BOARD OF DIRECTORS

Wednesday 27 April 2016 at 09:00 - 12:45 Boardroom, Level 1, Yeovil District Hospital NHS Foundation Trust

AGENDA - PART 1

Presenter Timings Enclosure 1 Welcome and Apologies for Absence Chairman 09:00 Verbal 2 Declarations of Interest Relating to Items on the Agenda All Verbal 3 To Hear a Patient Story and to Receive Feedback on Actions

from the Patient Story from 23 March 2016 The purpose of the patient story is to focus the attention of the Board on patient experiences, the learning from which is used to improve services across the organisation.

HR

Presentation

4 To Approve the Minutes of 23 March 2016 and to Discuss

Matters/Actions Arising Chairman 09:30 Appendix 1

5 To Note the Executive Director Report Execs 09:35 Appendix 2 6 To Receive a Verbal Update from the Governance Committee

Held on 18 April 2016 and to Note the Minutes of the Meeting Held on 27 January 2016

J HEND 10:05 Appendix 3

7 To Review and Note the Quality and Operational

Performance Report SS / SM

HR 10:15 Appendix 4

BREAK – 10:45

8 To Note the Safer Staffing Report and I Want Great Care Report HR 10:55 Appendix 5 9 10

To Review and Note the Workforce Performance Report To Receive a Verbal Update from the Workforce Committee Held on 21 April 2016 and to Note the Minutes of the Meeting Held on 21 March 2016

TN

MS

11:10 Appendix 6

Appendix 7

11 To Receive a Presentation on the Staff Survey Results MA/TN

MD/MS 11:20 Presentation

12 13

To Review and Note the Financial Performance Report and to Receive an Overview of the PMO Arrangements To Receive a Verbal Update from the Last Financial Resilience and Commercial Committee

TN JHIG

JG

11:40 Appendix 8

Verbal

14

To Receive a Verbal Update from the Audit Committee Held on 18 April 2016 and to Note the Minutes of the Meeting Held on 18 February 2016

PvdH JG

Appendix 9

15 To Discuss and Note the Symphony Highlight Report JM

11:55 Presentation

16 To Discuss and Note the TrakCare Highlight Report JMAC 12:10 Appendix 10 17 To Receive the Q4 BAF and Corporate Risk Register JR

JHIG 12:25 Appendix 11

18 Any Other Business and Meeting Close

Chairman 12:40 –

12:45 Verbal

19 Exclusion of the Public To resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting due to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

20 Date and Time of Next Meeting

25 May 2016 in the Boardroom, Level 1, Yeovil Hospital

APPENDIX 1 BOARD OF DIRECTORS

27 APRIL 2016 BOARD OF DIRECTORS

Minutes of the Board of Directors Meeting held on

Wednesday 23 March 2016 at Yeovil District Hospital

Present: Paul von der Heyde Chairman Maurice Dunster Non-Executive Director Jane Henderson Non-Executive Director Mark Saxton Non-Executive Director Jonathan Howes Deputy Chief Executive Paul Mears Chief Executive Tim Newman Chief Finance & Commercial Officer

Helen Ryan Director of Nursing & Clinical Governance In Attendance: Jonathan Higman Director of Strategic Development Shelagh Meldrum Director of Elective Care Jade Renville Company Secretary Simon Sethi Director of Urgent Care & LTC Mandy Seymour-Hanbury Interim Chief Officer for Integrated Care Presenters & Peter Dean Non-Executive Director (Designate) Observers: Ian Fawcett Public Governor Observer Simon Lilley Commercial Director (Observer) Jason Maclellan Chief Information Officer [Item 12] Jeremy Martin Symphony Programme Director [item 11] Muhammad Nadeem Specialty Doctor Apologies: Julian Grazebrook Non-Executive Director Tim Scull Medical Director

Ref: No Action 1-

33/16 1

1.1

WELCOME AND APOLOGIES FOR ABSENCE Paul von der Heyde welcomed everyone to the meeting of the Board. He extended a particular welcome to Peter Dean (who it was anticipated would be joining the Board as a Non-Executive Director), Ian Fawcett, Public Governor Observer, and to Muhammad Nadeem and members of the public observing in the audience. Apologies for absence were received as noted above.

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2 2.1

DECLARATIONS OF INTEREST Paul von der Heyde reminded the Board that he listed his declarations of interest at a previous meeting [item 1-2/16 refers]. There were no other declarations of interest relating to items on the agenda.

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3 3.1

3.2

3.3

PATIENT STORY Helen Ryan presented a patient story (the account of which has been anonymised to prevent the identification of specific patients) in relation to delayed transfers of care, from which the Board noted the following: • There are inpatients that remain at YDH even though they do not require

medical input but for whom transfer to a community hospital or residential / nursing care facility may be inappropriate, such as medically fit, younger patients who may be homeless and have nowhere to return following treatment at YDH.

• There is a need to find a solution for such cases that may not fit the

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3.4

3.5

3.6

traditional social care requirements and there appear to be a shortage of homeless shelters/supported flats for such individuals, which is having a system-wide impact.

• Solutions for such cases would be considered as part of the development of

new models of care and outcomes based commissioning which would incentivise system-wide funding and shared ownership for such arrangements in a way that the current contractual model does not.

• Paul Mears and Mandy Seymour-Hanbury would discuss the issue further

with social care services led by Somerset County Council. Helen Ryan provided feedback from the patient story presented at the Board on 24 February 2016, advising that YDH was successful in its bid for funding from ITV’s People’s Projects to provide more activities for older people, including live music, art, gardening, movement and dance.

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4 4.1

MINUTES/ACTIONS OF THE PREVIOUS MEETING The minutes of the meeting held on 24 February 2016 were approved as a true and accurate record, subject to amendment of the sentence structure at 6.3 (lapses of care). There were no due actions or matters arising not on the agenda.

JR

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5 5.1

5.2

5.3

5.4

5.5

EXECUTIVE DIRECTOR REPORT The executive directors presented a verbal report (supported by the Monitor Q3 Feedback and the Letter from the Somerset CCG Regarding CAMHS Services appended to the papers), from which the following was discussed and noted: Monitor Q3 Feedback The feedback confirmed a financial sustainability risk rating of 2 and a green governance rating. The Board discussed the points raised by Monitor about the Trust’s RTT and A&E performance, for which recovery plans are in place. CAMHS The letter from the Somerset CCG acknowledges the concerns raised by the Board last month [item 1-21/16 refers] in relation to CAMHS and sets out their action plan. Commenting on the proposed liaison support role for the Somerset acute trusts, Jane Henderson questioned whether they would be able to recruit to this post in a timely manner and the Board discussed more generally the challenges in recruiting to key roles within the NHS. Jon Howes said that further discussion is required with the Somerset CCG to ensure adequate CAMHS service investment, reflecting on the high number of referrals received by the YDH paediatric team in connection with behavioural difficulties in young people. CQC Inspection The executive team reflected on the recent CQC inspection and expressed their gratitude to Jo Howarth and Bernice Cooke in the Trust’s Clinical Governance Team for all the preparation and support during the inspection. Paul Mears also thanked staff across the Trust for their resilience and dedication during the inspection at a time of significant operational pressure. He added that YDH may still be subject to an unannounced inspection. Initial feedback highlighted a number of areas of good practice as well as opportunities for improvement, but the final report and ratings will not be published by the CQC until May/June. System-Wide 5 Year Sustainability and Transformation Plans (STP)

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5.6 5.7

Jonathan Higman and Paul Mears provided an update on the development of the Somerset STP, which would be implemented to meet the aims of the NHS Five Year Forward View and to guarantee long-term financial sustainability. The Board said that the STP should reflect the work of the Symphony programme in South Somerset and that the key tenant should be outcomes based commissioning. Matthew Dolman, who was Chair of the Somerset CCG, had been identified as the SRO for the STP and a system-wide group had been established for the production of the plan, which would need to be approved by the Boards involved prior to submission by 30 June 2016. In terms of the annual plan, Jonathan Higman explained that YDH is awaiting feedback on the first draft so it could then be amended accordingly and distributed to the Council of Governors and to the Board for approval prior to submission on 11 April 2016. Ian Fawcett asked about the arrangements for patients in Dorset if the geographic footprint for the STP relates only to Somerset. Paul Mears said that the acute services review in Dorset is ongoing and that YDH is involved in discussions on the periphery. He said that there may also be opportunities in future to apply some of the principles of the Symphony programme in North West Dorset, working closely with primary care. Genitourinary Medicine (GU) Helen Ryan advised that the GU medicine service at YDH would from 1 April 2016 be provided by Somerset Partnership NHS Foundation Trust. She confirmed that the Trust would write to all the affected staff thanking them for their service while at Yeovil Hospital. Mark Saxton asked whether the staff were supported through the TUPE process, which was confirmed. Following questions from the non-executives regarding the future locality of the service (noting that accessibility is of key importance) Helen Ryan said she would keep informed of developments and outcomes for patients.

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6 6.1

6.2 6.3 6.4 6.5 6.6

QUALITY AND OPERATIONAL PERFORMANCE REPORT The Board reviewed the previously circulated report, from which the following exceptions were discussed and noted: • Mortality rates remain within acceptable levels.

• Following questions from the non-executive directors, Helen Ryan

acknowledged that YDH has not seen a reduction in falls and pressures ulcers to the levels it aspired at the start of the year, although with the latter there is a decreasing trend overall. In response she said that we are reviewing the assessment process for pressures ulcers and that to maintain focus on falls prevention, the falls team had been strengthened.

• The rates of C.Difficile are below the targeted threshold. There were no

cases of MRSA in-month.

• Meeting targets for admission to a stroke ward within four hours has been challenging as a result of operational pressures, particularly due to demand in ED and bed capacity. Simon Sethi said that an audit is undertaken every month to understand in detail the reasons for the breaches. As a result of renewed focus, Simon Sethi said the position in March was improving.

• There was discussion about the number of delayed discharges, which Simon

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6.7 6.8 6.9

6.10

Sethi said had reached significant proportions and was adversely impacting patient flow through the hospital. He said a number of actions had been implemented internally to try and improve the situation but that there were still challenges in arranging social care assessments/placements and/or referrals to the community hospital beds operated by Somerset Partnership, although it was noted that the latter had been more responsive. The non-executive directors asked of the next steps and it was confirmed that the Director of Social Care will be coming to YDH to review a number of long-term cases and to discuss the short and medium term solutions. Paul Mears said that he had discussed the issue with David Slack, MD of the Somerset CGG, who would liaise with Somerset County Council. The Board agreed the RAG rating for the delayed discharges should be changed from “amber” to “red”. Reflecting on the operational pressures, the Board noted the high number of cancelled operations. Shelagh Meldrum said that she is working with her team to ensure that cancellations are handled robustly. She added that YDH had over-achieved against its RTT recovery plan in February but that the impact of the recently cancelled operations was not yet known [item 9.1 also refers]. The Board also expressed disappointment that as a result of demand, the inpatient and day case waiting lists remain high.

• The DNA rates were improving and so it was agreed that the RAG rating should be moved from “red” to “amber”.

• YDH did not meet its planned trajectory for diagnostic waits in February

mainly due to delays in the agreed transfer arrangements of overdue patients to Shepton Mallet NHS Treatment Centre. However, Simon Sethi expressed confidence that the Trust would be on-plan for the end of April 2016. He added that endoscopy services had not been cancelled.

• In line with other trusts across the country, A&E activity has increased

significantly. Simon Sethi spoke of the hard work and dedication of the ED team in managing these operational pressures, particularly last week with the CQC inspection taking place at the same time. The Board discussed the levels of increasing demand in ED, as well as the number of delayed discharges, reflecting that this is detrimentally impacting patient flow through the hospital. It was acknowledged that bed capacity is a challenge but would have been worse if the Trust had not built the modular ward. In response to concerns raised by the non-executive directors, Simon Sethi said that a number of internal actions are being undertaken to improve flow, particularly with the approaching Easter Bank Holiday weekend. This includes having additional staff on-site (such as the medical discharge team, managers, site managers and possibly pharmacy). Also, a fast forward day is taking place on 24 March 2016. Jane Henderson said the 6 month rolling figures may not tell the whole story and it would be important for YDH to articulate the actual position, which has been exceptionally challenging. Alongside the short-term internal actions, there was discussion about the long-term opportunities of working with primary care to help manage flow across the whole patient pathway. In spite of the pressures in ED, ambulance handovers are good and within targeted limits.

• While the two week cancer performance target was met in February, the data (still to be validated) has identified that the targets were not met for the 31 and 62 day treatment standards. Simon Sethi said that a case by case review is being undertaken and that the position is improving so far in March.

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6.11 • Discussion about the friends and family test data would occur later in the meeting [item 1-39/16 refers].

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7 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 7.9 7.10

SAFER STAFFING AND I WANT GREAT CARE REPORT The Board noted the safer staffing report. Further to detailed discussion last month [item 1-24/16 refers], Helen Ryan reiterated that in spite of a successful nurse recruitment campaign, agency utilisation remains high. The Board requested a breakdown of the reasons for the ongoing expenditure and in response, Helen Ryan explained that: • YDH has been subject to significant levels of operational pressure with

additional escalation areas open.

• Cover has been required for sickness absence.

• While the medically fit for discharge ward is functioning well, the consequence is that the other wards have a number of inpatients with complex needs which at times require additional resource.

There was discussion about the recent visit from Monitor and the workforce diagnostic on which they are working with YDH to identify efficiencies and opportunities for improvement. The key points of learning from the diagnostic (on which Jonathan Higman is working with the HR team) would be agreed with Monitor and the Workforce Committee would monitor progress on their implementation. This includes: • Encouraging greater uptake to the bank through a range of incentives and

improved communication/marketing to staff (including the clarification of pay rates); this will commence in April 2016.

• Alongside other trusts across the region, YDH is continuing to negotiate with agencies to reduce costs for the staff they supply. However supply and demand is such that these negotiations have proved challenging.

• Cover for nurses with supernumerary status awaiting their PINs, an issue

which has been considered by the Board at previous meetings, has been raised with the NMC and will be pursued by Monitor.

The Board asked Helen Ryan to pass their gratitude to the staff that are continuing to work hard in the face of ongoing operational pressures. They also discussed the challenges in balancing the financial impact of increased agency utilisation with the need to ensure service quality and patient safety. They stated that the latter would remain the Trust’s priority. The Board noted the i want great care report but questioned the response rates. Helen Ryan acknowledged that the current state of escalation may have had an impact on staff perusing the completion of the feedback forms, but she spoke positively about the overall rating of 4.71.

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8 8.1

WORKFORCE PERFORMANCE REPORT AND COMMITTEE MINUTES The Board noted the workforce performance report, commenting further on staffing rates and agency utilisation [item 1-39/16 refers], stating that delayed PINs require resolution. Shelagh Meldrum said that we need to ensure that each team at YDH is encouraged to think creatively to identify local solutions.

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8.2

8.3

Commenting on the overseas recruitment campaign, Mark Saxton said that it would be important to provide those appointed with practical support when they move to Yeovil, including things like housing and banking. In terms of medical staffing, national workforce challenges in certain specialties have resulted in a “seller’s market”, with high agency rates for locums in those fields. Nevertheless, as highlighted by the executive directors, progress had been made with recruiting to some of these hard-to-fill consultant posts. As discussed earlier in the meeting [item 1-39/16 refers], it would be important to improve uptake of the bank, the rates of which are better at other trusts. The Board asked whether increased bank utilisation would result in some staff reducing their contracted hours. Helen Ryan acknowledged that some staff may well reduce their hours, but said that the enhanced flexibility of this arrangement could be beneficial for YDH. Commenting on rates of sickness absence, Maurice Dunster said that there can be underlying reasons for staff absence (in addition to those which are reported) and said that it would be important for the HR team to ensure that return to work interviews are undertaken in a timely and robust fashion. The Board noted the (tabled) minutes of the Workforce Committee held on 19 February 2016. Mark Saxton provided a verbal update from the meeting held on 21 March 2016, advising that many of the items discussed had already been considered by the Board, particularly nurse agency expenditure [item 1-39/16 refers]. Speaking to this point, he said that the appointment of a staffing manager would bring focused and dedicated resource to this issue. Mark Saxton said that the Committee had also agreed that the information contained within the workforce performance report (chart 4) should be split by business as usual, vanguard and TrakCare. He said that the Workforce Committee had also welcomed the improvements that had been made to the notes within the workforce performance report although they could be made more succinct. The Workforce Committee also reviewed the results from the staff survey, an overview of which would be presented at the next meeting of the Board.

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9

9.1

FINANCIAL PERFORMANCE REPORT AND VERBAL UPDATE FROM THE LAST FINANCIAL RESILIENCE AND COMMERCIAL COMMITTEE Tim Newman presented the Financial Performance Report (which was reviewed in detail at the Financial Resilience and Commercial Committee) advising that YDH is currently favourable to the business as usual budget and should meet its expected year-end budget deficit of £18.4m (subject to achievement of the RTT plan and avoidance of any associated commissioner penalties). Delivery against the transformation budget remains balanced. The Board spoke of capital expenditure and the necessity of continuing upgrades to the ageing hospital site which requires investment in support of the delivery of high quality patient care.

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10 10.1

DRAFT BUDGET AND ANNUAL PLAN 2016/17 Tim Newman tabled the proposed budget for 2016/17, which had been revised following previous consideration by the Board (Part 2) and the Financial Resilience and Commercial Committee. He confirmed that the budget relates to business as usual activity as the transformation budget is expected to be cost neutral with income covering expenditure. The proposed budget deficit for 2016/17 (subject to any further amendments/variations prior to year-end) was £22.1m (which excludes income from the national sustainability fund as YDH is unable to accept the control total of £8.1m).

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10.2 10.3 10.4

Tim Newman explained the main changes to the budget following the last meeting of the Board (Part 2), including removal of any sustainability income from the national fund, a £400k risk against savings assumed from the Symphony programme, a £100k risk of negative impact to the Kingston Wing’s contributions and a number of development items agreed by the directors. Tim Newman confirmed that a risk/opportunities analysis had been undertaken, the details of which he summarised to the Board. The total loan support requested from the Department of Health was £25.3m. Proposed capital expenditure was £7.3m, which the Board had reflected upon earlier in the meeting [item 9.1 refers]. Overall it was agreed that critical to achieving the Trust’s proposed budget would be contract negotiations with the Somerset CCG to ensure that YDH receives the income for the activity it undertakes through a PbR contract (accepting there may be some risks associated with this). Simon Sethi added that any reduction in winter resilience funding would be unacceptable. The Board also said that it would be important to understand the tangible impact of any admission avoidance schemes advocated by the Somerset CCG. The non-executive directors asked how the proposed budget for YDH compares to other trusts of a comparable size. Tim Newman said that a recent report from the National Audit Office had identified that acute trusts across the country are operating in similarly financially challenged environments. He added that during their recent visit, Monitor had been unable to identify any significant efficiency savings that could be made to improve the position in the short-term of which YDH is not already aware and developing (such as the creation of a PMO office which will take a structured approach to delivering efficiencies). The investigation into the Trust’s finances led by Monitor and concluded last year had already identified that YDH has the right strategic plans in place to secure long-term sustainability. The Board said that in addition to any internal savings made by the PMO, YDH should start to quantify any system-wide benefits and savings as it starts to move towards new models of integrated care. Subject to any further amendments/variations prior to year-end, which would be communicated to the Board by email as necessary, the Board approved the proposed budget for 2016/17. The process for completion of the annual plan had been discussed earlier in the meeting [item 5.5 refers].

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11 11.1

11.2

11.3

GOING CONCERN ASSESSMENT The Board considered the (tabled) Going Concern assessment and mitigating actions, approving the following statement for inclusion in the annual accounts 2015/16: • ‘After making enquiries, the Board of Directors has reasonable expectations

that the NHS Foundation Trust has adequate resources to continue in operational existence for the foreseeable future. For this reason, they continue to adopt the going concern basis in preparing the accounts’.

Paul von der Heyde confirmed that this is concordant with advice from the Trust’s external auditors, KPMG, and aligns with the statement made last year.

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11 11.1

11.2

SYMPHONY AND NEW MODELS OF CARE Jeremy Martin presented an update on Symphony, vanguard and new models of integrated care, from which there was particular discussion of the following: Complex Care – Following the resolution of the design parameters, progress is now being made and recruitment to key posts is ongoing.

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11.3

11.4

11.5

Enhanced Primary Care (EPC) – implementation has been initiated across five sites in wave 1. Symphony Healthcare Services Limited – The operating company is being setup along with the transactions relating to the wave 1 practices, a further update on which would be presented in Part 2 session. Jonathan Higman asked when more detail about the outcomes from Symphony would be available and how it would be monitored in future. Jeremy Martin said that the methodology for capturing this information is being reviewed and that he would bring a further update to the next meeting of the Board.

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12 12.1

12.2

12.3

12.4

12.5

12.6

12.7

12.8

TRAKCARE HIGHLIGHT REPORT Jason Maclellan tabled the TrakCare Highlight Report, from which it was discussed and noted that: • The programme status remains RAG rated as amber and is on track for go-

live in May 2016, with the exception of the pharmacy system which would be de-coupled from the main go-live, a re-plan for which is currently underway. Following questions from the Board, Jason Maclellan said that as an interim solution, the current contract for the pharmacy system would continue.

• The operational transformation lead is leaving the Trust to take up a new role, which will leave a gap within the YDH TrakCare team. Until the role is replaced, the team would cover the role on an interim basis.

• Challenges with the resource being provided by InterSystems (as a result of

sickness absence) had continued to impact progress.

• The technical elements relating to the product build and delivery are broadly on track, with the exception of the pharmacy system. There is a risk relating to the PACs upgrade, the timetable for which had slipped to mid-April.

Simon Sethi raised concerns about the levels of resource, which was echoed by the non-executive directors. Paul Mears and Jason Maclellan said that they would discuss this issue with the MD at InterSystems as it would be important to ensure the build is not detrimentally affected. The non-executive directors raised concerns about the various project delays and questioned whether there was any further risk to go-live. They also asked if there was any support that could be provided by the Board to support Jason Maclellan. Jason Maclellan said there was nothing specific, but that he would welcome the support pf Paul Mears on the call to the MD of InterSystems, at which the delays to the project would be raised. He agreed that on the call he would express the concerns of the Board. Once TrakCare (phase 1) had been implemented, Jane Henderson asked whether YDH had reflected within its plan the potential for data accuracy to be impacted as a result of the changes. Simon Sethi said a number of lessons had been learned from the implementation of IT programmes in other trusts to help mitigate this risk, adding that the Somerset CCG had been informed that there may be some transitionary challenges.

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13 13.1

HEALTH AND SAFETY POLICY The Board ratified the Health and Safety Policy, acknowledging that it had been reviewed in detail and approved by the Health and Safety Committee.

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14 14.1

14.2

ANY OTHER BUSINESS On behalf of the Board, Paul von der Heyde thanked Ian Fawcett for his contributions as public governor during his three terms, which would be coming to an end in May 2016. In advance of the official opening later in the day, Helen Ryan advised that the dementia garden would be opened by Julia Jones, co-founder of John's Campaign. She reminded the Board that the garden was funded by last year's National Lottery's People's Millions, when the Trust won £49,020 to design an outdoor space for patients and families. Gardening, craft and music activities involving the wider local community would be provided in the garden to help patients interact and socialise. Helen Ryan thanked Janine Valentine, Dementia Nurse Specialist, for her hard work in driving the project.

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15 15.1

DATE OF NEXT MEETING The next meeting will be held on Wednesday 27 April 2016.

APPENDIX 2 BOARD OF DIRECTORS

27 APRIL 2016

Report to: Board of Directors Report from: Executive Directors Subject: Executive Director Report Date: 27 April 2016 Symphony Healthcare Services Limited On 7 April 2016, we took an important step in our journey to make the local NHS more sustainable, joined-up and patient-focused. After many months of hard work and careful negotiations, we have now launched a new, primary care operating company as part of the Symphony Programme, called Symphony Healthcare Services. This subsidiary of Yeovil Hospital has assumed responsibility for three local GP practices: Yeovil Walk-in Centre, Buttercross Surgery, in Somerton, and The Ilchester Surgery. As Symphony Healthcare Services practices, they – and other practices which choose to integrate in the future – will benefit from a larger infrastructure and shared support services such as financial management, IT, HR, and facilities management. As well as reducing duplication and expenditure, this will ensure that those working in primary care can concentrate on the most important thing: providing the best possible care for their patients. At the same time, it will enable our hospital to develop better pathways of care for our patients, potentially reducing emergency attendances, and enabling more care to be delivered within local communities, closer to people’s homes. Sustainability and Transformation Plan The NHS England planning guidance for 2016/17 requires Trusts and Health Systems to develop two plans: • A local health and care system ‘Sustainability and Transformation Plan (STP)’ which will

cover the period October 2016 to March 2021.

• An organisational plan for 2016/17 which reflects the emerging Sustainability and Transformation Plan.

The STP will be each health and care systems local blueprint for accelerating the implementation of the Five Year Forward View. It will create an overall vision and plan for each area and will seek to deliver the Five Year Forward View triple aim of better health, transformed quality of care delivery and sustainable finances. The deadline date for submission of the STP is 30 June 2016 and the final draft will be presented to the Board of Directors in June for agreement prior to submission. Dr Matthew Dolman (previously the Chair of Somerset CCG) has been appointed as the Senior Responsible Officer for the development of the Somerset plan supported by a team of senior leaders, drawn from all key stakeholder organisations, including Local Authority and Primary Care. Jonathan Higman is the YDH lead for this work. An initial outline of the emerging STP was submitted to NHS England on 15 April. A copy of the submission which includes details of the scale of the challenge and the emerging priorities is attached for information.

Operational Plan 2016/17 Following consideration by the Board and the Council of Governors by email, the annual operational plan for 2016/17 was submitted to NHS Improvement on 18 April 2016. Junior Doctor Strike Simon Sethi, Director of Urgent Care, will provide a verbal update on the Trust’s plans to manage the junior doctor strike. CQC Inspection Helen Ryan, Director of Nursing and Clinical Governance will provide a verbal update on the feedback and initial actions from the recent CQC inspection and follow-up visit.

SOMERSET SUSTAINABILITY AND

TRANSFORMATION PLAN Name of footprint and no: Somerset, one footprint Region: South

Nominated lead of the footprint including organisation/function: Dr Matthew Dolman, Somerset Clinical

Commissioning Group

Contact details (email and phone): Matthew.dolman@somersetccg.nhs.uk 07768 252764, PA 01935 384080

Organisations within footprints:

David Slack Pat Flaherty

Managing Director Chief Executive

Somerset Clinical Commissioning Group Somerset County Council

Dr Nick Broughton Sam Barrell

Chief Executive Chief Executive

Somerset Partnership NHS Foundation Trust Taunton and Somerset NHS Foundation Trust

Paul Mears Matthew Dolman

Chief Executive Senior Responsible Officer

Yeovil District Hospital NHS Foundation Trust

1

Leadership, Governance and Engagement (1/2) Collaborative leadership and decision making:

• We believe that in Somerset, we are in a good place to deliver on this

agenda with progress towards a new commissioning landscape and the

new models of care being trialled across the county.

