agenda - part 1 · 2019-03-01 · board of directors . wednesday 25 november 2015 at 14:00 - 17:30...
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BOARD OF DIRECTORS
Wednesday 25 November 2015 at 14:00 - 17:30 Boardroom, Level 1, Yeovil District Hospital NHS Foundation Trust
AGENDA - PART 1
Presenter Timings Enclosure 1 Welcome and Apologies for Absence PW 14:00 Verbal 2 Declarations of Interest Relating to Items on the Agenda All Verbal 3 To Hear a Patient Story (Sepsis Guidelines) and to Receive
Feedback on Actions from the Patient Story from 21 October 2015 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 EY
14:05 Presentation
4 To Approve the Minutes of 21 October 2015 and Discuss
Matters/Actions Arising PW 14:30 Appendix 1
5 To Receive a Verbal Update and the Minutes from the
Workforce Committee Held on 29 October 2015 and to Approve its Terms of Reference
MS/TN Appendix 2
6 To Receive a Verbal Update from the Governance
Committee Held on 6 November 2015 JHend Verbal
7 To Discuss and Note Items from the Executive Director
Report PM 14:50 Verbal
8 To Discuss and Note the Update on Symphony and New
Models of Care PM/JM 15:10 Appendix 3
Break – 15:30
9 To Discuss and Note the TrakCare Highlight Report JMac 15:45 Appendix 4 10 To Review and Note the Quality, Operational and Financial
Performance Report and to Receive a Verbal Update from the Last Financial Resilience and Commercial Committee
PM/TN SS/JHIG
16:00 Appendix 5
11 To Receive the Research and Development Annual Report
and to Approve the Operational Capability Document TS 16:30 Appendix 6
12 To Note the Safer Staffing Report and to Review Feedback
from iwantgreatcare.com HR 16:45 Appendix 7 &
Presentation
13 To Approve the Following Policies: • Fit and Proper Persons – Directors
JR 17:00 Appendix 8
14 To Review and Note the Q2 Board Assurance Framework JHIG
JR 17:10 Tabled
Presentation 15 Any Other Business and Meeting Close
PW 17:20 –
17:30 Verbal
16 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.
17 Date and Time of Next Meeting
16 December 2015 in the Boardroom, Level 1, Yeovil Hospital
APPENDIX 1 BOARD OF DIRECTORS
25 NOVEMBER 2015
BOARD OF DIRECTORS DRAFT
Minutes of the Board of Directors Meeting held on Wednesday 21 October 2015 at Yeovil District Hospital
Present: Peter Wyman Chairman Maurice Dunster Non-Executive Director Julian Grazebrook Non-Executive Director Jane Henderson Non-Executive Director Paul von der Heyde 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 Tim Scull Medical Director In Attendance: Berge Balian Associate Medical Director [Until item 1-138/15] Jonathan Higman Director of Strategic Development Jason Maclellan Chief Information Officer [Item 1-135/15] Jeremy Martin Symphony Programme Director [Item 1-134/15] Jade Renville Company Secretary Simon Sethi Interim Director of Urgent Care & LTC John Webster Public Governor Apologies: Leah Allen Director of Elective Care
Ref: No Action 1-
128/ 15
1 1.1
WELCOME AND APOLOGIES FOR ABSENCE Peter Wyman welcomed everyone to the meeting, particularly John Webster, public governor observer, and Simon Lilley, Commercial Director, Berge Balian and another member of staff observing in the audience. Apologies were received as noted above.
1-129/ 15
2 2.1
DECLARATIONS OF INTEREST Peter Wyman declared that he is Treasurer and Vice-Chairman of the Council of the University of Bath.
1-130/ 15
3 3.1
PATIENT STORY Tim Scull introduced an F2 doctor, who spoke of what they had learned from treating an older patient who had other complex conditions. They explained that they fully assessed the patient and made interventions appropriate to the condition with which they presented. The situation of the patient quickly deteriorated and the patient was moved to ITU at which point the registrar was called and, in discussion with the family, it was agreed the patient would receive only palliative care. The F2 doctor said the key learning had been to reflect earlier in the process whether intervention is required and to ensure a ward based plan is in place for her patients, including an indication of the patient’s wishes in respect of DNR, taking into account their full range of conditions. The non-executives acknowledged it is important to reflect and make improvements to practice based on hindsight.
