% 100% 90% 100% 1 0 91%

7 West 32 1:4 95% 101% 110% 103% 4 0 92%

7 North 24 1:4.7 107% 101% 104% 119% 3 0 97%

Beech 24 1:6 109% 102% 106% 71% 2 0 83%

Canterb'y 25 1:6.25 76% 63% 80% 87% 3 0 100%

Cedar 24 1:4 77% 99% 147% 114% 1 0 94%

Damson 24 1:6 92% 102% 112% 103% 1 0 100%

Wel'gton 39 1:6.5 89% 65% 81% 120% 0 0 90%

Surgery and Associated Services May 2016

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

Falls Attributable

Cdiff FFT Score

6 North 20 1:4 97% 105% 99% 75% 0 0 n/a

5 South 31 1:8 94% 96% 95% 97% 0 0 88%

Neonate RFH vary 83% 99% 68% 100% 0 0 n/a

Galaxy 30 1:4 82% 97% 10% 26% 0 0 n/a

Neonate BH vary 99% 94% n/a n/a 0 0 n/a

Delivery BH n/a 107% 102% 148% 101% 0 0 98%

Willow 16 1:5.3 137% 160% 155% 53% 1 0 88%

Victoria 48 1:8 90% 77% 103% 98% 0 0 97%

Womens and Childrens May 2016

Ward Beds

Registered nurse to

patient ratio

Day Shift



(RN days)



(RN nights)



(HCA days)



(HCA nights)

Falls Attributable

Cdiff FFT Score

12 Wesr 15 vary 99% 98% 98% 98% 3 0 100%

12 South 16 1:4 100% 99% 100% 100% 1 0 100%

12 East B 12 vary 97% 100% 97% 100% 0 0 100%

Private Practice April 2016

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The divisions continue to focus on reducing nurse and midwifery agency use. Overall in June there were 1,722 less agency hours used than in May. In June the overall % of nursing pay by agency by division was: urgent care – 15%, transplantation and specialist service – 7.7%, women’s and children’s – 8.7 % and surgery and associated services - 8%. The graphs to follow show the weekly position. The increase in urgent care has been as a result of the increase activity in the critical care units and the acuity of the patients in the unit, increased sickness in the ED departments and RMN usage. In womens and childrens the increase is due to significant increase in RMN’s required to care for CAMHs patients, some of whom are waiting for tier 4 beds to become available. The cost of the RMNs is met by the CCG’s

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.

Recruitment

A key driver to reducing agency cost is recruitment to substantive posts. The graph below shows the net starters and leavers and the forecast. The forecast has been revised following recent recruitment campaigns and the increase in the number of WTE’s in the pipeline.

The current pipeline is shown below:

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Report to Date Attachment number Trust Board

27 July 2016

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Paper title: Director of Infection prevention and control annual report 2015/16 Executive summary In line with the revised Health and Social Care Act (2008) trusts are required to have appropriate management and clinical governance systems in place to deliver effective infection prevention and control. This document reports on the activity for the year 2014/15 to provide assurance that the IPC programme has been taken forward, that IPC activity has striven to assure compliance with the Health and Social Care Act detailed below. This document also includes reports from the clinical divisions and associated departments. Action required The Board is asked to confirm that the report provides sufficient information to provide assurance of sustained compliance with the Hygiene Code. Trust strategic aims and business planning objectives supported by this paper

Improving clinical effectiveness Enhancing the patient experience To be in the top 10% of hospitals in England for quality including reductions in HCAIs

CQC outcomes supported by this paper Outcome 8 Cleanliness and infection control Risks attached to this project / initiative and how these will be managed (assurance) The revised Hygiene Code Risk matrix will be monitored at the Infection Control Committee. The risks associated with the Hygiene Code have been included in the Board Assurance Framework. Equality impact assessment

no adverse equality impact Public, patient and carer involvement All IPC reports available to public scrutiny and discussed at open Board meetings

Report from: Deborah Sanders Authors: Damien Mack, microbiology consultant, lead IPC doctor; Husam

El-Mugamar, consultant microbiologist, IPC doctor; Dianne Irish, consultant virologist; Yvonne Carter, head of IPC nursing

Date: July 2016

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1.0 Introduction and Summary This report outlines activity and events related to infection control for 2015/16 for the trust. As always, healthcare associated infection (HCAI) continues to be an important issue for the Trust and this report will include some site specific information to better enable actions for improvement and patient safety. The trust target remains ‘zero avoidable infections’. For reportable organisms, the threshold for the enlarged Trust C.diff, toxin positive, attributable infections was 66, with an actual outcome of 68 cases. There were 14 ‘lapses in care’ which means actions were identified that may have contributed to C.diff acquisition. Overall this is a reduction from 28 lapse in care cases in 2014/15, or a reduction of 50%. There were three MRSA bacteraemias against a target of zero. 2.0 Description of infection control arrangements Deborah Sanders, director of nursing is director of infection prevention and control (DIPC) and chair of the infection prevention and control committee (IPCC). The IPC team is headed by the DIPC, who is a board member and activity is directed by the lead infection control doctor and microbiologist and by the head of IPC nursing. The IPCC meets quarterly and has representation from across the Trust. The consultant microbiologists with special interest in antimicrobial prescribing are members of the IPCC and the Drugs and Therapeutics Committee and acts as a link between the two. Within the trust committee structure the IPCC reports to the clinical performance committee and the patient safety committee and directly through the DIPC to the Board. The IPCC is reported to by the Decontamination Committee and the fortnightly divisional leads IPC group and Clostridium difficile action group. The fortnightly meeting chaired by Deborah Sanders, DIPC and Dr Steve Shaw, Divisional Director of Urgent Care is held to review ongoing infection control data, infection control activity, activity to keep C.diff cases below threshold and current IPC issues. This is attended by the IPCT, divisional infection control clinical leads, divisional nurse directors and operational managers as well as allied healthcare professionals (AHPs). Monthly reports of infection control activity within each clinical division are recorded as part of the divisional clinical governance grid. 3.0 Infection Control Team Staffing Director of infection, prevention and control - D Sanders – director of nursing.

Royal Free Hospital Barnet hospital and Chase Farm Hospital Medical Staff Consultant microbiology 5 PA (infection control lead) Consultant microbiology 6.5 PA Virologist 1.5 PA Healthcare scientist 0.5 wte funded by Microbiology

Medical Staff Consultant microbiology 6.5 PA

Nursing Staff Head of IPC nursing 1 wte Clinical lead nurse 2 wte Clinical nurse specialist 2.8 wte Clinical nurse specialist (renal) 1 wte - funded by renal services Specialist sister IPC 1 wte Senior practice educator 1 wte IPC practice educators 2 wte, 1 vacancy Audit and surveillance nurse 1 wte Hand hygiene co-ordinator 1 wte Data administrator 1 vacancy

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4.0 Healthcare associated Infections 4.1 MRSA acquisitions New cases of MRSA are assessed as acquisitions if a positive screen or swab is identified more than 48 hours after admission. Acquisitions of MRSA thought to have occurred within the Trust are on average five per month which is a steady, low rate. There have been sporadic clusters of MRSA acquisitions, with one outbreak in NNU as discussed below. Since the beginning of 2009, the trust has commenced mandatory MRSA screening of elective admissions as per Department of Health requirements. This mandate has now been lifted, but the trust screens high risk patients and is reducing screening in groups such as out-patient and day cases Screening admissions helps to reduce MRSA acquisition by earlier identification, and management of colonised patients, as well as improving the accuracy with which the site of acquisition can be attributed. The IPCC agree to maintain high screening schedule to ensure patient safety. 4.2 MRSA and MSSA bacteraemia MRSA and MSSA bacteraemia episodes at RFLNHSFT

There were 3 attributable MRSA bacteraemias within the trust, the threshold remains zero. There was one case at the Royal Free Hospital, and two at Barnet hospital. A full post-infection review (PIR) was conducted for each case, shared with external stakeholders including the health protection units and the CCGs. Learning from the PIRs has been used to inform practice improvements such as dedicated medical staff training in blood culture taking. MSSA bacteraemias have been reported as part of the national mandatory reporting scheme, although no targets for reduction have been set. There were 20 MSSA bacteraemias for 2015/16 compared to 34 for 2014/15. Learning from case investigations always prompt care improvements, particularly in renal line site care. There has been targeted action in high risk areas such as renal services. For renal patients there is a screening and eradication programme for MSSA nasal carriage, which is regularly audited. A bundle approach to line care has been implemented and there is regular surveillance, feedback and teaching to all the satellite units.

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4.3 Clostridium difficile In April 2015, Monitor made a change to the C.difficile infections target, in that only ‘lapses in care’ leading to such infections should be recorded on the assessment framework. ‘Lapses in care’ infections are determined by the local clinical team applying a checklist based assessment developed by Public Health England, with outcomes reviewed and agreed by local commissioners. The trust achieved compliance with its national trajectory in each quarter of 2015/16. The target for the full year was to record fewer than 66 cases where a lapse of care was an underlying factor; over the period April 2015 to March 2016, the trust observed 68 confirmed cases, of which 14 were deemed to be lapses in care. Overall this is a reduction from 28 lapses in care cases in 2014/15, or a reduction of 50%. Although The Royal Free Hospital had two more cases than the previous year (8 compared to 6) Barnet hospital and Chase Farm hospital reduced from 22 cases to six. All cases were investigated and learning applied across the trust in revised antimicrobial policies and prescribing and safer practices including recognition and reporting of symptoms for timely sampling.

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. A report is provided to the Patient Safety Committee and Clinical Performance Committee, the commissioners at Clinical Quality Review Group and Monitor. The learning from the lapses in care have the actions agreed and included into the trust C.diff action plan. Examples include: Harmonisation of AB policies is nearly complete Re-education of staff in all areas in all trust areas in C.diff patient management, revision of the

‘stool chart’ to provide better identification of infectious diarrhoea and prompt testing of samples. ‘Typing’ of all PCR and toxin positive C.diff samples to identify possible transmission between

patients that may not be apparent in any other way. Revision of cleaning strategies to harmonise all cleaning with dedicated sporicidal agents for all

C.diff isolation rooms. Education with IPC PEs on recognition of infectious diarrhoea, when to send samples and

improving robust documentation.

2014/15 2015/16

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4.4 Carbapenemase producing enterobacteriaceae (CPE) and other non-fermenting (NF) organisms. CPE and NFs have previously been identified at the Royal Free Hospital only, but are now being identified at Barnet and Chase Farm. All cases are investigated for possible source and screening is instituted to ensure no further transmission.

The DH guidance, or ‘Toolkit’ for management of CPEs many recommendations are still being embedded, such as isolation for the period of screening, which impacts isolation facilities in general, particularly in renal dialysis services and the financial and time resources needed for the screening, education, care and follow-up of patients. The trust will be invited to participate in a review of the DH ‘Toolkit’ in 2016

Carbapenemase producing Enterobacteriaceae cases

2014 2015 2016 Total

Division Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2

SAS 4 3 4 1 12

TASS 5 2 3 1 3 2 4 4 5 6 35

UC 1 2 1 2 2 2 1 11

Total 5 3 5 1 4 6 9 10 8 7 58

Carbapenemase producing non-fermenters cases

2013 2014 2015 Total

GP 1 1 2

SAS 2 1 4 7

TASS 7 3 5 15

UC 1 3 4

Total 11 4 13 28

5.0 Virology Dr Dianne Irish, Consultant Virologist, From April 2015 to March 2016, there were 1357 laboratory confirmed viral infections that

required IPC interventions, 90% (n=1217) were from patients with respiratory viral infections (Figure 1).Of these, 1136 infections were identified on RFH site and 81 infections on the BCF site. In addition, there were 20 chicken pox/shingles infections, 6 measles infections and 67 norovirus infections recorded from the RFH site.

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Figure 1: Virology IPC Activities from July 2014 to March 2016

From April 2015 to March 2016, there were 309 influenza infections – with 222 influenza A and 87 influenza B infections. There were 196 influenza A infections and 79 influenza B infections at the Royal Free hospital. The dominant circulating strain in the winter season was A (H1N1 pdm09), with lower levels of influenza A (H3N) pdm09 and influenza B. Influenza A levels started to decline in February with a concomitant rise in influenza B cases. Other viral respiratory infections included rhinovirus infections which predominated with 391 infections recorded on the RFH site. In addition, there were 93 respiratory syncytial virus, 28 metapneumovirus, 66 adenovirus, 90 parainfluenza, 111 coronavirus, 5 parechovirus and 60 enterovirus infections detected (Figures 2 & 3). A number of patients with viral respiratory infections including influenza were not isolated. This resulted in a significant amount of contact tracing with prophylaxis being given to “at risk” ward patients who had significant exposure to influenza infection.

At the Royal Free hospital 150 patients had confirmed exposure to an influenza infection during the winter season. 110 (73%) were over 65 years and 2 (1%) were children under 6 months of age. 149/150 patients received oseltamivir prophylaxis and one patient received zanamivir prophylaxis. 2/150 of our patients developed influenza A in hospital while on prophylaxis. One of them was on inhaled Zanamivir and the other had only 7 days (of a 10 day course) of oseltamivir prophylaxis. There were and 15 cases on ITU between October 2015 and March 2016. 93% were influenza A (11 H1; 1 H3; 2 not-typed) and 7% influenza B.

Healthcare worker vaccine influenza vaccine uptake for 2015/16 winter season at Royal Free London NHS Foundation Trust was 26%. On the BCF site, 26 influenza A infections and 8 influenza B infections were identified from samples submitted to Virology at the Royal Free lab. In addition, there were13 rhinovirus, 3 human metapneumovirus, 3 respiratory syncytial virus, 3 adenovirus, 5 parainfluenza, 2 coronavirus and 10 enterovirus infections. RSV testing is also performed at Barnet hospital but this data is not available.

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Fig 2: Influenza cases at RFH from October 2014 - June 2016

Figure 3: Common Respiratory Viruses from Jul 2014 to March 2016

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Measles infections Six cases of measles were identified during the last quarter compared with 1 measles case last year. 5 of them were teenagers (15-18 yrs. old) and 1 was under one year of age. In two of the cases there were approximately 50 contacts each that the IPCT and/or virology doctors reviewed to identify at risk patients for post exposure prophylaxis and the virology doctors liaised closely with HPU to decide which patients should be offered post exposure prophylaxis. Six children were given post exposure prophylaxis – HNIG (human normal immunoglobulin). Staff contacts were followed up by Occupational health and Wellbeing.

Gastrointestinal viruses

At the Royal Free hospital, gastrointestinal infections identified other than norovirus included 10 adenovirus infections,3 astrovirus infections, 8 rotavirus infections, 4 sapovirus infections and 1 enterovirus infection.

Norovirus activity

There were 67 norovirus infections over the 12 month period at the Royal Free hospital. Most of these infections were identified in common variable immunodeficiency (CVID) patients who are chronically infected with norovirus. In the majority of cases, patients were already isolated by the time the laboratory had the positive results and phoned the relevant clinical teams. In February 2016, there were 10 patients affected with vomiting and/or diarrhoea on 8E, of which 4 cases were confirmed by the laboratory, and 14 staff members were off sick with gastrointestinal symptoms.

Figure 4: Norovirus PCR Positive Stool Samples Recorded from RFH: July 2014 – March 2016

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6.0 Surgical site infection surveillance One three-month module of orthopaedic surgical site infection surveillance per year is required under the mandatory surveillance scheme. Regular meetings have been incorporated within the orthopaedic specialty group audit programme to feedback and discuss results of surveillance. There has been a higher than ‘normal range’ infections reported for one quarter in above/below knee amputation surgery, but subsequent quarters have reported no infections. With low numbers the fluctuations that move reports out of ‘normal range’ have very narrow margins and are seen as trends to address more often than severe service issues. There were three hip replacement infections in patients from one theatre in Chase Farm which were investigated in partnership with the Health Protection Unit/PHE. Although no source was specifically identified, the actions focussed on the environmental and estates factors within theatres, the staff practice and theatre management and patient care pathways. No subsequent infections have been identified. Further practice review and environmental testing have been carried out as assurance that the measures instituted have remained consistent. 7.0 Outbreaks and incidents Follow-up of deaths related to MRSA and CDI. A formal process for the review of cases where MRSA or CDI has been included as a cause of death has been established. This process involves the trust’s risk management system and links to the root cause analysis process. There have been no deaths with MRSA bacteraemia or C.diff notified on part 1A of the death certificate. There have been 3 instances of increased incidence of C.diff (2 or more identified in close time proximity), but identification of the Ribotype has indicated most occurrence were not transmission between patients. Six babies were identified with MRSA in the neonatal unit of the Royal Free. Full IPC measures were put in place with no further transmission. There was a much larger number of influenza cases with transmission noted between staff to patients as well as patients to patients. This has been noted and forms the drive to the trust-wide flu campaign for this winter. Norovirus cases have been identified at Royal Free and Barnet Hospitals requiring closure of some ward bays. Full IPC measures were implemented, with rapid cessation of Norovirus transmission. There have also been an increase in CPO reports requiring contact tracing and screening across the Royal Free and Barnet wards. Within the last year there has been one recorded transmission within ITU (RFH) and one in 8 West (RFH). Several patients have now been identified with a CPO on transfer from Barnet to the Royal Free. A programme of screening is planned to mirror the screening at RFH to ensure patient safety. 8.0 Ebola Over the past two years, the IPCT has trained over 700 staff in the front-line management of patients presenting with Ebola, or suspected Ebola patients. This included identifying appropriate isolation space, sourcing and ordering PPE and accessories, training staff to don and doff PPE, facilitate mask/respirator ‘fit testing’ and training of staff to test others, advise staff within the trust on Ebola management (outside of the HLIU), provision of IPCT advice to HLIU.

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This will be reviewed in light of the Infectious Disease Teams revision of policies into a High Consequence Infectious Disease policy. This will identify activity for the year ahead. 9.0 Education Members of the IPCT provide mandatory infection prevention and control training for induction and annual updates for all relevant staff, particularly those who are unable to access e-learning modules easily. In addition, ad hoc training is performed in clinical areas depending on local needs. 10 Practice educators (PEs) PE’s have been recruited to the three hospitals (one new recruit yet to start), the IPC practice educators continue ward based teaching and skill competence assessments as part of their daily role. 11 Foundation Year (FY) doctors An infection control audit, related to the ‘Saving Lives’ high impact interventions is included again in the FY audit programme. Selected audits were presented to the infection prevention and control committee. This appears to be a popular and useful method of engaging trainee doctors in infection control as it was last year. 12 Audit and Surveillance The list of surveillance and clinical audit topics is included as appendix 1. This formed the basis of the surveillance and audit programme for 2015/16. 13 Antibiotic stewardship I Balakrishnan/ M Lanzman Antibiotic Stewardship Committee Report – 2015-16 The vast majority of antibiotic policies were harmonized across the Trust between April 2015-16. This involved extending the use of some antibiotics, such as temocillin, and the de-restriction of co-amoxiclav at the Barnet and Chase Farm hospitals. Amongst the key harmonized policies are urosepsis, community and hospital acquired pneumonia, skin and soft tissue infection, septic arthritis, sepsis, gastro-intestinal infection, infection in obstetrics, severe sepsis sexually transmitted infection and the aminoglycoside policy. The Microguide App has also been made available to staff at Barnet hospital and Chase Farm hospital. Key ongoing issues with harmonisation are the Surgical Prophylaxis Policy and Restricted Anti-infectives Policy. It is a particular concern that meropenem remains unrestricted at the Barnet hospital and Chase Farm hospital. There has also been considerable input into antibiotic policies in primary care, aiming to increase use of mecillinam and fosfomycin, whilst reducing the use of cephalosporins in light of the CQUIN. The development of the Joint Venture has seen much discussion around antibiotic susceptibility testing between the various partners. The meningitis B vaccine has now been introduced into the Trust, and a policy agreed for its use. The increasing prevalence of resistance has seen colistin being used in increasing numbers of patients. A policy has therefore been agreed to ensure that this relatively toxic drug is safely managed and dosed. Some new antibiotics have been launched, and are being looked into for their application within the Trust. Ceftibiprole has been undergoing in vitro testing on selected isolates, and an application to the Drugs and Therapeutics Committee is underway for ceftolozane/tazobactam. Susceptibility

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testing protocols have been developed for pristinamycin. A relatively old antibiotic, aztreonam, has been used increasingly in efforts to spare carbapenems and introduce an element of variability in prescribing. New antibiotics on the horizon include isavuconazole, ceftazidime/avibactam and aztreonam/avibactam. Much discussion is underway concerning the prescribing of antibiotics using EPMA, and the potential this system could have for antibiotic stewardship. A system of reminders to review and hard stops after five day courses is being designed. New laboratory initiatives, such as PNAFish have been introduced in order to expedite the identification of pathogens, facilitating antibiotic stewardship. Rapid methods of carbapenemase detection are being investigated – our study comparing CarbaNP, PCR and Rosco is being presented at Infection 2016. Other aspects of stewardship, such as education, audit and ward rounds, have been intensified across sites – there are now weekly antifungal stewardship ward rounds led by Dr Wey. A new session entitled “Multi-resistant Pathogens” has been included in the medical student Year 4 timetable. 14 Facilities – RFH The facilities and infection control teams have been working together across all three hospitals and have reviewed their cleaning and deep cleaning practices to ensure that they become a standardised hygiene practice across all three sites and satellite units and operate at the same level of performance and scrutiny.