• Two years ago we created a strategic leadership structure to drive

transformation and respond to the emerging needs of Somerset’s population

and the greater pressure on resources and sustainability. This includes

Chief Executives and Medical Directors (or equivalents) from the CCG and

Foundation Trust providers, Somerset Local Medical Council (LMC)

representing Primary Care and County Council, including Public Health.

• We have developed a governance structure to support a major

transformation programme, Somerset Together, to increase the focus on

prevention and self-management, improve collaboration between providers,

increase the attractiveness of Somerset as a place to work and to address

the sustainability issues of our provider community. A review of the current

governance arrangements has been agreed in order to progress Somerset

towards a place based approach, focussing ultimately on the best use of the

Somerset £

• Somerset Health and Wellbeing Board provides the strategic leadership for

the health and wellbeing system and has a robust Joint Strategic Needs

Assessment (JSNA) and Health and Wellbeing Strategy in place. All health

and care commissioners are represented. Our STP will fully align with the

Health and Wellbeing Strategy and the JSNA will be used to inform its

development

• The following arrangements have been put in place to support the STP:

- Our SRO, Dr M Dolman, will coordinate and drive the development and

implementation of the Somerset STP. Dr Dolman has protected time to

lead the development and delivery of the programme. Dr Dolman will

take responsibility for ensuring a dynamic programme plan is in place

and ensure system wide engagement of all key stakeholders.

Maintaining system energy and momentum will be crucial.

- He will be supported by a team of senior leaders drawn from all key

stakeholder organisations and with citizen representation.

- The STP leadership team will review, strengthen and re-focus existing

cross organisational working arrangements already in place with a

dedicated Programme Management Office.

An inclusive process:

• We will ensure that the STP reliably and demonstrably places meaningful

co-production at the heart of the design, delivery, monitoring and

improvement of all of its activities. We will do this by engaging and

empowering individuals, social networks and communities to manage their

own health and care and to become active partners in the design and

delivery of all relevant services.

• We will build on the engagement strategy and implementation plan

which is currently supporting the Somerset Together Programme including

our Primary Care colleagues. In addition, we will incorporate the joint

working and engagement that is being tested across our health and social

care system including the Primary and Acute Care Systems (PACs), South

Somerset Symphony Vanguard; Taunton Symphony, Mendip Symphony

and the Somerset Coast projects.

Local Government Involvement:

• Somerset County Council is a key and equal member of all leadership

and decision making forums as stated above, and District Councils are also

involved to ensure housing needs are properly represented.

• Somerset CCG and Somerset County Council already jointly commission

and manage a number of services including Learning Disability and carers

services

• Our proposals are consistent with the Heart of the South West devolution

proposals. The difference in footprint will be managed through the intention

to delegate responsibility for health and social care to local Health and

Wellbeing Board areas.

Engaging clinicians and staff from all organisations involved:

• A primary care clinician is a member of the STP leadership group

• The supporting structure underpinning the STP leadership group will include

clinicians from across primary, community , acute care and mental health

services

• Existing programme groups which include wide clinical representation, will

be refocused to support the development of our 5 year STP. They will have

a Somerset wide Institute for Healthcare Improvement (IHI) quality

improvement framework running through their work as a “golden thread”

2

Leadership, Governance and Engagement (2/2)

Governance Structure for STP:

FTs Boards NHS England

Area Team

Somerset CCG

Governing Body

Somerset

County Council

Cabinet

Sustainability and Transformation

Planning Group

Health and Wellbeing Board

Task and Finish Working Groups

(as required)

Health and Social Care Leadership

Group

3

Improving the health of people in your area Systematically increasing focus and investment on prevention is at the heart

of our STP. Our work to develop Outcomes Based Commissioning has

improved population health and wellbeing first and foremost and is

considered locally as a cornerstone to ‘flipping the system’ over time from a

demand-driven one to a prevention-driven one. The 9 domains of our

outcomes framework can be seen in the boxes below.

The Somerset Health and Wellbeing Board is currently developing a

Prevention Framework which will be used to help shape shared

understanding and leadership for this agenda. The framework will then be

used to develop a prevention strategy to agree a robust and systematic

approach to prevention. The framework takes a ‘prevention at all levels;

approach, highlighting the need to increase primary, secondary and tertiary

prevention at all levels of need, a golden thread running through the whole

system.

Our initial thoughts are that the prevention strategy should focus on the

following key themes:

Think Individual

• Seeking to improve the lifestyles of individuals. We know smoking,

alcohol, diet, and lack of physical activity cause four of our major public

health burdens (heart disease and stroke, cancer, lung disease and

Type 2 diabetes) that result in about two-thirds (64%) of all deaths in

Somerset. There will be a step change in the scale and pace of our joint

work, using evidence-based primary prevention programmes and

behavioural nudges which are cost-effective, as well as maximising the

local impact of national campaigns such as One You and Change.

• For patients identified as already having long-term physical and mental

health conditions, we will scale up the use of patient activation measures

and health coaching, to enhance and develop a person-centred

approach to health and care. This will also allow patients to take more

responsibility for their health and reduce demand on services. The South

West regional IPC programme will be used increase the number of

personal budgets held. We will also draw on evidence from the NHS

England ‘Realising the Value’ Programme and the 6 principles of

empowering people and communities board of the New Models of

Care programme and segment and stratify our population according to

assets and needs and offer care planning to those who are most likely to

benefit (assumed to be c 30% of people living with Long Term

Conditions).

• We already have cross-system agreement to deliver a Making Every

Contact Count (MECC) programme to support frontline staff to use brief

lifestyle interventions as part of their role. We also have agreement across

the system to increase focus on developing healthy workplace initiatives and

are currently considering this as a joint CQUIN across the system this year.

Think Family

• We know some families experience significant health and social inequalities

in the county, often these families need more tailored support, similar to that

of the Troubled Families approach, we will work jointly across organisations

to consider a more multi-agency prevention offer for these families.

Similarly, carers are a vital resource for the county and require a far more

robust and systematic approach to ensure they stay healthy and well.

Think Communities

• Developing a joined up and systematic approach to supporting communities

to be strong and resilient is an area that requires significant focus in the

STP. Asset-based community development has been shown to be highly

effective in supporting people through the voluntary and community sector

but requires more of a joined up approach across the county. In addition,

developing community connector models that help people access local

services and groups has been demonstrated in the Mendip area as being

highly effective in reducing isolation, these need to be developed at scale.

4

Improving care and quality of services (1/2)

Emerging hypotheses for improving care and quality across our

footprint:

• The Somerset Together programme is preparing the health and social

care community to move to Outcome Based Commissioning contracts

from 1 April 2017 and is designed to support the formation of a high

value integrated health and care system . The complexity of the issue

can only be delivered through a one system, one programme approach.

• Somerset CCG is currently developing a comprehensive strategy for

primary care. The aim of the strategy is to ensure that high quality,

sustainable primary care is available to the people of Somerset. It will

explicitly address both workforce and workload issues.

• The Symphony Programme, a Primary and Acute Care Systems

(PACs) model is being designed in joint partnership with Yeovil District

Hospital, Somerset CCG, Somerset County Council and Primary Care.

This Vanguard Programme will be scaled at pace with

transformational funding across the whole county.

• Somerset will take forward Right Care through the Somerset Together

programme which draws on these principles and is informed by the

Triple Aim of improved outcomes for individuals and populations at lower

cost . We will relentlessly focus on allocative efficiency by reducing

waste and unwarranted variation and by ensuring shared decision

making is happening reliably through the use of measures such as

CollaboRATE.

• Somerset has agreed to adopt the International Healthcare Institute (IHI)

quality improvement framework. We plan to develop a culture of

continuous quality improvement across health and social care, including

primary care. It is embedded in the Somerset Practice Quality Scheme

(alternative to QOF) and links to Secondary care quality programmes,

reinforcing collaboration and cross organisational working.

• Somerset is currently not delivering a number of core standards

including RTT, A&E and cancer. The system is developing recovery

plans for the current year but the future will be explored in the STP plan

where there will need to be a focus on those clinical services that can

be networked to be more effective and efficient whilst ensuring quality

and safety.

• Many of our workstreams will be refocussed, for example, our current

Urgent and Emergency Care workstream will be looking at rapid response

interventions, urgent primary care and psychiatric liaison.

• The regional networks will be developed through collaboration with our

neighbour STP footprints.

• Delayed Transfers of Care is a particular area of local challenge. A

system wide strategic group has been set up to understand key blockages

and resolve issues. As part of the Somerset Together Most Capable

provider process, the system will need to deliver credible joined up plans.

This year’s Better Care Fund will reinforce the delivery.

• For our key clinical priorities the following plans are in place/in development:

- Long Term Conditions: Supporting people to manage their conditions

effectively and prevent unnecessary admissions to hospital.

- Cancer: improve early diagnosis.

- Mental Health: deliver parity of esteem, transform community mental

health services, strengthen Child and Adolescent Mental Health

Services, and achieve new national access standards with a focus on

Improving Access to Psychological Therapies.

- Dementia: improve dementia diagnosis.

- Learning Disabilities: Enhance community provision and person

centred care planning.

- Out of hospital care: Strengthen community based health and social

care and preventing unnecessary hospital admissions.

- Maternity services: Implement the recommendations of the National

Maternity Review and reduce still births by 20% by 2020.

- Orthopaedics: Delivering access standards on a consistent basis,

managing the current imbalance between demand and capacity, and the

significant financial challenges.

- End of Life: Ensuring that people die in their stated place of choice.

5

Improving care and quality of services (2/2)

• There are several areas where there is a known requirement to improve

quality of services through regulatory inspection by the CQC and

Ofsted. The most significant areas are:

- Specialist learning disability services and jointly commissioned

learning disability services

- District nursing

- Quality of children’s social care, with a particular focus on

safeguarding and healthcare for looked after children

- Accident and Emergency department performance.

• Compliance with the Care Act will be a significant driver to support the

care and quality of service delivered by the Local Authority, reinforcing

and aligning the self care agendas and prevention.

Key enablers:

• Somerset Together is seen as a key enabler to improve care and

quality and is our key strategic response to the challenges we face in

Somerset. It has three elements: commissioning reform moving to a

multi- year capitated outcome based contract; provider reform

exploring new collaborative relationships; and new models of care which

will all have a focus on person centred care. The new outcomes

framework is the innovative, transformational component element.

• Workforce development and planning is key to ensuring our staff have

the skills and expertise to meet the health an care needs of our

increasingly frail older population including people with dementia and

associated co-morbidities:

• There is considerable learning from the South Somerset Vanguard

symphony care hub in developing complex care teams and new key

worker roles to guide patients through the health and care system. The

learning from the new care models in managing complex care in

defined hubs and Enhanced Primary Care is being diffused across the

county.

• The “social care market “, specifically , domiciliary care, needs to be

enhanced to provide a workforce that is so critical for health and social care

sustainability.

• We will establish a rigorous, reliable and theoretically principled local

workforce development strategy which will ensure that appropriate

sectors of the workforce acquire the key skills of care planning, health

coaching, making every contact count and shared decision making needed.

• System leadership at all levels needs to be enhanced and developed with

a new collaborative approach that cuts across organisations. Early

conversations have started with the South West Leadership Academy who

will work with NHS and Local Authority staff.

• Technology. We have an ambition to be at the leading edge of system

wide digital innovation. We will make best use of technology, improving

interoperability and data sharing between local IT systems and extending

mobile working capability. We will ensure that there is informational

continuity across the STP and that digital channels are exploited in order to

support patients to monitor and manage their own health and to make

decisions about their health and care. A system wide Digital Strategy group

is working on an Interoperability solution and Musgrove Park has the first

open source Electronic Patient Record solution in place. Yeovil has a

number of IT partners within the Symphony Programme and our Community

trust has mobilised remote working for its staff, linking to the Local authority.

• A Local Estates Strategy is being further developed and will consider the

priorities and opportunities of all stakeholders and risks for the estate as a

whole. Through working with health and social and where appropriate other

public and third sector organisations realisation of estates solutions is

expected.

6

Improving productivity and closing the financial gap

Work by GE healthcare Finnamore completed in 2015 to assess the

financial implications of “do nothing” option concluded that, if unaddressed,

the annual cost gap in the Somerset Health & Care System is expected to

increase within five years by over £212m (in nominal terms assuming 2%

inflation).

Since this work was undertaken in early 2015, Somerset Health & Care

System has become financially distressed as set out below:

• Excluding Sustainability Transformational Funding

Work will be undertaken to “refresh” the scale of financial challenge in the

context of the CSR 2015 and system demand and capacity issues.

The system approach to addressing the major efficiency and financial

challenges will be built from the “bottom” up, working with clinical teams,

identifying the key current and forecast cost drivers and developing a strategic

and operational plan for their resolution. Focus areas will be:

Commissioning Collaboration: There are a number of national and

international examples where outcomes based commissioning has been

implemented and system benefits realised. Though small, the number of

studies which have evidenced overall financial impacts, suggests that savings

of between 5 – 29% of current expenditure may be attributable to outcomes

based commissioning approaches. Somerset has assumed a conservative 5%

but with a potential to deliver higher level of savings.

System Cost Effectiveness and Efficiency: The system spent an estimated

£32m on agency and delayed transfers of care in 2015/16. Developing a

system plan to address these high cost areas and avoid significant escalating

costs over the next year is a key priority for Somerset and plans are currently

being developed to be then expanded to a five year plan. We will review the

outcomes of the Carter review to identify collective areas of priority.

Community and Estate Rationalisation: The system is currently developing

a local estates strategy to identify areas for estates rationalisation, linked to

future requirements for services. This will be a key focus area.

Demand and Capacity Management: A key element of the system plan will be

eliminating unwarranted variation and “right care” models and benchmarking

will comprise an important element of this programme. Alongside reducing

unwarranted variation, clinical service delivery models will be reviewed. Work is

now being undertaken through South Somerset Symphony “Vanguard” and our

other “Symphony” communities across Somerset to test innovative models of

care delivery.

Prevention and Patient activation: Shifting the focus from treatment to

prevention through the adoption of both prevention principles e.g. Making Every

Contact Count and a range of initiatives in order to optimise self-care and

management whilst quantifying the impacts of adopting this approach on future

demand costs.

7

Our emerging priorities (1/2)

The system has considered the emerging priorities that will shape the Sustainability and Transformation Plan. Our key objective over the course of the STP is to

redesign health and care services in Somerset to focus on prevention and deliver a fully integrated model that aims to keep people well. We aim to support people to

manage their own conditions, ensuring a parity of esteem between their physical and mental health needs and that, when they need access to services, these are high

quality, efficient and patient focussed.

To meet this aim our emerging priorities are:

1. Preventing people from dying prematurely and living healthier lives by promoting good health and discouraging decisions and behaviours that put mental and

physical health at risk. We will aim to add both ‘years to life’ and ‘life to years’ and focussing on improving the health and wellbeing of those most in need faster.

2. By segmenting our population we will develop and implement new models of care

focusing on the proactive support and management of patients living with multiple long

term conditions, including mental health. Our Symphony Vanguard Programme has identified

that the most complex 5% of our population account for 50% of the Health and Social Care spend

in Somerset. By rolling out the learning from the new care models being developed in South

Somerset we will develop a consistent approach across the county focussing on increasing patient

activation rates and supporting people to manage their own conditions

3. To develop a new model of urgent and emergency care. Our initial priority is to work

together and in partnership with Somerset County Council to tackle the increasing rate of DTOC

and develop a cost effective alternative model which reduces acute hospital length of stay and

supports people to return to their homes as soon as possible. We will look to support rapid

response and home based alternatives to hospital admission. In the long term we see

opportunities to redesign the urgent care system, using technology as a key alternative to

traditional methods of access.

4. Building on the developments underway as part of our PACS Vanguard Programme we will consider how we support Primary Care to ensure that services are

sustainable into the future,

5. Development of care networks. We see opportunities to build new, networked models of service delivery. Initial focus areas have yet to be agreed but are likely

to include maternity and paediatrics, emergency surgery and radiology.

8

Our emerging priorities (2/2)

6. Develop a new approach to managing demand for elective services through meaningful engagement between local GPs and hospital Consultants. We

will work with local services to drive innovation and efficiency, share data on referral and intervention rates and, starting with MSK services, develop clinical

models that ensure that referral to hospital take place only when necessary. We will consider the benefits of more ‘systematised’ surgical models and consider

adoption across the county.

7. Key to our strategy to deliver more integrated care is our programme of commissioner reform via Somerset Together. This will see a movement away

from traditional contracts to an outcome based contracting system that aligns incentives and provides the right climate to support organisations to work together

to deliver more integrated care models. Our aim is to move to an outcome based contract from April 2017.

We see these changes to be the basis of further reform across our system that will take place in the second part of the STP period. These changes could

facilitate:

• An alternative model of community service delivery – focussing on fewer community hospital beds and more home based alternatives

• A radical redesign of the current outpatient model.

Technology will be a theme throughout our vision for the future and will form a key part of our STP. We will develop innovative technology partnerships that

support the new care models and provide real time information to support both patient and system management.

The Big Decisions that we are considering as a system to support this programme of transformation include:

• How do we ensure that the ambitions of ‘Somerset Together’ are achieved at pace over the first year of the STP?

• How do we ensure that there is consistent clinical engagement across the county in the development and implementation of the new Care Models?

• What is the optimal organisational form and governance structure that supports the delivery of this vision?

• How do we balance our clinical service model development with the delivery of prescribed National standards within a rural geography?

• How do we balance the requirement to make short term savings with the need to prioritise investment to support a more sustainable long term model?

9

Support we would like

We would welcome the following support:

• Consideration of a move to a single system wide regulatory framework which supports integrated working between organisations and does not

detract away from it.

• Approval of collective financial and performance control totals.

• Support for the move to new types of NHS contracts such as Accountable Joint Ventures.

• Access to transformational funding support for the whole system, including continuation of exiting levels of Vanguard funding.

• Modelling and business intelligence support.

• National support for delivery of our digital strategy.

• Clearer communication to and from National bodies to avoid mixed messages .

• Sophisticated strategic communication programme to public at national and STP level.

• Support around engagement with academic / private sector research, building on Academic Health Science Network work.

National barriers:

• Review of the existing regulatory regime to ensure that it supports transformation and innovation .

• Move to a common language and joined up policy across government departments on health and social care matters.

• Autonomy to shape place based systems of care in response to national policy.

Areas that we can share good practice:

• We believe that Somerset is in a good place to deliver on this ambitious agenda. Many of the key building blocks are in place including, progress

towards new outcome based commissioning arrangements and the PACS Vanguard work in South Somerset . We would be keen to share the

learning from these.

• Emerging system leadership model.

Key risks:

• Collaborative ethos being compromised by individual organisational regulatory regimes.

• Need to prioritise investment to support prevention and transformation .

• Ability to deliver ‘system development’ and rapidly move culture and values to support integrated working.

• Creation of ‘headroom’ to drive the necessary change.

10

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GOVERNANCE ASSURANCE COMMITTEE (GAC)

Minutes of a meeting of the Governance Assurance Committee held on 18 January 2016 at Yeovil District Hospital

Present: Jane Henderson (Chair) Non-executive Director Maurice Dunster

Mark Saxton

Non-executive Director Non-executive Director

In Attendance: Mark Appleby Sue Bulley Karen Carter Bernice Cooke

Head of Workforce Performance and Organisational Development [item 05/16] Public Governor (Observer) Medical Records and Information Governance Manager [item 10/16] Head of Governance and Assurance [items 01/16-09/16]

Teresa Coombes Deputy Director of Transformation [items 11/16-16/16] Samantha Hann

Jo Howarth Kay Parmiter

Assistant Company Secretary Associate Director of Patient Safety and Quality [items 01/16-09/16] Palliative Care Nurse Specialist [items 11/16-12/16]

Helen Ryan Director of Nursing and Clinical Governance [items 1/16-13/16]

Glen Salisbury

Head of Safeguarding [items 05/16-07/16]

Apologies of those invited to attend:

BDO Representative Ian Fawcett Jason Maclellan Tim Scull Simon Sethi

Internal Auditors Public Governor (Observer) Chief Information Officer Medical Director Director of Urgent Care and Long Term Conditions

Action

1 1.1

WELCOME AND APOLOGIES FOR ABSENCE Jane Henderson welcomed everyone present to the meeting. Apologies for absence were received as indicated above.

2 2.1

DECLARATIONS OF INTEREST There were no declarations of interest relating to items on the agenda.

3 3.1

3.2

MINUTES OF THE GOVERNANCE ASSURANCE COMMITTEE The minutes of the Governance Assurance Committee meetings held on 14 October 2015 and 6 November 2015 were approved as a true and accurate record, subject to the following amendments: • 14 October 2015 – in relation to the Patient Safety, Quality and Experience

Report; ‘snap training sessions’ to be replaced with ‘snackbox training sessions’ • 14 October 2015 – in relation to the Corporate Risk Register; ‘could be

accepted’ to be replaced with ‘could not be accepted’ • 6 November 2015 – in relation to the Midwifery Services Annual Report

2014/15; ‘serious case review committee for’ to be replaced with ‘review of’ The actions were either noted as complete or on the agenda with the exception of action 27/15 (electronic staff record (ESR) data quality) which has been added to the work plan for the Workforce Committee.

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3.3 An update was provided to the Committee on the following items: • 31/15 - Jo Howarth had spoken with Simon Blackburn, Associate Director of

Communications, and the revised Quality Strategy would be communicated to staff alongside the Trust’s newly revised strategic objectives. Hard copies would be made available and a summarised version would be produced.

• 39/15 – The timeliness of complaint responses was discussed. Jo Howarth confirmed the online complaints module would enable the timeliness to be tracked. Sue Bulley asked who has responsibility for assuring internal responses are provided in a timely manner and it was confirmed this rests with individual senior managers with support from Ali Male, Complaints Manager.

• 40/15 - Jo Howarth confirmed the review of service level plans is underway and the Quality Committee would receive an update once completed.

• 41/15 – An update was requested from Helen Williams, Associate Director and Head of Midwifery, on the review of small acute services

HW

4 4.1

4.2

4.3

QUARTER 3 QUALITY COMMITTEE EXCEPTION REPORT Helen Ryan presented the Q3 Quality Committee Exception Report, highlighting that fire safety and ESR were reassessed in November 2015 and remain areas of focus. Jane Henderson asked whether topic areas which have been assessed as amber for a number of months should be progressed to blue/green or downgraded to red. Helen Ryan confirmed that progress had been made on those topics that remain scored at amber but in those cases the RAG rating remains appropriate. The Committee noted the lead for topic area 15 ‘discharge and multi agency working’ should be amended as Zoe Harris left the Trust in late 2015. Jane Henderson questioned whether there had been any recent action in relation to topic area 16 ‘transfer (clinical handover of care)’. Helen Ryan advised an additional doctor had been employed to cover 5pm-10pm which bridges the handover shifts and allows patient transfers to continue. She confirmed the implementation of phase 2 TrakCare would include electronic handovers.

BC

5 5.1

5.2

5.3

LAMPARD REPORT UPDATE The Committee reviewed the updated action plan in response to the Lampard Report recommendations. Helen Ryan explained that the review of volunteering services and the policy had been undertaken. Mark Appleby said the HR team is now working with Roger Hayward, Head of Patient Services, to ensure volunteers are subject to the same checks as substantive members of staff. In relation to recommendation R7, Mark Appleby said that DBS checks had been undertaken for 1,200 employees. Moving forwards, either 3 yearly DBS checks would take place at a cost of £55 or staff would be encouraged to complete an online DBS check at a cost of £10, for which they would be reimbursed. The Workforce Committee would review the process for undertaking these checks. Helen Ryan said that a flexible approach would be needed for staff that find it difficult to access information online. Mark Saxton asked if best practice could be adopted from other trusts. In response, Mark Appleby said that he would contact the HR Network Group. Helen Ryan confirmed Roger Hayward is undertaking DBS checks for all volunteers and the Committee agreed Trust governors should also be processed, which Samantha Hann said she had already started to consider. In relation to recommendation R10, Mark Appleby confirmed that the process for agencies is generally consistent with those of YDH, assurance on which is provided through spot checks. For contractors the recommendation is more challenging and this will be reviewed by the Workforce Committee as it is imperative that contractors working within clinical areas are suitably qualified and DBS checked.

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6 6.1

OVERVIEW OF DOMESTIC VIOLENCE SERVICES AT YDH Glen Salisbury provided an overview of domestic violence services at YDH which is to be enhanced in response to aa independent scoping exercise. The service should be available to staff who could be victims of domestic abuse as well as patients, carers and visitors. Challenges to enhancing the service have included staff workload and capacity, the implementation of new processes and the understanding of staff about how to raise concerns of domestic violence. To help address some of these issues, Jo Howarth advised that an authority to recruit form for a Domestic Violence Advisor had been submitted for Director approval. Once in post, the service could be further developed, including improving the way victims are identified and approached and how discussions are introduced as part of routine practice. The Committee acknowledged the sensitivities involved in introducing such questioning and Glen Salisbury said that lessons had been learned from the implementation in maternity services which would help with roll-out across the Trust. Staff that are subject to domestic abuse could be signposted to support through the occupational health service, where appropriate.

7 7.1

NATIONAL CHILD PROTECTION INFORMATION SHARING SYSTEM Glen Salisbury confirmed the system was devised in 2014 and links to the NHS Spine. Information about children or pregnant woman with child protection concerns should be captured on the system so local authorities are able to monitor the movement of children across England. Glen Salisbury advised that no central funds had been provided for implementation and therefore NHS trusts and local authorities must work in collaboration to ensure it is put in place as efficiently and effectively as possible. For contractual reasons, the project would not be progressed until 2017. Until then, Glen Salisbury advised that YDH would continue to admit any child as a place of safety if deemed appropriate. The Local Authority would be advised in such circumstances. Another limitation to the implementation of the system across England is that some areas have set up their own local processes, such as in Bristol. Glen Salisbury confirmed the Regional South West Stakeholder Group would meet by February 2016 to consider the proposals.

8

8.1

8.2

THE MENTAL CAPACITY ACT (MCA) 2005 LEGISLATION AND DEPRIVATION OF LIBERTIES (DOLs) AUTHORISATION POLICY Jo Howarth presented the revised Mental Capacity Act 2005 legislation and Deprivation of Liberties Authorisation Policy advising that it had been streamlined. Gaynor Appleby had been appointed as the Mental Capacity Lead working at a strategic level and the numbers of staff now able to undertake DOLs assessments and applications had increased as a result of significant training sessions. She confirmed that in April 2016 an external company would provide a training session for all matrons, sisters and out of hours staff. Helen Ryan, Jo Howarth and Jane Henderson would also attend a one day safeguarding adults level 4 and 5 training day. Jo Howarth advised the number of DOLS applications had continued to rise each year and the implementation of the Care Act 2014 (‘the Act’) has contributed to the increase in applications. Jo Howarth advised DOLS packs are available on the wards which include leaflets, checklists and flowcharts for staff. When asked by Mark Saxton who has central control at YDH for applications, Jo Howarth confirmed the clinical governance team holds a central register with details of all applications. Mark Saxton asked if the interaction with the MCA 2005 is monitored. Jo Howarth said that if a patient has no known next of kin, YDH refers them to the Independent Mental Capacity Advocate (INCA) service, the number of which is reported to the Somerset CCG on a quarterly basis. Sue Bulley asked if the number of DOLS applications and INCA referrals could be provided and it was agreed Gaynor Appleby and Janine Valentine would be invited to the next meeting to provide an update on the number of applications and the processes involved. When asked if further improvements could be made to current processes, Jo Howarth confirmed the team would like to incorporate DOLS application forms on YCloud.