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However, they (and the Board level clinicians) supported the decisions the F” doctor made at the time based on the information available. The Board asked about the feedback mechanisms where these experiences are discussed. Tim Scull advised that a debrief occurs at the time and that there is a near misses group. He added that work is ongoing with the senior medical workforce to ensure the feedback they give to junior doctors is done in a constructive way and that junior doctors continue to feel able to share concerns / difficulties in an open and honest way. Peter Wyman commented on the levels of responsibility assumed by junior doctors and asked the F2 doctor whether they felt supported by the Trust. They said that they did, especially in medicine, but suggested the process for escalation in specialities other than medicine should be clarified.
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4
4.1
4.2
4.3
MINUTES OF THE PREVIOUS MEETINGS Board of Directors The minutes of the meeting held on 29 July 2015 were approved as a true and accurate record subject to the removal of the word “minor” at 1-120/15. Governance Assurance Committee The Board noted the minutes of the meeting held on 17 July 2015. Commenting verbally on the meeting held on 14 October 2015, Jane Henderson said that the Committee received an update on progress with the action plan arising from the Royal College Obstetricians and Gynaecologists Report (particularly around improving leadership and teamwork), considered the Quality Improvement Strategy, the YDH action plan being implemented in response to the Lampard Report and reviewed the Quality Committee quarterly update (with a detailed discussion about the quality of ESR data). She said that they also reviewed in detail the Patient Safety, Quality and Experience Report, highlighting in particular that there was discussion about the levels of falls and ways in which patients can be protected from significant harm if they suffer a fall while in hospital. She said that the Q2 corporate risk register was also scrutinised. Audit Committee The Board noted the minutes of the meeting held on 17 July 2015. Commenting verbally on the meeting held on 14 October 2015, Paul von der Heyde said that the Audit Committee reviewed the internal audit reports into information governance and consultant job planning, the recommendations from which are being implemented by the key leads. He said that there are also a number of actions from older internal audits and counter fraud exercises which are overdue for implementation by the HR team, which Tim Newman would follow-up with them. It is now aimed for the actions to be completed by January 2016. Paul von der Heyde advised that they also reviewed documentation from the counter fraud service (from which no major issues were identified), the policy for the development and management of procedural documents, the finance report, the Q2 corporate risk register and annual reports relating to fire, health and safety and violence and aggression. He highlighted an action from the latter, saying that consideration is required whether to provide staff with more conflict resolution training, which Tim Newman would follow-up.
JR
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1-132/ 15
5 5.1
ACTION SHEET All actions were marked as completed, in progress or not yet due. It was agreed that action 1-15/15 in relation to staff turnover, would be reviewed on an ongoing basis by the Workforce Committee [item 1-136/15 refers] and therefore deleted from the Board action sheet.
1-133/ 15
6 6.1
6.2
6.3
6.4
6.5
EXECUTIVE DIRECTOR REPORT Paul Mears, Helen Ryan and Simon Sethi presented highlights from the executive director report, from which the Board noted: • The Remedial RTT Action Plan Failure to Agree Notice from the Somerset
CCG together with the response from YDH. In addition to ongoing dialogue with the Somerset CCG on the RTT recovery plan, the remedial action plan has now been provided to the Somerset CCG. Progress will be jointly monitored by the Somerset CCG and YDH and Monitor would also be informed as part of routine reporting processes. Jonathan Higman spoke of the potential financial impact of recovering the position, which will be reviewed in detail at the Financial Resilience and Commercial Committee in November 2015. A joint plan for managing winter pressures would also be essential to mitigate the risk of further backlog building over the winter period [item 1-138/15 refers].
• There remains uncertainty nationally regarding the proposed changes to the junior doctor contract and a number of marches in protest had been held by doctors across the country. Tim Scull had not been made aware of any major concerns being raised locally but the Board agreed that the Trust should continue to seek awareness of developments and to consider any implications for YDH and its junior doctors.