Dedicated Infection Prevention and Control training for all Facilities support staff and contractors have been increased throughout the past twelve months. This ensures that IPC measures are at the forefront of all aspects of facilities service delivery and best practice is adhered to.

PLACE is the annual self-assessment relating to all matters pertaining to the patient environment, cleanliness, catering, physical environment, privacy and dignity and more recently dementias. The Trust committed the 2016 annual PLACE scores on 6 June 2016. The outcomes are due to be published by HSCIC late summer 2016. All three hospital sites prepared a practical training session which was undertaken in April 2016 for all patient representatives. The focus within the training this year was on the dementia aspect, supported by Danielle Wilde, dementia lead.

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16.0 Estates –

New Issues Concerns Action Respons-ibility

Due Date

Itemise priority issues to report/discuss at IPCC

1. None

N/A

CQC compliance evidence Individual folders

Water Safety compliance evidence kept in files on S: Drive. Details of any other day to day IC issues occurring kept in local files.

Risk assessment review Augmented care RA

Existing RA reviewed in January and still deemed applicable for the Barnet site.

Incident reporting No IC related Incidents to report

N/A

Monitoring and Audit Water Sampling and Audit. Routine Water Sampling continues to confirm no systemic

problems with regard to the water system but isolated legionella positives on outlets which are cleared by point chlorination and a limited number of persistent pseudomonas positives which are resistant to usual control methods and currently have point of use filtration installed. These are in augmented care areas. Internal audit continues to identify some shortfalls in the contractor management system, however, this is now being addressed by the contractor.

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17.0 Divisional reports Infection Prevention and Control Committee – Private Practice Division Annual report 2015/16


Due Date

Itemise priority issues to report/discuss at IPCC The key priority issues for private practice in 2015/2016 are outlined below Due to private patients overseas market there was an increased risk of patients being admitted with MERS The commissioning of Hadley Wood Hospital

Planning for the refurbishment of 12North A

All patients referred to private practice both for inpatients and outpatients were risk assessed using a risk assessment tool agreed by infection control. Both theatres and outpatients are open, and during commissioning infection control and prevention have been involved to ensure compliance. Planning meetings were led to covert 12 North A into an inpatient area for haematology/oncology patients.

Director/DDN Director/DDN Director/DDN

CQC compliance evidence ie. exemplar projects, completed action programmes.

There have been ongoing issues within Lyndhurst Rooms regarding space and storage, a request for minor works has happened and authorisation continues to be discussed with the Director of PPU and Director of Estates. This is also registered on the divisions risk register.

Risk assessment review here have been three RCA for C.diff. key learning points shared across private practice

have been: Improving documentation on the stool chart, the new stool chart to be implemented

across the trust will help address this. Ensuring the sample leaves the ward as soon as it is taken. Escalating for further advice where a patient states it is normal for them to have

diarrhoea, particularly our overseas patients where the antibiotic history is not always clear.

No lapses in care were identified. A patient was found to have MRSA bacteraemia on admission to 12 East B, a PIR meeting was held and this case was not attributed to the Royal Free.

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ie, RCA’s for C.diff/MRSA Fit test compliance (HSE requirement)

Fit Testing – levels of staff trained at the end of March 2016

Clinical Area Percentage of staff trained 12 North 100% 12 West 100% 12 South 100% 12 East B 100% POTS 100%

Matron/ Ward managers

Incident reporting ie, Summary of incidents, outbreaks and associated learning.

Monitoring and Audit ie. - Hand hygiene – ward/department red RAG concerns,

average compliance and actions for improvement. - Clinical (HII) audits – ward/department red RAG

concerns, average compliance and actions for improvement.

- Cleaning scores - ward/department red RAG concerns, escalation, rectification, Nurse/Matron attendance.

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Infection Prevention and Control Committee – Transplant and Specialist Services Division Annual report 2015/16

New Issues Concerns/ Action Responsibility Due Date

Itemise priority issues to report/discuss at IPCC 1. CDT attributable cases

2. Hepatitis B exposure incident Mary Rankin Dialysis unit

3. Ebola refresher surge training

& PPE Kit

4. Standardisation of central line care across Trust

5. Environmental cleaning for

nursing staff

18 CDT attributable cases within TASS this year. These cases are a combination of avoidable cases and delays in samples being sent. SI carried out and all actions completed. No transmission One band 6 recruited to support surge training. Reinforcing aseptic technique, the ongoing care of all lines and documentation. Plan to launch OPAT/vascular access service at Barnet hospital and Chase Farm hospital in September 2016. Refreshing all clinical staff on their roles and responsibilities for cleaning clinical equipment and providing education around the 49 elements of cleaning.

April 2016 Dec 2015 On-going On-going On-going

CQC compliance evidence CQC inspections.

Reporting to trust board quarterly on self-assessment compliance CQC visit Feb 2016, awaiting final full report.

on-going July 2016

Risk assessment review CDT cases above trust trajectory Hep B incident

Matron hygiene checks Hand hygiene compliance Environmental audits Timely sampling/rapid isolation of symptomatic patient Antibiotic prescribing Line care Documentation Effective communication between medical and nursing staff on line management All procedures within renal dialysis units reviewed and risk assessed. E-learning module Blood Borne Virus (BBV) plan to roll out to all dialysis unit including doctors and nurses in quarter 2 when new IPCN for renal commence.

Paper 6.1

17

Incident reporting Hepatitis B BBV machine breech review

Hep B exposure incident action plan completed. Duty of Candor applied. Review BBV policy and standardisation of labelling high risks machines across wards and kidney care centre.

Aug 2015

Monitoring and Audit Overall compliance of hand hygiene/BBE

Environmental cleaning audits across the division are above 96% On–going challenges to improve hand hygiene compliance across TASS division, service line lead, senior Matrons and ward managers collaboratively to support junior staff to in challenging visiting staff to improve hand hygiene compliance.

On-going

Paper 6.1

18

Infection Prevention and Control Committee – Urgent Care Division Annual report 2015/16

New Issues Concerns Action Responsibility Due Date Itemise priority issues to report/discuss at IPCC Hand Hygiene compliance Continue to drive up handy hygiene compliance with all

members of the MDT Matrons January 2016

Risk assessment review HAI-C Diff – 1 on Larch and 1 on Juniper ( Barnet Site)

RCAs completed and action plans in place

Matrons/ward managers/consultants

July 2016 Ongoing

Incident reporting No other significant events to report Monitoring and Audit Environment ED at Royal Free continues to be challenged due to the

environment, facilities and estates are working closely with the matrons during the rebuild Barnet hospital, recent concerns with regard to the cleanliness of the ward environments all Matrons working closely with facilities and estates to drive up standards. Repairs outstanding are in hand, list for UC being prioritised by estates and facilities

Richard Pomphrey / Ruth Green Matrons Barnet Site

Will be complete in 2017 On going

Paper 6.1

19

Infection Prevention and Control Committee – SAS Division Annual report 2015/16 New Issues Concerns Action Responsibility Due Date

Itemise priority issues to report/discuss at IPCC

1. 3 Orthopedic Hip infections CF

2. Ophthalmology

3. Refurbishment of theatres

on Royal Free site

. 3 patients developed infection post hip replacement at CF site. Surgery performed on 3 consecutive days. Full investigation performed with action plan completed and monitoring in progress Clinic 3, RF, 2 cases of endophthalmitis reported, investigation conducted. Some refurbishment has been successfully completed however the fabric of Level 1 theatres remains poor.

Clinical Lead & Orthopaedic Surveillance Nurse Clinical Director and Lead Nurse Theatre Matron Royal Free

CQC compliance evidence ie. exemplar projects, completed action programmes.

Quarterly board reporting from all SAS areas has demonstrated marked improvement with increased green rag ratings.

Risk assessment review ie, RCA’s for C.diff/MRSA Fit test compliance (HSE requirement)

No MRSA bacteraemia reported for SAS 5 C Diff cases reported all fully investigated and all attributed to the Trust.

Incident reporting ie, Summary of incidents, Monitoring and Audit ie. - Hand hygiene – ward/department

red RAG concerns, average compliance and actions for improvement.

-

All Areas in SAS now using standardised hand yygiene audit form. Submission is monitored by the matron team with variable results across the sites. HII audits in place and monitored by matrons weekly. Cleaning audits within acceptable standards.

Paper 6.1

20

18.00 Decontamination New Issues Concerns Action Responsibility Due Date

Itemise priority issues to report/discuss at IPCC 1. Flexible

Endoscope

Decontamination

2. Sterile Service

Departments

3. Central

Decontamination Unit

Project

Flexible endoscope decontamination for the all sites remains compliant and monitored with regular audits to the following recommendations and requirements: Health and Social Care Act Codes of Practice, Choice Framework for Local Policy and Procedures (CFPP) 01-06, British Society of Gastroenterology (BSG) Decontamination Guidance, Joint Advisory Group (JAG) A manual decontamination system is in place at the RF endoscopy and clinic 9 units which his currently under review to update to an electronic system Both Sterile Service Departments are fully compliant with all mandatory Legislation, Standards and Guidance. The departments are registered to the requirements of ISO 13485 2012: Medical Devices, Quality management system requirements and the European Medical Devices Directive 93/42/EEC, through independent and assessment accreditation processes The departments were recently subjected to an external review by an independent accreditation body, and successfully completed the audit at the RF, however on the latest notified body BSI audit for Barnet there were a number of non-conformance received, which have been addressed. Both departments have retained full accreditation status in line with the European Medical Devices Directive 93/42 EEC (MDD) and the amendments of 2007/47/EEC and Quality Management System Requirements of BS EN ISO13485:2012 The Chair of the Programme Board (CMG) supported the off-site proposal submitted by the Decontamination Project Team in May it was approved in principle by the Shadow Group Board in June. Further detail is required to demonstrate the consolidation of the service and benefits reward.

Head of Decontamination Sterile Service Manager Decontamination Project Manager, CSSD Steering Group members

Ongoing Ongoing August 2018

CQC compliance evidence

Paper 6.1

21

4. Local Audits Decontamination audits of all local reprocessing areas are undertaken on a monthly basis. The audits are undertaken using the Infection Prevention Society Audit Tool (IPS). The Care Quality Commission (CQC) will audit the trust against this audit tool The results are presented to and discussed by the Decontamination Committee which convenes on a monthly basis The Decontamination Committee provides quarterly compliance reports to the Infection Prevention and Control Committee The Decontamination Committee remains focused on ensuring compliance with the Health & Social Care Act and associated Code of Practice, NHS Litigation Authority Management Standards, Choice Framework for local Policy and Procedure 01-01/01-06, CQC Outcome 8 Cleanliness and Infection Control, Joint Advisory Group and NICE IPG 196 is maintained

Head of Decontamination and Local Areas

Ongoing

Risk assessment review 5. Non-Compliance

All areas of non-compliance are managed by the Decontamination Committee, by way of a local decontamination risk register with action plan discussed with local areas

Head of Decontamination and Decontamination Committee members

Ongoing

Incident reporting 6. Incident Reporting All incident reporting is managed through the Decontamination Committee

There are currently no reportable major incidents


Ongoing

Monitoring and Audit 7. Trust audits Decontamination audits of all endoscopy units and outpatients areas reprocessing

nasendoscopes is undertaken on a monthly basis. The audits are undertaken using the Infection Prevention Society Audit Tool (IPS). The Care Quality Commission (CQC) will audit the trust against this audit tool


Ongoing

Paper 6.1

22

18 Service validation The trust has declared compliance to the Care Quality Commission in relation to IPC aspects of the Health and Social Care Act (2008) Hygiene Code. The CQC has agreed unconditional compliance. The CQC report for the inspection in Feb 2016 is still awaited, but no recommendations for improvement in IPC arrangements were received at the time of the inspection. PWC undertook the internal audit of the trusts infection prevention and control service, no recommendations for development. 19 Public and patient involvement The PLACE audit programme continues, including Patient representatives, Matrons, IPCNs and Facilities staff to enhance patient inclusion in maintaining a clean environment. The IPC Nurses are always available at the bed-side in all clinical areas to discuss face-to-face issues with patients, relatives and visitors.

Paper 6.1

23

Appendix 1 Infection Surveillance Programme 2015/16 Type of surveillance Performed by: Reported to: Frequency Complete Mandatory surveillance MRSA bacteraemia Consultant microbiologist

Audit & surveillance nurse DH, NHS London IPCC Division Boards Divisional leads IPC group Wards/Matrons

MESS website Quarterly – Jan, Apr, July, Oct Monthly Fortnightly Weekly

√

MSSA bacteraemias

Consultant microbiologist Audit & surveillance nurse

DH, NHS London IPCC Division Boards Divisional leads IPC group Wards/Matrons

MESS website Quarterly – Jan, Apr, July, Oct Monthly Fortnightly Weekly

√

Clostridium difficile in >2yrs

Consultant microbiologist Audit & surveillance nurse

DH, IPCC Divisional leads IPC group Wards/Matrons

Quarterly returns Quarterly – Jan, Apr, July, Oct Fortnightly Weekly

√

Orthopaedic SSI -Total knee replacement -Total hip replacement - Hemiarthroplasty - Above and below knee

amutations

Audit & surveillance nurse

DH, IPCC Orthopaedic surgeons Wards/Matrons

Quarterly returns Quarterly – Jan, Apr, July, Oct Twice per year Weekly

√

MRSA screening of all admissions (no-longer mandatory)

Ward staff NHS London Monthly √

Alert organism surveillance

Completed

Alert organism surveillance

IPCT Audit & surveillance nurse

IPCC Wards/Matrons

Quarterly – Jan, Apr, July, Oct Weekly

√

Paper 6.1

24

MRSA acquisitions – (MRSA acquisitions – (colonisation and infection)

IPCT Audit & surveillance nurse Consultant microbiologist Audit & surveillance nurse

Data maintained on IPC database, but reporting has not been possible due to lack of data analyst role. Recruitment has now been successful and reporting will re-commence in the year ahead.

ESBL acquisitions Other CompletedRFH - High impact intervention audit reports

All Matrons indicators

Monthly √

RFH Alert organism monthly list – changes, up-dates, new patients

IPCN’s Available on Freenet ‘Clinical applications’ All alerts appear automatically on patient records.

Daily up-date √

RFH MRSA Cerner alert

IPCN’s Cerner Daily up-date √

Isolation room in-patient data

IPCN’s Bed/site managers, patient pathway co-ordinators.

Daily up-date Annual audit

√

Hand hygiene audit All Matrons indicators

Monthly √

Antibiotic usage Pharmacy IPCT

Periodic √

Handgel usage Supplies IPCT

Periodic √

1

Equality impact assessment• Positive impact which supports equity of service

1. Introduction


Trust Board 27 July 2016 Paper 6.2

DIRECTOR OF INFECTION PREVENTION AND CONTROL (DIPC) QUARTERLY REPORT

Executive summaryThis is the trust report from the DIPC for The Royal Free London NHS Foundation Trust.

In line with the revised Health and Social Care Act (2008) trusts are required to have appropriatemanagement and clinical governance systems in place to deliver effective infection control. Includedat appendix A are the ten compliance criteria from the Health and Social Care Act to assist the boardin assessing the information provided.

In line with the Health and Social Care Act (2008, rev 2015) Code of Practice on the prevention andcontrol of infections and related guidance, trusts are required to have appropriate management andclinical governance systems in place to deliver effective infection control. Within criterion 1 of theCode of Practice is a requirement that there is a programme of activity and planned development forIPC within the organisation to keep to a minimum the risk for infection and the general means bywhich it plans to control such risks.

Action required / recommendationThe Board is asked to confirm that the report provides sufficient information to provide assurance ofsustained compliance with the Hygiene Code and to approve the Annual IPC programme.

Trust strategic priorities and businessplanning objectives supported by this paper


1 Improving clinical effectiveness R12 Enhancing the patient experience

CQC outcomes supported by this paperOutcome 8 Cleanliness and infection control

Risks attached to this project / initiative and how these will be managed (assurance)The revised Hygiene Code Risk matrix will be monitored at the Infection Control Committee.The risks associated with the Hygiene Code have been included in the Board Assurance Framework

Report From D Sanders, Director of Nursing and DIPC.

Author(s) D Mack, Microbiology Consultant, Lead IPC DoctorHusam El-Mugamar, Consultant Microbiologist, IPC DoctorDianne Irish, Consultant VirologistY Carter, Head of IPC Nursing IPC team

Date July 2016

2

The Health and Social Care Act (2008) Code of Practice on the prevention and control of infections andrelated guidance outlines the actions NHS Trusts in England must take to ensure a clean environmentfor the care of patients, in which the risk of infection is kept as low as possible. The 10 compliancecriteria are attached at appendix A. The criteria have been revised in 2015, including a larger focus onantimicrobial stewardship, an element of which has been included in CQUIN for 2016/17. Frontline staffInfluenza vaccination has also been included as a CQUIN for 2016/17

Monitoring Progress against the Health and Social Care Act, including internal audit.Hygiene Code compliance will continue to be monitored through the Infection Prevention and ControlCommittee. The Trust’s internal auditors annually assess trust arrangements and ensure robustevidence of compliance in all criteria. There are currently no recommendations for improvement. TheCQC inspection report from February is awaited, but there were no verbal recommendations forimprovement provided at the time relating to infection prevention and control.

2. Infection report

2.1 Meticillin-sensitive and Meticillin-resistant Staphylococcus aureus bacteraemia. (MRSA andMSSA)

Reduction of hospital acquired Staphylococcus aureus bacteraemias including those due to MRSAcontinue to be an important infection control priority for the trust. The target for 2016/17 is zero for allorganisations.

The last trust attributed case was in June 2015. There is an outstanding decision on attribution for a childwith MRSA bacteraemia identified in May in Barnet A&E.

Patient sampledate location Treatment Site doa directorate Assignment

1 4.5.2016 Galaxy BH 4.5.2016 WC Pending

2.2 MRSA trust acquisitionsThe trust MRSA acquisition rate remains low across all sites, (an acquisition is defined as any patient notpreviously known to be MRSA positive but has been swabbed whilst in the RFLNHSFT after the first 48hours of admission and found to be positive). Although the national requirement is no longer in place, thetrust screening process remains inclusive of in-patient admissions as it is felt to be integral in reducingacquisition rates and contributes to safer patient care.

2.3 Clostridium difficile (C.diff)The RFLNHSFT has integrated infection control measures across all sites to minimise the risk of C. difficile.Measures include educational programmes, comprehensive antibiotic policies, good bed management withearly isolation of symptomatic patients and enhanced environmental cleaning. The microbiology, IPC andpharmacy teams continue to perform Clostridium difficile ward rounds to ensure that all elements of thecare and treatment of patients with C. difficile are being appropriately managed.

The external threshold objective for The Royal Free London Trust for 2016/17 is again 66 attributablecases. The trust has now been below threshold in Q3 and Q4 last financial year and Q1 of 2016/17.

Following revisions to its risk framework Monitor confirmed that for the purposes of its governance riskratings of foundation trusts’ with effect from quarter one 2015/16 national performance against the C.difficile indicator will include only those infections that result from a lapse in care. Lapses in care infectionsare determined by the local clinical team applying a checklist based assessment developed by PublicHealth England, with outcomes reviewed and agreed by local commissioners. Currently the lapses in careeither agreed, or following arbitration are none for Q1.