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8.3

The Non-Executive Directors agreed they would like a seminar session on safeguarding children and adults at the Board of Directors. The Committee approved the Mental Capacity Act 2005 Legislation and Deprivation of Liberties Authorisation Policy.

JR

9 9.1

9.2

9.3

9.4

9.5

9.6

9.7

9.8

CORPORATE RISK REGISTER Jo Howarth advised there are 17 significant or high risks (12+) on the Q3 2015/16 Corporate Risk Register. No new risks have had added and 2 risks had been removed since Quarter 2 2015/16. Helen Ryan advised RTT remains challenging but additional capacity on the modular ward from 8 February 2016 would help to mitigate this risk alongside the other elements within the recovery plan. The Committee acknowledged there would be times when YDH would outgrow this additional capacity due to demand. Jane Henderson asked for an update on the impact of the junior doctor strike. Helen Ryan confirmed the risk relates to Q4 2015/16 and is reflected on the live risk register available on YCloud. She added that impact of the strike on 12 January 2016 was minimal. She confirmed that the next strike is scheduled to take place on 26 January 2016 and mitigation plans are in place to ensure the ongoing provision of high quality, safe patient care. In relation to risk OTH001, Bernice Cooke advised the wording of the risk would be reviewed as the 17 week target is now no longer in place. In relation to risks TW002 & TW003, Jo Howarth updated the Committee to advise the number of falls and pressure ulcers had increased in December 2015 but not to the levels that occurred in December 2014. Jane Henderson asked for further information in relation to risk SBUV008 ‘backlog of ophthalmology patients’ as this had deteriorated in Q3. Bernice Cooke advised that actions had been implemented and in Q4 to date the risk had reduced. The Committee discussed risk P002 ‘insufficient availability of CAMHS support’, which Helen Ryan confirmed is being reviewed with the Somerset CCG. In relation to risk M021 (best practice tariff), Bernice Cooke advised that Somerset Partnership NHS Foundation Trust has so far been unsuccessful in recruiting a CAMHS clinical psychologist and the issue is being discussed at the CQRM meeting taking place with the Somerset CCG on Thursday 21 January 2016. Bernice Cooke advised that risks EFM046 ‘fire alarm systems’, OP006 ‘emergency planning’ and MD002 ‘medical devices’, are being reviewed with Jonathan Higman, Director of Strategic Development and the relevant leads. For risk EFM031 ‘NHS Protect’, Jo Howarth advised an external review assessed YDH as amber. This is kept under review by the Audit Committee.

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10 10.1

INFORMATION GOVERNANCE UPDATE Karen Carter presented an update on the Information Governance Toolkit (IGT) version 13 2015/16 and Caldiott 2. She confirmed the IGT is a self assessment tool to measure compliance in handling information and consists of 45 requirements across 6 modules (information governance management, confidentiality and data protection, information security, clinical information, secondary use and corporate information). A baseline submission is required by 31 October each year with the final version due by 31 March. Karen Carter confirmed the aim of the IGT for YDH is to achieve level 2 (or more) across all requirements and to reach a minimum satisfactory score of 66%. Samantha Hann provided an explanation of the evidence that is required for the different levels.

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10.2

10.3

It was noted that an internal audit into information governance was carried out in August 2015 which identified a number of recommendations had been reviewed by the Audit Committee and which are being implemented. Karen Carter provided an update on the Caldicott 2 review which incorporated an additional 7th principle ‘the duty to share information’. She confirmed that the IGT had been amended to reflect the 7th principle and NHS trusts must provide evidence that they are complying with the duty. Jane Henderson asked of any significant risks raised by the Information Governance Steering Group. Samantha Hann confirmed the Group will closely monitor the implementation of the new General Data Protection Regulation (GDPR) which will replace the Data Protection Directive 95/46/EC and therefore the UK Data Protection Act 1998 once the text has been formally adopted by Council and Parliament. The GDPR will come into effect two years from formal adoption (2018). There was discussion about confidentiality and data security with reference to the security measures being put in place for TrakCare. Jane Henderson requested an Information Governance Annual Report be submitted to Committee in November 2016. A detailed update would be presented at a future Board seminar.

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11 11.1

CQC INSPECTION READINESS Helen Ryan advised that YDH is on track to submit the information request to the CQC by 19 January 2016 and is taking the opportunity to identify gaps for improvement. Also, teams across the Trust have been asked to complete self assessment packs for their services which has helped build confidence in identifying areas of good practice.

12 12.1

12.2

ARRANGEMENTS FOR PALLIATIVE AND END OF LIFE CARE AT YDH Teresa Coombes provided an overview of palliative and end of life care services at YDH which has a Trust-wide remit. She spoke of changes to the service including the provision of 7 day services following a 3 month pilot and establishing a multi-disciplinary team (MDT) with input from a range of professionals including a community palliative care team and psychologist. She provided an overview of the activity, statistics and reasons for referrals noting the increase in non-cancer diagnoses in the last year. Teresa Coombes added that the team is working with ward teams on the coding reasons for unspecified non-cancer referrals. She advised that an internal course has been provided to staff to help build their confidence in delivering bad news to patients and their families and having constructive discussions about their condition and treatment options. There was discussion about the abolition of the Liverpool Care Pathway and the new national guidance and updated NICE guidelines (care of dying adults in the last days of life) published in January 2016. She confirmed the focus of the guidance is to ensure early access, quality of care and delivery of 5 key priorities (recognising when people are entering the last few days of life, communicating and shared decision-making, clinically assisted hydration, medicines for managing pain, breathlessness, nausea and vomiting, anxiety, delirium, agitation and noisy respiratory secretions, anticipatory prescribing). Trusts are able to develop their own processes based on these priorities. Kay Parmiter confirmed YDH has developed a care plan pack on which YDH has received positive feedback. Mark Saxton asked how TrakCare will assist the service and Teresa Coombes confirmed within phase 1 flags will be built into TrakCare which will identify the patients on the end of life care pathway. In the longer term, it is anticipated an electronic version of the pack could be built into TrakCare but the Committee agreed hard copies should still be available. Jane Henderson asked if a similar pack is available for children. Teresa Coombes confirmed there is additional guidance and support for children and young adults including support from the Teenage Cancer Trust.

6 | P a g e

12.3 Teresa Coombes advised the End of Life Care Policy had been revised and was approved in early January 2016. A copy of the revised policy would be circulated to the Committee for information. She also provided an update on future developments for the team including the production of a Palliative Care and End of Life Care Strategy, expanding the team and developing staff competencies. The Committee noted the update on palliative care and end of life care services and thanked Teresa Coombes on the excellent presentation.

SH

13 13.1

13.2

13.3

13.4

PATIENT SAFETY, QUALITY AND EXPERIENCE REPORT Helen Ryan presented the Patient Safety, Quality and Experience Report asking the Committee if they had any questions. An update relating to many items within the report had already occurred during the course of the meeting. Maurice Dunster asked how patients with learning disabilities are identified by the Trust. Helen Ryan advised the YDH safeguarding team work closely with Somerset Partnership NHS Foundation Trust and the Local Authority and have access to a central register which has a flagging system in place. Jane Henderson asked if PREVENT training had been scheduled for 2016, which was confirmed. Jane Henderson noted from the report that a number of complaints now involve an RCA and this would be included in the report in the future. The Committee reviewed the Your Care questionnaire findings which provide the percentage of patients that answered ‘yes’ to each question. The Committee discussed the RAG scoring and it was agreed Helen Ryan would clarify them with the clinical governance team.

HR

14 14.1

14.2

14.3

TRAKCARE UPDATE Teresa Coombes advised that in her new role as Deputy Director for Transformation, she is responsible for the operational management and implementation of TrakCare. Teresa Coombes confirmed the revised go live date is 30 May 2016. Teresa Coombes confirmed clinics are being built within TrakCare and shared with staff to ensure they are fit for purpose. Teresa Coombes advised the development of the pharmacy system is challenging for while the updated software is on track for delivery at end of January 2016, the release contains a number changes which will need to be reviewed and as a result further gaps/issues may be identified. Teresa Coombes confirmed any impact on the go live date would be mitigated by de-coupling the pharmacy release, although she acknowledged that this could have an impact on the phase 2 timeline. Maurice Dunster questioned the forecasted 10-15% overspend on capital costs due to delays to implementing phase 1. Mark Saxton said the Board would ask for more information from Jason Maclellan at their January meeting.

JM

15 15.1

ANY OTHER BUSINESS There was no further business to discuss.

16 16.1

DATES AND TIME OF FUTURE MEETING 18 April 2016, Boardroom, Level 1, YDH 21 July 2016, Boardroom, Level 1, YDH 20 October 2016, Boardroom, Level 1, YDH 09 November 2016, Boardroom, Level 1, YDH (annual reports)

1

YDH │Quality and Operational Performance Overview March 2016

2

CONTENTS

1 Safe

2 Effective

3 Responsive

4 Caring

5 Well-led – Staffing

6 Well-led - Financial Performance

3

Safe [1]

Latest HSMR 12

Months to Nov 15

98.7

March Number of

Deaths

58

Mortality Rates

RAG Status: Significantly better than national average, Within expected range, Significantly higher than national average.

Please note: Due to the termination of the DrFoster Contract, HSMR data will no longer be available.

0

20

40

60

80

100

120

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Ma

y-1

5

Jul-

15

Sep

-15

No

v-1

5

Hospital Standardised Mortality Ratio (HSMR)

Monthly data 6 month moving average

0

20

40

60

80

100

Ma

y-1

2

Au

g-1

2

No

v-1

2

Feb

-13

Ma

y-1

3

Au

g-1

3

No

v-1

3

Feb

-14

Ma

y-1

4

Au

g-1

4

No

v-1

4

Feb

-15

Ma

y-1

5

Au

g-1

5

No

v-1

5

Feb

-16

Actual number of deaths

Monthly data 6 month moving average

4

Safe [2]

Patient Falls and Pressure Ulcers

Patient Falls

93 (83 in Mar 15)

Pressure Ulcers

8 (13 in Mar 15)

0

20

40

60

80

100

120

140

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Ma

y-1

5

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Ma

r-16

Patient falls

Monthly data 6 month moving average

0

5

10

15

20

25

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Ma

y-1

5

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Ma

r-16

Pressure ulcers +2

Monthly data 6 month moving average

5

Safe [3]

C.Difficile and MRSA cases

March C.Diff (Lapses

in Care)

0 (0 in March 15)

March MRSA

0 (1 in March 15)

0

1

2

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

De

c-15

Feb

-16

MRSA

Monthly data 6 month moving average

0

1

2

3

4

5

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

De

c-15

Feb

-16

Total C Difficile Cases

Monthly data 6 month moving average

Additional Notes

The Trust’s 15/16 Threshold for C.Diff cases due to

Lapses of Care is 8.

Total number of year to date cases of C.Diff is 15, of these

4 were due to Lapses in Care.

6

Effective [1]

Additional Notes

SSNAP Published figures for Q2Apr-Jun15:

National Average 4hr to Stroke Unit : 58.7%

National Average 90% Stay on Stroke Unit: 82.6%

National Average CT Scan in 1hr: 46.2%

90% Stay on Stroke

Unit

79% (Target: 80%)

Admission Direct

within 4hrs

45% (Target: 90%)

CT Scan in 1hr

69% (Target: 50%)

March 16

Stroke Services

0%

10%

20%

30%

40%

50%

60%

70%

80%

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

De

c-15

Feb

-16

Achievement 1HrCTScan

High Risk TIA within

24 Hours

67% (Target: 80%)

0%

20%

40%

60%

80%

100%

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

De

c-15

Feb

-16

4Hr Direct Admission

4Hr Direct Admission Target

7

Effective [2]

Additional Notes

Best Practice achievement in Financial Year 14/15 : 37.5%

The Length of Stay for the Trauma Ward is higher than other

Ward to a small number of patients who had a high length of

stay.

Best Practice

Achievement

58.6% (Int.Target: 60%)

YTD AvLoS Direct admission:

Trauma ward

20.8 days (vs 16.7 days Other wards)

March 16

Fractured Neck of Femur Services

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Operatedon within36 hours

GeriatricAssessment

within 72hours

Pre-op AMT Post-opAMT

FallsAssessment

BoneProtectionMedication

Post-opMDT

Best Practice Achievement Financial Year to Date

Overall BPT % Achieving each measure

Trauma Ward direct Admissions BPT

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Ap

r-14

May

-14

Jun

-14

Jul-

14

Au

g-14

Sep

-14

Oct

-14

No

v-14

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Ap

r-15

May

-15

Jun

-15

Jul-

15

Au

g-15

Sep

-15

Oct

-15

No

v-15

Dec

-15

Jan-

16

Feb

-16

Mar

-16

Average Length of Stay - #NOF patients

Trauma Ward Admission Other Admissions

8

Delayed Discharges

March 16

Lost Bed Days

685 (634 Mar 15)

In Month Bed Cost

£161,660 (£149,624 Mar 15)

Additional Notes

In Month Bed Costs are calculated using an average bed cost

of £236 multiplied by the number of lost Bed Days in Month.

Effective [3]

0

50

100

150

200

250

Completionof

Assessment

PublicFunding

Further nonacute NHS

care

ResidentialHome

NursingHome

Carepackage inown Home

CommunityEquipment

Patient orFamilyChoice

Disputes Housing

Monthly Split of Delayed Discharge Reasons (Bed Days)

01/2016 02/2016 03/2016

0

5

10

15

20

25

30

35

40

45

50

Number of Delayed Transfers of Care

9

DNA - Outpatients

Overall DNA Rate

7.2%

1st Appointment Rate

4.8% FU Appointment Rate

8.1%

Effective [4]

Additional Notes

Published National DNA rates for Q2 15/16 were 8.2%.

(Source NHS Better Care, Better Value Indicators)

The DNA cost is based on the average New appointment

costing £150 and the average FUP appointment costing £75

£60

£70

£80

£90

£100

£110

£120

£130

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-12

Jan-

13

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-13

Jan-

14

Mar

-14

May

-14

Jul-

14

Sep

-14

No

v-14

Jan-

15

Mar

-15

May

-15

Jul-

15

Sep

-15

No

v-15

Jan-

16

Mar

-16

Tho

usa

nd

s

DNA Cost

RAG Status: Less than 7%, 7-8%, Over 8%.

March 16

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

Ap

r-12

Jun

-12

Au

g-12

Oct

-12

Dec

-12

Feb

-13

Ap

r-13

Jun

-13

Au

g-13

Oct

-13

Dec

-13

Feb

-14

Ap

r-14

Jun

-14

Au

g-14

Oct

-14

Dec

-14

Feb

-15

Ap

r-15

Jun

-15

Au

g-15

Oct

-15

Dec

-15

Feb

-16

DNA Rate

Overall DNA rate First DNA rate Follow up DNA rate

10

0 2 4 6 8 10

Urgent Case took Priority

No Beds Available

Requires AlternativeSession/Specialty

More urgent case too priority -elective only e.g. cancer

Insufficent session time /session overrun

Hospital Non Clinical On the Day Cancellations of Elective Operations - February 16

Cancelled Operations

On the Day Non-

Clinical Reasons

43 (40 – Mar 15)

Rebooked within 28

Day Target

35

Total Cancelled due

to Lack of Beds

126

March 16

Additional Notes

The figure for Total Cancelled due to Lack of Beds includes

cancellations with more than 1 day notice given.

Note: For any elective operation cancelled by the trust on the

day of the operation/admission, an offer of a new date must be

made within 5 calendar days, and the newly offered date must

be within 28 days of the cancelled operation date.

Effective [5]

RAG Status: <=15 Cancellations, 16-24 Cancellations, >=25 Cancellations

0 50 100 150 200 250

Urgent Case took Priority

No Beds Available

Administrative Reasons

Session Cancelled

Requires Alternative…

Equipment Failure/Unavailable

THEATRE / OUTPATIENT STAFF…

NO ANAESTHETIST AVAILABLE

Hospital Non Clinical On the Day Cancellations of Elective Operations 2015 - 2016 YTD

11

First to Follow up Ratio

New to FU Ratio

1 : 2.3

6 Month Rolling

Average

1 : 2.3

Additional Notes

NHS Better Care, Better Value 15/16 Q2 Ratio: 1 : 2

Bristol and Somerset Area Team ratio : 1 : 1.89

(HSCIC Source 13/14)

Effective [6]

1.5

1.7

1.9

2.1

2.3

2.5

2.7

2.9

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Ma

y-1

5

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Ma

r-16

New:Follow Ratio

New:Follow Ratio 6 month moving average

March 16

0123456789

0

2000

4000

6000

8000

10000

12000

14000

16000

rate

att

end

an

ces

April 2015 - March 2016 1st to Follow Up Ratio by Speciality

1st Follow Up Rate

12

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

De

c-15

Feb

-16

RTT Completed Pathways - Admitted

Monthly data RTT target 6 Month Moving Average

85%

88%

91%

94%

97%

100%

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

De

c-15

Feb

-16

RTT Completed Pathways - Non admitted

Monthly data RTT target 6 Month Moving Average

Responsive [1]

Admitted Stops

80.1% (Target: 90%)

Non-Admitted Stops

89.4% (Target: 95%)

Total Incompletes

91.53% (Target: 92%)

Additional Notes

The trust did not achieve the 92% Total Incompletes

target in the month of March.

The penalties to the Trust are £300 for every incomplete

pathway over the 18 weeks target.

RTT Pathways

80.0%

85.0%

90.0%

95.0%

100.0%

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

De

c-15

Feb

-16

RTT Incomplete Pathways

Monthly data RTT target 6 Month Moving Average

Admitted

Incompletes

77.9% (Target: 92%)

Non-Admitted

Incompletes

96.4% (Target: 92%)

13

0

100

200

300

400

500

600

>18

wee

ks

>19

wee

ks

>20

wee

ks

>21

wee

ks

>22

wee

ks

>23

wee

ks

>24

wee

ks

>25

We

eks

>26

wee

ks

RTT Incomplete pathways - Aging

Non Admitted Admitted

Responsive [2]

Additional Notes

Patients that delay treatment through choice are counted as an

incomplete pathways until they receive their treatment, or it is

decided that they don’t need treatment.

Admitted Patients over

18 Weeks

547

Non-Admitted Patients

over 18 Weeks

255

Patients over 26

Weeks

217

Patients over 52

Weeks

0

March 16

RTT Incomplete Pathways

01,0002,0003,0004,0005,0006,0007,0008,0009,000

10,000

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

De

c-15

Feb

-16

RTT Incomplete Pathways with All Stops

RTT Incomplete Pathways RTT incomplete pathways > 18 weeks

Number of Stops

14

Responsive [3]

Inpatient & Day Case

Waiting List

2281 (+3.3% vs last FY)

Outpatient GP/DP

Waiting List

3389 (+7.0% vs last FY)

Notes

The IP/DC waiting list remains high which can be

attributed to the number of Cancelled Operations over

the previous few weeks.

March 16

Inpatient and Outpatient Waiters

0

500

1000

1500

2000

2500

Ap

r-1

2Ju

n-1

2A

ug-

12

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3Ju

n-1

3A

ug-

13

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4Ju

n-1

4A

ug-

14

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5Ju

n-1

5A

ug-

15

Oct

-15

De

c-15

Feb

-16

IP/DC Waiting List

1500

2000

2500

3000

3500

Ap

r-1

2Ju

n-1

2A

ug-

12

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3Ju

n-1

3A

ug-

13

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4Ju

n-1

4A

ug-

14

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5Ju

n-1

5A

ug-

15

Oct

-15

De

c-15

Feb

-16

OP Waiting List

15

Responsive [4]

Additional Notes

The Trust has recovered a significant amount of lost ground

caused by delays in the agreed transfer arrangements of overdue

patients to Shepton Mallet Treatment Centre. The Trust expects

to achieve the agreed diagnostic trajectory by the April deadline.

Overall Diagnostic 6

Week Waits %

97.9% (98.7% - Mar 15)

Imaging 6 Week

Waits %

100% (99.7% - Mar 15)

Physiological

Measurement Waits %

99.2% (97.5% - Mar 15)

Endoscopy 6 Week

Waits %

88.0% (95.0% - Mar 15)

March 16

Diagnostic Waits

0 10 20 30 40 50

March 16 Diagnostic 6 Week Wait Breaches

EndoscopyBreaches

PhysiologicalMeasurementBreaches

ImagingBreaches

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

Nov

-14

Dec

-14

Jan

-15

Feb

-15

Ma

r-1

5

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

Nov

-15

Dec

-15

Jan

-16

Feb

-16

Ma

r-1

6

Diagnostic 6 Week Waits %

Diagnostic 6 Week Waits % Target DM01 % - Trajectory

16

0

20

40

60

80

100

120

140

160

Ap

r-1

4

Ma

y-1

4

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-1

4

De

c-14

Jan

-15

Feb

-15

Ma

r-15

Ap

r-1

5

Ma

y-1

5

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-15

Jan

-16

Feb

-16

Ma

r-16

Avg A&E Attendances per Day

Avg A&E attendances per day Avg ambulance arrivals per day

Avg Emergency Admissions Per Day

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Apr

-12

Jun-

12

Aug

-12

Oct

-12

De

c-12

Feb-

13

Apr

-13

Jun-

13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Apr

-14

Jun-

14

Aug

-14

Oct

-14

De

c-14

Feb-

15

Apr

-15

Jun-

15

Aug

-15

Oct

-15

De

c-15

Feb-

16

A&E 4 hour performance - All Attendances

Monthly data 6 month moving average

Responsive [5] ED Attendances

A&E Performance

88.12% (93.6% Mar 15)

Average A&E

Attendances per day

137.5 (125.3 - Mar 15)

Average Ambulance

Arrivals per day

44.3 (41.4 – Mar 15)

Additional Notes

A&E activity over the two month period January and February

was up by 8.3% vs last year (+601 attendances).

YTD attendances (46553) vs last FY YTD (46776).

Average Emergency Admissions excludes Paediatrics and

Maternity.

Average Breaches

per Day

16.4 (8 – Mar 15)

March 16

Average Emergency

Admissions per day

47.9 (43.8 – Mar 15)

17

Responsive [6]

30 Minute Handovers

98.2% (99.7% Mar 15)

YTD Fines

£19,200 (£13,200 YTD 14/15)

Ambulance Handovers

£0

£2,000

£4,000

£6,000

£8,000

£10,000

£12,000

£14,000

£16,000

£18,000

0

200

400

600

800

1,000

1,200

1,400

1,600

Ambulance Handovers Per Month

Ambulance Handovers Fines

£400£600£1,000£600£800£600 £2,200 £2,200 £800 £2,000 £2,200 £5,800

£0 £2,000 £4,000 £6,000 £8,000 £10,000 £12,000 £14,000 £16,000 £18,000 £20,000

Jun

-05

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

18

Responsive [7]

Admission Avoidance

Additional Notes

March saw an improvement in numbers of 0 LoS patient

compared to last year but an increase in the numbers of

patients that were admitted to wards from AAU.

March 16

0 LOS % vs LY

31.1% (28.9% - Mar 15)

% Admitted to Wards

from AAU (CDU)

54.8% (52.3% - Mar 15)

0

100

200

300

400

500

600

700

800

40.0%

45.0%

50.0%

55.0%

60.0%

65.0%

% of Patients Admitted to Wards from AAU (CDU)

Change in CDU CDU & AEC Admission % Linear (CDU & AEC Admission %)

0

0.2

0.4

0.6

0.8

1

0

100

200

300

400

500

600

Emergency Admissions - Length of Stay

Start of FOPAS Change in CDU 0 Days LOS 1-2 Days LOS

19

Responsive [8]

Elective Admissions

1,728 (1,626 Mar 15)

Non-Elective Admissions

1,868 (1,740 Mar 15)

Elective LOS

3.8 Days (+0.3 vs Mar 15)

Non-Elective LOS

5.6 Days (+0 vs Mar 15)

Additional Notes

Both elective and non-elective admissions are higher than

the same period last year.

Both Length of Stay for Elective and Non-Elective have are

comparable to March last year.

March 16

Admissions and LOS

0

500

1,000

1,500

2,000

2,500

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

Dec

-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

Dec

-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

Dec

-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

Dec

-15

Feb

-16

Admissions

Total Elective admissions Non Elective admissions

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Ap

r-1

2

Jun

-12

Au

g-1

2

Oct

-12

De

c-12

Feb

-13

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-13

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-14

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

De

c-15

Feb

-16

Average Length of Stay (Days)

LOS Elective LOS Non Elective

20

Cancer 2 Week Wait Draft Data

2 Week Suspected

Cancer

95.7% (Target 93%)

2 Week Breast

97.1%

(Target 93%)

Additional Notes

Draft Data for March indicates that the trust has achieved

the 2 Week Wait Suspected Cancer and the 2 Week Breast

Cancer Targets.

March 16

Responsive [9]

0

20

40

60

80

100

0

100

200

300

400

500

600

Ma

y-1

2Ju

l-1

2Se

p-1

2N

ov-

12

Jan

-13

Ma

r-13

Ma

y-1

3Ju

l-1

3Se

p-1

3N

ov-

13

Jan

-14

Ma

r-14

Ma

y-1

4Ju

l-1

4Se

p-1

4N

ov-

14

Jan

-15

Ma

r-15

Ma

y-1

5Ju

l-1

5Se

p-1

5N

ov-

15

Jan

-16

Ma

r-16

no

. ref

erra

ls -

bre

ast

sym

pto

ns

No

. re

ferr

als

-su

spec

ted

ca

nce

r

Number of Referrals Seen

2WW Suspected Cancer 2WW Exhibited Breast Symptoms

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Ma

y-1

5

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Ma

r-16

2 Week Cancer Targets

2WW Suspected Cancer 2WW Breast

21

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Ma

y-1

5

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Ma

r-16

62 Day Treatment Standard

Achievement % 6 Month Rolling % Target %

Cancer 31 and 62 Day Targets Draft Data

Additional Notes

Draft Data for March indicates that the trust did not achieve the

31 Day Subsequent Surgery Target but did achieve the 31 Day

Treatment Subsequent Drugs Target.

The draft data shows the trust has not achieved the 62 Day

related Targets, however further validation is still to take place

before the Quarter End Submission.

31 Day Treatment First

97.0% (Target 96%)

31 Day Treatment

Subsequent Drugs

100.0% (Target 98%)

31 Day Treatment

Subsequent Surgery

70.0% (Target 94%)

62 Day Treatment

Screening

50.0% (Target 90%)

62 Day Treatment

Standard

84.2% (Target 85%)

62 Day Treatment

Upgrades

50.0% (Target 90%)

Responsive [10]

84.0%

86.0%

88.0%

90.0%

92.0%

94.0%

96.0%

98.0%

100.0%

Ma

y-1

2

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Ma

r-13

Ma

y-1

3

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Ma

r-14

Ma

y-1

4

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Ma

r-15

Ma

y-1

5

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Ma

r-16

31 Day Treatment First

Achievement % Target % 6 month rolling %

22

Cancer 62 Day Urgent GP Referral Pathway Draft Data

Additional Notes

Note that shared breaches with other organisations

show as 0.5 on the table above.