• The Severn Deanery visited YDH for their annual review of training
standards informed by the GMC survey of trainees. Overall it was a positive visit although they noted areas requiring improvement in both medicine and surgery, chiefly around workload and clinical supervision for foundation trainees, plans for which are being implemented. It is recognised that YDH is at a geographical disadvantage with the survey as it is understood anecdotally that many doctors who are placed at YDH may prefer to be placed in a cosmopolitan location, such as Bristol and these expectations have to be managed. The Severn Deanery has said that they will arrange a follow-up visit in circa six months. Paul Mears said that the executive team has recognised the pressure which junior doctors are under and in recent months and approved a number of support schemes. Mark Saxton said that he had recently read a report from Hays about managing an inter-generational workforce which he would share with Tim Scull as it may offer some additional insight. Tim Scull added that Consultant Nader Frances is now the lead for clinical education and he will work with the junior doctors and obtain more frequent feedback from them which going forwards could be immediately acted upon.
• The Care Quality Commission (CQC) has confirmed that they will be undertaking a comprehensive inspection of YDH from 15-17 March 2016, a seminar session on which would take place this afternoon.
JHIG
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6.6
6.7
6.8
6.9
• There have been a range of announcements nationally in respect of nursing, including advice to trusts to look at staffing in a flexible way which is focused on the quality of care, patient safety and efficiency rather than just numbers and ratios of staff, a consultation on proposals to cap the rates for agency staff and an agreement from the government to place nurses on the “shortage occupation list” on a temporary basis pending a full review by the Migration Advisory Committee. The latter was positively noted by the Board and Helen Ryan said the Trust would now consider overseas recruitment from India where there is a surplus of highly qualified nurses. In terms of the proposed cap on agency spend, the Board welcomed the framework which, as long as it is adhered to, should support a reduction in agency staffing expenditure. Following questions from the non-executives, Helen Ryan confirmed that there is some flexibility to use off-framework agencies on a shift by shift basis if not doing so would compromise the quality or safety of care. In such cases, Monitor would be informed. Ultimately, the safety and quality of care would remain the Trust’s priority.
• Sally Shead, Director of Quality, Dorset CCG, visited YDH on 8 October 2015 and it is was a positive and constructive visit.
• The items within the enclosed report in relation to urgent care.
As part of the Dorset acute services review, Jon Howes said that that the Dorset CCG had requested a meeting with YDH and Dorset County Hospital NHS Foundation Trust regarding paediatric services. It was a constructive meeting and will be followed-up with a written survey. Jonathan Higman confirmed he would ensure ongoing engagement in the process.
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7 7.1
7.2
7.3
SYMPHONY AND NEW MODELS OF CARE Jeremy Martin was welcomed to the meeting to present an overview from a programme management perspective of the Symphony Project and developing new models of integrated care, the key points of which were noted by the Board as follows: • A range of active working groups (complex care, enhanced primary care,
joint venture (finance and governance) and urgent and elective care) are overseen by the Symphony Programme Board.
• Good progress is being made with the complex care and enhanced primary care workstreams. Referrals to the complex care hub have increased since the publication of an information sharing agreement with primary care although further work is to be done to encourage a greater numbers of referrals. Accepting that the numbers are fairly low at this early stage of development, initial data from the hub is showing positive outcomes in terms of fewer admissions and reduced length of stay for its patients compared with their data last year. Five practices are now piloting the enhanced primary care model and are appointing health coaches. The non-executive directors asked about the role of health coaches and it was confirmed that they do not need to have had clinical training and their role will be to support a defined set of patients with one or more long term condition with care co-ordinating and planning. Many practices are recruiting to the role from within their practice and then backfilling those posts from Symphony. Jeremy Martin agreed to share the job description for the health coaches with Mark Saxton and Jane Henderson.
JMartin
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7.4
7.5
7.6
7.7
• The urgent and elective care groups are in the process of being
established and developing work plans.