The Trusts aspiration target is to reduce ‘lapse in care’ cases to 13 or less in 2016/17

The trust C.difficile ‘action log’ incorporates activity across the trust and is driven through the fortnightlydivisional lead/C.diff action group. Activity is summarised below:

3

Main activity• RCAs from all sites continue to be discussed at fortnightly meetings to disseminate learning to all

areas.• Learning from antimicrobial audits has provided evidence for a revised patient prescription chart

with enhanced antimicrobial section. This is now being rolled-out across Trust.• Harmonisation of policy and protocols in line with DH guidance almost complete• Revised guidance on C.diff recognition, signs and symptoms and prompts for sending samples now

on every ward IPC notice board.• Revised stool chart with indications for recognition and testing now in place.

Outstanding priorities• Final alignment of IPC policies and antimicrobial policies• Clinical audit programme being aligned across all sites.• PPI and laxative protocols to be reviewed.• Continue programme of re-skilling and competence assessment of ward staff to ensure patients with

C.diff are cared for by competent and knowledgeable staff in any ward area of the enlarged trust.

The reduction in ‘lapses in care’ is significant for safe patient care and for assurance of high standards ofinfection prevention practices. In line with the aspiration target of 13 or less ‘lapse in care and threshold of66 toxin positive cases, the trajectory for 2016/17 is shown below.

Apr-16 May16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar - 17

0

10

20

30

40

50

60

70

80

Apr-16May-16Jun-16 Jul-16Aug-16Sep-16Oct-16Nov-16Dec-16Jan-17Feb-17Mar-17

Apr-16

May-16

Jun-16

Jul-16Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17Feb-17

Mar-17

RFLNHSFT cumulative "lapse incare" cases

0 0 0

RFLNHSFT 2015/16 "lapse in care"cases

1 3 4 7 7 9 11 13 13 13 13 13

RFLNHSFT cumulative cases 6 8 14

RFLNHSFT cumulative objective 6 12 17 23 28 33 39 45 50 56 61 66

RFLNHSFT 2015/16 cases 7 16 20 29 32 39 43 49 53 58 62 68

RFLNHSFT 2016/17 C. difficile cases and "lapses in care"versus Trust objective trajectory and 2015/16

4

RFH 6 1 2

RFHcumul

6 7 9

BH 0 1 4

BHcumul

0 1 5

CF 0 0 0

CFacumul

0 0 0

Total 6 8 14

2.4 E.coli bacteraemiasAll E.coli bacteraemias are part of the mandatory reporting of health care associated infections (HCAIs),there is currently no improvement target associated with this infection. A breakdown by division and theapparent source of the infection is reported at the fortnightly divisional leads IPC meeting to guide futurereduction activity. The average case number per quarter remains around 20 cases with only minorvariation.

2.5 Carbapenemase producing enterobacteriaceae (CPE) and other non-fermenting (CP-NF)organismsThere have been sporadic cases of CPE and NF-CPOs and Rowan and Olive had CPO exposures duringthe month of June. The CPO’s were not identified on the wards but on screening at later dates, but in linewith national guidance contact tracing and screening was undertaken with no further cases identified. Themajority of other cases are positive on admission from high-risk coutries admitted to PPU.

2.6 Orthopaedic surgical site infection reportCurrently the mandatory requirements from DH for surveillance are being undertaken across all trust sites.There are no SSI infections to report from mandatory reporting this quarter. A full programme of SSIsurveillance will be undertaken following the recruitment of a surveillance nurse.

Royal Free HospitalTotal knee replacements 49 Operations 0 InfectionsTotal Hip Replacements 30 Operations 0 InfectionsHemi arthroplasties 10 Operations 0 InfectionsTotal 89 Operations 0 Infections

Barnet and Chase FarmTotal Knee Replacement 60 operations 0 InfectionsTotal Hip Replacements 48 operations 0 InfectionsTotal 108 operations 0 Infections

2.7 Virology Quarterly Report - April - June 2016 354 laboratory-confirmed viral infections were identified by the Virology Laboratory at Royal Free

Hospital (RFH) site between April and June 2016, which required IPC interventions from the Virologydoctors at Royal Free Hospital. The Microbiology Consultants at Barnet and Chase Farm (BCF)hospitals were telephoned with all positive results for the BCF site. (See Figure 1)

83% of the infections were due to respiratory viruses 9% of the infections were gastrointestinal infections 12 cases of chickenpox and shingles 15 cases of acute measles (13 at RFH and 2 at BCF) 2 cases of acute Hepatitis A infection and 1 case of acute Hepatitis E infection

Figure 1: Virology IPC Activities from July 2014 – June 2016 Fig 2: Influenza cases at RFH from October 2014 - June 2016

5

Respiratory InfectionsOf the 292 respiratory infections identified in the Virology laboratory at Royal Free Hospital, 10 were frompatients at Barnet and Chase Farm Hospitals and 282 were from Royal Free Hospital.At the RFH site, there were 51 influenza infections (34 type B and 17 type A). In addition, there were 94rhinovirus infections, 19 adenovirus infections, 35 coronavirus infections, 24 enterovirus infections, 2parechovirus infections, 16 human metapneumovirus infections, 36 parainfluenza infections and 5 RSVinfections.

Ten respiratory infections were identified by the Virology Laboratory at Royal Free Hospital from samplessubmitted from BCF site. There were 6 influenza B infections and 1 influenza A infection, 1 enterovirusinfection and 2 rhinovirus infections.

Figure 3: Common Viral Respiratory Infections Recorded from July 2014 –June 2016

Gastrointestinal InfectionsAt the RFH site, 2 sapovirus, 1 astrovirus, 5 rotavirus, 8 adenovirus and 14 norovirus infections wereidentified (see Figure 3), the majority of the norovirus infections were in CVID patients with chronicinfections. One adenovirus infection was identified from samples received from the BCF site.

Figure 4: Norovirus PCR Positive Stool Samples Recorded from RFH: July 2014 – June 2016

0

20

40

60

80

100

120

140

160

180

200

Ju

l-14

Sep

-14

No

v-1

4

Ja

n-1

5

Mar-1

5

May

-15

Ju

l-15

Sep

-15

No

v-1

5

Ja

n-1

6

Mar-1

6

May

-16

Resp Viruses Other Viruses

RFH

0

20

40

60

80

100

120

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

RFH-Influenza

0

10

20

30

40

50

60

70

80

90

Ju

l-14

Aug

-14

Sep

-14

Oct-1

4

No

v-1

4

De

c-1

4

Ja

n-1

5

Feb

-15

Mar-1

5

Apr-1

5

May-1

5

Ju

n-1

5

Ju

l-15

Aug

-15

Sep

-15

Oct-1

5

No

v-1

5

De

c-1

5

Ja

n-1

6

Feb

-16

Mar-1

6

Apr-1

6

May-1

6

Ju

n-1

6

Influenza RSV Rhinovirus Parainfluenza Coronavirus Swine Flu H1N1RFH

6

2.8 Serious Incidents, outbreaks related to HCAIs

1. Measles: There were 3 Measles exposure incidents at Barnet Hospital in the last quarter requiringcontact tracing and assessment of both staff and patients. A total of over 80 patients were riskassessed. Working in conjunction PHE prophylaxis was offered to those at risk.

2. Juniper is currently on special measures from 26/06/2016 with two C diff toxin positives healthcareinfections within a month period.

3. Rowan and Olive had CPO exposures during the month of June. The CPO’s were not identified onthe wards but on screening at later dates, but in line with national guidance contact tracing andscreening was undertaken with no further cases identified at this time

4.Month & no. of deaths Associated HCAI LocationJul 15 0 deathAug 15 0 deathSept 15 0 deathOct 15 0 deathNov 15 0 deathDec 15 0 deathJan 16 0 deathFeb 16 0 deathMar 16 0 deathApr 16 0 deathMay 16 0 deathJune 16 0 death

3. Hand hygiene

The DH Saving Lives programme High Impact intervention audit tool is used to audit, monitor and reporthand hygiene compliance.

Compliance rates are now included as part of the matrons indicators within the performance reportingsystem, monitored and reported by the Divisions. The Hand Hygiene campaign is planned for 2016/17, withclose focus on other hygiene issues related to the dress code.

4. Urinary catheter associated infection

A point prevalence survey was undertaken for all in-patietns on the three main sites in June 2016. Thesurvey found:

• 18% of all in-patients in Royal Free, Barnet and Chase Farm hospitals have a urinary catheter in-situ.

0

2

4

6

8

10

12

14

16

18

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

RFH - Norovirus

7

• All urinary catheters within the 3 sites at the time of survey had clinical indications to remain inplace.

• This year the survey found 85 urinary catheters within Royal Free Hospital, which is 1% decreasefrom last year.

• At Barnet hospital and Chase Farm hospital there were 91 urinary catheters in situ, an increase of3% compared to 2015

• Out of 176 (total number of patients with urinary catheter in all sites), 1 patient had catheterassociated urinary tract infection there is a decrease compared to 2014 survey result (5 out of 106)

8

5. Antimicrobial reportNew Issues Concerns Action Responsibility Due Date

Itemise priority issues to report/discuss at IPCC1. New policies being launched (see below)2. Antibiotic CQUIN (see below)

Policies, guidelines – reports and actions.New/updated policies being launchedon Microguide 25/07/2016

i. Surgical prophylaxis – cardiac implantable electronic devicesii. Infection in Obstetricsiii. MRSA Decolonisation (RFH)iv. Tropical Infectionv. Severe Sepsis in A&E/Medicine - RFHvi. Severe Sepsis in Obstetricsvii. Severe Sepsis in Renal Unitviii. Severe Sepsis in Surgeryix. Severe Sepsis in A&E – BHx. Ophthalmologyxi. Colistinxii. Aminoglycoside Policyxiii. Sexually Transmitted Infectionxiv. PD Peritonitisxv. Acute Epiglottitisxvi. Surgical prophylaxis – Open/Laparoscopic Urological Surgery

ASC 25/07/16

Risk assessment reviewGentamicin incidents 51 gentamicin related incidents over last year. Being reviewed by a Task Group chaired

by Dr C Laing. 1st

meeting 19th

July 2016.CL/IB 1

stMeeting

19/07/16Monitoring and AuditNephrectomy surgical site infectionauditA&E antibiotic use audit

CQUINTazocin and Carbapenem Use

Antibiotic prescription reviews within72h

Total antibiotic use

Policy now reviewed.

Meeting with A&E 21st

July 2016.

Encouraging but need to maintain improvement this year – data for 1st

quarter pending..

Consistently between 80-100% at all sites. Need to maintain improvement and achieve>90% by final quarter.

Data pending. New prescription chart should help, as will e-prescribing.

IB

IB/SB

All prescribers andPharmacy



Done

21/07/16

Ongoing

Ongoing

Ongoing

9

6 Facilities reportNew Issues Concerns Action Responsibility Due

DateItemise priority issues to report/discuss at IPCC

3. PLACE 2016

4. Roll out of new hand sanitising foam

• The Trust submitted the 2016 PLACE scores on 6 June 2016 prior to the requireddeadline. Performance data is due to be published by HSCIC late summer 2016;the Trust will receive formal notification prior to release.

• All three sites prepared a practical training session which was undertaken in April2016 for all non-Trust participants. The focus within the training this year was ondementia, supported by Danielle Wilde.

• The action plans are being collated with a view to circulating early in Q2 forrectification and improvement plans.

• The RFH site is planning on harmonising the use of hand sanitising foam during Q2– therefore bringing in line standardised practice on all sites

JDS – SC/JJ/CK

SC

Policies, guidelines – reports and actions.

1. Standard Operating Procedure’s (SOP) • As part of a trust wide strategy in harmonising the soft FM working practices andprocedures the soft FM teams across all three hospital sites have been working onrevised SOP’s with support from the IPC team.

• This work includes the standardisation of the Food and Nutrition Policy, FoodPantry Policy and Trust Cleaning Protocol.

IPC/SC/JJ/CK

Risk assessment review

1. Update COSHH • Revised risk assessments in the new Trust format are being created for the soft FMCOSHH folder.

• No risks associated with soft FM practices to report to the committee.

MH/SC

Incident reporting

1.Needle stick injuries • It is noted that there has been an increase in reported needle stick incidents acrossthe hospital sites. Facilities are working with risk and safety to review and additionaltraining is being provided.

MH/SK/AP

10

Cleanliness report:

The trust undertakes at least monthly cleaning audits across all areas within the trust. These are undertaken jointly with the facilities staff and matrons andward leaders. Any areas of concern are immediately identified and rectified. Any rectification keeps the trust in line with National Standards of Cleanliness(NPSA) level.]

Barnet hospital has measures in place with the cleaning contractors to improve the cleaning standards. The Trust have requested Medirest to increase thelevel of auditing in any areas where issues have been identified. These areas will be kept under review and observed until the improvements are met.

2016 BGH CFH RFH

Very High Risk - > 98%

April 94.00% 98.35% 98.00%

May 96.75% 98.41% 98.00%

June 96.86% 98.44% 98.00%

Average 95.87% 98.40% 98.00%

High Risk - > 95%

April 89.00% 97.65 96.00%

May 93.39% 98.22 96.00%

June 93.59% 97.35 96.00%

Average 91.99% 97.60% 96.00%

Significant risk < 83% -87%

April 90.00% 98.07% 92.00%

May 91.71% 96.89% 92.00%

June 90.95% 97.34% 94.00%

Average 90.89% 97.30% 92.67%

11

7. EstatesNew Issues Concerns Action Responsibilit

yDueDate

Itemise priority issues to report/discuss at IPCCBarnet HospitalPseudomonas Aeruginosa surface samplesidentified in two infants in Bay 1 Neo nataland a Pseudomonas bacteremia in a third.Identified since 4th July

All outlets have been fitted with point of use filters in Bays 1-3 and siderooms 1 and 2.All above outlets were sampled yesterday 12-7-16 in addition to those indirty utility where incubators are being cleaned and in the parentsexpressing room.Samples taken to PHE lab and results expected Thursday 14th or Friday15th.If water is found to be positive on any outlet then the isolate has been heldfor cross matching.

N.Trew 15-7-16

Policies, guidelines – reports and actions.Water Safety Plan Plan being harmonised across the Trust

Risk assessment reviewBarnet Hospital Risk Assessment completed and any outstanding actions being addressed

N.Trew TBC

Incident reporting

Monitoring and Audit

Water Safety Audit Next External Audit to be carried out at Barnet in August 2016 N.Trew 13-7-16

12

8 Decontamination report


DueDate

Itemise priority issues to report/discuss at IPCC1. SureStore System

2. Endoscopy Royal Free

4. Endoscopy Chase Farm New Unit

7. SSD Barnet

8. Sterile Services across site

8. Outpatient Clinic 5

9. Outpatient Clinics – Nasendoscope

Reprocessing

The SureStore system remains out-of-action. A final meeting has taken place with themanufacturers agreeing to undertake ‘Field Tests’ to include all endoscope families. Atesting protocol has been received which the Trust is currently reviewing and takingadvice from our external Laboratory

The matter of storage cabinets being changed to drying cabinets and a vacuum systemoperated is still under discussion, this will eliminate the need for the two non-compliantcarousels currently in use. Existing decontamination equipment will bedecommissioned and new equipment will be commissioned accordingly

The unit has reported high mycobacteria results, liaison with Estates Team and TrustMicrobiologist and review of Tristel Rinse Assure product for trial – which shouldeliminate high counts

Male and female changing facilities for staff has now been provided

An external audit is to be carried out by the AE(D) 15/07/16 using the JAG IHEEMaudit tool, which will assist the unit when applying for JAG accreditation

All sterile service departments have been externally audited by a notified body, RFSSD received no non-conformances however BGH SSD received a number of minornon-conformances which have been addressed

The environment provides for clean and dirty segregation for nasendoscopereprocessing between each patient, using the Tristel Three Wipe system.However there is no hand-wash sink basin the in dirty utility areas, this has beenaddressed with the Matron, Department and Estates and is still ongoing

A decision made at the Decontamination Committee Meeting in January agreed thatnasendoscopes reprocessing would continue using the Three Wipe system in anoutpatient setting. However, arrangements will be made for a business case to bedeveloped providing for more nasendoscopes to be purchased to allow reprocessingbetween each patient use in a washer-disinfector

13

Policies, guidelines – reports and actions

Risk assessment reviewAny areas of non-compliance are managed by the Decontamination Committee, byway of a local decontamination risk register and action plan This local register reportsinto the Estates Risk Register

An update of all decontamination risks is due to take place 26/07/16 between the HoD,Risk Facilitator and Capital & Estates Director

Incident reporting

IR1 Incident Reporting All incident reporting is managed through the Decontamination Committee

Monitoring and Audit

Monthly Decontamination Audits Monthly decontamination audits continue to take place and are reportable through theDecontamination Committee

Endoscopy and Nasendoscopy audits across site are currently undertaken using theInfection Prevention Society (IPS) Audit Tool. The CQC will audit against this audit tool

14

9. Occupational Health report

Paper 7

Page 1 of 14

Annual Complaints Report

Executive summary

This report provides information on the complaints received in the trust between 1 April 2015and 31 March 2016. It provides a summary of the complaints received, the areas concerned,the main issues raised and trends identified, as well as the actions taken in response orthose planned for the future. It also looks at our performance against agreed targets and thenumber of complainants who have come back dissatisfied following their initial response.

Action required/recommendationFor information and consideration.

Trust strategic priorities and business planning objectivessupported by this paper

Board assurance risknumber(s)

2. Excellent user experience – to be in the top 10% of relevantpeers on patient, GP and staff experience

4. Excellent compliance with our external duties – to meet ourexternal obligations effectively and efficiently

5. A strong organisation for the future – to strengthen theorganisation for the future

CQC Regulations supported by this paperRegulation 9 Person-centred careRegulation 10 Dignity and respectRegulation 11 Need for consentRegulation 12 Safe care and treatmentRegulation 13 Safeguarding service users from abuse and improper treatmentRegulation 14 Meeting nutritional and hydration needsRegulation 15 Premises and equipmentRegulation 16 Receiving and acting on complaintsRegulation 17 Good governanceRegulation 18 StaffingRegulation 20⃰ Duty of candour

Risks attached to this project/initiative and how these will be managed (assurance)N/A

Equality analysisNo identified negative impact on equality and diversity

Report from: Deborah Sanders, director of nursingAuthor(s): Deborah Sanders and Stephen Evans, head of complaints and Pals

Date: 15 July 2016



Paper 7

Page 2 of 14

Annual Complaints Report – 2015/16

Introduction

Feedback from patients, relatives and carers provides the trust with a vital source of insight

about people’s experiences of healthcare at the Royal Free London NHS Foundation Trust,

and how our services can be improved. The ultimate aim of the trust’s complaints process is

to listen and respond to the issues being raised and use the information received to improve

our services and, in turn, the experience of our patients.

This report provides information on the complaints received in the trust between 1 April 2015

and 31 March 2016. It provides a summary of the complaints received, the areas concerned,

the main issues raised and trends identified, and the actions taken in response or those

planned for the future. It also looks at our performance against agreed targets and the

number of complainants who have come back dissatisfied following receipt of their initial

response.

Background

The statutory instrument for complaints in the NHS is contained in the Local Authority Social

Services and National Health Service Complaints (England) Regulations 2009. The

legislation expects that each responsible body has arrangements for dealing with complaints

to ensure that:

1. complaints are dealt with efficiently;

2. complaints are properly investigated;

3. complainants are treated with respect and courtesy;

4. complainants receive, so far as is reasonably practical -

I. assistance to enable them to understand the procedure in relation to

complaints; or

II. advice on where they may obtain such assistance;

5. complainants receive a timely and appropriate response;

6. complainants are told the outcome of the investigation of their complaint; and

7. action is taken if necessary in light of the outcome of a complaint.

The Department of Health issued Listening, Responding, Improving: A guide to better

customer care in February 2009 to support organisations in responding to and learning from

complaints.

The Parliamentary Health Service Ombudsman (PHSO) Principles of Good Complaint

Handling has six principles:

1. getting it right

2. being customer focused

3. being open and accountable

4. acting fairly and proportionately

5. putting things right

6. seeking continuous improvement.