Target: 85%.

Responsive [11]

0

1

2

3

4

5

6

Mar-16

Number of 62 Day Patients Seen

Gynaecology Lower GI Lung Breast Head and Neck Upper GI Brain Haematology Sarcoma Other

Cancer SiteYTD

14/15

YTD

15/16

Brain 100% 1 (0)

Breast 95.6% 79.5 (3.5) 80% 5 (1) 100% 5 67% 3 100% 10 (1) 100% 3 95.7% 70 (3)

Gynaecology 85.3% 17.0 (2.5) 100% 3 100% 1.5 100% 1.5 0% 0.5 (0.5) 100% 5.5 95.8% 24 (1)

Haematology 55.0% 10 (4.5) 33% 3 (2) 67% 3 (1) 100% 3 64.1% 19.5 (7)

Head and Neck 14% 3.5 (3) 50% 2 (1) 0% 1.5 (1) 100% 1.5 (1) 0 (0.5) 0% 2 (2) 46.2% 13.0 (7)

Lower GI 76.1% 36 (8.5) 86% 7 (1) 33.3% 3 (2) 50% 2 (1) 50.0% 2 (3) 20% 5 (4) 63.8% 47 (17)

Lung 67.7% 16 (5) 70% 5 (1.5) 0% 0.5 (0.5) 92% 6 (0.5) 100% 2.5 89% 4.5 (0.5) 82% 45 (8)

Sarcoma 50% 2 (1) 100% 0.5 (0)

Skin 97.1% 171 (5) 100% 13 100% 11 96% 27 (2) 85% 13 (2) 95% 20 (1) 96.4% 181 (6.5)

Upper GI 64.0% 25.0 (9) 50% 3 (1.5) 50% 2 (1) 100% 2 100% 3.5 78% 32.5 (7)

Urology 88.6% 88 (10) 100% 6 95% 11 (0.5) 71% 7 (1.5) 67% 12 (5) 95% 10.5 (0.5) 88% 123.5 (14.5)

Other 100% 100% 2 (0)

All 88.4% 447 (52) 83.0% 47 (8) 83.1% 39 (6) 89.6% 53 (6) 82.8% 44 (12) 84.2% 50.5 (8) 87.3% 558 (71)

Number of

Referrals

(Breaches)

15/16 YTD

Number of

Referrals

(Breaches)

14/15 YTD

Nov-15 %

Referrals &

(Breaches)

Dec-15 %

Referrals &

(Breaches)

Jan-16 %

Referrals &

(Breaches)

Feb-16 %

Referrals &

(Breaches)

Mar-16 %

Referrals &

(Breaches)

23

Friends and Family Test Caring [1]

Overall Response

Rate

16.5% (18.8% Mar 15)

Additional Notes

From April 2015, the Friends and Family Test was extended

to include Outpatients, Daycases and children.

The Trust has engaged with provider Iwantgreatcare to

support the further rollout of the questionnaire to all areas and

to enable near real-time patient feedback to clinical teams.

March 16

72.7%72.1%72.6%69.3%73.8%68.1%72.9%72.6%71.9%74.5%72.2%77.4%74.9%74.0%69.2%67.8%69.2%70.6%

20.0%20.1%21.4%23.8%20.4%

21.8%21.6%21.6%23.1%20.2%21.5%

17.2%19.8%21.2%22.6%23.9%21.6%20.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Oct

-14

No

v-1

4

De

c-14

Jan

-15

Feb

-15

Ma

r-15

Ap

r-1

5

Ma

y-1

5

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-15

Jan

-16

Feb

-16

Ma

r-16

Friends and Family Test Inpatient / ED / Maternity Response to 'extremely

likely' and 'likely' to recommend YDH

% Extremely Likely % Likely

814 735 576 462 451 601 705 694 758 890 699 878414 631 656 774 575 890

34803239 3380

3119 28083202 2990 3190

4071

56455433 5432

53005311 5380

55775025

5390

0%

5%

10%

15%

20%

25%

0

1000

2000

3000

4000

5000

6000

7000

Oct

-14

No

v-1

4

De

c-14

Jan

-15

Feb

-15

Ma

r-15

Ap

r-1

5

Ma

y-1

5

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-15

Jan

-16

Feb

-16

Ma

r-16

Friends and Family Test % of Inpatient / ED / Maternity Responses

No of Respondants No of eligible Patients % of responses

Extremely Likely &

Likely to

Recommend

90.9% (89.9% Mar 15)

24

Patient Compliments and Complaints Caring [2]

Additional Notes

There were slightly more complaints this March compared to

last year and substantially less complements.

There were less PALs contacts than the same month last

year.

0 10 20 30 40 50 60 70 80 90

Kingston Wing

Emergency Department

Ward 6A

Macmillan Unit

Breast Care Department

Orthopaedics

Ward 6B

Highest Departments - Compliments YTD

0

20

40

60

80

100

120

No

v-1

4

Dec

-14

Jan-

15

Feb

-15

Mar

-15

Apr

-15

May

-15

Jun

-15

Jul-

15

Aug

-15

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan-

16

Feb

-16

Ma

r-1

6

Number of Compliments & Complaints

Complaints Compliments

Compliments

57 (104 Mar 15)

March 16

Complaints

13 (9 Mar 15)

PALS

112 (153 Mar 15)

25

Monitor

Target Period FY 14/15 Jan-16 Feb-16Mar-16

DraftQ1 Q2 Q3 Q4

FY

15/16

RTT 18 week RTT Incomplete pathways - All Specialties 92% M 93.9% 91.6% 92.1% 91.5% 89.4% 89.2% 90.6% 91.7% 90.4%

A&E A&E Clinical Quality: Total time of 4 hours in A&E 95% M 95.2% 90.5% 91.2% 88.1% 95.7% 96.1% 92.3% 89.9% 93.4%

Cancer Max waiting time of 2 weeks from urgent suspect cancer GP referral to first outpatient appt 93% Q 92.4% 95.7% 96.2% 95.7% 93.3% 91.7% 94.2% 95.9% 93.3%

Cancer Max waiting time of 2 weeks for symptomatic breast patients (cancer not initially suspected) 93% Q 93.03% 100.0% 100.0% 97.1% 92.9% 87.7% 95.3% 99.1% 92.9%

Cancer Max waiting time of 31 days from diagnosis to first treatment for all cancers 96% Q 97.8% 95.9% 97.1% 97.0% 98.4% 98.8% 99.0% 96.6% 98.4%

Cancer Max waiting time of 31 days for subsequent DRUG treatments for all cancers 98% Q 100% 95.2% 100.0% 100.0% 99.6% 100.0% 100.0% 98.3% 99.6%

Cancer Max waiting time of 31 days for subsequent SURGICAL treatments for all cancers 94% Q 94.3% 100.0% 77.8% 70.0% 94.8% 100.0% 95.7% 80.8% 94.8%

Cancer Max waiting time of 62 days from urgent GP referral to first treatment for all cancers 85% Q 85.6% 89.6% 82.8% 84.2% 87.3% 88.8% 83.7% 85.7% 87.3%

Cancer Max waiting time of 62 days from consultant screening service referral for all cancers 90% Q 100.0% 100.0% 100.0% 50.0% 89.2% 96.0% 60.0% 83.3% 89.2%

Safety C.Diff year on year reduction (lapses in care only) 8 pa Q 3 1 1 0 1 1 0 2 4

Indicators

Well Led

mg/lth14.3 - April 2016

Board of Directors Meeting April 2016

Director of Nursing Report

Monthly Report of Nurse/Midwifery Staffing Levels

1 March 2016 - 31 March 2016 EXECUTIVE SUMMARY The NHS National Quality Board published a new guidance in November 2013 to support providers and commissioners to make the right decisions about nursing, midwifery and care staffing capacity and capability “How to ensure the right people with the right skills are in the right place at the right time”: A Guide to Nursing, Midwifery and Care Staff Capacity and Capability. There are nine key expectations that apply to the Trust: 1. Boards take full responsibility for the quality of care provided. 2. Processes are to be in place to enable staffing establishments to be met on a shift by

shift basis. 3. Evidence based tools to be used. 4. Clinical and managerial leaders foster a culture of professionalism and responsiveness

where staff feel able to raise concerns. 5. Multi-professional approach is taken when setting staffing establishments. 6. Sufficient time to undertake care and duties in practice. 7. Boards receive monthly updates on workforce information and staffing capacity and

capability and is discussed at public Board meetings every six months. 8. Clearly display information about the nursing and care staff present on each ward,

clinical setting or service on each shift. 9. Provider to take an active role in securing staff in line with their workforce requirements. PURPOSE The purpose of this report is to provide the Board of Directors with monthly information regarding the nursing and midwifery registered and unregistered staffing levels on a shift by shift basis of the planned and actual nurse staffing levels across the organisation and across inpatient areas of the Trust as per the guidance received from NHS England and the Care Quality Commission. METHODOLOGY AND SCOPE FOR REVIEW This report focusses on all adult inpatient areas including Critical Care, inpatient maternity wards and inpatient paediatric wards. With the Trust working towards the 1:8 ratio as recommended in the National Safe Staffing Alliance for relevant adult wards. For the purpose of this report non inpatient areas such as the operating theatres, day theatre, endoscopy and emergency department are currently excluded. KEY POINTS National Unify Return Recruitment Current vacancy position Bank and Agency usage Monitor nursing agency rules

mg/lth14.3 - April 2016

Unfilled Shifts Unify Return

Day Night Day Night

War

d na

me R

egis

tere

d m

idw

ives

/nur

ses

Car

e St

aff

Reg

iste

red

mid

wiv

es/n

urse

s

Car

e St

aff

Ave

rage

fill

rate

- re

gist

ered

nu

rses

/mid

wiv

es (

%)

Ave

rage

fill

rate

- ca

re s

taff

(%)

Ave

rage

fill

rate

- re

gist

ered

nu

rses

/mid

wiv

es (

%)

Ave

rage

fill

rate

- ca

re s

taff

(%)

Tota

l mon

thly

pl

anne

d st

aff

hour

s

Tota

l mon

thly

ac

tual

sta

ff ho

urs

Tota

l mon

thly

pl

anne

d st

aff

hour

s

Tota

l mon

thly

ac

tual

sta

ff ho

urs

Tota

l mon

thly

pl

anne

d st

aff

hour

s

Tota

l mon

thly

ac

tual

sta

ff ho

urs

Tota

l mon

thly

pl

anne

d st

aff

hour

s

Tota

l mon

thly

ac

tual

sta

ff ho

urs

Jasmine 1052 1065 669.5 694.5 713 713 690 690 101.2% 103.7% 100.0% 100.0%

KW 713 713 682.5 682.5 713 713 365.5 365.5 100.0% 100.0% 100.0% 100.0% 6A 1069.5 1171 1387.5 1441 701.5 724.5 566 589 109.5% 103.9% 103.3% 104.1% 6B 2117 2130 2269 2274.5 713 706.5 713 713 100.6% 100.2% 99.1% 100.0% 7A 1287.5 1305 955 961.5 713 713 690 690 101.4% 100.7% 100.0% 100.0% EAU 1414 1427 1051 1039 1058 1081 713 713 100.9% 98.9% 102.2% 100.0% 8A 2133.5 2152 2003 2003 713 713 713 713 100.9% 100.0% 100.0% 100.0% 8B 2364.5 2358 1959.5 1959.5 713 724.5 713 724.5 99.7% 100.0% 101.6% 101.6% 9A 1414 1426 861 885 701.5 701.5 713 724.5 100.8% 102.8% 100.0% 101.6% 9B 2139 2153 2255 2302 713 724.5 713 724.5 100.7% 102.1% 101.6% 101.6% 10 1050 1038 320.5 327 1058 1058 0 0 98.9% 102.0% 100.0% - ICU 2079.5 2079.5 130 148.5 2151 2151 0 0 100.0% 114.2% 100.0% - CCU 1388.5 1406 0 12 860.5 860.5 0 0 101.3% - 100.0% - Freya 2671.5 2521 868 785.5 1858.5 1858.5 325.5 283.5 94.4% 90.5% 100.0% 87.1% SCBU 930 923.5 465 387 465 465 294.5 283 99.3% 83.2% 100.0% 96.1%

7B 1408.5 1391 1530.5 1575 1058 1058 701.5 690 98.8% 102.9% 100.0% 98.4%

Recruitment Migration Advisory Committee: The Migration Advisory Committee (MAC) has reluctantly recommended that nursing should remain on the Shortage Occupation List (SOL). It also said nurses will be exempt from an increase in the salary threshold for Tier 2 visas until July 2019. Nursing was temporarily placed on the SOL in the Autumn of 2015. The MAC recommends limiting the number of places available to non EEA nurses via the Tier 2 visa route to 5,000 with a gradual reduction in this limit over the next three years. There are currently national advertisements for ED, ICU and Theatres. To try and manage the current gap within these areas block booking is being obtained from agencies to try and ensure some continuity of care within the units and to promote team working. The advertisement for ED also includes paramedics to hopefully give us a wider choice of recruits to choose from. We are also exploring the possibility of ODPs working both in ICU and ED. Further Actions in Progress for Theatre Recruitment include advertisement for Return to Practice for ODPs and we are currently planning a Theatre Recruitment Open Day for 11 June 2016 to try and attract staff from other organisations.

mg/lth14.3 - April 2016

India We continue to remain in regular contact with the successful candidates from India but have yet to be notified of a candidate passing their IELTS. Until they have passed their IELTS at the required standard and completed their CBT we are unable to request a visa for them. Philippines Sister Perlas is currently on leave in the Philippines and is undertaking some networking on our behalf. She has an agreement in principle from the Director of Alumni Association De La Salle University which would need to be followed up with Gemma on her return. It is anticipated that we will only interview nurses in the Philippines who have achieved their IELTS in order to have a more readily available source of recruits to compliment the long term programme with India. Non EU UK Recruitment A recent advertisement was placed for the above with 106 candidates applying, 25 were shortlisted and a selection day is taking place on 25 April 2016. These candidates will require IELTS, CBT and OSCE. We are currently exploring additional funding from HEESW to support this within the Academy. Successful candidates will commence in post as a Band 2, rising to Band 4 on completion of their IELTS and CBT. EU Recruitment We continue to review CVs from EU applicants although this has now reduced considerably with the introduction of IELTS. The fortnightly rolling interviews continue and these candidates are added to the schedule. The following table indicates our current recruitment position with regards to registered nurses and going forward as of 4 April 2016; (‘+’ indicates an over recruitment position). There is an increase in the vacancy due to new rota costings and CQC recommendations. We are working towards the new rota costing, but will continue to use the old one until we are up to establishment. The key areas with vacancies are ICU, ED (CQC recommendations) and Theatres which accounts for 28.05 WTE vacancies. The rota costings for 201`6/17 accounts for 11.46 WTE. The remainder of the vacancies include 4 WTE for general wards for old rota costing and turnover in month. There are 13 WTE commencing May 2016 which start to meet the rota costings for 2016/17. See table overleaf.

mg/lth14.3 - April 2016

Band 5 Registered Nurse Vacancies - April 2016

Ward Vacancy Old Rota

March 2016

Vacancy New Rota Costing

9 May 2016 Starters

Ward 10 -0.02 -0.02 Ward 9B 1.13 -0.5 Ward 9A 1.16 1.32 Ward 8B 1.25 -4.90 2 ACCU -0.04 -0.04 Ward 8A -2.59 -3.76 2 EAU -0.18 -0.18 1 Ward 7A 2.77 1.29 MFFD -1.51 -1.51 2 Trauma and Orthopaedics 0.57 1.4 ICU -6.84 -7.92 Kingston Wing 0.36 -0.58 1 Elective -0.06 -2.57 Jasmine -4.54 -7.05 4 ED -10.30 -10.30 Main Theatre -5.08 -5.5 Day Theatre -4.33 -4.33 1 SCBU -0.63 -0.63 TOTAL 30.12 45.24 13 Unregistered Nurses A cohort of 11 unregistered staff will be commencing on 9 May 2016 which will fill all vacancies. A further 10 are also due to commence on the bank. The following graph indicates the current unregistered positon. It is anticipated that as the registered nurse vacancies fill the unregistered over recruitment positon will reduce. There is a turnover of unregistered nurses of three per month currently. This will be reviewed weekly and training programmes are in place for unregistered staff should they be required.

Bank Recruitment A recruitment drive is currently being planned for both registered and unregistered bank recruitment. This will take place during May 2016.

-15.00

-10.00

-5.00

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16

Closing Position HCA band 1-2

Closing Position HCA band 1-2

mg/lth14.3 - April 2016

Bank and Agency Usage The following table indicates the number of bank / agency used during March 2016:

Ward 10

9A

9B

8A

8B

7A

7B

6A

6B

ICU

KW

AC

CU

EAU

ED

JASM

INE

MA

TER

NIT

Y

SCB

U

TOTA

L

Registered Bank

2 6 20 18 2 3 4 16 1 5 8 31 1 54 18 189

Unregistered Bank

1 29 31 37 29 14 64 18 31 78 13 9 24 114 54 5 1 552

Total Bank 3 29 37 57 47 14 66 21 35 94 14 14 32 145 55 59 19 741

Registered Agency

39 29 31 37 29 14 64 18 31 78 13 9 24 114 54 1 585

Unregistered Agency

3 32 54 35 61 34 87 25 62 1 21 0 31 28 41 1 516

Total Agency

42 61 85 72 90 48 151 43 93 79 0 9 55 142 95 0 2 1067

TOTAL Bank & Agency

45 90 122 129 137 62 217 64 128 173 14 23 87 287 150 59 21 1808

The following table indicates the changes in booking from January - March 2016:

January February March Increase ED Registered Bank 166 178 189 11 31 Unregistered Bank 342 264 552 288 114 Registered Agency 345 428 585 157 54 Unregistered Agency

274 432 516 84 41

TOTAL 1127 1212 1808 596 287 There has been an increase in sickness, annual leave and specialling during March and the figures now include ED. Monitor, Nursing Agency Rules Following the initial visit by Monitor progress is being made against the actions for the diagnostic agency tool. Enhanced rates of pay for bank staff have been well publicised to increase bank usage and reduce agency. The current challenges are the use of agency due to escalation areas being open and framework agencies supply at above the capped rate. Unfilled Shifts

10

9A

9B

8A

8B

7A

7B

EAU

6A

6B

ED

CC

U

ICU

KW

JW

Mat

erni

ty

SCB

U

TOTA

L

Using Professional Judgement

Registered 6 3 1 3 3 1 6 2 1 2 2 2 105 6 143

Unregistered 6 6 2 2 8 2 14 4 12 19 2 4 8 89

Nurses Not Available

Registered 2 1 1 1 1 2 1 29 1 39

Unregistered 1 1 1 2 1 2 2 17 13 40

TOTAL 14 10 4 6 11 3 22 8 14 24 5 2 109 4 15 46 14 311

mg/lth14.3 - April 2016

RECOMMENDATIONS The Board of Directors is asked to note the information contained in this summary report and the actions currently in place.

Yeovil District Hospital NHSFoundation Trust

Date

01 March - 31March

Your average score for all questions this period

1 2 3 4 5 4.70Reviews this period

1186Your recommend scores

5 Star Score

4.63% Likely to recommend

91.8%% Unlikely to recommend

3.0%This period Last 6 months Questions

Nam

e

Resp

onse

s

Scor

e

Scor

e

Tren

d

Reco

mm

end

Dig

nity

/Res

pect

Invo

lvem

ent

Info

rmat

ion

Clea

nlin

ess

Staf

f

ACCU1 -- (30) 4.72 4.82

Ambulatory Emergency CareFollow up Clinic1 -- (35) 4.95 4.83

Cardiac Rehab1 -- (0) - -

Clinical InvestigationsDepartment (CID)1 -- (0) - 4.25

Day Surgery Unit (DSU)1 -- (21) 4.97 4.73

Dermatology1 -- (20) 4.80 4.86

Discharge Lounge1 -- (25) 4.60 4.59

EPAC - Early PregnancyAssessment Clinic1 -- (2) 4.72 4.86

Emergency Admissions Unit1 -- (47) 4.79 4.68

Emergency Department1 -- (34) 4.51 4.53

Emergency Department -Children1 -- (4) 3.43 4.62

Endoscopy Unit1 -- (34) 4.95 4.94

FOPAS (Frail Older PersonsAssessment Service)1 -- (64) 4.91 4.84

Freya Ward (Postnatal)1 -- (55) 4.74 4.71

Gastroenterology1 -- (6) 4.69 4.73

Gynaecology Assessment Unit(GAU)1 -- (0) - 4.83

ICU (Intensive Care Unit)1 -- (10) 4.80 4.81

This period Last 6 months QuestionsN

ame

Resp

onse

s

Scor

e

Scor

e

Tren

d

Reco

mm

end

Dig

nity

/Res

pect

Invo

lvem

ent

Info

rmat

ion

Clea

nlin

ess

Staf

f

Jasmine Gynae Ward1 -- (32) 4.56 4.57

Kingston Wing1 -- (53) 4.71 4.78

MacMillan Unit - Outpatients1 -- (17) 4.91 4.89

Ophthalmology1 -- (0) - -

Orthopaedic OutpatientsDepartment1 -- (78) 4.82 4.87

Physiotherapy1 -- (36) 4.77 4.75

Queensway Day Hospital1 -- (39) 4.83 4.79

Queensway Day Hospital -Other Services1 -- (12) 4.91 4.83

Stoma Care Clinic1 -- (0) - -

Urology1 -- (6) 4.97 4.88

Ward 10 (Children & YoungPerson's Unit)1 -- (16) 4.67 4.52

Ward 10 (Young Adults)1 -- (40) 4.45 4.35

Ward 6A 1 -- (66) 4.77 4.75

Ward 6B 1 -- (67) 4.35 4.42

Ward 7A1 -- (47) 4.51 4.52

Ward 7B 1 -- (14) 4.38 4.64

Ward 8A1 -- (43) 4.55 4.47

Ward 8B 1 -- (18) 4.93 4.63

Ward 9A1 -- (62) 4.40 4.49

Ward 9B1 -- (43) 4.49 4.54

YDH Sleep Clinic at SouthPetherton1 -- (83) 4.91 4.88

Yeatman Hospital - DaySurgery Unit3 -- (27) 4.89 4.88

Reviews by patient's age

0-20 21-30 31-40 41-50 51-60 61-70 71-80 81+

94 88 86 100 145 221 221 195

FemaleMale

Reviews by patient's ethnicity

White Mixed Asian Black Other

1087 0 2 6 5

Reviews by patient's conditions

Dea

f

Blin

d

Phys

ical

Men

tal

Illne

ss

Lear

ning

Non

e

127 40 188 67 366 24 486

Reviews by reviewer type

Patient Carer Parent Family

950 41 1 132

Demographics completion rate

Question Blanks % Completed

Age 37 96.88

Gender 44 96.29

Ethnicity 85 92.83

Long-term Conditions 174 85.32

Reviewer type 45 96.15

Top three services (with 5 reviews ormore)

Urology 4.97

Day Surgery Unit (DSU) 4.97

Ambulatory Emergency Care Follow upClinic

4.95

Bottom three services (with 5 reviewsor more)

Ward 9A 4.40

Ward 7B 4.38

Ward 6B 4.35

Key Location

1 Yeovil District Hospital

2 Community Services - Yeovil District Hospital NHS FoundationTrust

3 Yeatman Hospital

1

YDH │Workforce Performance Report Well Led - Staffing March 2016

2

Well Led [1]

Additional Notes

Total FTE has increased by 211 FTE compared to March

2015.

This increase is due to escalation areas, safer staffing,

modular ward, Cooksons Court, Symphony, TUPE of IT,

TrakCare, commercial team, HR, and appointment of

additional SHOs to support medical rotas.

Total FTE

2,146 (Mar 15 – 1,925)

March 16

Contracted & Temporary FTE

0

50

100

150

200

250

300

1,600

1,650

1,700

1,750

1,800

1,850

1,900

1,950

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Mar

-15

May

-15

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Mar

-16

Contracted Vs Temp FTE

Contracted FTE Temp Worked FTE

0 100 200 300 400 500 600 700

Senior Managers

Nursing & Midwifery Reg

Medical & Dental

HCA's

Estates

Ancillary

Allied Health Professionals

Admin & Clerical

Additional Prof Scientific & Technical

Additional Clinical Services

Symphony

Trakcare

Contracted & Temporary FTE - 3 Year Trend

Mar-14 Mar-15 Mar-16

3

Well Led [2]

Additional Notes

Contracted FTE has increased by 257 FTE compared to March

2015.

A review of the non-clinical workforce is taking place to ensure our

establishment is at the correct level.

Contracted FTE

1,966

(Mar 15 – 1,709)

March 16

Contracted FTE

* Contracted includes permanent and fixed term employees

1,500

1,550

1,600

1,650

1,700

1,750

1,800

1,850

1,900

1,950

2,000

Ma

y-1

3

Jul-1

3

Sep-1

3

No

v-1

3

Jan-1

4

Ma

r-1

4

Ma

y-1

4

Jul-1

4

Sep-1

4

No

v-1

4

Jan-1

5

Ma

r-1

5

Ma

y-1

5

Jul-1

5

Sep-1

5

No

v-1

5

Jan-1

6

Ma

r-1

6

Contracted FTE

Contracted FTE Rolling 6 mth avg FTE

0 200 400 600

Senior Managers

Nursing & Midwifery Reg

Medical & Dental

HCA's

Estates

Ancillary

Allied Health…

Admin & Clerical

Additional Prof Scientific…

Additional Clinical…

Symphony

Trakcare

Contracted FTE - 3 Year Trend

Mar-14 Mar-15 Mar-16

4

Well Led [3]

Additional Notes

This includes bank, agency and contractors.

Temporary FTE has decreased by 45 FTE compared to

March 2015.

Total FTE

181 (Mar 15 – 226 )

March 2016

Temporary FTE

0

50

100

150

200

250

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Mar

-15

May

-15

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Mar

-16

Temporary FTE

Temp Worked FTE Rolling 6 mth avg FTE

0 10 20 30 40 50 60 70

Senior Managers

Nursing & Midwifery…

Medical & Dental

HCA's

Estates

Ancillary

Allied Health…

Admin & Clerical

Additional Prof…

Additional Clinical…

Symphony

Trakcare

Temporary FTE - 3 Year Trend

Mar-14 Mar-15 Mar-16

5

Well Led [4]

Workforce Comparison

Skills GroupsContracted

FTE

Temporary

FTETotal FTE

Temporary

%

Contracted

FTE

Temporary

FTETotal FTE

Temporary

%

Total FTE

Difference

Trakcare 2 10 12 86% 8 18 26 69% 14

Symphony 6 - 6 0% 15 7 22 31% 16

Additional Clinical Services 42 4 46 8% 55 2 57 3% 11

Additional Prof Scientific & Technical 47 2 49 3% 49 3 52 5% 3

Admin & Clerical 361 24 386 6% 429 8 437 2% 52

Allied Health Professionals 90 0 90 0% 100 4 104 4% 13

Ancillary 156 40 196 21% 166 33 199 17% 3

HCA's 211 58 269 21% 234 40 274 15% 5

Estates 21 - 21 0% 23 - 23 0% 2

Medical & Dental 212 20 232 9% 230 18 248 7% 16

Nursing & Midwifery Reg 490 67 557 12% 564 49 613 8% 56

Senior Managers 72 0 72 0% 93 0- 92 0% 20

Total 1,709 226 1,935 12% 1,966 181 2,146 8% 211

Mar-16Mar-15

6

Additional Notes

Figures based on previous 12 months.