• The joint venture work is progressing but some risks have been identified, including: agreeing a way forwards with the Somerset CCG on outcomes based commissioning in a way that supports the Trust’s timeline, working with the national team on key issues such as VAT, underwriting and regulation, and finding the best way to engage with partners locally on their relationship with the joint venture. At a future meeting of the Board there will be further update on the proposed structure of the joint venture and how the governance arrangements will correspond with those of YDH to ensure the Trust Board receives the requisite levels of information and assurance.
• A Project Manager has been put in place to support the management of
the programme, working with Jeremy Martin.
• In terms of the transformation fund issued nationally to YDH, there was a milestone that by Christmas 2015 the Trust would have in place its second complex care hub. Accepting the time it took to receive the first tranche of the transformation fund, the second hub may not be fully developed by Christmas 2015.
1-
135/ 15
8 8.1
8.2
TRAKCARE HIGHLIGHT REPORT Jason Maclellan presented an update on the implementation of the electronic health record, TrakCare. He said that the project status is amber as the risks that had resulted in a red rating the previous month had broadly been mitigated now the go-live date had been set for spring 2016 rather than November 2015. He confirmed that high level planning has been completed based on the revised go live date but further details are still to be finalised. The non-executive directors asked whether the CQC inspection in March 2016 would impact on the new implementation timetable. The response was that detailed planning would take account of the CQC inspection but that the Trust must continue “business as usual” irrespective of its occurrence. Mark Saxton questioned whether the project status should be amber given that detailed plans have yet to be developed and little has changed since last month other than the go-live date. On balance the Board agreed that the status should remain amber on the basis that it continues to receive monthly updates and that plans are in place and being developed in order to mitigate risk. Paul von der Heyde asked whether there were any legal, contractual and/or financial implications of the delay, and Jason Maclellan provided assurance that there would not be any adverse implications of this type and although the profile of the payments may vary aligned to the new timeframe. There had been improved input and support onsite from InterSystems but the healthcare architect supplied by them had returned home abroad and a replacement had not yet been confirmed, which would be followed-up with InterSystems. Jason Maclellan said that YDH sent six people to support the North Tees go-live on the 19 October 2015. The visit provided a valuable learning experience, some of the key points of which were highlighted as: ensuring there are enough floor walkers to support staff with the transition and enough time for training and testing. It was also noted that the attitude and approach of staff at North Tees during the switch-over was good.
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1-136/ 15
9 9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
QUALITY, OPERATIONAL AND FINANCIAL PERFORMANCE REPORT The Board reviewed the previously circulated report, from which it was discussed and noted that: Operational and Quality Performance A presentation of the Trust’s mortality data would occur later in the meeting and was therefore not repeated here [item 1-137/ 15 refers]. The Board asked Helen Ryan about the levels of falls and pressure ulcers which had increased compared with the same period last year. She said that work is ongoing to review the incidences of falls and pressure ulcers and to ensure there remains an ongoing focus on improvement. She said that performance is considered every month at the Trust’s safety thermometer. Jane Henderson said this had been reviewed in detail at the Governance Committee and asked whether YDH shares examples of best practice with other areas. Helen Ryan said that YDH is part of local and regional networks where learning is shared and said that representatives have also visited other trusts, such as Salford, in order to learn from their positive work. Helen Ryan spoke of the six cases of C.Difficile cases, two of which were due to lapses in care, which is below the Trust’s target threshold. Nevertheless, focus is being maintained and targeted work is underway to raise awareness of appropriate levels of antibiotic prescribing (which can be associated with increased incidence of the infection). Simon Sethi advised that YDH is meeting all is stroke performance targets with the exception of admission to a stroke ward within four hours of admission but the position had improved compared with the previous month which is positive given the operational pressures being experienced by the Trust. The Board said that it would be paramount to avoid a decline in performance over the winter period and to ensure that good patient outcomes are maintained. Matthew Hall, Consultant Orthopaedic Surgeon, gave a presentation at the previous meeting of the Board [item 1-115/15 refers] on the ways to improve the care for patients requiring fractured neck of femur services. As discussed at previous meetings, the number of lost bed-days as a result of delayed discharge (across community