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Page 3 of 14

Patient Association review

Following the acquisition in July 2014, the Trust commissioned the Patients Association to

review the complaints processes from both the Royal Free Hospital and Barnet and Chase

Farm Hospitals. The complaints policy was subsequently revised and practice aligned,

incorporating the Patient Association feedback, so that there is one unified approach to

dealing with complaints across the trust. The key changes to have been implemented are:

• The default response deadline has increased from 25 to 35 working days.

• Standardisation of Datix subject and sub-subject codes (also aligned to new Health

and Social Care Information centre requirements).

• Production of easy-read leaflets for each site (also available on the website).

• Earlier use of local resolution meetings.

• Adoption of the Royal Free style response letter.

• Adoption of the Royal Free reporting structures and report templates.

• Adoption of the Royal Free use of Datix to record the complaint chronology i.e. all

letters, statements, file notes, e-mails etc are to be attached to the Datix record.

• Adoption of the Royal Free policy appendices.

Complaints

There were 1,456 complaints received between 1 April 2015 and 31 March 2016. 785 of

those were complaints regarding Royal Free Hospital services, 538 were regarding Barnet

Hospital services and 133 were regarding Chase Farm Hospital services. This is more than

the combined total of 1,159 complaints received in 2014/15 – 698 of which were for Royal

Free Hospital services and 461 for Barnet & Chase Farm Hospital services.

The increase in number for the Royal Free Hospital is largely accounted for by a significant

increase in transport complaints. We received 22 transport complaints in 2013/14, 18 in

2014/15 and 100 in 2015/16. The significant increase for Barnet and Chase Farm Hospital

complaints is predominantly due to less issues being sent to PALS for resolution and a

clearer separation between what is a PALS issue and what is a complaint. In addition, car

parking complaints were not previously a regularly reported issue but they have been since

the introduction of the new number plate recognition car parking system in October 2014.

There have been 86 complaints received in the last financial year about parking.

The 1,456 complaints received are from 1,071,599 in-patient and outpatient episodes, which

equates to a complaint ratio of 0.1%, the same percentage as 2014/15.

To date, 1,368 of the complaints have been responded to. Of those, 198 have been fully

upheld, 621 have been partially upheld and 549 have not been upheld. There have been

1,447 response target dates in this time period and we have met 1,051 of them, which

equates to an overall response rate of 73%.

Q1 Q2 Q3 Q4 Overall

Deadlines met 195 of 334 248 of 365 319 of 391 289 of 357 1,051 of 1,447

Percentage 58% 68% 82% 82% 73%

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Page 4 of 14

As can be seen from the above table the overall response rate was affected by poor

performance in Q1 and Q2, which was the result of change-over of staff on the Royal Free

site during April (a new interim head of complaints & PALS, and a new interim complaints

manager for the urgent care division) and ongoing sickness issues within the TASS

complaints team.

It has also been affected by the poor performance of the contracted transport provider when

dealing with complaints about transport both in the timeliness and quality of the information

provided. Only 32 of 100 targets have been met for complaints involving transport.

The figures demonstrate that proactive updates to complainants and extensions where

necessary were not undertaken as they should have been. As a result, in Q3 weekly

complaints meetings with the director of nursing were reinstated and a new weekly meeting

between the complaints managers and the head of complaints & PALS, and the corporate

complaints teams once again became more involved in the extending and negotiating of

deadlines process.

Complaints re-opened following receipt of their first response

As demonstrated by the table below, the number of complainants who have re-opened their

complaint regarding services provided by the Royal Free Hospital, following receipt of their

first response letter, has fallen gradually since 2010/11 but would appear to have now

plateaued. Despite the increase in numbers received, there has been a decrease in the

number of re-opened complaints regarding services provided by Barnet & Chase Farm

Hospitals.

NB: the numbers for 2015/16 are accurate as of 12 July 2016 and will continue to change

over the next 12 months.

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Royal FreeHospital

86 of 877(10%)

75 of 797(9%)

57 of 709(8%)

50 of 653(8%)

60 of 698(8%)

27 of 785(3%)

Barnet Hospital &Chase Farm

Hospitals

53 of 225(24%)

59 of 207(29%)

53 of 295(18%)

31 of 337(9%)

26 of 461(6%)

38 of 671(6%)

Top 10 Subjects (primary)

A breakdown of the complaints by primary subject follows over the page, along with a

comparison of the primary subjects reported in last year’s annual report.

Paper 7

Page 5 of 14

2014/15 2015/16

Clinical treatment 304 Clinical treatment 376

Communications 223 Communications 304

Values and behaviours (attitude) 137 Appointments 158

Delay 129 Values and behaviours (attitude) 142

Clinical diagnosis 74 Car parking 129

Car parking 61 Transport 88

Cancellation 41 Nursing care 76

Discharge 32 Admission / discharge 42

Nursing care 24 Access to treatment / drugs 14

Transport 20 Waiting times 13

The subject and sub-subject codes have been unified since 1 January 2015. The top 10

subjects are very similar to 2014/15 but have changed order slightly.

Clinical treatment complaints are again the most common primary subject of a complaint but

the number has increased in line with the general increase in numbers. Communication and

attitude continue to be a feature and there are significant increases in the car parking and

transport complaints received. There is also an increase in the number of nursing complaints

received, although some of that increase is accounted for by the subject codes that were

previously in use at Barnet and Chase Farm Hospitals NHS Trust, which recorded nursing

complaints under the subject of clinical treatment.

Further analysis of the top 3 subjects

A more detailed analysis of the top three subjects i.e. complaints regarding clinical treatment,

communication and appointments will follow below, along with examples of actions taken and

changes implemented in response to those complaints. In addition, the same analysis will be

undertaken for the nursing care complaints received.

Clinical treatment

There were 439 complaints received where clinical treatment was recorded as a subject of

the complaint – in 376 cases it was the primary reason for the complaint. The 439

complaints were received from 1,071,599 inpatient and outpatient episodes and equates to a

complaint ratio of 0.04% (last year was 0.02%). There is no identifiable trend in terms of staff

member.

Of the 439 complaints received, 26 have been fully upheld. Detailed explanations have been

provided to each complainant along with apologies and information regarding the action

taken as a result. There has been escalation to the serious incident process whenever

appropriate and/or the involvement of human resources for further investigation.

The table over the page breaks the clinical treatment complaints down by primary specialty

and primary sub-subject of the complaint for the 10 most complained about specialties.

Delays with treatment taking place is the common theme and the adult section of our

emergency departments is the most common specialty referred to.

Paper 7

Page 6 of 14

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Emergency Dept - Adults 6 4 1 0 2 10 18 0 1 5 0 0 47

Orthopaedics & Trauma 2 1 1 0 2 7 5 3 1 3 0 1 26

Obstetrics/Maternity 0 2 2 1 0 7 4 0 1 3 0 0 20

Gynaecology 1 5 0 0 2 5 2 2 1 1 0 0 19

Plastic Surgery 0 0 0 0 1 11 0 2 1 0 0 0 15

Cardiology 1 1 0 1 0 6 2 0 0 1 1 0 13

General Surgery 0 2 1 0 1 4 2 0 1 2 0 0 13

Elderly Medicine 0 0 0 0 1 3 5 2 0 0 0 0 11

Urology 0 1 0 0 0 3 5 0 1 1 0 0 11

Colorectal Surgery 0 0 0 0 0 0 5 0 1 1 0 1 8

Totals 10 16 5 2 9 56 48 9 8 17 1 2 183

Example actions are listed below:

• The paediatric audiology waiting list has been growing over the past year. Consequently,

the service has recently been experiencing delays for routine hearing assessment

appointments in some areas. This is one of the reasons why a senior doctor reviews all

referral letters received i.e. to ensure that those referrals that need to be prioritised are

identified and the patient seen as quickly as possible. The team hope to recruit further

paediatric audiologists in order to address the demand for the service.

• A percentage of subtle un-displaced talar fractures are missed on examination and x-ray

but we now have virtual fracture clinics, which means that each morning the consultants

review all radiographs taken in the emergency department the day or evening before and

action further where appropriate. The orthopaedic team also discussed this complaint

with the radiology team so that the lessons could be learned and shared.

• We are committed to providing dedicated slots for the colorectal one-stop clinic and

ensuring that capacity is improved for on the day scopes, and we are working to ensure

this happens in the near future. However, there may continue to be occasions in future

where emergency situations result in the one-stop clinic slots being unavoidably used.

Paper 7

Page 7 of 14

The trust is putting in significant equipment, infrastructure and staffing resource to

address the current pressures within the endoscopy service.

• The trauma and orthopaedic service is currently recruiting a full-time substantive

consultant who will help reduce patient waiting times. The service has also commenced

weekend operating, offering patients greater choice as well as increasing their capacity to

treat patients. As a further measure to reduce patient waiting times, the service has

arrangements with a number of private provider sites, where patients are treated by

Royal Free London Hospital consultants within a private provider setting.

Communication

There were 366 complaints received where communication was recorded as a subject of the

complaint – in 304 cases it was the primary reason for the complaint.

The complaints related to a wide range of departments and specialties and there is no

obvious trend in terms of numbers received or the departments or staff member(s) involved.

The table below breaks the communication complaints down by specialty and the sub-

subject of the complaint for the 10 most complained about specialties.

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Emergency Department - Adults 0 1 0 17 4 1 1 0 0 0 2 26

Obstetrics/Maternity 0 0 0 24 0 0 0 0 0 0 0 24

Elderly Medicine 0 0 0 6 14 0 0 0 0 0 0 20

Outpatients Appointment Centre 1 0 0 15 0 0 0 0 1 0 0 17

Dermatology 1 0 0 12 0 0 1 0 0 0 0 14

Gynaecology 0 0 1 11 0 0 2 0 0 0 0 14

Plastic Surgery 0 0 0 11 0 0 0 0 0 0 0 11

General Medicine 0 0 0 4 5 0 0 1 0 0 0 10

Orthopaedics & Trauma 0 0 0 8 1 0 1 0 0 0 0 10

Cardiology 1 0 0 4 1 0 2 0 0 1 0 9

Total 3 1 1 112 25 1 7 1 1 1 2 155


Paper 7

Page 8 of 14

• There is to be a patient information leaflet produced to better explain the cryotherapy

treatment and healing process.

• The cardiology department plan to add some wording to the second section of their

appointment letter template in order to make it clearer what the patient is attending for.

• We have now put in place a process that enables all histology results to be reviewed by

the Specialist Early Pregnancy Unit nurses. The Specialist Early Pregnancy Unit nurses

will keep track of the outstanding cases and will then liaise with the team on-call to

ensure that information is sent promptly to patients regarding the results and/or any

expected delays.

• The doctor concerned has reflected on her consultation with the patient and accepts that

she need not have been so direct with the patient. The clinical director also took the

opportunity to review the doctor’s communication skills and offered advice on how best to

discuss this element of care in future.

• The ante-natal department has appointed to and are developing a team of clinical

pathway co-ordinators. Their role will be to support patients through their pathway,

ensuring that they have the correct outpatient appointments, diagnostic tests and know

who to contact. They will also help ensure that patients are not passed from one member

of the team to another with queries and, if at all possible, any queries will be dealt with at

the time of the patients’ phone call.

• Patients in 3 East ward and 10 South ward are given an information leaflet after having

undergone new renal access procedures. However, it is recognised that these leaflets

need updating and the access team have produced a new and much more detailed

leaflet, which also incorporates information about renal dialysis access surgeries. This

leaflet is being finalised.

• A patient attended Barnet Hospital for a CT scan but could not have it performed as they

were more than 10 days past the start of their last menstrual cycle. The service has now

made amendments to the appointment letter, explaining the issue around the 10 day

restriction and the fact that patients can telephone in and change their appointments if

they do not fit the pregnancy criteria.

Appointments

There were 174 complaints received where appointments were recorded as a subject of the

complaint – in 158 cases it was the primary reason for the complaint.

The complaints related to a wide range of departments and specialties and there is no

obvious trend in terms of numbers received or the departments involved. Appointment delay

is the most common sub-subject of the complaints and, not surprisingly, the outpatient

appointment centre is the most referred to specialty. Dermatology and ophthalmology

feature highly and both have had capacity issues throughout this financial year.

The table over the page breaks the appointment complaints down by specialty and the sub-

subject of the complaint for the 10 most complained about specialties.

Paper 7

Page 9 of 14

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Outpatients Appointment Centre 6 10 1 0 0 0 0 4 0 0 21

Dermatology 6 5 6 0 0 0 2 0 0 0 19

Ophthalmology 1 2 8 0 2 0 0 0 0 0 13

Urology 2 2 3 0 0 0 0 1 0 1 9

Orthopaedics and Trauma 1 1 5 0 0 1 0 0 0 0 8

Cardiology 2 0 2 0 0 1 1 1 0 0 7

Neurology 1 1 2 0 0 0 0 0 1 1 6

Pain Management 0 0 5 0 1 0 0 0 0 0 6

Plastic Surgery 2 0 1 1 0 0 0 0 0 1 5

Paediatrics 0 0 4 0 0 0 0 1 0 0 5

Total 21 21 37 1 3 2 3 7 1 3 99


• The pain service management team is currently reviewing their patient pathways in

conjunction with the roles of the multidisciplinary team that are involved in treating

patients under the pain service. They are looking at ways of ensuring that patients are

referred to the most appropriate clinician early on in their treatment pathway, and our

musculoskeletal department is looking at ways of advising patients of actions to take to

minimise their pain whilst they wait to be seen. Additionally, we are looking at putting in

place additional clinics to bring down the waiting lists and are working with the local

clinical commissioning groups and GPs to work out ways in which more patients can be

treated in the community.

• We are looking at extending our ophthalmology clinic times into the early evening and

have opened a further eye clinic at St Pancras Hospital, allowing us to meet the

increasing demand for ophthalmology services.

• The usual process when an abnormality is found on an ultrasound scan is for the

sonographer to contact the Fetal Medicine Unit, where an appointment is made for the

patient to see a doctor immediately. To facilitate this process our antenatal clinics are

held Monday to Friday in the morning, so that doctors are available. However, there are

no antenatal clinics held on a Friday afternoon so doctors are not always readily available

at this time. As a result, we have now put into place a process for patients to be seen on

a Friday afternoon if they need to see a doctor urgently.

Paper 7

Page 10 of 14

• The trust is working to redesign the fracture clinic so that it can treat patients

appropriately, without such long waits, by ensuring that only those patients who need to

be seen in clinic attend on specific days. We have recently started to use the Glasgow

Virtual Fracture clinic model, which has been successfully trialled in various units around

the UK. We now aim to review the ongoing fracture care of many patients by telephone,

saving them an unnecessary visit to the clinic for review and reducing the number of

attendees who need to be seen in the clinic on that day.

• Regrettably, we have had issues with regard to capacity in the dermatology service and

we currently have an improvement plan in place to enable us to meet the demand on the

service – this includes improving systems of referring patients, seeing patients and

reporting results. We are also in the process of recruiting more clinical staff.

Nursing and midwifery care

There were 88 complaints received where nursing/midwifery care was recorded as a subject

of the complaint – in 76 of those complaints it was the primary reason for the complaint.

The director of nursing reviews all complaints and signs off complaint responses, ensuring

that appropriate explanations and apologies have been provided in each case and action

taken in response to the points raised. The director of nursing is also informed of any issues

raised regarding unsafe practice or potential serious incidents.

The table below breaks the nursing complaints down by the primary location and sub-subject

for the nursing complaints received.

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Labour Ward - - 1 - - - - 1 - - - - - - - - - - 2

CDU - - 1 - - - - - - 1 - - - - - - - - 2

CCU - - 2 - - - - - - - - - - - - - - - 2

Surgi-Centre - - - - - - - - - - - - - - - - 1 - 1

Recovery - - - - - - - - - - - - - - - - 1 - 1

3 North A - - - - - - - - - - - 1 - - - - - - 1

5 East B - - 1 1 - - - - 1 - - - - - - - - - 3

5 West B - - - - - - - - - - - 1 - - - - - - 1

6 South - - 2 - - - - - - - - - 1 - - - - - 3

6 North - - 1 - - - - - - - - - - - - - - - 1

7 North - - - - - - - - - - - - 1 - - - - - 1

Paper 7

Page 11 of 14

7 West - - 1 - - - - - - - - - - - - - - - 1

8 East - - 1 - - 1 - - - - - - - - - 1 1 1 5

8 West - - 2 - - - - - - - - - - - - - - - 2

9 North - - 1 - - - - - - - - 1 - - 1 - - - 3

9 West - - - - - - - - - - - 1 - - - - - - 1

10 South - - 4 - - - - - - - - - - - - - - - 4

10 West - - - - 1 - - - - - - - - - 1 - - - 2

10 North - - - - - - - 1 - - - 1 - - - - - - 2

10 South A - - 3 - - - - - - - - 1 - 1 - - - - 5

11 South - - 1 - - - - - - - - - - - 1 - - - 2

11 North - - 1 - - - - - - - - - - - - - - - 1

Adelaide - - - - 1 - - - - - - - - - - - - - 1

Beech - - 2 - - - - - - - - - - - - - - - 2

Canterbury - - 1 - - - - - - - - - - - - - - - 1

Capetown - - 3 - - - - - - - - - - - - - - - 3

Cedar - - 2 - - - - - - - - - - - - - - - 2

Damson - - 1 - - - - - - - - - - - - - - - 1

Galaxy - - - - - 1 - - - - - - - - - - - 1 2

Juniper - - - - - - - - - - - 1 - - - - - - 1

Mulberry - - 2 - - - - - - - - - - - - - - - 2

Napier - - - - - - - - - - - - - - - - 1 - 1

Rowan - - 1 - - - - - - - - - - - - - - - 1

Spruce - - 1 - - - - - - - - - - - - 1 - - 2

Victoria - - 4 - - - - - - - - - - - - - - - 4

Walnut - - 5 - - - - - - - - - - - - - - - 5

Willow - - - - - - - - - - 1 - - - - - - - 1

Wellington - 1 - - - - - - - - - - - - - - - - 1

Total 1 1 48 1 2 5 2 2 1 1 1 7 2 1 4 2 5 2 88

The data above highlights that the concerns raised about nursing care are spread across a

number of wards, with no area receiving a high number during the year and no identifiable

trend in terms of staff members involved.

Example actions taken in response to the complaints are listed below:

• Pre-admission nurses are usually able to take a patient’s blood but, unfortunately, the

nurse who saw the patient was new to the department and did not take blood at that time.

The nurse has now been booked onto a phlebotomy course. Furthermore, as a result of

the complaint, the blood test department have made arrangements with pre-admissions

for patients to have their blood taken by them, without requiring an appointment, if the

pre-admission nurses have not done so. All reception staff and phlebotomists have been

informed that patients coming from pre-admissions should be prioritised, although this will

not mean they are seen immediately. Pre-admissions staff will inform their patients

appropriately and mark their request forms so that the phlebotomy department may

identify them when they arrive in clinic.

• The 7 East B ward matron discussed the point about nurses being distracted during their

medication rounds with the ward sister and, as a result of the patient’s experience, they

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Page 12 of 14

are looking to re-introduce ‘do not disturb aprons’ for the medication rounds. They are

also in the process of trying to set up a nurse-led post-discharge medication review clinic,

so that any medication problems post-discharge can be resolved quickly.

• As a result of a student midwife failing to follow procedure with regard to medication

administering (not performing the task with the support and direct supervision of her

supervisory midwife), the student midwife has been referred her to the university who are

undertaking a formal investigation.

• To improve the support that amyloidosis patients and their families receive, we have

appointed a cardiac amyloidosis link nurse for 10 West ward – someone with a keen

interest in this very specialist area who has spent time with senior doctors to learn about

the disease but also to learn about what specific nursing needs this group of patients

have and what input the family require. This nurse’s role will also support the discussions

around prognosis. Although we have a dedicated specialist haematology nurse for

myeloma and amyloidosis, this nurse is part of the 10 West ward team and we hope that

this new role will greatly improve communication with families and address any concerns

they may have as early as possible.

• The senior matron on 5 East B ward has identified and interviewed the staff involved and

it has been made very clear to them that IV paracetamol should not have been withheld

from the patient. The explanations provided by the staff as to why the IV paracetamol

was withheld were unfounded and, although there was no breach in policy, their actions

fell below the standard of nursing care expected. This incident has been managed as

part of the trust’s performance management process.