Excludes bank staff and doctors in training.

A review of HCA leavers is currently taking place to better

understand reasons. We have 230 HCAs. 3 HCAs left in

March and April combined. All HCAs are asked for their

reasons for leaving and offered a ‘stay interview’.

Well Led [5]

15.6% (Mar 15 – 15.3%)

March 16

Labour Turnover

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

Ma

y-1

3

Jul-1

3

Sep-1

3

No

v-1

3

Jan-1

4

Ma

r-1

4

Ma

y-1

4

Jul-1

4

Sep-1

4

No

v-1

4

Jan-1

5

Ma

r-1

5

Ma

y-1

5

Jul-1

5

Sep-1

5

No

v-1

5

Jan-1

6

Ma

r-1

6

Labour Turnover

Turnover Target Lower Limit Target Upper Limit

0% 5% 10% 15% 20% 25% 30%

Senior Managers

Nursing & Midwifery Reg

Medical & Dental

HCA's

Estates

Ancillary

Allied Health Professionals

Admin & Clerical

Additional Prof Scientific…

Additional Clinical Services

Labour Turnover by Skills Group

7

Well Led [6]

Additional Notes

Figures based on the previous 12 months.

New exit interview process is now underway.

We have been informed of 11 leavers and arranged 9 exit

interviews.

March 2016 Leavers

Number of Leavers

31

(Mar 15 – 8)

0 50 100 150 200 250

Resignation

End of Fixed…

Retirement

Redundancy

Dismissal

Death in…

Transfer

Pregnancy

Rolling Year Leavers by Reason

0 20 40 60 80 100

Other/Not Known

Relocation

Work Life Balance

To undertake further…

Promotion

Lack of Opportunities

Health

Incompatible Working…

Child Dependants

Better Reward Package

Adult Dependants

Rolling Year Leavers - Resignations

0 20 40 60 80 100 120

Senior Managers

Nursing & Midwifery Reg

Medical & Dental

HCA's

Estates

Ancillary

Allied Health Professionals

Admin & Clerical

Additional Prof Scientific…

Additional Clinical Services

Rolling Year Leavers by Skills Group

8

Well Led [7]

Vacancies by Skills Group

March 2016

Additional Notes

Nurse vacancies include 9.41 FTE theatre vacancies, 10.30 FTE ED vacancies (5.2 FTE due to CQC recommendations),

7.92 FTE ICU vacancies, and 11.46 FTE for new rota costings (to cover night shifts). There are 14 FTE nurses due to start

in May.

Vacancies shown as positive and over establishments shown as negative. Bank nursing budgets are not included in

budgeted FTE. Employees on maternity leave and career break are not included in contracted FTE.

Skills Group

Additional Clinical Services 51 54 -3 -5%

Additional Prof Sci & Tech 52 47 5 10%

Admin & Clerical 405 429 -25 -6%

Allied Health Professionals 111 98 14 12%

Ancillary 187 164 23 12%

HCA's 229 229 0 0%

Estates 23 23 0 0%

Medical & Dental 262 227 35 13%

Nursing & Midwifery Reg 591 546 45 8%

Senior Managers 99 97 2 2%

Total 2010 1912 97 5%

%Vacancies Budget FTE Contracted FTE Vacancy FTE

9

Well Led [8]

Vacancies in High Risk Areas

March 2016

Additional Notes

Nursing vacancies shown is a subset of Nursing & Midwifery Registered and HCA’s.

Vacancies shown as positive and over establishments shown as negative.

Registered Nursing

Emergency Department 4 4

ICU 5 6

Midwifery -1 -1

Theatres 14 11

Wards 20 12

Preceptorship Nurses -23 -22

Medical & Dental

Consultant 11 13

Middle Grade 11 8

Foundation Doctor 2 1

Training 13 14

Other M & D -1 -1

Vacancies FTE Mar-16Feb-16

10

Well Led [9]

Employee Relations

Registered Nurse Pins Awaited

Additional Notes

The outstanding Pins are due to the NMC’s backlog.

The NMC advise that they aim to assess applications between

40 and 70 working days.

Jul-15 1 5%

Sep-15 2 11%

Nov-15 6 25%

Jan-16 4 31%

Mar-16 5 56%

Month Joined Pins Outstanding %

Performance Dismissal 13 4

Sickness Dismissal 6 10

Protected discusssion leading to termination 6 10

Redundancy 2 12

MARS 1 19

Total 28 55

Grievances 1 8

Dismissals and Grievances 2015 -16 (to date) 2014-15

11

Well Led [10]

Additional Notes

Sickness is reported one month in arrears.

E-Rostering is able to provide up to date sickness absence

information on reasons and dates by employee. Reporting data

is being reviewed by HR team and managers on a more regular

basis to ensure there is effective management of sickness.

Training has also been provided to the ward sisters to be able to

report each persons sickness absence dates and reasons when

they require it.

Percentage

3.3% (Feb 15 – 3.4%)

February 16

Sickness

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

Ap

r-1

3

Jun

-13

Au

g-1

3

Oct

-13

De

c-1

3

Feb

-14

Ap

r-1

4

Jun

-14

Au

g-1

4

Oct

-14

De

c-1

4

Feb

-15

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

De

c-1

5

Feb

-16

Sickness Absence vs Target

Total for YDH Target

0% 1% 2% 3% 4% 5% 6% 7% 8%

Senior Managers

Nursing & Midwifery Reg

Medical & Dental

HCA's

Estates

Ancillary

Allied Health…

Admin & Clerical

Additional Prof…

Additional Clinical…

Sickness Absence by Skills Group

Dec-15 Jan-16 Feb-16

12

Well Led [11]

Additional Notes

The percentage of staff up to date with their Mandatory

Training has remained at 91%, against a target of 90%.

Compliance

Percentage

91%

(March 15– 85%)

March 16

Mandatory Training

.

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Mar

-15

May

-15

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Mar

-16

Mandatory Training Compliance vs Target

Total for YDH Target

75% 80% 85% 90% 95% 100%

Senior Managers

Nursing & Midwifery Reg

Medical & Dental

HCA's

Estates

Ancillary

Allied Health…

Admin & Clerical

Additional Prof…

Additional Clinical…

Mandatory Training by Skills Group - % Compliant

Jan-16 Feb-16

13

Well Led [12]

Additional Notes

The percentage of staff remaining in date for their Annual

Appraisal has increased from 84% to 85% against a target of

90%.

Compliance

Percentage

85%

(March 15 – 78%)

March 16

Appraisals

0% 20% 40% 60% 80% 100%

Senior Managers

Nursing & Midwifery Reg

Medical & Dental

HCA's

Estates

Ancillary

Allied Health…

Admin & Clerical

Additional Prof Scientific…

Additional Clinical…

Annual Appraisal by Skills Group - % Compliant

Jan-16 Feb-16 Mar-16

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Mar

-15

May

-15

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Mar

-16

Appraisal Compliance vs Target

Total for YDH Target

14

Well Led [13]

Monitor Agency Caps

Additional Notes

Programme launched to increase Bank usage by promoting the benefits of working on the Bank . This includes:

• Internal and external marketing awareness campaigns

• Training events and seminars for Bank staff

• Simplified payment and bonus schemes

• Building new incentive programmes to increase retention

• Making joining and working through the Bank easier

• Reducing time to recruit to Bank

• Increasing the conversion rate from enquiry to sign up

• Launching a new texting communication system

15

Well Led [14]

Monitor Agency Caps

Additional Notes

Negotiations are taking place with incumbent locums (medical and admin) to reduce hourly rates or move agency.

Review of operational requirements and bank pay for AHPs is taking place .

16

Well Led [15]

Bank Fill %

17

Well Led [16]

Skills Group 2014 2015 Movement

Additional Clinical Services 3.74 3.66

Additional Prof Scientific & Technical 3.80 3.83

Admin and Clerical 3.72 3.78

Allied Health Professionals 3.77 3.85

Ancillary 3.61 3.82

HCAs 3.46 3.75

Estates 3.61 3.64

Medical & Dental 3.79 3.92

Nursing & Midwifery 3.69 3.81

Senior Managers 4.33 4.28

Staff Survey Engagement Scores

Additional Notes

Engagement scores have improved in every area except Additional Clinical Services (Physio Assistants / Pharmacy

Assistants / Audiology Assistants / Radiology Assistants) and Senor Managers.

Staff survey improvement plans will be agreed for every department by end May 2016.

18

Well Led [17]

Workforce Assurance

Workforce

Contracted FTE 2010 55 49 437 100 166 23 233 567 101 236 1967 1711

Vacancy Rate 10% -5% 10% -6% 12% 12% 0% 13% 8% 2% 0% 5% 8%

Turnover

Turnover 10% - 15% 18% 14% 17% 14% 13% 0% 14% 15% 10% 23% 16% 15%

Sickness Absence

Sickness Absence (Feb-16) 3.0% 3.4% 6.9% 3.2% 1.8% 3.5% 0.0% 0.7% 4.1% 1.2% 5.3% 3.3% 3.3%

Sickness Absence (Rolling Yr) 3.0% 2.3% 3.3% 2.5% 1.4% 5.0% 1.5% 0.7% 3.3% 1.6% 5.1% 3.0% 3.5%

Performance Compliance

Mandatory Training 90% 86% 92% 93% 93% 83% 84% 91% 92% 91% 90% 91% 85%

Appraisal 90% 85% 93% 87% 85% 89% 94% 89% 84% 74% 80% 85% 78%

Trustwide

Senior

ManagersHCA'sMar-16 Target

Nursing &

Midwifery Mar-16 Mar-15

Additional

Clinical

Services

Add'l Prof

Scientific &

Technical

Admin &

Clerical

Allied

Health

Professional

Medical

& DentalAncillary Estates

19

Well Led [18]

Workforce Assurance

Trauma & Orthopaedics 22 21 6% 37 36 3% 105% 25% 7.6% 87% 98% 98% 1 0 0

Elective Ward 14 14 -4% 25 29 -15% 100% 15% 5.2% 93% 88% 85% 3 0 0

Surgery & Gynae Ward 16 17 -5% 27 31 -14% 101% 32% 1.5% 94% 88% 69% 4 0 0

Kingston Wing 12 14 -16% 30 33 -8% 100% 18% 3.5% 92% 93% 91% 0 0 0

ICU 44 38 14% 45 40 10% 100% 16% 4.3% 86% 96% 100% 1 0 0

Gynae, Breast and MFFD 14 17 -20% 26 36 -36% 101% 16% 4.7% 85% 84% N/A 0 0 0

Midwifery 60 61 -1% 78 79 -1% 95% 12% 6.4% 85% 91% 86% 5 2 0

EAU 19 20 -6% 31 37 -18% 101% 24% 3.1% 86% 91% 94% 2 0 0

Ward 8A - Medicine 16 11 31% 27 25 9% 100% 36% 5.1% 63% 96% 86% 1 0 0

Stroke & Elderley Care 15 15 1% 29 32 -10% 100% 15% 2.2% 79% 97% 83% 2 0 0

Ward 9A - Medicine 19 20 -7% 30 33 -9% 101% 33% 6.1% 100% 94% 90% 1 2 0

Ward 9B - Medicine 16 15 5% 27 28 -3% 101% 49% 4.7% 73% 95% 88% 5 0 0

Ward 10 16 15 7% 19 19 -1% 100% 7% 8.3% 92% 95% 84% 2 0 0

CCU 17 17 4% 17 17 4% 101% 20% 1.7% 100% 82% 87% 0 0 0

SCBU 11 11 2% 16 15 3% 96% 9% 5.7% 87% 92% N/A 0 0 0

Total Vacancies 329 312 5%

*

Registered Nursing All Staff

Budgeted

FTE

Contracted

FTE Pals Complaints GrievancesFFT *

Mandatory

Training %

Appraisal

%

Ele

ctiv

e C

are

Extremely Likely and Likely to recommend

Turnover

%

Sickness

Absence %

Urg

en

t C

are

Mar-16Vacancy

Rate %

Budgeted

FTE

Contracted

FTE

Vacancy

Rate %

Average

Fill Rate %

20

Well Led [19]

Key Developments in Month Graduate Management Trainee – we have been successful in our application to host a ‘general’ GMTS student

Recruitment – Trac Recruitment System gone live which will improve the efficiency and performance of our

recruitment processes

Temporary staffing – new incentives have been launched to increase bank usage, and reduced rates for 2

agencies (negotiated £17 per hour less for theatre nurses)

New junior doctors contract – steering group established and implantation plan developed

Payroll – procurement process for a new payroll provider nearing conclusion with a planned go-live date of

1 June 2016

Workforce planning – new system developed with key areas piloting template

Coaching and mentoring (ILM level 5) – 10 managers commencing training in April (cohort 1) with 10 more

undertaking training in the autumn (cohort 2)

Training other people – reputation of Academy as a training provider is growing with us now providing training for

Abbey View and Somerset Care thereby generating income for YDH

Equality and diversity – agreement to develop a training video in partnership with Somerset CCG which would

support our new e-learning programme

Equality Delivery System 2016/17 (version 3) – plan completed setting out how we are going to become a fairer

and more inclusive employer

HR Helpdesk proving popular - 1,072 calls answers in March, compared to 921 in February

Trackcare support – 192 new Smartcard requests were received in addition to the 224 already being processed

WORKFORCE COMMITTEE Minutes of the Workforce Committee

held on 21 March 2016 at Yeovil District Hospital

Present: Mark Saxton [Chair] Non-Executive Director Mark Appleby Associate Director of HR and Organisational Development (OD) Maurice Dunster Non-Executive Director Tim Newman Chief Finance & Commercial Officer [until item 6] Attendance: Sue Bulley Public Governor Observer Paul von der Heyde Trust Chairman [until item 6] Tracy Jones Head of HR Ali Morris Head of OD & Recruitment Jade Renville Company Secretary

Action 1

1.1

WELCOME & APOLOGIES Mark Saxton welcomed everyone to the Committee, especially the Chairman, Paul von der Heyde. There were no apologies for absence from members of the Committee but there were apologies for absence from the following regular attendees/observers: Sue Oliver - Head of HR (Symphony), Yvonne Thorne - Staff Governor Observer.

2 2.1

DECLARATIONS OF INTEREST There were no declarations of interest relating to items on the agenda.

3 3.1

MINUTES OF THE PREVIOUS MEETING AND MATTERS ARISING The minutes of the meeting held on 19 February 2016 were approved as a true and accurate record, subject to the addition of “should” to the sentence at 5.12. There were no actions/matters arising not on the agenda or scheduled for discussion at future meetings.

4 4.1

4.2

4.3

PERFORMANCE AGAINST THE MONITOR AGENCY CAP Tracy Jones spoke of the workforce diagnostic undertaken by Monitor, the key points from which were to reduce agency staff costs and utilisation. She listed the actions to achieve these goals from which there was particular discussion of the following: -Referencing discussion at the last meeting [item 4 refers] Tracy Jones said work had been undertaken to understand in greater detail the reasons for agency staff utilisation and additional shifts, all of which she said were confirmed by Maddie Groves, Associate Director of Nursing, as warranted. Ward sisters are engaged in the process and training has taken place with them to ensure they understand how to allocate shifts on the electronic system. There is also a monthly meeting between the ward sisters, Maddie Groves and Tracy Jones. -An experienced staffing manager has been recruited to manage and centralise the processes for agency staff utilisation. Mark Saxton asked why this additional role was required. Tracy Jones explained that the staffing manager was required to provide dedicated, focused resource. They would collaborate with the nursing team but report to Tracy Jones, who would provide strategic oversight.

2 | P a g e

4.4

4.5

4.6

4.7

4.8

Mark Saxton said it would be important for the staffing manager to understand that the role is about managing change and Tim Newman said they would be responsible for taking control of agency staff utilisation and driving efficiencies, where appropriate. In terms of authorising the booking of agency nurses, the numbers involved would necessitate a tiered approval process rather than resting solely with the staffing manager. It was agreed that once the manager had settled at YDH, they would be invited to give an overview of the improvements they have made to the Trust’s processes. -There was discussion about encouraging greater uptake to the bank and Maurice Dunster asked of the incentives for staff. Tracy Jones said the key areas would be weekly pay and clarifying the levels of pay. She said that she has been working with the commercial team to produce a brochure for staff to resolve the latter point and Ali Morris confirmed that in future payroll should be able to have a weekly pay run. These objectives would be supported by a range of other mechanisms to streamline the bank system and to improve communications about it with staff. Mark Saxton said that increasing the bank is an achievable aspiration and the Workforce Committee agreed it should be an area of focus. -Alongside other trusts across the region, YDH is continuing to negotiate with agencies to reduce costs for the staff they supply. However, as raised by Tim Newman, supply and demand is such that these negotiations have proved challenging. This has been further exacerbated as YDH uses a number of agencies and does not obtain its agency staff from one source. Regionally, NHS trusts have considered whether to collaborate and refuse to use those agencies that provide the highest volume of staff. However, as explained by Tracy Jones, removal of even the smaller agencies has resulted in concerns about the clinical implications and risks to ward staffing levels and the provision of safe, high quality patient care, which would remain the Trust’s priority. Mark Saxton added that it would be important to take account of competition rules, a point which had been raised by the Public Accounts Committee. -Mark Saxton reaffirmed the support of the Board in addressing the levels of expenditure on agency staff. He added that Simon Lilley, Commercial Director, and Helen Ryan, Director of Nursing and Clinical Governance, would be key links for Tracy Jones. It was agreed that Tracy Jones would approach Monitor to identify other organisations across the country that had safely reduced their expenditure on agency staff so that YDH can learn from them. In terms of next steps, the key points of learning from the Monitor diagnostic would be agreed with them and the Workforce Committee would monitor progress on their implementation (including those areas highlighted above). The Workforce Committee would then be able to summarise progress at the Board of Directors. Mark Saxton thanked the HR team for their hard work in addressing the challenges discussed and said that directionally YDH is heading in the right direction.

TJ

TJ

3 | P a g e

5 5.1

5.2

5.3

5.4

5.5

WORKFORCE PERFORMANCE REPORT Mark Appleby presented the workforce performance report, advising that it had been enhanced following discussions at the last meeting [item 5 refers]. The Workforce Committee welcomed the improvements, particularly to the additional notes. The Workforce Committee reviewed the content of the report, noting in particular that: -The number of contracted FTEs continues to increase but positively the number of temporary staff has decreased. Mark Saxton challenged the increasing trend of contracted FTEs, particularly in admin and clerical. Accepting that many of the additional posts are required for safe clinical practice, to manage demand and/or for the delivery of the Trust’s strategic objectives, Mark Saxton said we need to ensure that line managers are only recruiting staff when it is essential to do so. Tim Newman confirmed that the authority to recruit new staff is overseen by directors (excepting posts such as nursing where there is a continual need for recruitment). In addition, work is ongoing as part of the Lord Carter efficiency programme. Paul von der Heyde said that the information contained within the workforce performance report should be split by business as usual, vanguard and TrakCare, which was agreed. -In terms of the temporary staff listed on the workforce comparison slide, the percentage of HCAs and ancillary staff were noted as outliers. Mark Saxton asked whether this was a satisfactory position. The number of temporary ancillary staff was expected given the scope of work, but the situation regarding HCAs was acknowledged as an area for improvement and Mark Appleby said a number of HCAs had been recruited on a substantive basis which should have a positive impact. Discussions at the last meeting about resolving the issue of HCAs being categorised as apprentices was also under consideration, which may also improve the levels of turnover in this staff group. -There was discussion about turnover (of 15.8% - excluding junior doctors, bank staff and foundation doctors) and leavers, the data for which had been improved. As discussed at the last meeting, improving the processes in relation to leavers is a key area of focus and Mark Saxton said he wanted to hear an example of where the new process resulted in a member of staff choosing to stay at the YDH rather than leave. -The Trust’s vacancy levels and recruitment campaign had been discussed in detail at previous meeting and progress continues. The Workforce Committee welcomed the more detailed information included in the workforce performance report and from next month the vacancy predicator would be included as standard. Ali Morris confirmed that YDH continues to consider ways to expedite the receipt of PINS for nurses that are recruited from overseas.

MA

4 | P a g e

5.6

5.7

5.8

-There was discussion about absence from work and sickness rates and Mark Appleby confirmed that e-roster should improve levels of reporting and that a new form is being launched for those staff not on the system. Maurice Dunster said that as well as the reported reasons, there can often be underlying causes for staff not coming to work and that it would be important to ensure managers undertake robust return to work interviews. Mark Saxton said it would be important to address long-term sickness absence, and Mark Appleby confirmed this is an area of focus for the HR business partners, working with the relevant managers. - The Workforce Committee welcomed the new slide entitled “key developments in month”, commenting that it should link with the Trust’s people plan and employee value proposition. The remaining items in the workforce performance report were noted, (including employee relations, mandatory training and appraisal rates (a deep dive on which had occurred at the previous meeting), the Monitor agency cap, bank fill and the workforce assurance slide.

6 6.1

6.2

6.3

6.4

DEEP DIVE – STAFF SURVEY The actions undertaken in response to the 2014 staff survey were taken as read. Mark Appleby presented a summary of the staff survey results for 2015 (produced by capita) and corresponding action plan, from which the following key points were discussed: -The response rate for YDH was 61% in 2015, which is in the in the highest (best) 20% when compared to other acute trusts, although is lower than the previous year (which was 66%). The non-executive directors congratulated Mark Appleby on the response rate but said that it would be important in future years to ensure at least 2/3 of staff contribute to the survey. -The key results are broadly positive with demonstrable improvement compared to the previous year and with a number of elements better than average when compared to other trusts. One such example is health and wellbeing and the non-executive directors commented on initiatives such as step jockey, the new occupational health service, the People Plan and the employee value proposition, among others, as contributing to this achievement. -There was discussion about the fairness and effectiveness of procedures for reporting errors, near misses and incidents, and the associated questions, which had been identified as an area for improvement through the survey. Maurice Dunster and Mark Saxton said that significant work had taken place to ensure YDH has a strong reporting and learning culture. In terms of reporting, YDH benchmarked well against other trusts and work is ongoing to improve the consistent implementation of learning and feedback. Similarly, the incidences of bullying and harassment are closely monitored by YDH.

5 | P a g e

6.5

6.6

-The non-executive directors challenged the way the staff survey data was presented by Capita. It was agreed that before the results are communicated to staff in order to develop their departmental response plans, the key messages should be more clearly articulated and one theme identified. It was agreed that Mark Appleby would undertake this piece of work, with Simon Blackburn – Communications Manager, and circulate the amended version to the Workforce Committee prior to sharing with staff, the key outcomes of which Maurice Dunster and Mark Saxton would support Mark Appleby in presenting to the Board in April 2016. It was also acknowledged that the organisational response plan (and departmental plans) should link with the People Plan and employee value proposition and have buy-in from Trust staff. Mark Saxton added that messaging to staff should make it clear that the Trust values their time in providing feedback and that it is listened to and acted upon. The non-executive directors spoke positively of the progress that had been made. As discussed above, the next steps would involve tailored and constructive communication of the results to staff and Mark Saxton added that it might be helpful to start issuing some of the positive points in CONECT before sending the formal messages to staff. In addition to discussion at the Board in April 2016, an overview would be provided at the Council of Governors in June 2016.

MA

MA/MS MD

MA/JR

7 7.1

ACTIONS ARISING FROM THE PEOPLE PLAN The actions arising from the People Plan were noted. It was agreed that the item would remain as a standing agenda item.

8 8.1

ANY OTHER BUSINESS There was no further business to discuss.

9 9.1

DATE OF THE NEXT MEETING 21 April 2016, 13:00 – 15:00, Boardroom, Level 1, YDH.

YDH │Financial Performance Month 12 – March 2016

Executive Summary (Business as usual – BAU) Full year deficit including loss on disposal £18.6m – excluding £0.4m loss on disposal £18.2m deficit, £0.2m favourable to budget.

Su

rplu

s /

(D

efi

cit

) £

m

(2.00)

(1.80)

(1.60)

(1.40)

(1.20)

(1.00)

(0.80)

(0.60)

(0.40)

(0.20)

0.00

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Budget 15/16 Actual 15/16 Actual 14/15 Actual Adj for loss on disposal

£18.6m

YTD

deficit

£0.2 m YTD

adverse vs budget

£1.8m in

month

deficit

Trend in month surplus / deficit

Executive Summary In month March 2016 BAU favourable variance to budget £53k (excluding loss on disposal). Whole trust including transformation £53k favourable to budget in month.

(312)

(1,029)

(239)

670

212

226

98

(1,390)

(1,764)

(2,000)

(1,800)

(1,600)

(1,400)

(1,200)

(1,000)

(800)

(600)

(400)

(200)

Underspend

Overspend

Su

rplu

s /

(D

efi

cit

) £

’00

0

1.1 1.2 1.3 2.1 2.2 2.3 2.3

Presentation ref – see

section for more details

Includes

(£427k) loss

on disposal

Executive Summary – Year to date summary BAU budget Year to date £18.6m deficit; £0.2m adverse to budget

1

2

3

4

Income

Expenditure

Capital

Cash

-Income is £1,181k (1%) favourable to budget.

Clinical income is £667k favourable, private patients is £69k adverse

and RTA income is £120k favourable. £150k Dorset CCG and £272k

Specialist Commissioning contract over-performance.

Other income £463k favourable, Additional staff rental, R&D and

education income.

-Expenditure is £1,834k (1.4%) adverse to budget.

Pay is £770k adverse, £1,311k overspend on nursing staff is offset

by underspends in medical, admin and other staff groups.

Non pay is £1,064k (2.3%) adverse, main items of overspend

additional expenditure on rental accommodation setup, nursing home

beds and outsourced waiting list work.

-Total capital expenditure, £10.4m, this was £11k overspent against

plan.

-Cash at 31st of March is £4.7m.

Focus

Point

Contents

1 Income

2 Expenditure

3 Capital

4 Cash

1.1 NHS Clinical Income

1.2 Non NHS Clinical Income

1.3 Other Income

2.1 Pay Expenditure and Temporary Staffing

2.2 Drugs

2.3 Other Non Pay Expenditure

2.4 CIP (Cost Improvement Programmes)

2.5 Transformation Budget

3.1 Capital Projects

4.1 Cash Flow

4.2 Balance Sheet

1.1 | NHS clinical income YTD £667k favourable & £670k in month favourable variance.