hospitals, residential and nursing care and delays with arranging care packages) is an increasing trend. Discussions are ongoing across providers, co-ordinated by the Somerset CCG, to plan for the winter period [item 1-138/15 refers]. The non-executive directors welcomed the improvement in DNA rates compared to the previous month which Simon Lilley said should continue to improve as a result of the implementation of the outbound call and text reminder service and plans to roll-out an online appointment booking and management tool place during winter 2015/16. DNA rates would continue to be reviewed through the hospital effectiveness work stream, the outcomes of which are reported to the Financial Resilience and Commercial Committee. Commenting on cancelled operations, the non-executive directors noted a significant number were due to no bed availability. Simon Sethi spoke of the operational pressures currently being experienced by YDH and the challenges in managing urgent demand combined with the complexity of the Trust’s inpatients’ conditions. This had necessitated the cancellation of some elective procedures to ensure patients needing urgent intervention could be
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9.9
9.10
9.11
9.12
9.13
9.14
9.15
cared for safely. Discussions are ongoing across providers, co-ordinated by the Somerset CCG, to plan for the winter period [item 1-138/15 refers] which the Board said would be essential to avoid the significant and unprecedented levels of operational pressure experienced last year. Reflecting that some operations appeared to be cancelled as a result of insufficient session time, Jane Henderson asked whether there is adequate planning of theatre sessions. Tim Scull said this can be as a result of complications identified during the procedure and Paul Mears added that this would be a further point of evaluation as part of the review of theatre efficiency being undertaken as part of the hospital effectiveness work stream. Discussion of RTT had occurred earlier in the meeting and was therefore not repeated here [item 1-133/15 refers]. Simon Sethi said the Trust met the 95% target of patients seen and discharged within 4 hours from A&E in September 2015 and across Q2. There was discussion about the range of initiatives which YDH has put in place to improve the care for patients requiring urgent attention which has in turn helped YDH maintain strong performance against the target (such as FOPAS and ambulatory care). Simon Sethi said that he is working with the information team on a way to capture this within the data presented to the Board. It was noted that while the number of attendances at A&E had decreased, the number of admissions had increased which demonstrates the complex conditions with which patients are presenting. Ambulance handovers continue to be good. Simon Sethi advised that YDH is achieving the 62 day cancer treatment target but not the 2 week screening wait as a result of patient choice. Following discussions at the previous meeting [item 1-124/15] the Contact Centre is now making a note of the occasions when a patient has not been made aware by their GP at the point of referral of the urgency of attending the appointment. The friends and family results were noted for September [1-139/15 refers]. Workforce and Financial Performance Tim Newman, Mark Saxton and Peter Wyman proposed the establishment of a Workforce Committee of the Board to provide greater scrutiny of the strategic agenda in relation to workforce as well as operational HR performance. The establishment was agreed and the terms of reference would be submitted to Board for approval following the first meeting of the Workforce Committee. In terms of operational HR, the Board noted that performance was broadly in line with the previous month but commented that mandatory training rates had improved and that appraisal targets are still not being met, which Tim Newman said is being picked up by the HR team. Financial Performance Tim Newman advised that YDH is currently in line with budget (£1.5m deficit in-month and £9.1m deficit year-to-date, which is £0.02m favourable to budget). The key adverse variance and risk to budget continues to relate to nursing expenditure, a detailed presentation on which had been received at the previous meeting [item 122/15 refers]. Tim Newman said this would be considered further, along with the forecast for the rest of the year, at the Financial Resilience and Commercial Committee taking place on 23 October.
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1-137/ 15
10 10.1
10.2
10.3
10.4
10.5 10.6 10.7 10.8
OVERVIEW OF MORTALITY RATES Tim Scull presented a detailed overview of the Trust’s mortality rates, from which it was noted that there are a range of data sources which must be critically and collectively considered (not just HSMR in isolation) in order to have a thorough understanding of the Trust’s position, the key points of which were noted as follows: • The HSMR is a ratio of in-hospital deaths : to the expected number
deaths, (multiplied by 100) for 56 specific clinical classification system groups (which accounts for 30% of the Trust’s activity) in a specified patient group taking account adjusted for a variety of factors such as demography and the patient’s conditions. It accounts for 80% of in-hospital deaths. The data is issued from Dr Foster and there is a time-lag of up to six months. Given these limitations, other health systems do not use the measure.