Examples of actions taken in response to other complaints received

In addition to apologies and explanations, the majority of our complaint responses will

include details of specific action(s) taken as a result of the complaint that has been received.

Some general examples of actions taken/changes implemented are listed below:

• We have changed practice following a complaint and now, as soon as a parent and child

reports to the reception area, they are escorted by a nurse or healthcare support worker

to Galaxy ward. All children are now admitted and discharged from Galaxy ward. Galaxy

ward is better equipped and more comfortable for children. Our admissions are now

staggered and the DSU aim for children to be nil-by-mouth for as short a period as

possible. All children are now admitted to Galaxy ward, prepared for surgery (including

consent) on Galaxy ward, taken back to Galaxy ward following surgery and then

discharged from Galaxy ward. The theatre staff are contacted by Galaxy ward when a

patient arrives on the ward and they do not go to theatre until all checks and preparations

have been completed on the ward.

• Following a medication issue in Lloyds Pharmacy, all grades of Lloyds Pharmacy staff

have been provided with an educational update on Wilson’s disease, the diagnostic

processes used in association with this condition and the treatment plan options for

patients diagnosed with this condition.

• Dementia leads in the emergency department are working on designing cubicles with

facilities for dementia patients.

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Page 13 of 14

• It is acknowledged that the physical environment on 6 North ward is deteriorating and the

hospital has a programme of ward upgrades which it is progressing at the moment. We

expect to fully rebuild the children’s ward in 2017 but, in the interim, plans for a less

comprehensive repair and cosmetic programme have been provided, contractors have

been appointed and work will be starting imminently.

Complaints referred to the Parliamentary & Health Service Ombudsman (PHSO)

The PHSO continue to record any preliminary reviews of complaint files as investigations in

their annual figures, as opposed to only those cases that went on to be formally investigated.

The draft reports produced by the PHSO continue to make recommendations for financial

payment in recognition of distress caused but the number of cases this has applied to has

decreased over the last 12 months.

Of the 1,456 complaints opened in this financial year, 10 have so far been escalated to the

PHSO by the complainant. 6 of those were complaints regarding services provided by

Barnet & Chase Farm Hospitals and 4 were regarding services provided by the Royal Free

Hospital. 1 Barnet Hospital case has been closed and not upheld and the other 9 cases are

currently under investigation.

Complainant satisfaction questionnaire

As previously reported a complainant postal satisfaction questionnaire has been introduced

be sent to a random selection of complainants at least three months after the completion of

their complaint with the trust. The questionnaire is anonymous and two batches of the

questionnaire were sent out to complainants who received responses from the trust in April

2015 and October 2015.

There were 41 questionnaires returned out of 160. The Royal Free Hospital received 10

from April 2015 and 14 from October 2015. Barnet Hospital and Chase Farm Hospital

received 3 from April 2015 and 14 October 2015. An overview of the key questions and

results is provided in the table over the page:

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Page 14 of 14

APRIL 2015 OCTOBER 2015

Was your complaint treated

seriously and with sensitivity?

Yes = 42% Yes = 62%

No = 58% No = 38%

Were all points raised in your

complaint addressed by the

response?

Completely or mostly = 50% Completely or mostly = 61%

Partially or not at all = 50% Partially or not at all = 39%

Was the response letter clear and

understandable?

Yes = 58% Yes = 82%

No = 42% No = 18%

Were you kept updated about any

delays with the investigation?

Yes = 9% Yes = 61%

No = 62% No = 25%

N/A = 29% N/A = 14%

Overall, how well do you think

your complaint was handled?

Very well or well = 33% Very well or well = 50%

Average = 17% Average = 29%

Poor or very poor = 50% Poor or very poor = 21%

Was your disability taken into

account during the process?

Yes = 0% Yes = 18%

No = 8% No = 3%

N/A = 82% N/A = 79%

Overall, the results are reflective of a period in which our complaint investigations were

taking longer than expected and updates to complainants about those delays were not

happening routinely and proactively.

There is a positive trend in every question with October’s data, which it is felt is largely

reflective of the improvements that have been made since October 2015 with regard to

turnaround times for completion of investigations, updates to complainants about delays and

stability within the divisional complaints teams.

Summary

Policy and procedure and the way in which complaints are recorded and dealt with is

harmonised.

The primary subjects remain largely the same as the last financial year, with the most

common subjects being clinical treatment, communication, delays and appointment issues.

However, the actions outlined in this report demonstrate that trends are acted upon and the

complaints received in the trust are used to inform pieces of work aimed at improving the

patient experience. The responses provided invariably outline action(s) that have been taken

in response to the concerns raised or explain what is planned as a result of issues identified

during the investigation.

We have systems in place to systematically review the complaints received and ensure that

investigations are undertaken appropriately, in line with legislation, and escalated within the

trust as necessary. The data collected is used to inform reports, is disseminated amongst

divisional teams and taken to various committees to inform ongoing work within the trust.

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1X:\ Chair and CEO report 27 July 2016

CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT

Executive summary

This is a combined chairman’s and chief executive’s report containing items ofinterest/relevance to the board.

Action required

The board is asked to note the report.

Report From D Dodd, chairman and D Sloman, chief executiveAuthor(s) A Macdonald, board secretaryDate July 2016



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CHAIRMAN’S AND CHIEF EXECUTIVE’S REPORT

A TRUST DEVELOPMENTS

ROYAL FREE HOSPITAL EMERGENCY DEPARTMENT UPDATE

Contract 1 of the emergency department redevelopment has recently been handed over,which will provide the following new facilities over a phased programme in early August:

• New dedicated paediatrics' emergency department and waiting area that will comeinto use on Friday 12th August, along with the temporary clinical decision unit (CDU -previously known as George Qvist ward) on 8th August

• New staff facilities and office accommodation will come into use between 4-20August

• A new ambulatory care unit including TREAT (triage and rapid elderly assessmentteam) services will then go live on Monday 15th August

Contract 2 will start shortly, which will be undertaken in three phases. The first phase ofthe construction works will start on 5 September, which will deliver Part 1 of majors, a newreception desk, and the rapid assessment and treatment area including new LAS handoverfacilities. Phase 2 will provide a new imaging facility including two x-ray rooms and one CTsuite, and a six bedded resuscitation unit. The final phase completes the majors facility anddelivers a new 30 bedded CDU, which replaces the temporary facility. Contract 2 isprogrammed for completion in March 2018.

CHASE FARM HOSPITAL REDEVELOPMENT UPDATE

The Chase Farm Redevelopment programme is continuing at pace, with detailed workforceand service transformation plans under development. The construction programme isrunning on time and on budget. The trust signed a contract in June with EDF Energy who willbe the trust’s ESCo (Energy Services Company) at Chase Farm. The contract is to build themechanical and electrical plant within the energy centre, and to operate it for 15 yearsproviding the trust with guaranteed energy savings. The project team are working throughthe details of the IHP contract to exclude these items from their scope of works, which isexpected to be cost neutral.

B REGULATION

NHS IMPROVEMENT (FORMERLY MONITOR) RISK ASSESSMENT FRAMEWORK

NHS Improvement assigns each NHS foundation trust a risk rating for governance, financeand the provision of mandatory goods and services every three months.

A green risk rating indicates that a foundation trust’s governance arrangements comply withits terms of authorisation and a red risk rating indicates that there are concerns that a trustis, or may be, in significant breach of its terms of authorisation.

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The trust recorded a green rating under NHS Improvement’s risk assessment framework ineach quarter of 2015/16 with a green rating also forecast for quarter one 2016/17.

C BOARD AND COUNCIL MATTERS

COUNCIL OF GOVERNORS

Mr David Brown (public elected governor) has resigned. Cllr Donald McGowan hassucceeded Cllr Ayfer Orhan as London Borough of Enfield appointed governor.

At the recent council of governors meeting, the following matters were discussed in additionto the standing items:

• Local representation and engagement – in light of group development• Governor development seminar programme• Update on sustainability and transformation plan

ANNUAL MEMBERS’ MEETING

The annual members’ meeting took place on 20 July 2016. At the time of writing more than70 people had booked a place at the meeting to join the governors and board to receive theannual report and accounts for 2016/16, to hear about key trust developments in the pastyear and to ask questions.

TRUST BOARD CHANGES

Will Smart, chief information officer, will be leaving the RFL to take up the newly-created roleof chief information officer for NHS England and NHS Improvement. He has been with theRoyal Free London for more than six years and successfully implemented a number of keyIT systems across the trust during a time of great change for the organisation. The boardwill want to thank him for his hard work and wish him well in his new role.

NON EXECUTIVE DIRECTOR APPOINTMENTS

The process for the recruitment of two non-executive directors is continuing. It is currentlyexpected that a recommendation by the nominations committee will be presented at thescheduled council of governors meeting on 15th November 2016.

ORGAN DONATION COMMITTEE

The trust’s organ donation committee has been chaired by a lay person for someconsiderable time and whilst it is not a formal responsibility of the council of governors, JudyDewinter has been chairing this committee but has recently resigned in order to concentrateon her new role of lead governor. Because of his past experience as a kidney transplantpatient and as treasurer and president of the Royal Free Hospital Kidney PatientsAssociation (RFHKPA), the chairman has nominated David Myers to chair the committeewho has kindly agreed to do so.

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D LOCAL NEWS AND DEVELOPMENTS

WORKFORCE RACE EQUALITY STANDARD UPDATE

BME board mentoring – mentees’ feedback

Board mentors have been asked to complete a feedback questionnaire for the first cohort ofthe BME trust board mentoring scheme which was rolled out in October 2015 and whichconcludes in October 2016. Mentors’ feedback will enable learning from the first cohort toinform the second cohort of the programme.

Diverse panels and recruitment and selection training

A total of 272 BME staff are now trained to sit on recruitment panels in the trust and thereare approximately 165 interviews held monthly. The number of trained BME panel membersis sufficient to start the process. In future the recruiting manager will be receiving a list ofBME trained staff to choose from for their interview panels at the shortlisting stage.

The recommended implementation date for diverse panels will be 1 September 2016, toallow any adaptations that may be necessary from discussions held in the divisions.

Further work is on-going with the OD team to scope how 527 managers in the Trust will betrained in recruitment and selection before the deadline of 1st April 2017.

GROUP MODEL UPDATE

The Royal Free London has been successful in its application to become an acute carecollaboration vanguard site.

The trust’s vanguard focuses on developing a group model, which other trusts may wish tojoin and be part of. The group model will enable the trust to work with other trusts to sharegood practice and consider opportunities to work more efficiently together. Possible areas offocus for the group include aligning back office functions, sharing the provision of trainingand development or looking at joint ventures for new services and products, as has beendone with pathology.

There are three main potential partners currently in discussion with the trust:

• North Middlesex University Hospital NHS Trust (NMUH) – a joint partnership boardhas been set up with North Middlesex University Hospital NHS Trust to explore itspossible membership

• The trust has signed a peer support agreement with West Hertfordshire HospitalsNHS Trust (along the same lines as with Basildon and Thurrock University Hospitals)

• The trust is working in partnership with the Royal National Orthopaedic Hospital NHSTrust particularly around developing elective orthopaedic capacity at Chase FarmHospital.

NORTH MIDDLESEX UNIVERSITY HOSPITAL NHS TRUST (NMUHT) UPDATE

The NMUHT’s emergency department (ED) has been facing a number of challenges which haveinvolved interventions by regulators including the CQC and NHS Improvement. A number of NHSorganisations, including the Royal Free London NHS Foundation Trust, have been working with

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NHS England to see how they could best support the NMUHT, as clearly any decisions regardingits ED would have an immediate impact on the RFL ED.

The NMUHT recently announced that its chief executive, Julie Lowe, is on leave. As a result anew interim chief executive, Libby McManus, will be joining the NMUHT. Ms McManus hasrecently joined the Royal Free London from Chelsea and Westminster Hospital NHS FoundationTrust where she was chief nurse and acted for a period as chief executive. In addition the RFLchief executive will be supporting Ms McManus as NMUHT’s interim accountable officer, but on aday to day basis the responsibility for running the NMUHT will lie with Ms McManus.

Separately, RFL has been approached by the board of the NMUHT who expressed an interest inbeing part of the Royal Free London NHS Foundation Trust group of hospitals. It is important tonote that although the NMUHT has expressed an interest in joining the Royal Free Londongroup, the RFL chief executive’s appointment as interim accountable officer is completelyunconnected with this interest and is solely to ensure a neighbouring NHS organisation has allthe support it needs in tackling its challenging emergency department position.

IHI QUALITY IMPROVEMENT DIAGNOSTIC VISIT: INITIAL FEEDBACK NOW AVAILABLE

The Institute for Healthcare Improvement (IHI), the global leading organisation for pioneering andteaching quality improvement (QI) conducted a quality improvement readiness diagnostic at thetrust from 28-30 June 2016. In total, IHI met more than 500 staff in over 70 sessions acrossprofessions and sites, as well as patients and key external stakeholders. Key points emergingfrom the diagnostic include:

• All staff were open and welcoming, demonstrating genuine receptiveness to the visit andan exceptional level of energy and commitment to patients

• Senior leadership team is highly engaged and well regarded in the organisation• Teams and individuals have an intrinsic motivation and talent for improvement• There are excellent examples of quality improvement already happening within the trust,

benefitting both patients and boosting staff satisfaction at work• The trust can significantly improve its data collection and use of data to drive

improvement• The trust can partner more deeply with patients in the co-development and delivery of

services, as well as improving patient experience• There are many initiatives going on across the trust and people are overburdened:

positioned correctly quality improvement offers the opportunity to provide coherence andan overarching theme for how we work across the trust, in clinical and non-clinicalservices

The insights from the diagnostic are important to how quality improvement is taken forwardacross the trust. A summary report will shortly be available, with a fuller report from IHI to follow.

NORTH CENTRAL LONDON SUSTAINABILITY AND TRANSFORMATION PLAN

The national planning guidance for 2016-17 outlined a new requirement for the developmentof STPs, or area plans. STPs are a means of planning services systemically rather thanorganisationally and bring together commissioners, providers and local authorities from alocality to plan health and social care over a five year timeframe.

There are 44 STPs, each headed up by a triumvirate of a commissioner, provider andcouncil representative, with one of these taking the lead as convenor. The main STP for RFLpurposes is NCL, David Sloman being the convenor of this area plan. Royal Free London

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has an interest in 3 STPs – North Central London, North West London and Hertfordshire &West Essex.

The first major submission deadline for plans was 30 June and the attached papersummarises this submission. It is anticipated that this plan will be worked up in more detailfor October, developing the identified work streams in the chosen priority areas. A summaryof the submission that was sent to NHS England at the end of June is attached at AppendixA.

CARE QUALITY COMMISION REPORT – CAMDEN AND ISLINGTON NHS

FOUNDATION TRUST

Camden and Islington NHS Foundation Trust received an overall requiring improvementrating following the publication of the CQC inspection report 21 June 2016. The Royal FreeHospital health-based place of safety and liaison service are cited in both the publishedCamden and Islington NHS Foundation Trust quality report and mental health crisis servicesand health- based places of safety quality report as contributing to the trust’s overallrequiring improvement in relation to safety.

Mental health crisis services and health-based places of safety are defined as: “A health-based place of safety is a room, or suite of rooms, where people who have been detained bythe police under section 135 or 136 of the Mental Health Act are taken for assessment.People will usually stay in a place of safety for a very short period of time and no longer than72 hours.”

The Royal Free Hospital accident and emergency department is a Camden and Islingtondesignated place of safety as part of Camden and Islington NHSFT registration. The CQCinspection found that some aspects were not satisfying the required standards of care inrelation to MH crisis services and health base places of safety.

The CQC makes a rating of requiring improvement in relation to MH services if the CQCidentifies there is an increased risk that people are harmed or there is limited assuranceabout safety.

Following the publication of these reports the trust has undertaken a risk assessment reviewat Royal Free Hospital A&E and Chase Farm urgent care centre focused on themanagement of environmental risks associated with the provision of care to patients thatpresent a high risk of self-harm. Interim controls were discussed with staff during eachreview and a more detailed risk assessment will be conducted at each site, which will includekey stakeholders as part of the assessment process.

The trust attended a quality summit in relation to C &I NHSFT inspection outcome and thedirector of nursing continues to work with Camden and Islington NHS Foundation Trust onthe action plan.

NON-EMERGENCY PATIENT TRANSPORT CONTRACT

SRCL (the company which provides the non-emergency patient transport (NEPT) service)will no longer provide the Trust’s NEPT service after 20 August 2016. The trust has securedthe services of DHL as an interim service provider whilst the service is subject to a fullreview and undergoes a full re-tender.

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There will be a service transition between 20 August and 1 October from SRCL to DHL andthis will be overseen by the trust NEPT team which has an increased level of resource inplace to be able to manage all aspects of the service transition.

In terms of the patient experience, the transport team has maintained a consistent level ofservice provision and will continue to ensure that this is the case. The Trust KPIs have yet tobe achieved and therefore, this remains a principal reason why the contract had to bebrought to an end with SRCL as they could not provide the level of service the trust’spatients deserve.

DHL operate a number of NEPT contracts including, notably, for the Imperial CollegeHealthcare NHS Trust.

2016/17 ANNUAL PLAN

The RFL annual plan was submitted to NHS Improvement in April 2016. The trust has beenrequested to resubmit the annual plan for 2016/17 to reflect a revised control total of £15.5m(including profit on land disposal). This resubmission will also be used as an opportunity toupdate the plan to reflect key changes since the original submission in April.

100K GENOMES PROJECT

Staff at the Royal Free London have now recruited 100 patients to the ground-breaking100,000 Genomes Project. Patients enrolled in the project are asked to donate a bloodsample for sequencing of their entire genome. In patients with cancer, the cancer itself willalso be sequenced to find the exact genetic changes that caused their disease.

The project aims to improve the diagnosis and increase our understanding of cancer andrare diseases and will create a new Genomic Medicine service for the NHS – transformingthe way people are cared for by bringing personalised medicine to the clinic.

At the Royal Free London patients with kidney, neurological, metabolic, eye, paediatric andother rare diseases are eligible for enrolment in the project. Kidney and other cancerenrolment is due to start at RFL later this year. The trust has been given an allowance ofover 1,000 patients to be recruited over the next 18 months, and it is hoped that by filling thisgenerous allocation we will provide maximum benefit to our patients.

This project will enable a better understand of genetic changes and how they link to disease,as well as facilitating the development of targeted and, where necessary, individualisedtherapies.

PATHOLOGY JOINT VENTURE UPDATE

Last year pathology services at the Royal Free Hospital moved to Health ServiceLaboratories (HSL), a joint venture in which the Royal Free London is a partner.

The trust is now considering the future of pathology services at Barnet Hospital (BH) andChase Farm Hospital (CFH).

HSL has made an offer to the trust for these services and the trust is currently in a period ofnegotiation with them. If an agreement is reached it would be written up into a businesscase, which would need to be approved by the trust board.

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The cytology service at CFH will move into the North Central London Cytology Service aspart of the on-going strategy from NHS England before April 2017 and this would bemanaged as part of the negotiation with HSL.

Pathology staff at Barnet Hospital and Chase Farm Hospital are receiving regular updatesand open staff briefings will be organised in the near future. A working group will also beestablished to ensure that any potential changes have no negative impact on clinicalservices.

A report on the joint venture will be provided for the September confidential board meeting,following receipt and review of the HSL annual accounts, and discussion at the shadowgroup board.

HIGH-INTENSITY SPECIALIST-LED ACUTE CARE AT WEEKENDS (HiSLAC)

The trust is participating in a study on this subject being run by researchers at the Universityof Leister and which is part of a larger project led by the University of Birmingham. Theoverall aim is to evaluate high-intensity specialist-led acute care at weekends (HiSLAC) as ameans of improving the care of acutely ill medical patients admitted as emergencies. Theproject is funded by the National Institute for Health Research. As part of this project,researchers from the University of Leister are conducting a qualitative sub-study to find outmore about how hospitals organise systems for weekend care.

The project has further aimed to test the hypothesis that the weekend effect is attributable toreduced senior staffing. The results of a cross sectional analysis performed for the financialyear 2013-2014 did not detect a correlation between weekend staffing of hospital specialistsand mortality for emergency admissions (Lancet, published online May 10 2016).

PATIENTS’ FRIENDS AND FAMILY TEST (FFT) UPDATE

The NHS friends and family test (FFT) was introduced in 2013 to enable patients to feedback on their care and treatment to enable hospitals and other providers to improveservices.