1 2 3 4

6,560 6,366

1,303 1,155

569

297

454

578

716

536

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Other High Cost Drugs

Specialised Commissioning Dorset CCG

Somerset CCG

March 2016

Actual

£9.60m

March 2016

Budget

£8.93m

7,750

8,250

8,750

9,250

9,750

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

15/16 Budget 15/16 Actual 14/15 Actual

£’0

00

£’0

00

Notes

• Somerset CCG favourable variance in month due to

RTT income and part completed spells.

• NHS England Specialised Commissioning recognising

£272k of contract over performance YTD.

• Dorset CCG favourable includes £150k extra income.

• In month less income was received for high cost pass

through drugs due to lower expenditure. Other includes- Overseas patients, Local Authority, Military, Public

Health & NCA

1.2 | Non NHS clinical income - 1.3 | Other non clinical income Favourable variance in month £438k, favourable by £514k YTD

1 2 3 4

1,357

1,132

295

44

167

205

900

1,100

1,300

1,500

1,700

1,900

Private Patients Other Non NHS Clinical Income

Other Non Clinical Income

March 2016

Actual

£1.82m

March 2016

Budget

£1.38m

£’0

00

1,000

1,100

1,200

1,300

1,400

1,500

1,600

1,700

1,800

1,900

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

15/16 Budget 15/16 Actual 14/15 Actual

£’0

00

Other non clinical includes: R&D, education and training, catering, car

parking, commercial contracts, donated asset income.

Notes

• £38k adverse in month on private patients income,

£69k adverse year to date. Compared to prior year this

is £172k favourable (8%) YTD. Kingston Wing £537k

contribution YTD, £110k higher than YTD 2014/15.

• £251k favourable Other Non NHS Clinical Income due

to Injury Cost Recovery Scheme, variable income

stream, offset by bad debt shown in M12 non pay.

• Other Non Clinical Income £225k favourable in month,

£140k favourable timing variance on donated asset

income. Trackcare adverse timing variance of £85k,

plus additional accommodation, maintenance contract

and education income offset by costs.

(136)

(178)

106

(53) (50)

(200)

(150)

(100)

(50)

0

50

100

150

2.1 | Pay expenditure & temporary staffing Pay YTD is £770k overspent & £312k overspent in month.

1 2 3 4

3,000

3,500

4,000

4,500

5,000

5,500

6,000

6,500

7,000

7,500

8,000

Agency Actual Bank & Locum Actual Substantive Actual

Agency Budget Bank & Locum Budget Substantive Budget

£’0

00

Variance to Budget

in Month

£312k Adv

Notes

• Nursing pay is £136k overspent due to higher sickness than planned £43k,

supernumerary staffing for overseas and preceptorship nursing £28k, specialing

patients £17k, staffing escalation beds £46k, and one off year end adjustments £68k.

• Medical staff costs are higher than budget due to continued usage of agency staff to

cover vacancies offset by savings on recruitment fees.

• Estates, Admin & Clerical are underspent due to vacancies partly offset by additional

emergency maintenance call outs.

£’0

00

2.1 | Pay expenditure & temporary staffing Nursing Staff - £136k overspent in month, £1,311k YTD

1 2 3 4

100

150

200

250

300

350

400

1,400

1,600

1,800

2,000

2,200

2,400

2,600

2,800

3,000

Oc

cu

pie

d B

ed

Da

ys

Agency Actual Bank Actual Substantive Actual Agency Premium Budget

Bank Budget Substantive Budget Prior Month Budget Average Occupied Bed Days(exc Cookson Court)

Notes

• Substantive costs reduced by £105k in month, however this is mainly due to the correction of relocation costs for overseas

new starters that were charged to nursing pay in Feb’16. Substantive WTE increased in month.

• Agency costs increased by £84k in month. Additional costs were incurred as a result of escalation, high sickness,

specialing and supernumerary time.

• Registered nursing agency expenditure as a % of total registered nursing expenditure was 15.3%. The target is 8%.

£’0

00

2.1 | Pay expenditure & temporary staffing Medical Staff Analysis - £178k overspent in month, £35k underspent YTD. Agency spend in month £276k, YTD £2,752k.

1 2 3 4

1000

1200

1400

1600

1800

2000

2200

2400

2600

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

Regular payroll Additional payroll Bought in services

Agency Budget 2015/16 incl risk budget Budget 2015/16 excl risk budget

£’0

00

Notes

Medical staffing is overspent in month which is due to the reduction of

available risk budget. Recruitment fees have not been spent and £44k of non

pay budget underspend in month offsets this overspend.

Elective Care in month spend is for backfill of vacancies across Middle Grade

and SHO posts in Surgery, Gynae, Orthopaedics and Anaesthetics.

Urgent Care in month spend is for backfill of vacancies across Consultant,

Middle Grades and SHO posts in Radiology, ED and Medicine. ED consultant

costs relate to locum cover starting for maternity leave .

In monthYear to

dateIn month

Year to

date

Respiratory Consultant 35 390 13% 14%

Care of the Elderly Consultant 31 384 11% 14%

Stroke Consultant 0 231 0% 8%

Radiology Consultant 76 294 28% 11%

ED Consultant 28 126 10% 5%

Paediatrics 21 21 8% 1%

Elective Care 43 610 16% 22%

Other Urgent Care 49 721 18% 26%

Other Corporate -7 -25 -3% -1%

Totals 276 2752

Expenditure (£'000s) % of expenditure

1 2 3 4 2.2 | Drugs YTD spend £13.6m, £351k underspent against budget. Of this £660k is offset by underachieved income.

-

200

400

600

800

1,000

1,200

1,400

CDF - Actual Spec Comm - Actual All other drugs - ActualCDF - Budget Spec Comm - Budget All other drugs - Budget

Notes

• From April – Mar £13.6m has been spent on drugs and £8.3m of income received to directly pay for high cost items.

• In month the net drugs position is £68k adverse, YTD £309k adverse to budget. This is due to additional expenditure

on tariff drugs.

• Cost of Specialised Commissioning drugs lower than budget offset by lower income.

£’0

00

2,856 2,856

3,554 4,516

1,910 1,604

0

2,000

4,000

6,000

8,000

10,000

Cancer Drugs FundSpecialised CommisioningSomerset & Dorset CCG

March 2016

Actual

£8.3m

March 2016

Budget

£9.0m

YTD High Cost Drugs Income

£’0

00

1 2 3 4 2.3 | Other non pay expenditure Overspent by £960k in month, overspent by £1376k YTD.

(203)

36

(793)

(800)

(700)

(600)

(500)

(400)

(300)

(200)

(100)

0

100

Variance to

Budget in Month

£960k Adv

750

1,250

1,750

2,250

2,750

3,250

3,750

4,250

High Cost Consumables Actual Consumable M&SE Actual Other Non Pay Actual

High Cost Consumables Budget Consumable M&SE Budget Other Non Pay Budget

Consumable M&SE – Medical & Surgical Equipment

High Cost Consumables – Includes high cost prostheses

£’0

00

Notes

• Consumable M&SE overspent by £203k in month, £202k overspent YTD. Additional

expenditure in pathology related to activity £50k, radiology for a service to cover pay

vacancies and year end stock adjustment £46k adverse impact.

• High cost consumables are underspend by £36k in month, £944k YTD, favourable

variance for RTT costs incurred in other non pay payment to another provider, £8k

underspend in orthopaedics theatres.

• Other non pay is overspent by £793k in month, additional RTT costs for patients

transferred to Shepton Mallet Treatment centre offset by underspend in high cost

consumables. £443k of costs offset by income (accommodation, RTA, Academy). £84k

for new BT line. Minor work £91k adverse in month and £63k for ward curtains and

cleaning systems.

£’0

00

0

50

100

150

200

250

300

350

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

CIP Recurrent CIP Non Recurrent CIP Plan

2.4 | CIP Achievement In month £257k achieved against plan of £286k. YTD £2,785k achieved against plan of £2,802k.

1 2 3 4 £’0

00

In Month Year to Date Annual Plan

Project Actual

Recurrent Acutal Non Recurrent

Total Achieved Plan Variance

Actual Recurrent

Acutal Non Recurrent

Total Achieved Plan Variance

Annual Forecast Recurrent

Non Recurrent Total

Procurement 34 0 34 23 11 233 2 235 230 5 230 0 230

1% Items 42 45 87 114 (27) 332 719 1,052 984 67 0 1,102 1,102

Facilities 10 0 10 16 (6) 150 0 150 148 2 57 100 157

Corporate 21 0 21 8 13 238 0 238 100 139 100 0 100

Energy 9 0 9 9 (0) 164 0 164 125 39 125 0 125

Commercial 12 0 12 8 4 135 0 135 104 31 104 0 104

CNST 5 0 5 5 0 63 0 63 63 0 63 0 63

Non Pay Inflation 40 0 40 39 2 362 0 362 362 0 362 0 362

Hospital Effectiveness 0 0 0 25 (25) 0 0 0 300 (300) 0 300 300

Urgent Care 37 0 37 37 0 386 0 386 386 (0) 386 0 386

Total 211 45 257 286 (29) 2,064 721 2,785 2,802 (17) 0 1,426 1,502 2,929

2.5 | Transformation Budget £0k adverse in month; £0k adverse YTD.

0

200

400

600

800

1,000

1,200

1,400

1,600

Planned Income & Expenditure Actual Expenditure Actual income

1 2 3 4

Notes

• Costs incurred year to date include extended FOPAS service pay costs, Health Coaches,

Complex Care Hubs as well as project teams and external support to facilitate implementation.

• YTD breakeven in line with agreed transformation fund.

• Pay and non pay expenditure will vary to the original plan incorporating adjustments in the

revised value proposition developed with NHS England and Monitor. This reflects a revised

timetable for implementation.

£’0

00

All expenditure is planned to be

offset by income

2,218

3,089

5,306

0

1,000

2,000

3,000

4,000

5,000

6,000

Pay Non Pay Income

£’0

00

YTD

Expenditure

£5.3m

YTD

Income

£5.3m

3.1 | Capital 2015/16 total expenditure £10.4m, £11k variance to budget.

1 2 3 4

0

500

1000

1500

2000

2500

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Plan

Actual

Forecast

Notes

• General site capex overspend is mostly due to

additional SCBU work, additional costs due to

asbestos for Theatres Air Handling Unit

replacement and new Front Entrance/ OPD

works.

• Medical equipment now purchased via lease

arrangements.

• Radiology equipment now being funded via a

lease agreement.

• New ward works all complete.

£’0

00

Capital Expenditure In Month Year to Date Annual

Actual Variance Actual Variance Forecast Variance

Operational Capital Spend

Total General Site Capex 1,240 (1,124) 3,387 (513) 3,387 (513)

Medical Equipment 135 (15) 507 620 507 620

Radiology (7) 7 77 399 77 399

IT Upgrad / Replacement 0 11 48 60 48 60

IT / Developments 50 (50) 172 (28) 172 (28)

Major Developments

Energy Project 35 (35) 231 39 231 39

New Ward 373 (113) 3,674 (674) 3,674 (674)

IT - Smartcare 305 (70) 1,850 407 1,850 407

MSCP Land 2 (2) 325 (325) 325 (325)

Donated Schemes in Year 22 (10) 146 3 146 3

Total 2155 (1,400) 10,414 (11) 10,414 (11)

4.2 | Cash Outflow in month was £1.7m, cash balance at 31st March; £4.7m

1 2 3 4 £’0

00

Notes

• At end of March 2016 cash balance was £4.7m which is £3.5m greater than plan. The variance is

mainly timing as loan support is drawn down in the middle of each month maintaining a minimum

balance of £1m. YTD end of March £23m loan has been drawn down.

• Interim loan papers have been received from DoH for April 2016 for a working capital allowance

of £10.6m prior to formal loan agreements after annual plan review by NHS Improvement. This

will cover expenditure until August 2016.

4,000

400 -

9,600

5,828

-

3,172

0

2,000

4,000

6,000

8,000

10,000

Actual Cash Actual / Planned Cash Support Planned cash Revised forecast

Total planned cash support of £23.0m to

cover revenue and capital.

4.2 | Balance Sheet 1 2 3 4 Mar 15 Mar 16 Mvt In Year

Non Current Assets 51,968 58,437 6,469

Current Assets

Stock 2,136 2,102 (34)

NHS Trade Debtors 1,428 1,029 (399)

Non NHS Trade Debtors 802 1,035 233

Accrued Income 1,795 2,149 354

Prepaid Contracts 760 796 36

Cash in Hand and at Bank 2,053 4,654 2,601

Total Current assets 8,974 11,765 2,791

Current Liabilities

Trade Creditors (3,067) (1,990) 1,077

Other Creditors (2,694) (3,084) (390)

PDC Dividend Creditor 0 (23) (23)

Capital Creditor (1,404) (2,532) (1,128)

Accruals (5,700) (10,024) (4,324)

Borrowings <1yr (130) (126) 4

Deferred Income (48) (341) (293)

Current Liabilities (13,043) (18,120) (5,077)

Net Current Assets (4,069) (6,355) (2,286)

Total Assets less Current Liabilities 47,899 52,082 4,183

Trade and other Payables >1yr (11) 0 11

Borrowings> 1yr (1,660) (24,505) (22,845)

Provisions >1yr (1,047) (999) 48

Net Assets employed 45,181 26,578 (18,603)

Financed by:

I&E Reserve Current year (10,558) (18,605) (8,047)

Public Dividend Capital 41,823 41,823 0

I&E Reserve Previous year 5,918 (4,618) (10,536)

Revaluation Reserve 7,998 7,978 (20)

Total Financed 45,181 26,578 (18,603)

Summary Statement of Comprehensive Income For business as usual operations – excluding transformation.

1 2 3 4

Financial Summary

£000's Jan-16 Feb-16 Actual

Variance to

Budget % var Actual

Variance

to

Budget % var

Annual

Budget

2015/16

Income

Clinical Income 8,676 8,491 9,602 670 (7.0%) 103,591 667 (0.6%) 102,924

Non NHS Clinical Income 246 227 462 212 (46.0%) 2,942 51 (1.7%) 2,891

Other Income 1,125 1,406 1,357 226 (16.6%) 14,409 463 (3.2%) 13,946

Total Income 10,047 10,124 11,421 1,108 (9.7%) 120,941 1,181 (1.0%) 119,761

Pay

Registered Nursing (2,156) (2,219) (2,235) (116) (5.2%) (25,680) (735) (2.9%) (24,945)

Unregistered Nursing (556) (588) (550) (20) (3.7%) (6,579) (576) (8.8%) (6,003)

Medical Staff (2,239) (2,270) (2,414) (178) (7.4%) (27,561) 35 0.1% (27,596)

Estates, Admin & Clerical (1,275) (1,312) (1,261) 106 8.4% (15,361) 755 4.9% (16,116)

Pay - Scientific, Therapeutic & Technical (678) (687) (732) (53) (7.2%) (7,971) 51 0.6% (8,022)

Pay - Ancillary (376) (364) (404) (50) (12.5%) (4,435) (300) (6.8%) (4,135)

Total Pay Expenditure (7,279) (7,440) (7,597) (312) (4.1%) (87,587) (770) (0.9%) (86,817)

Non Pay

Drugs (1,239) (1,130) (1,146) 98 8.6% (13,578) 351 2.6% (13,929)

Consumable M&SE (644) (617) (945) (203) (21.5%) (8,381) (202) (2.4%) (8,179)

High Cost M&SE (210) (167) (254) 36 14.2% (2,527) 944 37.4% (3,471)

Other (1,957) (1,847) (2,533) (862) (34.0%) (22,410) (2,157) (9.6%) (20,253)

Total Non Pay Expenditure (4,050) (3,761) (4,878) (931) (19.1%) (46,897) (1,064) (2.3%) (45,833)

EBITDA (1,281) (1,077) (1,054) (135) (12.8%) (13,543) (654) (4.8%) (12,889)

Other Technical (368) (406) (711) (240) (33.7%) (5,061) 481 9.5% (5,542)

Surplus / (Deficit) (1,649) (1,483) (1,764) (374) (18,604) (173) (18,431)

Prior Months Actuals In Month - Mar 16 Year to Date

Summary Statement of Comprehensive Income For whole trust including business as usual operations and transformation.

1 2 3 4

Financial Summary

£000's Jan-16 Feb-16 Actual

Variance to

Budget % var Actual

Variance

to

Budget % var

Annual

Budget

2015/16

Income

Clinical Income 9,214 9,203 10,822 1,174 (10.9%) 108,741 (988) 0.9% 109,729

Non NHS Clinical Income 246 227 462 212 (46.0%) 2,942 51 (1.7%) 2,891

Other Income 1,123 1,407 1,488 356 (23.9%) 14,564 618 (4.2%) 13,946

Total Income 10,583 10,838 12,772 1,743 (13.6%) 126,247 (319) 0.3% 126,566

Pay

Registered Nursing (2,173) (2,236) (2,251) (29) (1.3%) (25,852) (109) (0.4%) (25,743)

Unregistered Nursing (562) (594) (556) (23) (4.1%) (6,651) (609) (9.2%) (6,042)

Medical Staff (2,359) (2,406) (2,468) (100) (4.1%) (28,167) 594 2.1% (28,761)

Estates, Admin & Clerical (1,406) (1,412) (1,547) (49) (3.2%) (16,418) 1,065 6.5% (17,483)

Pay - Scientific, Therapeutic & Technical (774) (805) (788) (60) (7.6%) (8,282) 55 0.7% (8,336)

Pay - Ancillary (376) (364) (404) (50) (12.5%) (4,435) (300) (6.8%) (4,135)

Total Pay Expenditure (7,650) (7,816) (8,015) (312) (3.9%) (89,805) 696 0.8% (90,501)

Non Pay

Drugs (1,239) (1,130) (1,146) 98 8.6% (13,578) 351 2.6% (13,929)

Consumable M&SE (644) (617) (945) (203) (21.5%) (8,382) (203) (2.4%) (8,179)

High Cost M&SE (210) (167) (254) 36 14.2% (2,527) 944 37.4% (3,471)

Other (2,121) (2,185) (3,467) (1,498) (43.2%) (25,499) (2,125) (8.3%) (23,374)

Total Non Pay Expenditure (4,215) (4,099) (5,812) (1,567) (27.0%) (49,986) (1,032) (2.1%) (48,954)

EBITDA (1,281) (1,077) (1,055) (136) (12.9%) (13,544) (655) (4.8%) (12,889)

Other Technical (368) (406) (711) (240) (33.7%) (5,061) 481 9.5% (5,542)

Surplus / (Deficit) (1,649) (1,483) (1,766) (376) (18,605) (174) (18,431)

Prior Months Actuals In Month - Mar-16 Year to Date

5.1 | Service Line Reporting Urgent Care SLR YTD contribution by specialty

Notes

• The above shows Medicine (which includes FOPAS, Ambulatory care and Geriatric medicine, along with General

medicine) as making the most significant contribution (Income less direct costs). However, as a percentage of its

total revenue this contribution is only 7%.

• The division is making an overall loss of £10.5m

5.1 | Service Line Reporting Elective Care SLR YTD contribution by specialty

Notes

• The above shows several large contributions in Ophthalmology and Orthopaedics.

• Overall, the division is making a £8.1m loss.

• Ward stay apportionments have been reviewed in month, substantially improving the contribution of the services.

YDH │Programme Management Office (PMO) Overview and Update – April 2016

22

PMO Overview

• One of the key recommendations of the Monitor review of the Trusts 2016/17 Operational Plan was to strengthen the ‘quantum and quality’ of CIPs through a more robust PMO structure

• Need to put in place a more structured approach to transformation and the delivery of the Cost Improvement Programme

• Build capability and support business units to deliver

• Brings together: - Delivery of our annual CIP - Hospital transformation work - Symphony project

23

Deputy Director of Elective Care Deputy Director of Urgent Care Symphony

Project/OpCo: EPC Complex Care Outcome

Based Commissioning

Voluntary Sector

Chief Information Officer

Directors of Urgent and

Elective Care

Director of

Strategy and

Transformation

Programme Management Office

24

2016/17 CIP

2016/17 Operational Plan target (cost reduction and income generation)

£5.1 million

Current opportunities £6.2 million

Other opportunities for in-year savings (not currently in plan):

Reduced agency spend – medical staff

Reduced agency spend – non-clinical staff

Workforce review

New model for managing delayed transfers of care

Outpatient redesign

Realising the Trakcare Business Case

25

2016/17 CIP – Current Opportunities

Project Exec Sponsor Project Manager 16/17

Savings

target

(£M)

Risk

Theatre Improvement (avoiding additional RTT costs over 15/16 levels) Shelagh Meldrum Kerry White 1

Reduce Agency Spend - Nursing Helen Ryan Maddie Groves 1

Ophthalmology - New contract arrangements 0.1

Pathology - Joint Venture Contribution 0.08

Increasing commercial income Simon Lilley Ian Creek 0.2

Medicines - additional savings/income Simon Sethi Jon Standing 0.2

Procurement savings Tim Newman Dean Stevens 0.5

Realisation of Bed Reductions from roll out of Complex Care model Mandy Seymour-Hanbury Tracey Fletcher 0.8

NHS Revenue generation - Somerset CCG 15/16 overperformance Simon Lilley Stacy Barron-Fitzsimons 1.5

NHS Revenue generation - Dorset CCG 15/16 overperformance Simon Lilley Stacy Barron-Fitzsimons 0.2

Net Contribution - 16/17 NHS contractual growth Simon Lilley Stacy Barron-Fitzsimons 0.6

TOTAL 6.18

26

Transformation Projects

Project Director Lead Project Manager

TrakCare Jason McClellan Trakcare team

Urgent Care Flow Improvement Simon Sethi Sarah Riley

MSK Pathway Redesign Shelagh Meldrum Kerry White

Systematised Surgery Jon Howes Kerry White

Health and Social Care College Jonathan Higman Debs Mathewson

Networked services (Dermatology) Jonathan Higman Joint PM with MPH and RDE

Acute Service Redesign Jonathan Higman New Project Manager

Project Director Lead Project Manager

Outcome Based Commissioning Jeremy Martin

Voluntary Sector partnerships Jeremy Martin Appointment underway

Development of the Complex Care Model Mandy Seymour Tracey Fletcher

Enhanced Primary Care Jeremy Martin Matthew Butt

1. Symphony

2. Hospital Transformation

27

Activities

• Initial priorities:

- Recruitment to key PMO posts

- Communication and engagement

- Establish systems/processes and standard documentation

- Governance – reporting and Hospital Transformation Group

- ‘Ideas’ hopper

• Building links with other successful PMO’s – Caulderdale and Huddersfield FT

• Benchmarking, including Carter review

AUDIT COMMITTEE

Minutes of the Audit Committee held on 19 February 2016 at Yeovil District Hospital

Present: Paul von der Heyde (Chair) Non-Executive Director Julian Grazebrook Non-Executive Director Jane Henderson Non-Executive Director In Attendance: Jon Brown KPMG [excluding item 20/16] Chris England Deputy Head of Procurement [item 20/16] Nicky Croxon Business Manager [item 6/16] Ali Morris Head of Organisational Development and

Recruitment [item 8/16] Sheena Morrow Assistant Director of Finance Aimee Newton Counter Fraud Service [excluding item 20/16] Paul Mears Chief Executive John Park Elected Public Governor - Observer Adrian Pickles Fire, Health and Safety Manager

[items 16/16 – 18/16] Jade Renville Company Secretary Greg Rubins BDO – Internal Auditors [excluding item 20/16] Mark Thouless Financial Controller Mark Saxton Non-Executive Director Adam Spires BDO – Internal Auditors [excluding item 20/16] Alison Whitman Elected Public Governor - Observer Apologies: Tim Newman Chief Finance and Commercial Officer Dean Stevens Assistant Director of Finance Action 1/16 WELCOME AND APOLOGIES

Paul von der Heyde welcomed everyone present to the meeting. Apologies for absence were received as noted above.

2/16 DECLARATIONS OF INTEREST RELATING TO THE AGENDA There were no declarations of interest relating to items on the agenda.

3/16 MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on 17 July 2015 were approved as a true and accurate record. In terms of matters arising: • an update on actions relating to the consultant job planning internal audit

would be presented at the Audit Committee in April 2016 • an update on the actions relating to HR from previous internal audits

would be presented later in the meeting [item 8/16 refers] • an update on the actions relating to the violence and aggression annual

report would be presented later in the meeting [item 16/16 refers]

TS

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4/16 KPMG PROGRESS REPORT / TECHNICAL UPDATE Jon Brown presented the external audit progress report, which was noted by the Audit Committee. He confirmed that since the last meeting, KPMG had met with core members of the finance team to agree the key deliverables for the 2015/16 audit. He also advised that KPMG had reviewed the accounting treatment for the development of the multi-storey car park and prepared the audit plan for 2015/16, which would be discussed later in the meeting [item 5/16 refers]. He added that the interim audit of systems and controls would be undertaken next week and that in the next quarter KPMG would hold planning sessions based on the changes to the annual reporting manual and the impact of changes to the quality report. Jon Brown spoke to the key items contained within the technical update advising that the guidance documents for the production of 2015/16 quality reports are currently under consultation and would be published in final form shortly thereafter. For YDH, the two mandatory indicators that would be tested by KPMG as part of the audit are ‘RTT within 18 weeks for patients on incomplete pathways’ and ‘A&E four hour wait target’. John Park asked about the indicator chosen by the Council of Governors, which remains ‘quality of discharge’. It was confirmed that if the Council of Governors wish to amend the indicator, they would need to do so prior to the start of the financial year to ensure sufficient data is available for testing at year-end for 2016/17. Jon Brown spoke of the requirements issued by Monitor to produce a five year system-wide transformation plan and an annual plan for 2016/17 which reflects the emerging strategic position and aims of the NHS Five Year Forward View (which would include returning the NHS system to financial sustainability, improving quality and meeting operational performance targets). The Audit Committee noted the remaining items within the technical update.

5/16 KPMG - DRAFT AUDIT PLAN 2015/16 Jon Brown summarised the draft audit plan for 2015/16 (the details of which were contained within the enclosed paper) advising that it would involve providing opinions on the Trust’s accounts, a conclusion on the use of resources and the assurance opinions on the quality report. The draft accounts require submission by 22 April 2016 and the final audited accounts require submission by 27 May 2016. This timetable is in line with the previous year, although there are slightly fewer audit days overall. Jon Brown highlighted the valuation on non-current assets and the recognition of NHS and non-NHS income as two areas of audit opinion risk requiring focus. It was confirmed that the Going Concern would be prepared on a similar basis to last year and presented to the Board of Directors in March 2016. Following a question raised by Paul von der Heyde, Jon Brown confirmed that KPMG does not have significant concerns relating to materiality. Julian Grazebrook questioned whether the recommendations from the audit of the quality report in 2014/15 had been implemented. Jon Brown confirmed this would be followed-up as part of the 2015/16 audit. Julian Grazebrook queried the data set out on page 8 as the income is not correct for YDH, which Jon Brown agreed to check and amend. The Audit Committee approved the draft audit plan 2015/16, an update on which would be presented at the next meeting in April 2016.