• The SHMI (produced quarterly by the Health and Social Care Information Centre) is the ratio between the actual number of patients who die following hospitalisation and the number that would be expected to die on the basis of average England figures, taking account of the characteristics of the patients treated there.
• The Charlson Index provides a rating and categorises the comorbidities of
patients based on the International Classification of Diseases (ICD) diagnosis codes.
Tim Scull presented the trends at YDH from analysis across the range of measures for mortality data, from which it was noted that: • The YDH HSMR is stable and within acceptable limits which is supported
by other safety indicators
• The Charlson Index indicates that coding is not fully commensurate with patient health which may account for the Trust’s “expected” mortality rate being higher than other trusts. TrakCare should improve the YDH’s coding.
The Board welcomed the assurance provided by Tim Scull and asked whether weekend vs weekday mortality is monitored, which was confirmed.
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11 11.1
11.2
11.3
WINTER PLANNING Simon Sethi tabled a presentation on winter planning, from which the Board discussed and noted that: • The operational pressures experienced last year were significant and
there has been a 7% increase in admissions compared to last year and ongoing challenges in terms of increasing acuity of the Trust’s inpatients and numbers of delayed discharges demonstrating that the pressures this year are likely to be as challenging if not more so.
• YDH is taking a number of actions internally to manage operational pressure, including increasing capacity by building a modular ward and utilising space at Cooksons Court nursing home as well as reviewing and improving internal processes.
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11.4 11.5
• Winter resilience funding had been agreed locally, the focus of which had been on supporting acute capacity as well as recognition of the need for additional input from social care. It would be important to continue discussions between partners locally to collaborate on winter planning to ensure winter pressures are co-ordinated across the health and care system and Somerset Partnership NHS Foundation Trust, South Western Ambulance Service NHS Foundation Trust and Social Care are also implementing a range of mitigating actions.
The Board discussed the next steps and ongoing risks, including: capacity in order to meet growing demand, further challenges with social care and increasing numbers of delayed discharges which YDH is hoping to mitigate through its internal actions and those being taken by external partners. Consideration would also take place of options to utilise home care services.
1-139/ 15
12 12.1
SAFER STAFFING REPORT The Board noted the safer staffing report. Helen Ryan provided a demonstration of iwantgreatcare.org (now being used by YDH) which provides an independent service for patients to leave meaningful and honest feedback on their care. She added that the tool would also enhance the Trust’s existing mechanisms for obtaining and responding to “friends and family” feedback. As YDH started using the system at the start of October 2015, Helen Ryan confirmed she would bring the full report to the Board at its meeting in November 2015.
HR
1-140/ 15
13
13.1
13.2
POLICY APPROVAL Fit and Proper Persons Consideration of the Fit and Proper Persons Policy was deferred until the meeting of the Board on 25 November 2015. Development and Management of Procedural Documents Noting it had been already been reviewed by the Audit Committee, the Board approved the Policy for the Development and Management of Procedural Documents and delegated authority to the Audit Committee to review and approve the document in future.
1-141/ 15
14 14.1
14.2 14.3 14.4
14.5
Q2 CORPORATE RISK REGISTER AND BAF Jonathan Higman presented the Q2 corporate risk register confirming there are currently 19 significant or high risks (12+) recorded with two new risk added and five risks reducing in score since the last review by the Board in July 2015. He advised the Board that to aid interpretation, the risks had been grouped into three broad areas under the following headings:
• risks linked to the significant operational pressure experienced by YDH • a set of clinical risks that would exist regardless of operational pressures • the remaining corporate risks Noting that the risk register had been reviewed by the assurance committees, the Board asked the chairs of those committees to highlight any areas of particular note. Paul von der Heyde said that in addition to the risks identified as a result of the operational pressures (discussed during the course of meeting) a key point of discussion was M009 regarding the skills of midwives to scrub and assist with a caesarean sections occurring between 17.00 and 8:00, if required.