The NHS friends and family test (FFT) was introduced in 2013 to enable patients to feedback on their care and treatment to enable hospitals and other providers to improveservices.

It asks patients whether they would recommend hospital wards, A&E departments andmaternity services to their friends and family if they needed similar care or treatment. TheJune results are below.

Royal Free Londoncombined data

% likely/extremely likely torecommend June 2016

(range: 0 – 100%)

Number of patient responses

In-patient 90% 1351

A&E 80% 4676

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Barnet Hospital % likely/extremely likely torecommend June 2016

(range: 0 – 100%)


In-patient 88% 439

A&E 77% 2458

Antenatal care 95% 58

Labour and birth 96% 138

Postnatal hospital ward 92% 106

Postnatal community care 99% 135

Out-patients 94% 130

Chase Farm Hospital % likely/extremely likely torecommend June 2016

(range: 0 – 100%)


In-patient 90% 144


Royal Free Hospital % likely/extremely likely torecommend – June 2016

(range: 0 – 100%)


In-patient 90% 771

A&E 84% 2218

Antenatal care 94% 62

Labour and birth 93% 88

Postnatal hospital ward 90% 88

Postnatal community care 99% 135


NEW CHIEF EXECUTIVE APPOINTED AT UNIVERSITY COLLEGE LONDON HOSPITALNHS FOUNDATION TRUST

Professor Marcel Levi has been appointed as chief executive at UCLH. He is due to take upthe post on 3 January 2017, succeeding UCLH’s current chief executive, Sir Robert Naylor.Professor Levi has had a distinguished career as a clinician, academic and clinical leader inthe Netherlands. Sir Robert Naylor will retire from UCLH on 30 September 2016. NeilGriffiths, Deputy Chief Executive, will become interim chief executive until 3 January 2017.

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COMMUNICATIONS REPORT – JUNE 2016

Media coverage

During June, the trust was mentioned positively in national and local media coverage as theEvening Standard ran a story about the Royal Free London using the AlcoChange app. Thetrust also featured in local media as Princess Anne opened a new specialist heart scanningcentre at the Royal Free Hospital. The New Scientist’s story from May about the trust’s data-sharing agreement with Google DeepMind was picked up in national reports and the trustwas mentioned in several other articles about patient consent and AI companies inhealthcare. The A&E at the Royal Free Hospital was criticised in the Camden and IslingtonNHS Foundation Trust CQC report, in The Evening Standard. Chase Farm Hospital wasmentioned in national and local media reports about North Middlesex Hospital’s A&Epressures.

Figure 1 shows the number of positive stories that the trust had during June. The trust wasmentioned in 99 positive stories.

Figure 1

Figure 2 shows how much this positive coverage would cost if these pieces were paid foradvertorials, the total cost would be £159,798.88

Figure 2

85

410

0

10

20

30

40

50

60

70

80

90

Royal Free Hospital Barnet Hospital Chase Farm Hospital


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Figure 3 shows the sentiment of our press mentions split as positive, neutral and negative.The sentiment of our coverage is analysed through the tone of our mentions.

Figure 3

Royal FreeHospital

BarnetHospital

Chase FarmHospital

Total

Positive 85 4 10 99

Neutral 370 1 7 378Negative 9 5 27 41

Total 464 10 44 518

Figure 4 shows how many media requests the trust received and how many statements andwebsite stories the external and digital communications team issued during the month ofJune.

Figure 4

Trust total

Statements 3Mediarequests

17

Websitestories

18

Figure 5 shows the daily breakdown of the trust’s volume of news stories compared to howmany people they reached. Reach can be calculated as higher if the trust is mentioned innational coverage compared to local. On Sunday 12 June, The Guardian mentioned thetrust’s data sharing agreement in a story about tech companies in healthcare. OnWednesday 22 June, the trust was mentioned in national and local reports about Sir DrMichael Jacobs, infectious disease consultant, receiving his knighthood.

£156,137.36

£2,953.07 £708.45£0.00

£50,000.00

£100,000.00

£150,000.00

£200,000.00


RFL value June 2016


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Figure 5

Website visitors

The trust received 154,450 visits to the website in June.

Our top three news stories on the website during June were:

• Gastroenterologist receives award: 489 views (5.19% of news page views)• Trust to host spinal service in GP surgery: 299 views (3.18% of news page views)• Clinical trials day 2016: 296 views (3.14% of news page views)

Facebook activity

Figure 6 shows the number of reactions (likes) and comments our posts received, and thenumber of times they were shared across the month.

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Figure 6

• The spike on 15 June shows the reaction to a post about a bell that young patients

can ring at the end of their cancer treatment. This post reached 1,243 people.

• The spike on 17 June shows the reaction to a post about acute medicine. This post

reached 5,283 people.

• The spike on 28 June shows the reaction to a post about our LGBT team at Pride.

This post reached people 2,504.

Twitter activity• Total number of followers: 10,548

• Increase of 212 compared to April 2016

• Percentage increase YOY: 30.32%

• No. of posts: 256

• Our most popular tweet was about one of our

specialist registrars being named

gastroenterologist of the year. It reached 5,645

people. It also received the most retweets (18), the

most clicks (28) and the most likes (27).

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LinkedIn activity

Figure 7 shows the number of clicks our posts received over the month.

Figure 7

• The spike on 7 June shows the reaction to a post advertising a MRI radiographer

role. This post received 117 clicks and reached 7,945 people.

• The spike on 13 June shows the reaction to a post advertising a HR business

partner role. This post received 20 clicks and reached 3,936 people.

• The spike on 21 June shows the reaction to a post about acute medicine. This

post received 37 clicks and reached 3,719 people.

• The spike on 27 June shows the reaction to a post about our orthoptic web

chat. This post received 5 clicks and reached 4,772 people.

Internal communications

Figure 8 shows a breakdown of how many items the internal communications teamuploaded to our staff intranet, Freenet, during June compared to the previous month of Apriland May.

Figure 8

Landing page news Landing page notices Freenet news Events

April 36 26 31 22

May 30 33 31 14

June 47 19 44 13

0

10

20

30

40

50

RFL Intranet three months

Paper 8


Figure 9 shows how many stories and notices the internal communications team publishedin the monthly staff magazine, Freepress and the weekly staff e-letter Freemail.

Figure 9

Total stories andnotices

Freenet 123

Freepress 18

Freemail 60

Managers briefing 15

Figure 10 shows how many briefings and visits the internal communications team arrangedduring the month of June.

Figure 10

Total amount

Chief executivebriefing

3

Executive shadowing 1

Go-see visits 6

In this time the internal communications team also:• Provided internal communication support for key trust projects including the group

model structure, EPMA, Cerner upgrade, equality and diversity, staff health and

wellbeing, NHS sustainability day, patient safety programme, pathology joint

venture, and the redevelopment of Chase Farm Hospital.

• Continued working closely with the IM&T department on the development of a new

trust-wide intranet.

E NATIONAL NEWS AND DEVELOPMENTS

NEW MINISTERIAL TEAM

The Prime Minister has made a number of ministerial changes at the Department of Healthas follows. However, Jeremy Hunt (Secretary of State) and Lord Prior (Under Secretary ofState for Health) have remained:

Minister of State for Health Philip Dunne (previously Defence)Parliamentary Under-Secretary of State Nicola Blackwood (first ministerial appointment)Parliamentary Under-Secretary of State David Mowat (first ministerial appointment)

NHS IMPROVEMENT CONSULTATION ON ‘SINGLE OVERSIGHT FRAMEWORK’

NHS Improvement has published its new ‘single oversight framework’ for consultation. Thesingle oversight framework aims to provide an integrated approach for both NHS foundationtrusts and trusts, across regulation and performance management and to emphasise NHSImprovement’s renewed offer of support to the sector.

Paper 8


Under the proposals, all trusts will be placed in one of four segments depending on theirperformance. The five domains within the framework are:

• Quality of care (using ratings in 4 of the 5 CQC domains plus progress againststandards for implementing 7 day services)

• Finance and use of resources (being developed with the CQC and including progressagainst control totals and efficiencies)

• Operational performance (largely reflecting existing national targets and based on atrust’s agreed ‘performance trajectory’)

• Strategic change (a domain yet to be fleshed out in detail, this section will focus on‘progress in implementing STPs’, and where applicable ‘devo deals’)

• Leadership and improvement capability (building on the existing well led frameworkto capture good governance and leadership and to introduce a focus on capacity forimprovement).

NHS England proposes to segment the provider sector according to the scale of issuesfaced by individual providers. This will be informed by data monitoring and, importantly,judgement based on an understanding of providers’ circumstances. Figure 1 below sets outthe proposed approach.

It is intended to make a response to the consultation which will be co-ordinated by theinterim trust secretary, head of group performance and head of planning.

Paper 8


APPOINTMENT OF NATIONAL GUARDIAN

Dr Henrietta Hughes has been appointed as new National Guardian for the NHS. DrHughes, who is currently the Medical Director for NHS England’s North Central and EastLondon region and practising GP, has been appointed as the new National Guardian forspeaking up freely and safely within the NHS.

Her selection for appointment was made by a panel consisting of representatives of the CareQuality Commission (CQC), NHS England and NHS Improvement, as co-sponsors for theNational Guardian’s Office, as well as the Patients Association and Sir Robert Francis QC,whose independent review from February 2015 into ‘whistleblowing’ across the NHSinstigated the creation of the National Guardian role.

She will lead the healthcare system on a journey alongside the Freedom to Speak UpGuardians within NHS trusts and NHS foundation trusts, so that ultimately, patients receivesafe, high quality and compassionate care. The trust’s guardians are Ms Jenny Owen andMr Jim Mansfield (staff side)/

NHS IMPROVEMENT BOARD MEETING – 26 MAY 2016

CQC BOARD MEETING – 22 JUNE 2016

CQC performance report

• Good overall performance against key operational indicators to end April 2016• Spend against budget is in line with expectations• Concerns over the timeliness of producing inspection reports in the hospitals

directorate – around 100 days on average• The next target date for the hospitals directorate is to complete the first ratings

of acute specialist, community and ambulance trusts by end June, which are ontrack

Update from the hospitals directorate

• The ED at North Middlesex University Hospital has been rated inadequate.

Workforce race equality standard (WRES) report publication

• The inaugural report published on 2 June, looking at four indicators across alltrusts, shows variation across the health service

• 75% of acute trusts show a higher percentage of BME staff experiencingharassment, bullying or abuse from other staff in the last 12 months

• In future years this survey will inform the CQC’s assessment of well-led.

Healthwatch England Update

• Healthwatch England’s purpose and relationship with strategic partners will bereviewed once the permanent Healthwatch England chair has been appointed.

• Interviews for the chair will take place in September, led by the Department ofHealth

Paper 8


• The national director appointment process will be led by the CQC withinterviews in September/October.

• Priorities for 2016/17• To provide leadership, support and advice to local Healthwatch to enable

them to deliver their statutory activities and be a powerful advocate forservices that work for people

• To bring the public’s views to the heart of national decisions about the NHSand social care

• To build and develop an effective learning and values based HealthwatchEngland.

N C L North Central London

Sustainability and Transformation Plan

North Central London Sustainability and Transformation plan Summary of progress to date June 2016

Appendix A



2

Background and objectives

Vision

STP governance framework

Case for change

Content

Stakeholder engagement

Current position

Next steps

Workstreams

STP programme structure

1

2

3

4

5

6

7

8

9

Appendix A



1. The NHS Five Year Forward View team set out a challenging vision for the NHS. Its aim is to bring local health and care partners together to set out clear plans to pursue the Forward View’s ‘triple aim’ to improve:

• the health and wellbeing of the population • the quality of care that is provided • NHS finance and efficiency of services

The NHS England 2016/17 planning guidance outlines a new approach to help ensure that health and care service are planned by place rather than around individual organisations. There are 44 Sustainability and Transformation Plans (STPs) being developed in local geographical areas or ‘footprints’ across the country that are being submitted to NHS England for approval. North Central London (NCL) is one of the five London footprints.

3. The most compelling and credible STPs will secure funding from April 2017 onwards. NHS England will consider:

• the quality of plans, particularly the scale of ambition and track record of progress already made. The best plans will have a clear and powerful vision. They will create coherence across different elements, for example a prevention plan; self-care and patient empowerment; workforce; digital; new care models; and finance. They will systematically borrow good practice from other geographies, and adopt national frameworks;

• the reach and quality of the local process, including community, voluntary sector and local authority engagement; • the strength and unity of local system leadership and partnerships, with clear governance structures to deliver them;

and • how confident are NHS England that a clear sequence of implementation actions will follow as intended, through

defined governance and demonstrable capabilities.

The background of Sustainability and Transformation Plans N C L North Central London


3

1 Appendix A



North Central London has a complex health and social care landscape

2

NCL CCGs activity stats Vanguards in scope • Royal Free multi-

provider hospital model

• Accountable clinical network for cancer (UCLH)

Total health spend £2.5b

NHS England • Primary care

spend ~£180m • Spec. comm.

spend ~£730m

Total care

spend c.£0.8b

A&E 522,838

Elective 134,513

Non-elective 163,487

Critical Care 25,718

Maternity 45,528

Outpatients 1,803,202

Whittington Health NHS Trust (incl Islington and Haringey Community)

University College London Hospitals NHS FT

North Middlesex University Hospital NHS Trust

The Royal Free London NHS FT

BEH Mental Health NHS Trust (main sites, incl Enfield community)

Camden and Islington NHS FT (and main sites)

Central and North West London NHS FT (Camden Community)

Central London Community Healthcare NHS Trust (Barnet Community)

£293m

£940m

£249m

£951m

£185m

£136m

N/A – not in scope for NCL STP

finance base case

The specialist providers are out of scope: GOSH and RNOH Tavistock and Portman NHS FT is out of scope financially but within scope for mental health

£0.7m

-£12.4m

-£8.3m

-£51m

-£31m

-£14.8m

15/16 OT

Our population • Our population is diverse and growing. • Like many areas in London, we experience significant

churn in terms of people using our health and care services as people come in and out of the city.

• There is a wide spread of deprivation across NCL – we have a younger, more deprived population in the east and south and an older, more affluent population in the west and north.

• There are high numbers of households in temporary accommodation across the patch and around a quarter of the population in NCL do not have English as their main language.

• Lots of people come to settle in NCL from abroad. The largest migrant communities arriving during 2014/15 settling in Barnet, Enfield and Haringey were from Romania, Bulgaria and Poland. In Camden and Islington in 2014/15 the largest migrant communities were from Italy, France and Spain.

Total GP registered population 1.5m

University College Hospital

Barnet General Hospital

Chase Farm Hospital

North Middlesex Hospital

Royal Free Hospital

St Ann’s Hospital

The Whittington Hospital

Edgware Community Hospital

Finchley Memorial Hospital

St Michael’s Primary Care Centre

London Ambulance Service East of England Ambulance Service

Moorfields Eye Hospital

Great Ormond Street Hospital

Central Middlesex Hospital

Highgate Hospital

St Pancras Hospital

Enfield CCG / Enfield Council ~320k GP registered pop, ~324k resident pop

48 GP practices CCG Allocation: £362m (-£14.9m 15/16 OT)

LA ASC, CSC, PH spend: £184m

Barnet CCG / Barnet Council ~396k GP registered pop, ~375k resident pop

62 GP practices CCG Allocation: £444m (£2.0m 15/16 OT)


Camden CCG / Camden Council ~260k GP registered pop, , ~235k resident pop



Haringey CCG / Haringey Council ~296k GP registered pop, , ~267k resident pop

45 GP practices CCG Allocation: £341m (-£2.8m 15/16 OT)


Islington CCG / Islington Council ~233k GP registered pop, , ~221k resident pop



Stanmore Hospital

Tavistock Clinic, Portman Clinic, Gloucester House Day Unit

Note: all OT figures are normalised positions

£202m £2m Moorfields Eye Hospital NHS FT

1 Appendix A



We have agreed a number of objectives for the NCL STP

The goals of our STP are: • To improve the quality of care, wellbeing and outcomes for the NCL population • To deliver a sustainable, transformed local health and care services • To support a move towards place-based commissioning • To gain access to a share of the national transformation funding which will ensure our hospitals get

back to being viable, to support delivery of the Five Year Forward View, and to enable new investment in critical priorities

Goals

Outputs

Process

The STP needs to deliver several key outputs: • A compelling clinical case for change that provides the foundation for the programme and is embedded

across the work, and supports the identification of priorities to be addressed through the STP • A single version of the truth financial ‘do nothing’ base case with quantified opportunity impacts based

on the priorities identified • A robust and credible plan for implementation and delivery over five years • A governance framework that supports partnership working across the STP and collective decision

making • The resource in place to deliver transformation at scale and pace in the key areas identified

The process to developing our STP needs to: • Be collaborative, and owned by all programme partners in NCL • Be structured and rigorous • Move at pace, ensuring quick wins are implemented and transformation is prioritised • Involve all areas of CCG, local authority and NHS England commissioned activity, including specialised

services, primary care and reflecting local HWB strategies 5



1 Appendix A



11

The NCL STP Transformation Board meets monthly to oversee the development of the programme and includes representation from all programme partners. It has no formal decision making authority, but members are committed to steering decisions through their constituent boards and governing bodies. There are three subgroups supporting the Transformation Board. The Clinical Cabinet provides clinical and professional steer and input with CCG Chair, Medical Director, nursing, public health and adult social services and children’s services membership. The Finance and Activity Modelling Group is attended by Finance Directors from all partner organisations. The Transformation Group is a smaller steering group made up of a cross section of representatives from organisations and roles specifically facilitating discussion on programme direction for presentation at the Transformation Board. Every workstream has a senior level named SRO to steer the work and ensure system leadership filters down across the programme. The Clinical Reference Group will be mobilised over the summer of 2016 and will provide a forum for input, review and co-design with a broader pool of clinicians and practitioners.

We have developed a robust governance structure that enables collaborative input and steer from across the STP partners

2

* Programme Governance Structure to be reviewed as programme moves into implementation

P r o g r a m m e D i r e c t o r : D a v i d S t o u t

P r o g r a m m e M a n a g e r : A l i c e H o p k i n s o n P M O L e a d : A b i H o l l a n d P r o g r a m m e s u p p o r t :

J u l i e C h a n J o n e s S e u n F a d a r e C o m m s a n d e n g a g e m e n t l e a d : D e n i s e S h a w

N C L T r a n s f o r m a t i o n B o a r d

C h a i r : D a v i d S l o m a n S R O s : D a v i d S l o m a n ( C o n v e n o r ) , D o r o t h y B l u n d e l l , M i k e C o o k e

M e m b e r s

• S R O s

• N H S C C G r e p s

• N H S A c u t e p r o v i d e r r e p s

• N H S C o m m u n i t y p r o v i d e r r e p s

• N H S M e n t a l H e a l t h p r o v i d e r r e p s

• L o c a l a u t h o r i t y r e p s

• L A S

• H E N C E L

N C L C C G s C O L L A B O R A T I O N

N H S P R O V I D E R S G R O U P

H E N C E L

N H S E N G L A N D L O N D O N

H E A L T H Y L O N D O N P A R T N E R S H I P

L A C E O s

D s P H

C C G C O s

D A S S s

H W B s

H A R I N G E Y A N D I S L I N G T O N W E L L B E I N G

A L L I A N C E B O A R D

N C L S T P P M O

F i n a n c e a n d A c t i v i t y M o d e l l i n g G r o u p L e a d : T i m J a g g a r d

C l i n i c a l R e f e r e n c e

G r o u p

T r a n s f o r m a t i o n G r o u p L e a d : D a v i d S l o m a n

C l i n i c a l C a b i n e t L e a d s : D r R i c h a r d J e n n i n g s & D r J o S a u v a g e

• U C L P

• N H S s p e c i a l i s e d c o m m i s s i o n i n g

• N H S E n g l a n d

• N H S I m p r o v e m e n t

• H e a l t h w a t c h

• C l i n i c a l l e a d

• F i n a n c e l e a d

• P r o g r a m m e D i r e c t o r

P r o g r a m m e s t r u c t u r e – s e e s e c t i o n 6

Appendix A



Case for Change

• The Clinical Cabinet has met five times, since its inception, to develop a robust and accurate Case for Change for North Central London’s health and social care

• On 13 June, the Clinical Cabinet agreed the draft Case for Change, pending some outstanding issues; this was then endorsed by the Transformation Board on 22 June

• Draft Case for Change was part of the submission sent to NHS England on 30 June; their feedback is expected in July • From now until the end of September, the Clinical Cabinet will move the Case for Change from draft to a

comprehensive, final document which will be published in late Summer.