JR

JB

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6/16 BDO INTERNAL AUDIT REPORTS Progress Report Greg Rubins presented the internal audit progress report advising that good progress is being made against the 2015/16 work plan, with three internal audit reports to be presented today to the Audit Committee (in summary), leaving one outstanding for completion by year-end (which is a suggested amendment to the workplan agreed with the executive directors to include learning from complaints, incidents, SIRI and unexpected deaths). The three internal audit reports presented in summary form (as they all received moderate assurance) were discussed as follows: Budgetary Control The internal audit identified a number of areas of good practice including agreeing the budget setting process in advance, ensuring this was well communicated to staff and monitoring the budget on a monthly basis (undertaken by the business units, the Financial Resilience and Commercial Committee, HMT and the Board of Directors). In terms of areas for improvement, which were accepted by the Audit Committee, Greg Rubins said that the process would benefit from being formalised and standardised and that more user friendly guidance should be issued to budget holders. Key Financial Systems The controls in place relating to the key financial systems are generally good, including having in place a cash flow forecast and having set stock lists for each ward and minimum stock for each item. However, BDO has identified a number of recommendations in relation to stock management, mainly to formalise the arrangements and systems. Greg Rubins confirmed he would continue to work with the key leads on the recommendations as agreement on their implementation had not yet wholly been reached. Private Patient Income Overall, BDO obtained moderate assurance that there are sufficient controls in place to ensure private patient income is received. However, there were recommendations requiring action such as moving from a paper-based to electronic system, putting in place a formal process to highlight private patients with outstanding debt and to prevent them from getting more treatment until that debt has been paid and ensuring that when NHS patients upgrade to stay on the Kingston Wing, they are required to pay a deposit. It was discussed and noted by the Audit Committee that the implementation of the latter action is challenging as such patients are often unwell when they are upgraded. The possibility of having a credit card payment system on the Kingston Wing was discussed. The internal audit report into waiting list management (presented in full by Adam Spires as it received limited assurance) was discussed as follows: Waiting List Overall, BDO obtained only limited assurance of the controls in place to ensure waiting lists (breaches of the RTT targets) are effectively managed. Seven recommendations had been made (five medium, one high and one low). Nicky Croxon presented the action plan saying that progress is in place against all the recommendations that had been made.

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In particular she highlighted from the action plan that: • the access policy had been re-drafted which defines the roles and

responsibilities of staff based on latest guidance

• improvements to the pre-operative assessment process is in progress, overseen by the Hospital Effectiveness Group

• a staff training plan has been developed

• an app has been developed (currently in draft form) which will provide

visibility of the placement of patients on RTT pathway

• analysis of the waiting list and speciality level breaches had been undertaken

In terms of the various limitations with PAS, as noted by BDO in their report, it was acknowledged by the Audit Committee that TrakCare should result in improvement, subject to successful migration of RTT data to the new system. Paul Mears said that YDH is on track with the delivery of its RTT recovery plan (despite significant operational pressures and ongoing challenges in reducing the number of delayed discharges). He added that after considerable work the Trust is now more assured of its RTT data quality

7/16 BDO STRATEGIC AND OPERATIONAL WORKPLAN 2016/17 Greg Rubins presented the internal audit plan for 2016/17, which had been reviewed by the executive directors. The full details were contained on pages 9-10 of the enclosed report and provide a balance of items aligned to the YDH strategic objectives, with a focus on quality and caring for the Trust’s population. In addition, Greg Rubins advised of additional items that had been recommended by BDO following analysis of the Trust’s corporate risks, details of which are included on page 11 of the enclosed report. These items could be reviewed at a later date as the plan evolves and/or if YDH choses to purchase additional audit days. Mark Saxton and Maurice Dunster questioned the value in undertaking internal audits into workforce planning and sickness management as these areas are now being reviewed in detail at the Workforce Committee. It was agreed these items would be re-considered between BDO and Tim Newman. Jane Henderson asked when there would be a follow-up from the internal audit into information governance, which Greg Rubins said would take place through the BDO follow-up of recommendations report. Jade Renville added that there would be a seminar session focussed on information governance at the Board in March 2016. The Audit Committee approved the workplan for 2016/17, subject to the considerations discussed above and ensuring that the plan remains flexible and can evolve throughout the year as necessary.

BDO

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8/16 BDO FOLLOW-UP OF RECOMMENDATIONS REPORT Adam Spires presented the follow-up of recommendations report. He said the majority of the actions had been completed, adding that those which were overdue for implementation related predominantly to business continuity, progress on which is being made, an update on which would be presented at the Audit Committee in April 2016. Ali Morris spoke of the actions relating to HR and recruitment, progress on which had been made. She added that the implementation of the Trac Recruitment System should aid the resolution of the outstanding recommendations (which is going live in April 2016). The Audit Committee noted the follow-up of recommendations report and the positive progress which had been made.

YT

9/16 COUNTER FRAUD PROGRESS REPORT The Audit Committee noted the progress report, the key elements of which highlighted by Aimee Newton as follows: • the Trust is piloting a new pre-attendance form as recommended by the

Home Office to improve the process for the identification of chargeable overseas patients [item 13/16 refers], which Aimee Newton will follow-up after the trial period

• no new investigation referrals were received during the reporting period although one referral has been made since the writing of the report

• exercises in relation to pre-employment checks and procurement are in

progress and will be presented at the next meeting

AN

10/16 COUNTER FRAUD WORKPLAN 2016/17 Aimee Newton presented the counter fraud workplan for 2016/17 which is currently in draft form as NHS Protect had not reissued the standards for 2016/17 and the NHS standard contract for next year is in draft form, which together forms the basis for the plan. She did not, however, envisage there being significant changes. Following queries from the non-executive directors, she confirmed that YDH had agreed the provision of 70 days but said the workplan would remain flexible to address any risks to the as they arise. She also explained that the counter fraud service currently provided in-house by Dorset Healthcare University NHS Foundation Trust is being externally procured, due for completion on 1 April 2016. Should the provider change, it had been agreed that the cost and number of work days for YDH would remain unchanged. Aimee Newton confirmed that the final version of the workplan would be presented at the Audit Committee in April 2016 for approval, together with a summary of any key changes.

AN

11/16 INVOICE FRAUD RISK ASSESSMENT Aimee Newton presented findings from the invoice fraud risk assessment which had been undertaken in line with NHS Protect standards. She said that the assessment did not identify any significant control weaknesses although eight recommendations (of relatively low level) had been made to strengthen the Trust’s existing controls, all of which had been accepted by YDH. Julian Grazebrook asked about the risk of high level mismatches between purchase orders and invoices and it was confirmed that there were mechanisms in place to mitigate this risk and further recommendations had been made to further improve controls. The Audit Committee noted the invoice fraud risk assessment.

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12/16 COUNTER FRAUD RECOMMENDATIONS TRACKING REPORT Aimee Newton explained that actions arising from the activities of the Trust’s counter fraud service are monitored through the recommendations tracker. She advised of progress since the last meeting saying that 14 recommendations had been added to the tracker and 24 recommendations had been marked as complete with no issues relating to those that were outstanding. Members of the Audit Committee asked how actions were evidenced as completed. Aimee Newton said that managers are asked to provide an update on a quarterly basis and in future would be required to provide additional evidence to support their statements. Following a question from the non-executive directors, Aimee Newton said that she is supporting Ali Morris with the recommendations relating to HR. .

13/16 FINANCE REPORT Mark Thouless presented the finance report providing the current status for debtors, year to date losses and compensation payments. He reported the position as at 30 November 2015 which showed total debtors of £5.779m, primarily due to the timing of invoice payments. He said there were no issues in relation to NHS debt. He spoke of the key risks with the growing bad debt provision which were discussed by the Audit Committee: • overpayment of salaries, the key reason for which is the late submission

of leavers forms - Mark Saxton said this had been an area of focus for the Workforce Committee

• overseas visitors are informed at admission that there will be a cost associated with their stay but recovering costs had, in some cases, been challenging

• a paper detailing the issue and recommendations relating to the Yeovil

Eyecare debt (discussed at previous meetings) would be prepared for discussion by the Board in March 2016

Mark Thouless confirmed the above areas are being reviewed. There were no major issues in relation to losses and special payments.

14/16 POLICY FOR THE DEVELOPMENT AND MANAGEMENT OF PROCEDURAL DOCUMENTS Jade Renville presented the revised Standards of Business and Ethical Conduct Policy, advising that it had been reviewed by the counter fraud service. Subject to the following amendments (which were raised by the non-executive directors and discussed in detail by the Audit Committee), the revised policy was approved: • page 5 – typo – ‘three choices’ to read ‘two choices’ • staff declarations to be proactively sought on an annual basis rather than

filtered through the appraisal process • ‘associated policies list’ to include reference to policies relating to

working with the pharmaceutical industry • page 4 - clarify the process relating to trading and canvassing to make it

clear that it’s only prohibited ‘without permission’ • the processes contained within the policy to be highlighted to doctors

and cross-referenced with their study leave forms

JR

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15/16 STANDING FINANCIAL INSTRUCTIONS AND SCHEME OF RESERVATION AND DELEGATION UPDATES Chris England presented a summary paper outlining the amendments to the Standing Financial Instructions and Scheme of Reservation and Delegation, which were approved by the Audit Committee.

16/16 VIOLENCE AND AGGRESSION REPORT FOLLOW-UP Following discussion at the previous meeting [item 79/15 refers] Adrian Pickles updated that conflict resolution training which conforms to NHS Protect guidelines is now available to frontline staff, feedback from which has been positive. Going forwards uptake of training would be monitored by the Workforce Committee as part of the Workforce Performance Report. The Audit Committee noted the update.

17/16 FIRE, HEALTH AND SAFETY REPORT UPDATE Following discussion at the previous meeting [item 79/15] Adrian Pickles advised he was able to provide greater assurance on fire safety compliance, the action plan for which is ongoing and overseen by the Quality Committee, which had recently re-categorised compliance risk as amber rather than red. Following questions from the Audit Committee, Adrian Pickles advised that the item would remain at its current score on the corporate risk register until the action plan had progressed 6-8 months. The Audit Committee noted the update.

18/16 FIRE, HEALTH, SAFETY AND SECURITY COMMITTEE MINUTES The Audit Committee noted the minutes from the Fire, Health, Safety and Security Committee.

19/16 Q3 CORPORATE RISK REGISTER AND BAF The Audit Committee noted the Q3 Corporate Risk Register and BAF which were not discussed in detail as they were reviewed by the Board of Directors and the Governance Committee in January 2016.

20/16 EXTERNAL AUDIT SERVICES BDO, Counter Fraud and KPMG were excluded for this portion of the meeting. Chris England presented proposals to re-procure external audit services, the process (as described in the enclosed paper) for which was accepted by the Audit Committee. Approval would be sought from the Council of Governors on 3 March 2016.

CE

21/16 REGISTERS OF SEALINGS, HOSPITALITY AND INTERESTS The registers of sealings, hospitality and interests were noted.

22/16 ANY OTHER BUSINESS There was no further business to discuss.

23/16 MEETING WITH AUDITORS AND COUNTER FRAUD SERVICE There was an opportunity for Audit Committee members to meet with the auditors and counter fraud service in the absence of officers of the Trust.

BOARD OF DIRECTORS Report to: Board of Directors Report from: Jason Maclellan Subject: SmartCare Electronic Health Record (TrakCare) Update Date: 21 April 2016 Executive Summary Overall status is amber. We are still planning and focused on an end of May go-live. End user training has started and while there are still some remaining process issues we are confident that these will be resolved and finalised prior to go live. The biggest risk remaining is around the readiness of the product with a large number of high priority issues which require resolution. It’s inevitable that some of these fixes are going to be delivered close to go-live which compromises our validation time. We are taking a risk based approach to our testing to try and mitigate this issue. The next 2 weeks will be key as we require the vast majority of these issues to have been resolved or it could put an unacceptable level of risk on the go-live. Process In the first week of April we completed a 2-day workshop focused on full end to end pathway walkthroughs of the process and system. These sessions were well attended on both sides and extremely valuable. The health architect from ISC and product experts attended both days. These sessions drove out a number of issues, both process and system, and the focus is on resolving these prior to go-live. Software The biggest area of concern is still the completeness and quality of the software. We have identified 140+ issues which need to be resolved prior to go-live. The latest patch exp. 26th April will contain a significant number of fixes however we expect 40+ to still be outstanding. This is much higher than we would expect at this stage in the project and more than previous estimates from the supplier. A session is planned for next week to review each of these individually and assess the impact, timeline to fix/resolve and any potential workarounds. Any which affect clinical safety will be reviewed and signed off via CDA. Build The remaining build item to complete is the letter configuration. Currently this blocked due to system issues with the output of the generated letters. This is also holding up configuration of Neopost our letter printing solution. These issues were due to be resolved w/c 11th however the release did not fully resolve the problem. The issue is now with Sydney and a fix is expected 26th April. If this is not fixed then this could delay go-live. Data migration & reporting The other area of work which is currently blocked is the final phase of data migration and operational report testing. This is blocked due to delays to the delivery of data extracts from Trakcare. A subset of these extracts was delivered this week with the remainder expected

next week. This has meant we have had to significantly compress our final phase of testing. We believe we can achieve the required level of testing however any significant issues will jeopardise the go-live dates. Training End user training started on the 18th April. So far attendance has been good and the majority or the feedback has been positive. The main negatives has been around those areas of the system where issues remain. Cut-over Cut-over planning is progressing with the timeline now agreed and resource plans being finalised. Comms Programme communication has been ramping and we are confident that awareness and understanding is high within the organisation. The key now will be really embedding the process change which will be done through training and also the final end to end walkthroughs. Readiness for change Readiness assessment have been rolled out to all areas and are forming the basis for tracking any outstanding issues within each area/specialty. The operational steering group is resolving and assuring these readiness assessments. ATP We are now reviewing go/no go criteria twice weekly and a formal Authority to proceed (ATP) document has been created which will cover all of the above areas and capture any remaining issues and concerns, mitigations and recommendations. This will be agreed through the operational groups, CDA and programme board. I will present this at the next board.

Appendix REPORT TO: Audit Committee, Governance Committee, Board of Directors REPORT BY: Jade Renville, Company Secretary PRESENTED BY: Jade Renville, Company Secretary Jonathan Higman, Director of Strategic Developments TITLE: Board Assurance Framework Q4

DATE: 13 April 2016 What is this item about and what is the Board/Committee asked to do? The Board Assurance Framework (BAF) forms part of the Trust’s risk management process and is the framework for identification and management of strategic risk. It is supported by the corporate risk register and regular review of progress by the Board of Directors and the Audit Committee against the Trust’s strategic priorities. This suite of documents is reviewed at least a quarterly basis. The BAF has been revised to take account of the newly updated strategic objectives and priorities for the Trust and has been formatted using best practice guidance from KPMG. The Board of Directors, the Audit Committee and the Governance Committee are asked to NOTE the BAF and to discuss the RAG scoring for the current period. Are there legal, financial, procedural, workforce implications and/or legislative requirements? N/A Is this paper clear for release under the Freedom of Information Act 2000? Yes What are the next steps/future actions? The BAF, together with the corporate risk register, is submitted on a quarterly basis. Links to the Trust’s strategic objectives and/or priorities: The BAF provides a RAG score of delivery against the Trust’s strategic priorities and links to the corporate risk register which contains details of key risks/issues together with the mitigating action plans. The reporting and management of risks links with the CQC key Line of Enquiry (KLOE) under ‘Well-Led’. Links to the Board Assurance Framework/Corporate Risk Register (if applicable): N/A. References to the corporate risk register are contained within the BAF where applicable. Risks relating to the Trust’s short-term financial challenges and risk F006 should be noted as a key challenge impacting all the Trust’s strategic objectives and is a primary driver of developing new models of integrated care to create long-term sustainability.

Reference to CQC domains: The BAF and corporate risk register sets out out how strategic risk is managed and makes clear the Trust's risks where they are related to quality of care and treatment. Regulation 17: Good governance 17.—(1) Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. (2) Without limiting paragraph (1), such systems or processes must enable the registered person, in particular, to— (a) assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services); (b) assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity; Report history: The BAF has been revised to take account of the newly updated strategic objectives and priorities for the Trust agreed by the Board of Directors on 30 September 2015 [item 1-121/15 refers]. The Board reviewed the Q3 BAF on 27 January 2016.

Objective 1: Care for our population

P4: Recover RTT performance

LP ST010, TW023, OTH001, SBUV008, F006

1,

2, 4

Objective 2: Develop our people

P7: Secure an elective care partner

LP ST010, OTH001 1, 4

P8: Achieve full staffing across the hospital and reduce the reliance on agency staffing

LP UC006, TW025, UC005, TW023, ST010, MTH021, F006, OG027, M022, M023

1, 4,

5, 6

P9: Develop a new model of clinical leadership and staff incentives

LP UC005, UC006,

TW025

5

Objective 3: Pioneer the future

P10: Develop a staff engagement strategy/improve capability for leading change

LP UC005, UC006,

TW025

1,

5

P11: Develop a career college

LP UC005, UC006,

TW025

1,

4,

5

P12: Secure capitated outcomes based contract for 2016/17

LP 1, 4

P14: Complete the roll-out of the complex care model

P13: Establish a joint venture structure with local GPs

LP 1, 7 LP F006 1,

7

Objective 4: Put technology at the heart

P16: Develop new partnership model with neighbouring hospitals (dermatology)

LP

Yeovil Hospital Board Assurance Framework 2015/16 Q4 Notes: The box colour represents the RAG score in the current period. Where boxes are left blank, these programmes are yet to commence. The box labelled LP represents the score in the last period. The reference in the lower middle box provides any links to the corporate risk register (where applicable). The numbers in the lower right hand box indicate which committee is responsible for overseeing the priority (“p”): 1. Board, 2. Audit, 3. Governance, 4. Finance/Commercial, 5. Workforce, 6. SBUs/HMT/Directors, 7. Symphony Programme Board, 8. TrakCare Programme Board.

P18: Start talking to the public about our plans

P19: Improve the internal physical environment of the hospital

P17: Develop new models of care in partnership with local nursing and domiciliary care

P20: Build a multi-storey car park

P21: Develop a retail partner P22: Bid to run Shepton Mallet NHS Treatment Centre

P23: Implement our digital strategy

P24: Introduce a new electronic patient record

P25: Launch an online booking system

P26: Develop a system for collecting and sharing outcome data

6 LP TW023 1, 6

LP 1,

6

LP EFM053, EFM046,

MD002

2,

4, 6

LP 1, 4 LP 1, 4 LP

1, 4

LP EHR001 1 LP EHR001

1,

3, 8

LP EHR001

1, 4 LP EHR001 6

P1: Demonstrate that we provide high quality care

1, 3, 6 LP TW002, TW023, UC006, UC005, EFM031, ED010, ED001, P002, F006, OG027, M022, M023, ED011

P2: Install a new ready built ward

LP TW023, ST010,

OTH001

1,

4

P3: Ensure safe patient flow through the hospital

LP TW023, UC006, ED010, UC005, P002, M021, ED001

1,

4, 6

P5: Standardise and showcase best practice

LP TW002, M021, ED011

3, 6

P6: Develop internal efficiencies/CIP so we can continue to develop services

LP F006 1,

4

P15: Commence the

enhanced primary care model

LP F006 1, 7

Appendix REPORT TO: Audit Committee, Governance Committee, Board of Directors REPORT BY: Head of Governance & Assurance PRESENTED BY: Director of Strategic Development and Company Secretary TITLE: Corporate Risk Register Report at end of Quarter Four – 2015/2016 DATE: 13 April 2016 What is this item about and what is the Board asked to do? The risk report aims to provide details of the key operational risks and activity from Quarter four 2015/2016 relevant to risks scoring Significant or Higher (12+) on the risk matrix. The risk report provides the necessary information for the Assurance Committees and the Board of Directors that is a fundamental part of the Governance arrangements required by Monitor and the Care Quality Commission. The Board of Directors is asked to NOTE the report and corporate risk register. Are there legal, financial, procedural, workforce implications and/or legislative requirements? • Legally? Yes. The Health and Social Care Act and Health and Safety at Work Act,

including Regulations apply to some risks

• Financially? Yes. Some of the issues discussed reflect the current position against Trust performance

• Regarding Workforce? Yes. Staffing risks are highlighted Is this paper clear for release under the Freedom of Information Act 2000 YES What are the next steps/future actions? The Corporate Risk Register is submitted to the Board of Directors on a quarterly basis. In Q1 2016/17, two new risks will be added to the corporate risk register: • A risk to take account of moving to a PbR contract with the Somerset CCG (including

risks to the Trust’s financial position as well as the need to change internal process).

• Risks relating to the outcome of the CQC inspection (expected in May 2016).

Links to the Trust’s straegic objectives and/or priorities: The report identifies key areas of risks under subheadings: • Operational pressures • Clinical • Corporate Links to the Board Assurance Framework/Corporate Risk Register (if applicable): Reference to CQC domains: [safe, effective, caring, well-led, responsive] Well Led – Does the governance framework ensure that responsibilities are clear and that quality, performance and risks are understood and managed? The Corporate risk register and documents setting out how strategic risk is managed, this should make clear the trust's highest risks related to quality of care and treatment Regulation 17: Good governance 17.—(1) Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. (2) Without limiting paragraph (1), such systems or processes must enable the registered person, in particular, to— (a) assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services); (b) assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity; Report history: Since the completion of the quarter four risk register, a number of updates have been made which will be reflected in the quarter one risk register Further to my email below, please find below updates I have received and who I have received these from: • EFM046 – Fire Compartmentation and Fire Stopping Survey complete February 2016

which will now be used to progress the review of Fire Risk Assessments by end Sept 2016. Fire Strategy building plans have been updated across the hospital site which are used to direct departments to safe areas. Evacuation plans have been developed for all departments which are located in departments under management control. Records of Fire Risk Assessments, building plans and safety works are held in separate systems which don't link without manual input taking excessive time to update. An IT based system is currently under review to improve recording and linking to risk priorities thereby creating a more efficient flow and priorisitation of fire safety works. All building works are subject to fire strategy review with areas being upgraded as part of projects. EAU and New SCBU area meet HTM Firecode Standards.

• M021 – Confirmation that this post has now been filled and new psychologist starts 4th July 2016. Risk significantly reduced from 12 to 4 and no longer on Corporate Risk Register

• M023 –Locum in post for 12 months whilst Dr Bickerton seconded to Symphony role. Dr Bickerton keeping several existing clinical commitments and is providing extra/new clinics e.g. Young Adult and Pump clinics. Drs Fadl and Pramodh will be able to provide Ward Cover (either by ward round OR Golden Hour daily with the new rota which means patients will be seen more regularly. There is also better cover for Podiatry. Review after 3 months

• P002 – Positive meeting with new lead for CAMHS at SomPar on 31/3/2016. Confirmed that recruiting to Band 7 and Band 6 posts and reviewing structure for all of CAMHS provision. Also agreed that there is a need to SHARE care planning so all parties can understand best management for patients when they present. Agreed to share MPH protocols so YDH can review suitability. Explained that extended outreach service Mon-Sun 0800-2000 with liaison nurses working in house to compliment outreach teams - hope to have this in post by end of the Summer. Community based eating disorders tea - new posts including dietician. Kerry also keen to review "Oxford Triage" system for ED/adapt it and will ask both Trusts to review. Will be introducing robust training programme to include Junior Drs and nursing staff on rolling training courses. Band 7 secondment opportunity for nurse to work with Kerry to project manage all the proposed changes. Further CAMHS meeting 3rd week April 2016. Risk remains at high level until confirmation that changes have firmer dates attached - update following next meeting

• UC005 – ED – ED Consultant accepted 12 month fixed term position which commences in October 2016 with locum use until October. 2 additional doctors have started in ED and another 2 are in the pipeline. Respiratory - the Trust has recruited and Dr to commence employment in August 2016. Radiology – 2 Drs recruited – 1 starting April 2016 and the other June 2016. The post of Consultant Breast Radiologist is out to advert as the person recruited has left. Care of Elderly & FOPAS – an interview has been arranged with a candidate. The Trust will host a recruitment stand at the Geriatric Conference 11-13 May 2016 with the Recruitment Team and the Medical Director attending.

• UC006 – Advised further to discussion with Jonathan Higman and Maddie Groves the risk in its current form, which was developed to reflect a particular pressure in medicine at that time, to be replaced with a revised Trustwide risk which takes into account the risks associated with the agency cap and will flag up the risks in particular areas for instance ICU, theatre etc. New risk TW027 to risk register and UC006 has been archived.

This report presents the Corporate Risk Register as at 7 April 2016. Since the last update to the Board of Directors in January 2016, the following is noted:

• There are 25 Significant or High risks (12+) recorded at the time of this report on the Corporate Risk Register;

• 6 new significant risks were added in Quarter 4 – 2015/16, and; • 1 risk has been archived • It has been identified that 4 risks in the Quarter 3 2015/16 Corporate Risk Register

showed the ‘initial risk score’ and not the ‘risk score’, which has been reported to Information team to ensure the system is reviewed. This has been corrected in the Quarter 4 2015/16 Corporate Risk Register (Risks ED001, ED010, ST010, MD002, remain on the Risk Register)

To aid interpretation of the risks they have been grouped into three broad areas under the following headings:

• Risks that are linked to the level of operational pressure that the Trust has been

experiencing • A set of other clinical risks that would exist regardless of operational pressures • The remaining corporate risks

The table attached to this paper summarises the most significant risks and details the actions that are being taken to mitigate these. A full copy of the risk register can be found on YCloud – Click on this link The hospital continues to experience significant increases in pressure especially in times of escalation. This is manifesting itself in a set of risks that are linked to these. Broadly, these are: • Overcrowding in the ED when number of patients in the department exceeds 30 patients • Increased demand resulting in escalation areas open, cancellation of elective activity and

risks to quality of care; risks include falls, pressure ulcers, medication errors and staff sickness

• Inability to maintain safe staffing and safe services in times of escalation • Medical Patients being nursed in non-medical environments, lack of medical

support and lack of medical skills in workforce • In times of escalation, utilisation of Stage 1 recovery area of Gynae theatre as

Theatre admission, 2nd stage recovery and discharge area which can lead to poor patient experience, criteria for discharge compromised, staff undertaking roles which aren’t their primary responsibility could lead to mistakes and staff dissatisfaction due to ongoing pressures to utilise space

• No trained medical nurses leaving a risk to the safety of the women with medical disorders as cohort of patients on the ward are medically for discharge / medical, on the female surgical / gynae ward

• Lack of experienced qualified scrub staff due to difficulties in recruitment linked to general national shortages. Particularly difficult filling short term maternity and sickness backfill posts resulting in high agency use

• The risk associated with the delivery of RTT standards, resulting from the cancellation of elective surgery

• Nurse staffing vacancies resulting in budget pressures and reduced quality of services and inability to recruit experienced registered nurses and newly qualified due to reduced numbers of registered nurses available in the UK

• Orthopaedics - Lack of capacity to meet the Local Delivery Plan contract and National 18 week RTT Targets in our admitted pathway

• The risk of serious harm as a result of patent falls There are a series of other clinical risks that are not specifically linked to the operational pressures. These are: • Urgent Care – Consultant and Middle Grade Medical Staffing Vacancies • Management of the planned waiting list in Ophthalmology • Paediatrics – Increased demand for children with mental health needs. Insufficient

inpatient capacity and CAMHs support for children requiring acute admission to paediatrics

• Medicine – Best Practice Tariff (BPT) income and Quality of Service in Diabetes Clinical Psychologist left post and Somerset Partnership have not yet been able to replace. The Clinical Psychologist is part of the MDT and needs to be in place if we are to meet all the BPT criteria and receive payment

• Diabetes consultant capacity insufficient to meet needs of acute inpatient services • Lack of governance for the process for notifying, updating and removing care

plans for high risk patients on ADASTRA and special patient notes

The key corporate risk areas are as follows: • Financial Performance: Reduced income and increased costs resulting in less cash in

bank. The impact of running out of cash is that the Trust will not be able to meet its payment obligations

• Estates and Facilities - Ageing Fire Alarm Systems and building engineering systems do not prevent the spread of fire and smoke in an emergency which leads to evacuation delay and potential for evacuation areas to be compromised

• Security - NHS Protect Standards. The self-review tool assesses the Trust’s compliance against the 26 standards and the most recent assessment returned an Amber rating

• Electronic Health Record Trust wide – Failure to realise and agree the risk associated with implementation of the EHR project (Smartcare) to allow management decisions to be made on high risk areas

• Asbestos Contamination - It has been identified that there is asbestos contamination within the ceiling void on most wards and lift lobbies with the main tower building. Restricting safe access to essential services above ceilings

• Medical Devices - Key Performance Indicators for Medical Devices schedule services falling below acceptable targets

Symphony Risks are currently being recorded and managed within the programme with an intention to create a subsection on the Trusts risk register for next quarter reporting. The mitigating actions being taken to address each of these risks are detailed in the attached table.