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14.6 14.7 14.8
Following review at the assurance committees, Helen Ryan said that further discussion with the Head of Midwifery had sought to mitigate this risk and she has identified a core group of staff who would be trained to do this. The corporate risk register would be amended accordingly. Responding to questions from the non-executive directors about the risk associated with ophthalmology (SBUV008), it was confirmed that the mitigating actions are expected to be completed by spring/summer 2016. In terms of the risk relating to nursing (TW025), while significant actions had been undertaken with recruitment, as expenditure continues to be adverse to budget, it was agreed this risk should remain on the corporate risk register. The Board also accepted the level of risk in relation to TrakCare (EHR001) citing the assurances from Jason Maclellan earlier in the meeting. Now that payroll staff had been appointed, risk HR013 could be removed from the corporate risk register. Acknowledging agreement at the previous meeting [item 1-121/15 refers], Jonathan Higman and Jade Renville said that the Board Assurance Framework is being updated to align with the newly revised corporate objectives and priorities and the item was therefore deferred until the meeting in November 2015.
1-142/ 15
15 15.1
ANY OTHER BUSINESS There was no further business to discuss.
1-143/ 15
16 16.1
DATE OF NEXT MEETING The next meeting will be held on Wednesday 25 November 2015.
APPENDIX 1b BOARD OF DIRECTORS
25 NOVEMBER 2015
BOARD OF DIRECTORS – ACTION SHEET 25 NOVEMBER 2015
Minute Action Outcome Due By
ACTIONS FROM 30 SEPTEMBER 2015 1-115/15 Executive team to work with Matt
Hall to further develop fractured neck of femur service proposals. Update to be presented at a future meeting of the Board
Not yet due September 2016
Matt Hall
1-116/15 Update to be presented on the Trust’s processes relating to depravation of liberty.
Additional seminar session to be arranged to review this topic
November 2015
Helen Ryan
1-122/15 (10.4)
Overview of DNA performance to be considered as part of the hospital effectiveness work stream and reported to the Financial Resilience and Commercial Committee
Not yet due December 2015 /
January 2016
Simon Lilley
ACTIONS FROM 21 OCTOBER 2015 1-133/15 Financial impact of the RTT
recovery plan to be reviewed by the Financial Resilience and Commercial Committee.
On agenda 23 November
2015
Jonathan Higman
1-134/15 Jeremy Martin agreed to share the job description for the health coaches with Mark Saxton and Jane Henderson.
Complete
1-139/15 Iwantgreatcare report to be presented at the Board
On agenda 25 November
2015
Helen Ryan
Appendix: 2 REPORT TO: Board of Directors REPORT BY: Jade Renville, Company Secretary PRESENTED BY: Mark Saxton, Non-Executive Director
Tim Newman, Chief Finance and Commercial Officer TITLE: Workforce Committee Terms of Reference DATE: 25 November 2015 What is this item about and what is the Board asked to do? Following approval at the previous meeting of the Board to establish a Workforce Committee, the Board is asked to approve its terms of reference and to receive a verbal report on the items discussed at its first meeting. The Board governance structure has been amended to take account of the establishment of the Workforce Committee, as well as the reconciliation of some of the working groups, and is attached for reference. Are there legal, financial, procedural, workforce implications and/or legislative requirements? No. The proposals adhere to the Trust’s constitutional documents. Is this paper clear for release under the Freedom of Information Act 2000? Yes What are the next steps/future actions? The “business as usual” functioning of the Workforce Committee as a Committee of the Board. Responsibilities of the Committee to be delivered as set out in its terms of reference. Links to the Trust’s strategic objectives and/or priorities: By setting the governance framework in which the strategic objectives are overseen and monitored. Links to the Board Assurance Framework/Corporate Risk Register (if applicable): N/A Reference to CQC domains: Well-led Report history: N/A
Board Governance Structure – Revised Draft
Governance Committee
Equality &
Inclusion
Patient Safety
Patient Experience
Audit Committee
Hospital Management Team (HMT)*
Board of Directors
Information Governance & Caldicott
Emergency Planning
& Bus Continuity
Clinical Outcomes Committee
Data Quality Nutrition, Patient Voice
Remuneration Committee
Elective Care Strategic Business Unit (SBU)
Financial Resilience and
Commercial Committee
Executive Directors*
Board of Trustees
Urgent Care Strategic Business Unit (SBU)
Infection, Prevention & Control, Safeguarding, Medical Devices, Safer Medicines Mgt, Harm Free Groups (falls, pressure ulcers, recognition and rescue), Maternity Risk Mgt, Obstetric Interventions
Fire, Health & Safety & Security
Board Assurance Committees Board and Committees of the Board Operational Groups and Strategic Business Units
Quality Oversight Sub-Committees Working Groups
-See SBU meetings matrix -CBU Rolling Governance - Peer Review
Resuscitation, Patient Blood Mgt, Drugs and Therapeutics, Point of Care Testing
Note*: Terms of Reference set out what should be reported to HMT / Executive Directors and the relationship between them
Operational updates provided to the Board via CEO Report and Operational Report
Workforce Committee
[Established
21.10.15]
Quality Committee
Workforce Committee Terms of Reference - DRAFT
1. Formation, Accountability and Reporting Structure 1.1 The Workforce Committee (“the Committee”) is constituted as a standing committee
of the Board of Directors (“the Board”). 1.2 The Committee is authorised by the Board to investigate any activity within the scope
of its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee.