7

Development and

engagement process to

date

Clinical cabinet • The NCL STP Clinical Cabinet is responsible for the Case for Change. Their role is to is lead the further development of

STP work • The Clinical Cabinet will sign off the Case for Change with ultimate responsibility falling to the NCL STP clinical lead



3

• Some high level messages from analysis relating to our population’s health and wellbeing are: • People are living longer but in poor health • Our different ethnic groups have different health needs • There is widespread deprivation and health inequalities • High levels of homelessness and households in temporary housing • Lifestyle choices put people at risk of poor health and early death • There are poor indicators of health for children • High rates of mental illness among both adults and children

• When analysing our care and quality metrics, we identify the following: • There is not enough focus on prevention across the whole NCL system • Disease could be detected and managed much earlier • There are challenges in provision of primary care • There is a lack of integrated care and support for those with a LTC • Many people are in hospital beds who could be cared for at home • There are differences in the way planned care is delivered • There are challenges in mental health provision and in the provision of cancer care • Some buildings are not fit for purpose • Information technology needs to better support integrated care.

• Initial financial analysis show we face a significant financial challenge. If we continue on our current spending path, the deficit will rise substantially over the next five years

Initial messages from

the Case for Change

Appendix A



In response to the case for change, we have collectively developed an overarching vision for NCL which will be delivered through the STP

7

4

This means we will: • help people who are well, to stay healthy • work with people to make healthier choices • use all our combined influence and powers to prevent

poor health and wellbeing • help people to live as independently as possible in

resilient communities • deliver better health and social care outcomes,

maximising the effectiveness of the health and social care system

• improve people’s experiences of health and social care, ensuring it is delivered close to home wherever possible

• reduce the costs of the health and social care system, eliminating waste and duplication so that it is affordable for the years to come

• at the same time we will ensure services remain safe and of good quality

• enable North Londoners to do more to look after themselves

• have a strong digital focus, maximising the benefits of digital health developments.

Our vision is for North Central London to be a place with the best possible health and wellbeing, where no-one gets left behind. It will be supported by a world class, integrated health and social care system designed around our residents.

Our core principles are: • residents and patients will be at the heart of what we

do and how we transform NCL. They will participate in the design of the future arrangements.

• we will work together across organisational boundaries and take a whole system view

• we will be radical in our approach and not be constrained by the current system

• we will harness the world class assets available to us across the North Central London communities and organisations

• we will be guided by the expertise of clinicians and front line staff who are close to residents and patients

• we will build on the good practice that already exists in North Central London and work to implement it at scale, where appropriate

• we will respect the fact that the five boroughs in NCL have many similarities, there are significant differences which will require different responses in different localities.

Appendix A



8

The vision will be delivered through a consistent model of care 4

S e c o n d a r y c a r e ( h o s p i t a l ) s u p p o r t

S p e c i a l i s t c o m m u n i t y b a s e d s u p p o r t

C o o r d i n a t e d c o m m u n i t y , p r i m a r y a n d s o c i a l c a r e

L i v i n g a f u l l a n d h e a l t h y l i f e i n t h e c o m m u n i t y

W h e n n e e d s c a n ’ t b e m e t i n t h e c o m m u n i t y , p e o p l e h a v e

a c c e s s t o a s s e s s m e n t f o r h o s p i t a l c a r e a n d t r e a t m e n t . 2 4 / 7

s u p p o r t i s a v a i l a b l e t o p e o p l e w i t h a c u t e o r e m e r g e n c y n e e d s , i n c l u d i n g a m b u l a t o r y c a r e a n d d i a g n o s t i c s . T h i s

i n c l u d e s h o s p i t a l a d m i s s i o n i f r e q u i r e d .

P e o p l e w i t h c o m p l e x n e e d s , s u c h a s l o n g t e r m c o n d i t i o n s , r e c e i v e

o n g o i n g s u p p o r t c l o s e t o h o m e . H i g h q u a l i t y s p e c i a l i s t s e r v i c e s a r e

a v a i l a b l e w h e n t h e y n e e d t h e m .

H e a l t h a n d w e l l b e i n g n e e d s a r e s u p p o r t e d i n t h e c o m m u n i t y o r c l o s e t o h o m e . P e o p l e

r e c e i v e c o n t i n u i t y o f c a r e , h a v e t h e o p p o r t u n i t y t o c o - p r o d u c e t h e i r c a r e w i t h p r o f e s s i o n a l s , a n d i n s o m e c a s e s r e c e i v e c a s e m a n a g e m e n t t o s u p p o r t m u l t i - d i s c i p l i n a r y i n p u t a n d r e v i e w

o f t h e i r c a r e p a c k a g e s .

“ I g e t t h e c a r e I n e e d w h e n I n e e d i t ”

I n d i v i d u a l s a n d c o m m u n i t i e s i n N C L a r e s u p p o r t e d t o e f f e c t i v e l y m a n a g e t h e i r w e l l b e i n g , c l o s e t o h o m e , w i t h a

f o c u s o n p r e v e n t i o n a n d r e s i l i e n c e

T e r t i a r y s p e c i a l i s t s e r v i c e s

T h e r e a r e c l o s e l i n k s t o

c o m m u n i t y s e r v i c e s s o t h a t s t a y i n h o s p i t a l i s o n l y a s l o n g a s i t n e e d s t o b e a n d

f o l l o w i n g a s t a y i n h o s p i t a l p e o p l e a r e s u p p o r t e d i n

t h e i r r e c o v e r y .

H i g h l y s p e c i a l i s e d c a r e i s a v a i l a b l e t o

p e o p l e w h o n e e d i t .

Appendix A



We are in the process of designing a cohesive programme that is large scale and transformational in order to meet the challenge

13

5

Health and wellbeing

• Improves population health outcomes

• Reduces demand

1. Population health including prevention (David Stout, STP PD)

2. Primary care transformation (Alison Blair, ICCG CO)

3. Mental health (Paul Jenkins, TPFT CEO)

Care and quality

• Increases independence and improves quality

• Reduces length of stay

4. Urgent and emergency care (Alison Blair, ICCG CO)

5. Optimising the elective pathway (Richard Jennings, Whittington MD)

6. Consolidation of specialties (Richard Jennings, Whittington MD)

Productivity

• Reduces non value-adding cost

7. Organisational-level productivity including:

a) Commissioner b) Provider

(FDs) 8. System productivity

including: a) Consolidation of

corporate services b) Reducing

transactional costs and costs of duplicate interventions (Tim Jaggard, UCLH FD)

Enablers

• Facilitates the delivery of key workstreams

9. Health and care workforce (Maria Kane, BEHMHT CE)

10. Health and care estates (Cathy Gritzner, BCCG CO and Dawn Wakeling, Barnet Council DASS)

11. Digital / information (Neil Griffiths, UCLH DCEO)

12. New care models & new delivery models (David Stout, STP PD)

13. Commissioning models (Dorothy Blundell, CCCG CO)

High level impact

Initiatives

A B C D

Appendix A



11

What we aim to achieve from each of our workstreams 6

Health and wellbeing

Focus on preventative care to achieve better health and care at a lower, cost, with a reduction in health inequalities

Population health

Reduce demand by upgrading out of hospital care and support, for individuals with different types of needs

Primary care transformation

Joining up of mental and physical health, analysis of social determinants and supporting population to live well

Mental health

Care and quality

Improve care through integrated approach across health and social care Urgent and emergency care

Understand the variation in delivery between acute providers to improve patient safety, quality and outcomes

Optimising the elective pathway

Identifying clinical areas which might benefit form consolidation Consolidation of specialities

Productivity

Efficiencies gained through better alignment of health and care services Organisational-level productivity

Improved delivery opportunities in areas such as: workforce management, pharmacy, medical, surgical and food procurement and distribution, pooled digital information and corporate functions

System productivity

Enablers

Develop new workforce model, focused on prevention and self-care, including review of existing roles and requirements

Health and care workforce

Management of One Public Estate to maximize the asset and improve facilities for delivering care Health and care estates

Develop the digital vision: inc. digitally activated population, enhanced care delivery models, integrated digital record access and management

Digital/ information

Work with Kings Fund to develop our delivery model for population health for NCL New care models & new delivery models

Develop strong commissioning through partnership working to develop whole population models of care, improve patients outcomes and financial and quality gaps

Commissioning models

A

B

C

D

Appendix A



Current position

Understanding the size of the

challenge

• We have undertaken analysis to identify the gaps in health and wellbeing, and care and quality in NCL in order to prioritise the areas we need to address

• Our draft Case for Change provides a narrative in support of working in a new way and provides the platform for strategic change through identifying key areas of focus

• Finance directors from all organisations have been working to identify the projected NCL health and care position in 20/21 should we do nothing

Delivering impact in year

one

• There is already work in train that will ensure delivery of impact before next April, in particular, CCG plans to build capacity and capability in primary care and deliver on the 17 specifications in the London Strategic Commissioning Framework (SCF).

• However, further work must be done to broaden our out of hospital strategy and address issues with regard to the short-term sustainability and viability of general practice

• The implementation of our Local Digital Roadmap will support the delivery of the mental health, primary care and estates work, and our two Vanguards are continuing to progress with their plans.



12

7

Establishing effective

partnership working

• NCL-wide collaborative working is a relatively new endeavour and we continue to build relationships across the programme partners to ensure that health and care commissioners and providers are aligned in our ambition to transform care

• We have established a governance framework that supports effective partnership working and will provide the foundation for the planning and implementation of our strategic programme going forward

• The SROs are working to bring CCGs, providers and local authorities together across the 5 boroughs together recognising the history and context that underlies working together in a new way

Appendix A



• Forward planning underway to join up all partners and stakeholders in NCL footprint

• Dedicated communications lead now in place to undertake this

• Stakeholder mapping underway for external and internal bodies through integrated work approaches with CCG communications and engagement leads to include partners such as local authorities, NHS providers, GP practices and others to be determined

• In addition to partners and stakeholders already consulted, we will identify opportunities for more STP partners clinicians/staff to have input into specific work streams asap, particularly local political engagement which will be key for community leadership of change

• Plan to engage more formally with boards and partners after the July conversations

• Effective communications channels will be established for all stakeholders and partners for transparent contributions to ongoing plans and discussions, including staff, clinicians, patients, politicians etc.

• A core narrative is being created to cover our health and care challenges and opportunities, STP purpose, development, goals, strategic approach and priorities – in person-centred, accessible language

• Review requirements for consultation before March 2017

We will ensure all our stakeholders and wider programme partners are appropriately involved in the development of the programme

30

8

Engagement to date Communications & engagement

objectives Delivering the objectives

• To support the engagement and involvement of STP partners across all organisations at all levels

• To ensure a strong degree of organisational consensus on the STP content and on the approach to further developing the strategic plan and implementation approach, in particular political involvement and support

• To support and co-ordinate STP partners in engaging with their stakeholders to raise awareness and understanding of:

• the challenges and opportunities for health and care in NCL

• how the STP – specifically the emerging priorities and initiatives - seeks to address the challenges and opportunities so that we can develop the best possible health and care offer for our population

• what the NCL strategic plan will mean in practice and how they can influence its further development and implementation

• To encourage and gather feedback from stakeholders – NHS, local government, local and national politicians, patients and the wider community – that can:

• influence our emerging plans and next steps

• help build support for the STP approach • To ensure equalities duties are fulfilled, including

undertaking equalities impact assessments

Workstreams have been engaging with relevant stakeholders to develop their plans. • The general practice transformation

workstream has worked collaboratively with the London CCGs (and local groups of GPs) to develop pan-London five year plan

• Mental health workstream was initiated at stakeholder workshop in January 2016 and a further workshop in May. Further service user and carer engagement is done via programme updates and specification for a citizens panel is being developed

• Significant engagement was undertaken through reprocurement of 111 process in urgent and emergency care workstream

• The estates workstream has been developed through a working group, with representatives from all organisations in scope including Moorfields, the Office of the London CCGs, Community Health Partnerships, Healthy Urban Development Unit (HUDU) and GLA

• NCL Digital Roadmap Group meets to define, shape and contribute to the interoperability programme with representation from all key organisations

• Early engagement with Health & Wellbeing Boards and the Joint Overview & Scrutiny Committee

Appendix A



Next steps for development of the STP

14

July/August 2016

- Refine and develop initial approach

- Engage more broadly with clinicians and local leaders

September/October 2016

- Develop a more comprehensive plan

- Confirm the existing governance arrangements support implementation

- public engagement underway

To January 2016

- Develop more detailed implementation plans

9 Appendix A

of 2

Risk Assessment Framework Ratings Summary

Performance summary 2015/16The Royal Free London NHS Foundation Trust recorded a Green rating under Monitor’s riskassessment framework in each quarter of 2015/16.

May 2016With all data now available for May, apart from C. difficile, the trust failed four targets duringthe month:

1. A&E 4-hour standard2. Cancer 62 days from GP referral3. Cancer 2 week wait4. RTT 18-weeks Incomplete Pathways

In calculating the governance rating the Monitor framework adjustment (setting asidestandard failure) is applied to the RTT 18-weeks incomplete pathway indicator. This thereforeequates to four non-compliant standards and therefore compliance against the governanceregime with a Green rating achieved for the month.

Action required/recommendation For information and agreement

Trust strategic priorities and business planning objectives

supported by this paper

Board assurance risk

number(s)

1. Excellent outcomes – to be in the top 10% of our peers on

outcomes

X

2. Excellent user experience – to be in the top 10% of relevant

peers on patient, GP and staff experience

X


relevant peers on financial performance

4. Excellent compliance with our external duties – to meet our


X

5. A strong organisation for the future – to strengthen the

organisation for the future

X

CQC Regulations supported by this paper

Regulation 8 ⃰ General

Regulation 9 Person-centred care

Regulation 10 Dignity and respect

Regulation 12 Safe care and treatment

Regulation 17 Good governance

Regulation 18 Staffing

Regulation 20A⃰ Requirement as to display of performance assessments


Trust Board Meeting 27 July 2016 Paper 9

of 2


Failure to achieve and maintain compliance against Monitor risk assessment framework

standards and targets.

Equality analysis

• No identified negative impact on equality and diversity

Report from Will Smart

Chief information officer

Author(s) Darrien Bold

Deputy head of performance

Date 20 July 2016

Trust Board Performance DashboardPerformance For June 2016

Produced on 20 July 2016

1

Paper 9

June 2016 Monitor Risk Assessment Scorecard April 2015 to June 2016

Royal Free London NHS Foundation Trust

Monitor Indicators of Governance Concerns - April 2015 - June 2016 Q1 Q2 Q3 Q4 Apr-16 May-16 Jun-16 Q1 Target WeightingRolling

Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours 97.2% 95.8% 93.4% 87.8% 90.3% 92.5% 90.2% 91.0% >= 95% 1.0 High

**C difficile number of cases against plan 4 5 5 0 Q1 <= 17 1.0 Low

**Maximum time of 18 weeks from point of referral to treatment inaggregate for patients on an incomplete pathways 88.5% 88.0% 86.7% 89.6% 90.4% 91.9% 92.2% 92.2% >=92% 1.0

**Cancer: two week wait from referral to date first seen

All cancers 95.0% 94.7% 96.2% 92.9% 93.0% 92.97% >=93%

Symptomatic breast patients 98.7% 95.3% 96.4% 89.1% 94.6% 94.1% >=93%

**All cancers: 31 day wait from diagnosis to first treatment 99.5% 98.9% 99.2% 98.1% 96.5% 98.4% >=96% 1.0 Low

**All Cancer 31 day second or subsequent treatment -surgery 98.2% 100.0% 100.0% 99.1% 100.0% 97.0% >=94%drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% >=98%radiotherapy 100.0% 100.0% 100.0% 99.2% 100.0% 100.0% >=94%

**All Cancer 62 days wait for first treatment:from urgent GP referrals: 76.4% 69.1% 73.3% 72.6% 79.7% 80.9% >=85%from a screening service 90.5% 94.8% 93.0% 83.3% 92.5% 100.0% >= 90%

Compliance with requirements regarding access to healthcare for people with learning disabilities

Compliant Compliant Compliant Compliant Compliant CompliantMeeting the

6 criteria1.0 Low

Monitor overall governance thresholds: Trust Rating: Green1 Green1 Green1 Green1 Green1 Green1

Green: a service performance score of <4.0 and <3 consecutive quarters' breaches of a single metric

Weighting: 1 1 2 3 3 3

Red: a service performance score of >=4.0 and >=3 consecutive quarters' breaches of a single metric

* Denotes actual data for April 2016**18-weeks and Cancer data is not available for April 2016Note: C. difficile RAG rating applied on the basis of the cumulative quarterly expression of the trajectory

2015/16

High

1The overall trust rating has been modified following application of the Monitor governance framework adjustment, refer to commentary

Low

High

1.0 High

1.0

1.0

2016/17

2

Paper 9



2016/17


Risk Assessment



**Maximum time of 18 weeks from point of referral to treatment inaggregate for patients on an incomplete pathways 90.8% 80.6% 87.5% 89.7% 90.8% 92.8% 92.7% 92.7% >=92% 1.0 High


All cancers 97.4% 97.9% 98.7% 97.4% 97.4% 97.4% >=93%


**All cancers: 31 day wait from diagnosis to first treatment 98.7% 97.8% 98.5% 96.5% 93.8% 97.1% >=96% 1.0

**All Cancer 31 day second or subsequent treatment -surgery 96.9% 100.0% 100.0% 100.0% 100.0% 95.5% >=94%drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% >=98%radiotherapy 100.0% 100.0% 100.0% 99.2% 100.0% 100.0% >=94%




6 criteria1.0 Low






2015/16


1.0 Low

1.0 Low

1.0 High

Low

3

Paper 9




Risk Assessment



**Maximum time of 18 weeks from point of referral to treatment inaggregate for patients on an incomplete pathways 91.6% 92.4% 91.6% 91.6% >=92% 1.0 High


All cancers 93.0% 92.5% 94.5% 91.0% 92.8% 91.0% >=93%


**All cancers: 31 day wait from diagnosis to first treatment 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% >=96% 1.0

**All Cancer 31 day second or subsequent treatment -surgery 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% >=94%drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% >=98%radiotherapy N/A N/A N/A N/A N/A N/A >=94%




6 criteria1.0 Low






2015/16


1.0 High

1.0 Low

1.0 High

Low

2016/17

4

Paper 9



2016/17


Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours 100.0% 100.0% 99.9% 100.0% 100.0% 100.0% 100.0% 100.0% >= 95% 1.0 Low


*Maximum time of 18 weeks from point of referral to treatment inaggregate for patients on an incomplete pathways 87.8% 88.4% 87.8% 87.8% >=92% 1.0


All cancers 95.1% 94.1% 95.5% 90.8% 88.1% 90.5% >=93%



**All Cancer 31 day second or subsequent treatment -surgery 100.0% 100.0% 100.0% 96.3% 100.0% 100.0% >=94%drug 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% >=98%radiotherapy N/A N/A N/A N/A N/A N/A >=94%




6 criteria1.0 Low





* Denotes actual data for March 2016**18-weeks and Cancer data is not available for March 2016Note: C. difficile RAG rating applied on the basis of the cumulative quarterly expression of the trajectory

2015/16


1.0 High

1.0 Low

1.0 High

High

5

Paper 9




Risk Assessment

*A&E - 95% of patients admitted, transferred or discharged within 4-hours >= 95% 1.0

**C difficile number of cases against plan Q1 <= 0 1.0

**Maximum time of 18 weeks from point of referral to treatment inaggregate for patients on an incomplete pathways >=92% 1.0


All cancers 95.7% 94.1% 93.4% 79.7% 84.6% 81.8% >=93%



**All Cancer 31 day second or subsequent treatment -surgery >=94%drug >=98%radiotherapy >=94%




6 criteria1.0 Low

Monitor overall governance thresholds: Trust Rating:





2016/172015/16


1.0 High

1.0

1.0 High

6

Paper 9

High Risk Indicators Commentary and Exception Report

Month: June 2016

Risk Assessment Framework - commentary

Trust performance overview

The table below summarises the performance against standard for each site of the Royal Free London, showing that we are currently non-compliant on:

• A&E;

• RTT;

• 2 week wait cancer; and

• 62 day cancer.