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

1

Operational risks: Risk No Date

added Risk Description Risk

Score Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static

Moving towards risk

reduction MTH021 08/03/16

NEW Lack of experienced qualified scrub staff due to difficulties in recruitment linked to general national shortages. Particularly difficult filling short term maternity and sickness backfill posts resulting in high agency use

12 = Significant

08/03/16 Agency use to fill gaps where possible but understaffed lists will be cancelled to ensure patient safety. Actions outstanding: Action 1 - ongoing national and overseas recruitment including India Action 2 - use skills database to try and keep training staff throughout speciality Action 3 - awaiting confirmation of potential training line in budget to allow further increase in training capacity

Elective Care

Business Unit

4 = Moderate

UC006 28/08/14 Nurse staffing vacancies resulting in budget pressures and reduced quality of services Risk to the continued provision of quality services as a result of increased agency spend to maintain escalation capacity; financial risk above the budget of circa £100K per month

20 = High

14/01/16 Daily operational meetings focussing on facilitating discharge and closing escalation capacity; daily review of ward staffing levels to minimise use of agency nursing; discussion and daily operational management with CCG and other partner agencies. Action 6 - Opening of new ward and associated bed moves to reduce reliance on escalation areas, added after discussion with Jonathan Higman. Residual score agreed to be reduced as a result of adding action 6 and discussion with Jonathan Higman. From 12 to 9.

Urgent Care

Business Unit

9 = Significant

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

2

Risk No Date added

Risk Description Risk Score

Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static Moving

towards risk reduction

TW023 19/12/14 Clinical Trust-wide - Increased demand resulting in escalation areas open, cancellation of elective activity and risks to quality of care; risks include falls, pressure ulcers, medication errors and staff sickness.

16 = High

08/01/16 Actions complete in quarter: Action 3 - Use of 18 beds at Cookson Court to accommodate patients who require further rehabilitation or "time to think" who are medically fit for discharge Action 4 - Installation of modular ward to provide 24 additional acute beds Action 5 - Head of Patient Flow position appointed Action outstanding: Action 6 - Patient flow and escalation process updated and being rolled out Trustwide

HMT 9 = Significant

ED001

20/12/15 Overcrowding in the ED when number of patients in the Dept exceeds 30. This increases the likelihood of delays for patients due to the volume of patients. Co-ordination and ability to escalate can be compromised when the ED experiences overcrowding.

12 = Significant

07/03/16 Actions reviewed and update on progress. Actions complete in quarter: Action 2: New EAU opening on 8/2/2016 including an improved model of care for managing acute medical patients - will accept Medical Specialty patients directly. Action 3: Additional General Medical F2 recruited into evenings to meet demand. Action 5: Recovery plan in place to focus on ED Performance - shared with CCG - being monitored through the Weekly Patient Flow Meeting. Actions outstanding: Action 1: Review of escalation process and internal professional standards to support patient flow and reduce delays. Action 4: Additional ED Middle Grade recruited into evenings, focus will be on Rapid Assessment and Treatment of ambulance arrivals (Majors patients). Action 5: Recovery plan in place to focus on ED Performance - shared with CCG - being monitored through the Weekly Patient Flow Meeting.

HMT 12 = Significant

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

3

Risk No Date added

Risk Description Risk Score

Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static Moved

towards risk reduction

ED010 12/10/15 Escalation Area – CDUP - inability to maintain safe staffing and safe services in times of escalation

12 = Significant

12/03/16 Reviewed and re-allocated to Patient Flow sub area, in line with Matron Lead. Actions complete in quarter Action 1 - Develop local SOP for clarification of reporting and actions in hours and out of hours for staff to follow and be clear how escalation occurs and contact details. Including shift checklist for set up and maintaining CDUP in DSU on start-up checklist. Action 4 - Access fobs to be available at handover for Nursing staff to be included on checklist. Action outstanding: Action 6 - Hand Hygiene training in CDUP supported by visual cues with redesigned posters. Environmental audit to be carried out asap with actions accordingly.

HMT 9 = Significant

ST010 27/06/14 RTT - Insufficient capacity to prevent breach of RTT targets from December 2014, resulting in specialty and aggregate breach and significant numbers of patients waiting over 18 weeks. Risk has increased as a result of significant level of cancelled operations over Winter 2014/15

12 = Significant

08/03/16 Trajectory model developed with CCG – aim to deliver all specialities other than T&O by end of Qtr 3 15/16. Action plan developed alongside this with all business managers & costed. All ongoing pathways validated to ensure accuracy. Additional activity in key performance areas of concern continuing. Focused senior management input into understanding and improving the RTT position. More robust governance in place around RTT. Reviewing options to manage the orthopaedic backlog and also reviewing at executive level the bed modelling for electives with the aim to reduce the number of cancellations. Actions outstanding: Action 2 - Secure additional activity in general surgery and oral surgery, including outsourcing of work Action 3 - Recovery plans by specialty to be introduced and embedded. Action 4 - Determine actions to clear the orthopaedic backlog. Action 5 - To finalise IMAS tool for all specialties to better understand activity capacity and demand Action 6 - Training for admin and booking clerks on RTT

Elective Care

Business Unit / HMT

9 = Significant

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

4

Risk No Date added

Risk Description

Risk Score

Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static

Moved towards risk

reduction TW002 20/03/14 Clinical Trustwide -

Serious injury to patients at high risk of falls resulting in major harm

12 = Significant

12/01/16 New multifactorial falls risk assessment has now been rolled out Trust wide which is NICE compliant. Corporate action plan continues to be updated following discussion and development through the Falls Prevention Group. Falls Prevention Group to implement testing of new style hip protectors. Actions outstanding: Action 1 – Ongoing review of learning from RCA's. Ongoing monitoring of falls for trends through the Falls Prevention Group and monitoring progress against the Corporate Workplan Action 3 – Development of the older people’s service to provide targeted MDT support - business case developed, to enhance complex needs assessments and care planning. Bid put in for a band 6 post. Action 4 – Undertake audit of compliance with the falls risk tools and care plans

Falls Prevention Working Group / PSSG

6 = Moderate

TW025

25/03/14 Clinical Trustwide - Inability to recruit experienced registered nurses and newly qualified due to reduced numbers of registered nurses available in the UK.

12 = Significant

01/03/16 Nursing recruitment events overseas and Return to the Acute Care Environment (RACE) course commenced in 2015. Over recruitment of unregistered staff. Numbers of European Nurses have commenced employment within the Trust. Over recruitment achieved November 2015, but recruitment needs to continue in order to maintain levels and reduce agency usage. Still a risk due to IELTS requirement for EU and non EU registered nurses. Recruitment drive to India in January 2016, 140 interviews and 120 offered. As of February 2016 there are currently 10 WTE vacancies therefore the risk has reduced but remains a possibility. Actions outstanding: Action 3 – Recruitment campaign commenced, including overseas recruitment and Associate Director of Nursing now has overall responsibility Action 6 – Active recruitment of unregistered staff as now significant gaps.

HMT 6 = Moderate

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

5

Risk No Date added

Risk Description

Risk Score

Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static

Moved towards risk

reduction OTH001

16/04/14 Orthopaedics - Lack

of capacity to meet the Local Delivery Plan contract and National 18 week RTT Targets in our admitted pathway.

12 = Significant

11/03/16 Dec 2015 - Feb 2016. Significant reduction in elective activity, particularly joint replacements, due to ongoing increase in Urgent Care demand for beds. Efforts are being made to re-establish the restricted access criteria to 6A. This will commence with temporary phasing (5 side rooms and 1 bay will initially provide clean elective beds by reverse barrier nursing orthopaedic patients). SOP for 6A has been reviewed and signed off by Infection Control Team. This is a temporary solution and every effort will continue to restore 6A to restricted access elective ward as soon as possible to enable Trust to manage our elective pathways. Continues to be risks with delivery due to cancellations with emergency demand. Actions complete in quarter: Action 3 - Demand and Capacity Modelling is currently being undertaken to confirm our "as is" position against contract. There is internal and county wide CCG modelling underway. Tool completed but is an ongoing live document. Action 5 - Business plan has been submitted requesting Saturday operating lists: approx 42 per year in addition to consultant substantive contract. Constraints include: lack of theatre staff & reduced access to arthroplasty beds due to breaching 6A bed criteria. Funding agreed. Actions outstanding: Action 1 – Weekly reporting and monitoring of RTT position. Feedback to Strategic Business Unit and Trust Board. Action 2 - Review options to clear orthopaedic backlog. Action 6 - Staffing of theatres to support Saturday operating and confirm medical cover.

Elective Care

Business Unit

6 = Moderate

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

6

Clinical Risks: Risk No Date

added Risk Description Risk Score

Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static Moving towards risk reduction

MTH020 05/03/16 NEW

In times of escalation, utilisation of Stage 1 recovery area of Gynae theatre as Theatre admission, 2nd stage recovery and discharge area which can lead to poor patient experience, criteria for discharge compromised, staff undertaking roles which aren’t their primary responsibility could lead to mistakes and staff dissatisfaction due to ongoing pressures to utilise space

12 = Significant

05/03/16 Concerns raised by recovery staff, incident reports and patient complaint. Existing controls include daily bed meetings assessing demand for Jasmine, daily review of theatre demand for gynae theatre (patient volume, patient urgency category procedure, likely duration of stay), team brief pre operating session describing patient group, formulating plan for flowing patient across session, staff allocation to Gynae Recovery, Band 6 in place, Band 7 lead based in Main theatre. Ability to escalate to both Matron and Business Manager. Action complete in quarter: Action 2 - Implementation of AM huddle – Band 7 lead and team lead for Gynae theatre. Action Outstanding: Action 1 - SOP setting criteria for utilisation of Gynae Recovery as Admission, 2nd stage recovery and discharge area.

Elective Care

Business Unit

4 = Moderate

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

7

Risk No Date added

Risk Description Risk Score

Date last reviewed

Progress Has deteriorated

Where Reviewed

Residual Risk

Static Moving

towards risk reduction

M023 14/03/16 NEW

Diabetes Consultant capacity insufficient to meet needs of acute inpatient services

12 = Significant

14/03/16 16 - 20% of inpatients have Diabetes as a secondary reason for admission. Diabetes Nurse team requires additional support from Consultant due to complexity of patients. Action Outstanding: Action 1 – Medical Governance meeting to include discussion around this risk and how this is managed and reduced. Action 2 – Develop a Business Case for an additional Consultant Action 3 – Locum cover to be provided discussed with Simon Sethi and Sian Jones - use of Vanguard finances Action 4 – Ongoing review of workplans - outpatient activity reviews ongoing

Urgent Care

Business Unit

6 = Moderate

ED011 14/03/16 NEW

Lack of governance for the process for notifying, updating and removing care plans for high risk patients on ADASTRA and special patient notes

12 = Significant

14/03/16 Trying to maintain paper copies of care plans within the department, however not always informed of a plan being added, updated or removed on the system. Some patients also have more than one plan on the system and it is not clear which should be followed. Internal specialist teams have been asked to review their plans. Action Outstanding: Action 1 - Reconvene SPN project group Action 2 – Contacting Somerset Partnership for updated plans for those patients known with existing plans that are currently out of date Action 3 – Further communications required to inform specialist teams of ADASTRA and SPN before it goes

Urgent Care

Business Unit

6 = Moderate

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

8

Risk No Date

added Risk Description Risk Score Date last

reviewed Action / Progress Has

deteriorated Where

Reviewed Residual

Risk

Static Moving towards risk reduction

UC005

30/06/14 Urgent Care – Consultant and Middle Grade Medical Staffing Vacancies

16 = High

27/05/15 Action outstanding: Action 3 - Talking to CCG to review additional costs in Urology and Dermatology.

Urgent Care

Business Unit

9 = Significant

SBUV008 18/11/14 Inconsistencies of Management of the planned waiting list in Ophthalmology and Endoscopy

15 = High 12/01/16 Back log issues were not identified by electronic systems. Risk updated with Jonathan Higman. New actions added: Investigation of current management Trust wide Review of Access Policy Review of Standard Operating Procedure – training and education of admin and booking staff. Endoscopy element removed and will be added as a separate risk. Comprehensive action plan pulled together to address backlog of follow ups in Ophthalmology. There are currently 6 actions outgoing/pending. It is anticipated that all actions will be completed by the end of March 2016.

Elective Care

Business Unit

9 = Significant

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

9

Risk No Date added

Risk Description Risk Score Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static

Moving towards risk

reduction P002 18/05/15 Urgent Care - Paeds

– Increased demand for children with mental health needs. Insufficient inpatient capacity and CAMHs support for children requiring acute admission to paediatrics

15 = High 01/03/16 Risk score increased. Ongoing discussion with CCG regarding service provision. Training has been instigated from specialist services support. Modular accredited training for senior team member identified&commenced. Need to review all vacancies and align to activity and capture CAMHS activity. Patient risk assessment & placement /observation policy to be review at March's PSSG meeting. Actions outstanding: Action 1 – Review of admission criteria to paeds&young adults service by Head of Ops, ADN Patient Safety/Quality, Matron Paeds. Update - Jo Howarth in communication with operational lead Mandy Carney regarding suitability&admission criteria for all Mental Health admissions within 0-25 yrs amended completion date for this. Action 3 – Implementation of patient risk assessment &placement/observation policy. Update-Observation Policy in draft to go to PSSG meeting. Action 4 – Development of protocol for the management of long stay inpatients requiring CAMHs support with Head of Contracting, Joint Commissioner for Mental Health, CAMHs Lead, Matron for Paeds, Named Nurse for Children's. Update - Anna met with CCG&others & is progressing in house liaison service for urgent presentation of mental health corporately until in place will remain an action. Action 5 – Collate admission data on Mental Health admissions onto Ward 10 - to support evidence of need to CCG&others. Update-To collate admission data&activity&report to appropriate Governance meeting for monitoring. Anna discuss with Gaynor Appleby Adult Mental Health Lead and Director of Nursing requirement for a generic Mental Health practitioner for global support&teaching instead of employing on Ward 10 from current establishment.

Urgent Care

Business Unit

12 = Significant

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

10

Risk No Date added

Risk Description Risk Score Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static

Moving towards risk

reduction M021 10/08/15 Urgent Care –

Medicine – Best Practice Tariff (BPT) income and Quality of Service. Clinical Psychologist left post and SomPar have not yet been able to replace. The Clinical Psychologist is part of the MDT and needs to be in place if we are to meet all the BPT criteria and receive payment

12 = Significant

10/03/16 At present reliant upon SomPar successfully recruiting to their vacancy as we would be very unlikely to secure our own cover for 0.4wte if we would be to advertise ourselves. Contact made with lead in Dorset to ask for their help if we are unsuccessful with Somerset so have the beginnings of Plan B but do not want to progress until Somerset have exhausted all their possibilities. The business manager is monitoring the CCG situation. Linda Deeley informed YDH that Som Par have shortlisted two strong applicants with interviews on 9th March. Jo Kennington (YDH) on the interview panel. Await outcome as soon as it has been agreed.

Urgent Care

Business Unit

9 = Significant

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

11

Corporate Risks:

Risk No Date added

Risk Description Risk Score Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static Moving towards risk reduction

OG027 07/03/16 NEW

No trained medical nurses leaving a risk to the safety of the women with medical disorders as cohort of patients on the ward are medically for discharge / medical, on the female surgical / gynae ward

12 = Significant

07/03/16 Reviewing staffing on a daily business, alerting Director of Nursing and Director responsible for staffing trust wide. Action Outstanding: Action 1 - Meet with Maddie Groves, Associate Director of Nursing to formulate action plan

HMT 12 = Significant

M022 09/03/16 NEW

Medical Patients being nursed in non-medical environments, lack of medical support and lack of medical skills in workforce

12 = Significant

09/03/16 Existing controls in place include daily bed meetings (x3) where risk and discharge discussed and monitored, additional medical support provided (locum medic and Twilight Clinical Site support added) and escalation plan in place. Actions complete in quarter: Action 2 – 12 beds on 7A been identified for patients to be managed by Gastroenterology and Endocrinology team, these patients have been assessed as low risk medical patients Action 3 – 6B have 6 beds identified to be covered by Care of Elderly Consultant these patients will be assessed as moderately low risk Action 4 - Jasmine Ward being used for Medically Fit for Discharge - assessed internally prior to move Action outstanding: Action 1 - New ED Consultant to commence at end of April

HMT 9 = Significant

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

12

Risk No Date added

Risk Description Risk Score

Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static

Moving towards risk

reduction F006 01/10/15 Financial

Performance: Reduced income and increased costs resulting in less cash in bank. The impact of running out of cash is that the Trust will not be able to meet its payment obligations.

20 = High

12/01/15 The Trust is working with Monitor to identify loans required to support 2016/2017 Trust plans Sheena Morrow reviewed the risk with Tim Newman and the risk was increased to a high risk after controls and gaps identified.

HMT 8 = Significant

EFM046 28/11/14 Estates and Facilities - Ageing Fire Alarm Systems and building engineering systems do not prevent the spread of fire and smoke in an emergency which leads to evacuation delay and potential for evacuation areas to be compromised.

15 = High

11/01/16 Working with Strategic Partner to survey L2 Fire Stopping. Fire doors replaced on L2 £182,000 allocated 15/16 for Fire Alarm upgrade. Fire stopping checks completed on L2, training increased for Fire wardens and key staff. Fire alarm upgrade plan being reviewed. Prioritised plans in place to mitigate risk. Progress with Fire Compartmentation survey across all areas of Hospital taking place from 12/15 until 03/16. The compartment-tation survey will provided prioritised actions for upgrading building safety which will allow develop-ment of Fire Risk Assessments. Number of streams of works being undertaken including Fire Damper survey with Fire Doors being prioritised as a result of the compart-mentation survey. Work plan now in place to prioritise building areas from Surveys and Fire Risk Assess-ments. Number of upgrades taking place on the Fire Alarm system: 1 changeover all alarm cause &effects to new system and upgrade key areas of the hospital buildings including the Deep Duct, Logistics department, ED & the Ground Floor level of Women's Hospital. Upgrade plans for Fire Alarm system will be developed for the forthcoming years prioritised against risk. Level of risk remains significant 3 x 5=15 until surveys and Fire Risk Assessments are completed. Reporting to Quality Committee remains in place.

Health and Safety

Committee

5 = Low risk

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

13

Risk No Date

added Risk

Description Risk

Score Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static Moving towards risk reduction

EFM031 11/12/13 Security - NHS Protect Standards self-review tool completed and has identified overall Trust risk as Amber. The self-review tool assesses the Trust’s compliance against the 26 standards and the most recent assessment returned an Amber rating

12 = Significant

01/03/16 From July 2015 NHS Secure are providing LSMS cover for the Trust. A review and submission of the annual Violence and Aggression (VAS) report has been sent to NHS Protect as an annual report to NHS England. Reporting of incidents has been reviewed and LSMS is working with Clinical Governance to improve reporting and data capturing processes with involvement of Matrons and Ward Managers. Investigations have been taking place and warning letters to patients and others who threaten violence or who are verbally abuse staff are being sent with visits as necessary. The Violence and Aggression Policy has been updated and procedures strengthened in this area. At the end of November a Self-Review Tool (SRT) is being developed to report to NHS protect, this report will include an action plan going forward into 2016. 4 Hour Conflict Resolution Training (key to complying with NHS Standards) started in November 2015 with a training programme being developed to target the high risk staff groups and departments identified from incident reporting. Induction and Mandatory training includes awareness conflict resolution training which has been updated by the LSMS. Actions complete in quarter: Action 1 - SRT work plan to be monitored through Security Committee and submitted to NHS protect and CQC. Latest one to be submitted November 15 which indicated the overall Trust as Green however some areas remain amber which is being picked up 2016 work plan, such as policies to be reviewed and training to be delivered as part of this plan. Action 3 - Developing a suitable Conflict Resolution Training programme to commence 2015 Action outstanding: Action 6 - Security Policy and Procedures to be updated

Security Committee

6 = Moderate

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

14

Risk No Date

added Risk

Description Risk

Score Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static Moving towards risk reduction

EHR001 17/04/15 Electronic Health Record Trust wide – Failure to realise and agree the risk associated with implementation of the EHR project (Smartcare) to allow management decisions to be made on high risk areas

12 = Significant

13/01/16 Action complete during quarter: Action 4 - Operational risks – addition of change mgr with an operational background to ensure good links with operational teams and knowledge. Addition of dedicated operational lead roles for inpatients and outpatients to ensure operational processes and risks are owned and managed - complete Actions outstanding: Action 1 - Agree a risk reporting process to Board level committee to communicate risk and agree level of acceptable risk as implementation progress goes forward for Assurance. Action 2 - Clinical safety and risks – established core group of clinicians to own and drive clinical safety and risk management within each area. Formal training is being provided in Jan to equip this team with the knowledge to perform this effectively. – in progress Action 3 - Clinical working group – dedicated clinician group to sit below CDA to allow for more detailed sessions relating to process and risks with changes – in progress Action 5 - Specialty steering groups setup - steering groups within each area to identify and manage risks within in each area – in progress

EHR Team 6 = Moderate

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

15

Risk No Date added

Risk Description

Risk Score

Date last reviewed

Action / Progress Has deteriorated

Static

Moving

towards risk reduction

Where Reviewed

Residual Risk

EFM053 23/07/15 Asbestos Contamination - It has been identified that there is asbestos contamination within the ceiling void on most wards and lift lobbies with the main tower building. Restricting safe access to essential services above ceilings

12 = Significant

07/03/16 At present cannot access key areas above ceilings without using a specialist contractor. Risk - if a heating issue, blocked drain, water leak can’t quickly access the area to resolve the issue, which could mean clinical areas flooded and disrupt the hospitals operations/closing wards etc. Additionally water circulation problems in areas of the site which require investigation which entails removing asbestos ceilings. Unable to remove due to recent operational pressures, leading to an increased legionella risk in these areas. Applied for an additional £120,000 in next year’s asbestos budget to allow us to tackle these issues. Asbestos 2016/17 budget under review and still to be agreed. Provisional agreement in place with Senior management to free up one ward for refurbishment this year which will enable asbestos removal. Operational pressure still high and therefore access still an issue Actions outstanding: Action 1 - Identify specific areas of contamination Action 2 - Agree programme of works to decant wards to allow removal of ACMs Action 3 - Remove/encapsulate asbestos on lift lobbies.

Estates and

Facilities

6 = Moderate

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

16

Risk No Date added

Risk Description

Risk Score

Date last reviewed

Action / Progress Has deteriorated

Static Moving towards risk reduction

Where Reviewed

Residual Risk

MD002 03/09/15 Medical Devices - Key Performance Indicators for Medical Devices schedule services falling below acceptable targets. Devices that are passed service date, which include high risk devices. Failure to comply with good practice guidance (MHRA) April 2015. Failure to comply with manufacture instructions

12 = Significant

01/04/16 Some progress has been made and we are now measuring the level of backlog to monitor the position: December 2015 Schedule service completion 85% Backlog 104 January 2016 Schedule service completion 67% Backlog 67 February 2016 Schedule service completion 81% Backlog 55. Unable to recruit the band 5 technician 14/3/2016 due to visa issues. This was immediate and will affect the on-going action plan whilst we recruit/replace and train a replacement. We have another staff member that will be having planned leave (operation) for 2/3 months from mid-March. This will mean they are unavailable for the period. Process of moving one of our new band 3 staff into a development post to replace the band 5 vacancy as unable to recruit an experienced band 5 technician. Will then recruit and replace them with a Band 3 ASAP. Only completed 59% of scheduled services due for March, with an outstanding backlog of 107 Work requests. Expectation is that the schedule service completion will fall and the backlog will increase over the coming months. Technical cover will also be an issue, and for some devices may be in a position where unable to support them for periods, or support will need to be provided by manufactures. There may be impact with the associated time delays and additional costs attached to this. Our focus will be on maintain service provision and schedule servicing of High Risk devices. Actions completed in quarter: Action 1 - Push forward recruitment of the two band three posts and to ensure induction and device training. Second advert has closed. Interviews planned for early December. Replacement band 3 post in place. Additional band 3 post recruited and due to start shortly. Action 3 - Possible recruitment of agency staff (technicians) to review lower spec equipment until band 3 staff are fully

HMT 9 = Significant

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

17

trained. We have been unable to recruit currently, but have requested the agencies to continue to look for candidates. Actions outstanding: Action 2 - Space provision for staff as currently not enough room to accommodate. Project manager (Estates & Facilities) is currently reviewing options. Action 4 - Increase level of service contracts which would realise technician time, although this would have a financial implication on the Trust

Corporate Risk Register – Quarter Four 2015/2016 Updates since Quarter 3 2015/16 are in bold

18

Risks Reduced/Archived from the Risk Register since last Board review:

Risk No Date added

Risk Description

Risk Score Date last reviewed

Action / Progress Has deteriorated

Where Reviewed

Residual Risk

Static Moving towards risk reduction

TW003 ARCHIVED

RISK

19/03/2014 Clinical Trustwide - Failure to implement actions for patients at risk of developing pressures ulcers whilst in hospital resulting in skin deterioration, extended length of stay and expose to infection control risk

12 = Significant

01/03/16 Risk reviewed and remains significant risk. Action 1 removed and marked as completed as it is the same as action 2. Action 3 added: Increase in pressure relieving resources including heel protectors, hybrid mattresses and high risk cushions which was completed in December 2015. Risk Score (after controls and gaps have been identified) changed from 4 Likely x 3 Moderate to 3 Possible x 4 Major. Changed by Jo Howarth. Risk archived - All actions complete. The risk remains as 6 - low risk and managed through Trustwide and ward action plans. This is also reviewed bi-monthly at the Pressure Ulcer Steering Group.

Pressure Ulcer

Steering Group

reporting to the Patient

Safety Steering Group

6 = Moderate