Period Reported Indicator Description Standard STF All Royal

Free Barnet

Chase

Farm Other

Jun-16 AE Patients admitted, transferred or

discharged within 4 hours 95% 93% 90.20% 89.90% 87.40% 100.00%

Jun-16 C Difficile Cases Lapses in care <=0 0 N/A N/A N/A N/A N/A

Jun-16 RTT Patients on incomplete pathways

waiting less than 18weeks 92% 91% 92.20% 92.70% 91.60% 87.80%

May-16 Cancer

2 week waits - All cancers 93% 92.97% 97.40% 91.00% 90.50% 81.80%

2 week waits - Symptomatic breast 93% 94.10% 95.40% 93.10% 94.40% 50.00%

31 day waits diagnosis to first

treatment - All cancers 96% 98.40% 97.10% 100.00% 100.00% 100.00%


treatment - Surgery 94% 97.00% 95.50% 100.00% 100.00%

7

Paper 9


Month: June 2016


treatment - Drug 98% 100.00% 100.00% 100.00% 100.00%


treatment - Radiotherapy 94% 100.00% 100.00%

62 day waits from GP referral to

treatment 85% 76.10% 80.90% 82.70% 80.20% 77.30% 100.00%

62 day waits from screening service

referral to treatment 90% 100% 100.00% 100.00% 100.00% 100.00%

Our focus remains on our areas of sustained non-compliance in A&E and Cancer. RTT performance this month represents a further improvement of 0.3

percentage points on May’s performance which now makes us compliant at trust level one month ahead of our trajectory.

A&E

Performance this month is below our STF trajectory ambition. We will analyse the causes of this with our system, but system issues in North London, such

as those relating to the North Middlesex may be a factor. We are, however, progressing with our short-listed improvement plans for the emergency access

pathway, aiming to bring these together with those from our System Resilience Group (SRG). The most significant of these are:

• The redesign of our front end A&E services at Barnet Hospital to improve access to short-stay care, and

• Work on a Discharge to Assess programme to expedite discharges for medically optimised patients.

Cancer 62 day

We have now agreed our cancer 62 day improvement trajectory with NHS England and NHS Improvement, shown in the table below.

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

Cancer 62 days from GP Referral 79.7% 75.2% 76.1% 77.4% 78.1% 74.4% 78.2% 83.8% 85.2% 85.3% 85.2% 85.2%

8

Paper 9


Month: June 2016

To develop this trajectory, we have reviewed current demand and capacity, estimated the number of additional patients that need to be diagnosed and/or

treated for each tumour site service in order to return each service to standard (building in a degree of resilience) and estimated the number of weeks it

will take each tumour site to deliver. Overall, this commits us to a return to standard in December 2016. The ambition for each tumour site is shown in the

table below.

Current number of patients in backlog Weeks to return to compliance Month of compliance

Breast - Already compliant Already compliant

Gynaecological 101 14 Dec 2016

Haematological 21 20 Feb 2017

Head & Neck 32 5 Sep 2016

Lower Gastrointestinal 222 17 Dec 2016

Lung 50 15 Dec 2016

Other 15 30 Small numbers

Sarcoma - Already compliant Already compliant

Skin - Already compliant Already compliant

Upper Gastrointestinal 91 12 Dec 2016

Urological 106 13 Dec 2016

TOTAL 638 16 Dec 2016

To support delivery, we are:

• Engaging with clinicians and operations managers in each tumour site to agree actions that need to be taken,

• Modelling in more detail the capacity we will need to diagnose and/or treat the backlog and agreeing with each element of the pathway,

• Refreshing our cancer governance structure, including the reporting we use to track performance, and

9

Paper 9


Month: June 2016

• Reviewing the clinical leadership for the cancer service with a view to putting a business case to TEC for some additional dedicated clinical time for

this.

We anticipate that the actions taken to ensure a return to performance on the 62 day standard will also support resilience on the 2 week wait standard.

The Strategic Transformation Fund (STF)

For 2016/17 NHS Improvement has allocated additional funding from the STF to trusts delivering against agreed target recovery trajectories. The rules for

this funding allocation have also now been shared with us. We have agreed trajectories for all indicators, these are summarised in the table below – green

indicates that we have met the trajectory, red that we have not.

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

A&E 4 hour standard 90% 92% 93% 95% 95% 95% 92% 90% 91% 91% 92% 92%

18-weeks RTT Incomplete Pathways 90% 91% 91% 92% 92% 92% 92% 92% 92% 92% 92% 92%

18-weeks RTT Volume of 52 Weeks

Breaches 5 5 5 5 5 5 0 0 0 0 0 0

99% of Diagnostic Pathways to be

Seen within 6-weeks 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%

Cancer 62 days from GP Referral 79.70% 75.20% 76.10% 77.40% 78.10% 74.40% 78.20% 83.80% 85.20% 85.30% 85.20% 85.20%

10

Paper 9


Month: June 2016

11

Paper 9

of 1

FINANCE PERFORMANCE REPORT 2016/17 – Month 3

Chief Financial Officer’s Message

Year to date

actual deficit of

£14.2m; in line

with Q1 plan

1 The Trust delivered an actual deficit of £14.2 at end of Quarter 1 in line with the

revised financial plan. Key risks that will impact on delivery of the FY17 outturn are

1. Slow progress in identifying cost reduction programmes against the £46.3m

savings target – currently there are firmed up plans for £7.4m and ideas of

£21.4m

2. Emerging CCG challenges to pay for income over performance - NEL

commissioners have already issued the Trust with a AQN (Activity Query

Notice), raising their concerns about their ability to fund a forecast outturn

of £30m over performance. These are CCG estimates of expected over

performance.

3. Delivery of agency targets in Quarter 3 and 4

4. Availability of cash

Action required/recommendation

For Discussion





relevant peers on financial performance


Regulation 13 Financial position


Equality analysis

• No identified negative impact on equality and diversity

Report from Caroline Clarke

Author(s) Senior Finance Team

Date 13-July 2016


Trust Board Public 27 July 2016 Paper 10

Financial Performance Report

June 2016

1

FINANCIAL PERFORMANCE EXECUTIVE SUMMARY

June 2016

Measure Description Status Position Trend Variation

Normalised

Net Surplus /

(Deficit)

Net income and

expenditure excluding

profit from fixed asset

disposals and fixed asset

impairments

Net surplus/(deficit) in month:

Plan (£4.8m), Actual (£1.4m),

Variance £3.4m favourable

Net surplus/(deficit) YTD:

Plan (£14.3m), Actual

(£14.2m), Variance £0.1m

favourable

NHS Clinical Income: The year to date (YTD) clinical income values as at 30 June

shows an over performance positon of £3.2m, of which (£2.2m) relates to drugs

and devices and £5.4m relates to other activity.

Other Income: (£1.4m) adverse from plan in month and (£4.7m) adverse YTD. The

adverse variance relates primarily to private patient reduced activity and pharmacy

wholesaling.

Pay excluding Integration: (£0.3m) adverse from plan in month and (£1.3m)

adverse YTD. Overspend is mainly due to unallocated CIP targets.

Non-Pay excluding Integration & TEDD: (£0.5m) adverse from plan in month and

(£2.7m) YTD. Key overspent areas are outsourcing and unallocated CIP targets.

Integration: £0.4m favourable in month and £0.6m favourable YTD.

CIP Savings

Savings against the

recurrent CIP savings

plan. The plan includes

both cost efficiency or

income generation

schemes.

CIP in month:

Plan £0.8m, Actual £0.6m,

Variance (£0.2m) adverse

CIP year to date:



Actual delivery of plans in Q1 of £1.4m fell short of the £1.6m CIP plan for the

period mainly owing to delays in scheme development and implementation. The

forecast is for full achievement of the £46.3m target.

Capital

Expenditure

Year to date cumulative

expenditure in non-

current assets.

CAPEX in month:



CAPEX year to date:



Capital expenditure for the month is £4.4m which is £3.2m lower than plan.

All programmes besides the A&E programme are on track and witin CAPEX limit.

Cash

Cash held with the

government banking

service and in commercial

banks.

Cash flow in month:



Cash balance:



The cash balance is below the planned level in June due to the lower then expected

receipts of the planned prior year NHS over performance. In addition the delay in

the land sale has also impacted the cash position for the trust whist the GP Lead

programme that the Trust is hosting continues to impact cash due to non payment

and late receipts for GP salaries.

The £22.6m cash balance reflects the Income and Expenditure deficit position and

non-recovery of NHS debts.

2015/162016/17

Actual 2016/17 Plan

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Capital Service Cover 1 1 1 1 1 1 2 3

Liquidity 4 4 4 4 2 4 4 4

Normalised I&E Margin 1 1 1 1 1 1 1 2

I&E Margin Plan Variance 2 2 2 2 2 4 4 4

Overall 2 2 2 2 2 2 2 3

Monitor

Financial

Sustainability

Risk Rating

(FSRR)

Monitor measures an

organisations financial

risk on a scale of 1-4 with

4 being the lowest risk

and 1 the highest risk.

Monitor FSSR: Trusts with a Normalised I&E margin of less than -1% are rated as 1

for this metric. A rating of 1 on any metric means the overall rating cannot exceed

2.

0

2

4

6

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

£m

Plan

Actual

0

2

4

6

8

10

12

J u l… A u g… S e p…

O c t… N o v… D e c… J a n… F e b…

M a r… A p r… M a y… J u n…

£m

Plan

Actual

0

50

100

150

J u l… A u g… S e p…

O c t… N o v… D e c… J a n… F e b…

M a r… A p r… M a y… J u n…

£m

Plan

Actual

R

-10

-8

-6

-4

-2

0

2

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

£m

Plan

Actual

A

R

A

G

2

Paper 11

Shadow group board report – Board July 2016

SHADOW GROUP BOARD REPORT

Executive summary

The Shadow Group Board (SGB) met on 14 July 2016.

The key issues discussed were:

- Discussions with providers, suppliers and stakeholders- NCL digital roadmap and RFL digital strategy- Key worker accommodation.

Action required

To note.

Trust strategic priorities and businessplanning objectives supported by this paper


3. Excellent financial performance – to be inthe top 10% of relevant peers on financialperformance

5. A strong organisation for the future – tostrengthen the organisation for the future


Regulation 12 Statement of purposeRegulation 13 Financial position

Equality impact assessment


Report From Dominic Dodd, chairmanAuthor(s) Mark Redhead, head of planningDate 18 July 2016



Paper 12

F,I&P report – 20.07.16 1

REPORT FROM FINANCE, INVESTMENT AND PERFORMANCE COMMITTEE HELD ON 21JULY 2016 - QUARTER 1 2016-17 MONITOR SUBMISSION

Executive summary

At its meeting on 21 July 2016, the finance, investment and performance committee was asked torecommended to the board that the following statements were approved for submission toMonitor (NHS Improvement) as part of the Quarter 1 2016-17 monitoring submission. As theboard papers were circulated prior to the committee meeting taking place, their agreedrecommendation will be reported to the board verbally

For Finance, that:The board anticipates that the trust will continue to maintain a financial sustainability risk rating ofat least 3 over the next 12 months.

The Board anticipates that the trust's capital expenditure for the remainder of the financial yearwill not materially differ from the amended forecast in this financial return.

For Governance that:The board is satisfied that plans in place are sufficient to ensure: ongoing compliance with allexisting targets (after the application of thresholds) as set out in Appendix A of the RiskAssessment Framework, other than the 62 day cancer target and the A&E target; and acommitment to comply with all other known targets going forwards.

A verbal update would be given on the other matters discussed at the meeting.

Action required

The board is asked to approve the above statements for submission to Monitor (NHSImprovement)

Equality impact assessment

No negative impact on equality or diversity.

Report From Dominic Dodd, interim chair of the finance and performance committeeAuthor(s) Veronica Jackson, committee secretaryDate 11 July 2016



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VJ, DCO, SP, DS

REPORT FROM THE PATIENT SAFETY COMMITTEE HELD ON 4 JULY 2016

Executive summary

The patient safety committee (PSC) met on 4 July 2016. It was agreed at the meeting thatthe following would be reported to the trust board on 27 July 2016.

PATIENT SAFETY METRICS

The committee received its regular patient safety metrics report. The metrics were seen asimportant indicators of patient safety and the data was provided in three views: trust wide,Royal Free Hospital, and Barnet and Chase Farm Hospitals.

MRSA

The committee was pleased to note that no bacteraemia was recorded in the months July2015 to May 2016. It was noted that the trust had moved up in the league tables; against the25 English teaching hospitals the trust was ranked 9th lowest (or 17th highest) in terms of theMRSA rate per 1,000 bed days. The committee congratulated all concerned on this successand asked that this be highlighted to the trust board.

C difficile

It was noted that performance was off track with the trust having recorded 68 infectionsagainst the target of 66 therefore exceeding the full year (2015-16) trajectory. The director ofnursing confirmed that a number of ‘’lapses in care’’ cases had been under review but hadsince been completed, resulting in a total of 14 attributed cases for the trust. The director ofnursing highlighted that the total number of attributed lapses of care cases for the previousyear was 25 and although the final figure for the current year was not yet established, it wasevident that good progress was being made in reducing the number of infections.

The associate medical director for patient safety noted that lapses in care infections weresubject to a rigorous checking process by local clinical teams and local commissioners. Hesuggested that it may be possible to benchmark the trust’s lapses of care rates against othercomparable teaching trusts; the committee agreed that this would be helpful

Medication errors

Further work was required to add more granularity to the medication error report. However,the associate medical director for patient safety reported that a breakdown of data, includingin relation to top medication errors, was available as system changes had been made toDatix to facilitate more detailed data which was being used to its full capability in advance ofe-prescribing. The pharmacist for clinical governance would be invited to attend a future



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Page 2 of 4FINAL 13/07/16 at 1342

VJ, DCO, SP, DS

committee and present a detailed report on medication errors.

The director of nursing added that following the CQC’s inspection of the trust earlier that yeara number of themes were identified in relation to improving the trust’s medicinesmanagement. She added that she would be chairing the medicines managementprogramme, supported by the chief pharmacist and deputy director of nursing for transplantand specialist services division.

Noting that medicines management was a wide ranging issue, the chair welcomedassurance that focus was being given to the priority areas. The associate medical directorfor patient safety suggested that it may be helpful if the medicine safety committee reportedinto PSC. He also highlighted that work was ongoing outside of the meeting more generallyon this and other patient safety related matters, including by way of medical bulletins. Thechair suggested it would be helpful to take stock of this issue (medicines management, e-prescribing in more detail, including assurance) at the September committee.

Ms Oakley, non-executive director asked whether there was a clear idea of what the benefitsof e-prescribing would be as there had been with the implementation of Datix, the trust’sincident reporting system. She welcomed a report at a future meeting on benefits realisationand risks and issues. The director of quality added that following the introduction of any suchsystem there would likely be a significant increase in error data initially. He suggested itwould be helpful to liaise with those trusts that had implemented e-prescribing to get a senseof the benefits, challenges and risks and share learning.

24/7 FALLS FREE CARE WORKSTREAM

Falls was one of the highest reported clinical incidents and was the second highest clinicalincident that resulted in harm within the trust. Furthermore, the trust’s falls preventionassessment documentation needed to be standardised and in line with national guidance.The aim of the 24/7 falls free care project was to reduce trust wide falls by 25% whilstreducing the proportion of patients who experienced harm from falls by 20% by 31 March2018. It was noted that during the inception phase, 10 wards across four of the trust’s sites(Royal Free, Barnet, Chase Farm and Edgware) had been identified for participation; thesewards had a bed-base of approximately 300 with a 100% risk of inpatient falls so it was clearthat the right areas of focus had been chosen.

The committee was pleased to note that there had been a reduction in the number of fallsresulting in harm. The associate medical director for patient safety considered that there wasnow more robust data on falls following alignment of Datix across the trust’s main hospitalsites. He added that consultants were learning from junior staff and there had been patientand carer involvement at a local ward level in terms of identifying changes to improve thepatient’s toilet area. The chair asked whether the outcomes from this work were being fedback into the design work on the rebuild of Chase Farm Hospital. The director of capital andestates commented that there was broad sign off from clinicians across all wards on thedesign elements, but he would ensure the issue of the toilets was discussed outside of themeeting as this was an important matter.

Ms Oakley, non-executive director noted that the trust had achieved its 25% target for sometime and therefore had made good progress, so it would be wise to say that it had deliveredagainst the target and within the timeframe.

The committee congratulated the team on their shortlisting in the national patient safetyawards 2016, and for the improvements made in reducing the number of falls resulting inharm. It was suggested that a presentation on the project, with representatives from the pilotwards in attendance, be given a future public trust board meeting.

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VJ, DCO, SP, DS

SUPERVISOR OF MIDWIVES ANNUAL REPORT 2016-17

The committee received the annual report from the team of supervisors of midwives (SoM) atthe trust outlining achievements for 2016/17, a summary of the local supervisor authority andthe SoM team action plan.

It was noted that in January 2015, following reports from the parliamentary health serviceombudsman and the Kings Fund, the nursing and midwifery council (NMC) decided that therole of SoM should be removed from its legislation. This requirement would come into effectfrom April 2017 and the aim was for the current SoM role to transition to the role of midwiferyadvocate for quality.

The committee noted the achievements made, in particular those related to the integratedmaternity services action plan which the patient safety committee regularly reviewed.Specific reference was made to the reduction in 3rd degree tear rates. It also noted thechallenges which centred on the change in role of the supervisory statutory function(objectives, revalidation, where staff stood).

It was noted the local supervisory authority undertook an audit of the combined maternityteam in December 2015. Of the four domains for statutory supervision, three had been met(1 – interface with clinical governance; 3 – leadership and teamwork; and 4 – interface withservice users) and one required improvement (2 – statutory supervision). Since the audit, anumber of additional actions had been taken to address domain 2, namely introduction of astaff experience survey, business case for increased midwifery staffing to meet the ratio of1:28 and world class care training for all midwifery staff. It was noted, however, that workwas ongoing to improve staff morale, including a ‘caring for you’ programme led by the royalcollege of midwives.

MANDATORY AND STATUTORY TRAINING

The committee noted that performance had not changed significantly since the last meeting;overall compliance against the 10 core competencies was 77%, 85% for permanent staff and54% for bank staff (down from 55%). It was noted that the trust had been selected as a pilotorganisation to work with IBM in validating the requirements and redesigning the userinterface etc. The chair wished to see priority given to improving the front-end of the system.The director of workforce and organisational development added that this was feeding intothe wider work on improving MaST.

Action required

The board is asked to note the report, in particular the success in relation to the trust’s MRSA

performance and the 24/7 falls free care worksteam.



Board assurance risk

number(s)

1. Excellent outcomes – to be in the top 10% of our peers on

outcomes

x

2. Excellent user experience – to be in the top 10% of relevant

peers on patient, GP and staff experience

x

4. Excellent compliance with our external duties – to meet our


x

5. A strong organisation for the future – to strengthen the

organisation for the future

x

Paper 13

Page 4 of 4FINAL 13/07/16 at 1342

VJ, DCO, SP, DS


Regulation 4 Requirements where the service provider is an individual or partnership

Regulation 5 ⃰ Fit and proper persons: directors

Regulation 6 Requirement where the service provider is a body other than a partnership

Regulation 7 Requirements relating to registered managers

Regulation 8 ⃰ General

Regulation 9 Person-centred care

Regulation 10 Dignity and respect

Regulation 11 Need for consent

Regulation 12 Safe care and treatment

Regulation 13 Safeguarding service users from abuse and improper treatment

Regulation 14 Meeting nutritional and hydration needs

Regulation 15 Premises and equipment

Regulation 16 Receiving and acting on complaints

Regulation 17 Good governance

Regulation 18 Staffing

Regulation 19 Fit and proper persons employed

Regulation 20⃰ Duty of candour

Regulation 20A⃰ Requirement as to display of performance assessments


As outlined in the paper.

Equality analysis


Report from Stephen Ainger, non-executive director and chair of the patient safety

committee

Author(s) Veronica Jackson, committee secretary

Date 12 July 2016

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