1.3 The Committee is authorised to obtain independent legal or professional advice and
to secure the attendance of any other persons with relevant expertise as necessary. 1.4 The minutes of each meeting shall be formally recorded and, once approved at the
subsequent meeting, reported to the Board (Part 1). The Chair of the Committee shall also provide verbal updates from the most recent meeting, together with any specific recommendations, to the Board (Part 1).
1.5 The Workforce Committee will have oversight of the following group, which will report
to it: Equality and Inclusion. 2. Purpose, Duties and Responsibilities 2.1 The primary purpose of the Committee is to advise the Board on the strategic,
transformational workforce agenda, providing support to the HR team to ensure its implementation. The Committee will also review the monthly HR data sent to the Board, with a focus on mandatory training, appraisal, occupational health, sickness management (including long term), and ESR data quality.
2.2 The Committee will give support and advice and oversee plans for the following
areas:
• People policy and organisational development plan, which it will approve and keep under review.
• Workforce planning. • Equality and Inclusion. • Recruitment initiatives. • Training programmes and associated commercial opportunities. • Workforce implications of new models of care (Symphony integration). • Agency spend and compliance with Monitor requirements. • Progress with the 3 Year Education and Training Plan. • HR key performance indicators.
Employee Relations • People engagement programme. • Employee value proposition. • Annual review of staff survey outcomes and follow up plans.
2.3 The Committee will be made aware of any overlapping programmes from NHS
England, NHS Health Education England and other bodies with an interest in people development, including the Joint Consultative Negotiating Committee and Local Negotiating Committee where appropriate.
3. Membership, Attendance and Quorum 3.1 The core membership of the Committee will consist of:
• Two non-executive directors, one who will act as Chair and one who will act as Vice-Chair
• Chief Finance and Commercial Officer • Associate Director of HR and Organisational Development
3.2 Notwithstanding the provision of section 3.1, all non-executive directors including the
Chairman of the Trust shall be deemed members of the Committee for the purposes of establishing a quorum. Where an appointed non-executive director cannot attend, another may attend in their place and shall count towards a quorum.
3.3 Where a member is unable to attend, they may nominate a deputy to attend in their
place provided this is agreed in advance with the Chair. 3.4 In regular attendance will be:
• Medical Director* • Director of Nursing* • Director of Urgent Care and Long Term Conditions* • Director of Elective Care* • Head of Organisational Development and Recruitment • Head of HR • Head of HR – Symphony • Company Secretary (who shall act as secretary to the Committee)
3.5 All members and attendees shall be expected to come to meetings and the dates
shall be agreed so as to enable this as far as possible. Attendees marked with a * shall be invited to all meetings but are not obliged to attend unless demanded by the agenda. The Trust Chairman or Chief Executive shall not be members or designated attendees but will receive copies of the papers and may attend if they so wish.
3.6 The Council of Governors shall nominate one of their members to attend meetings as
an observer.
3.7 The Committee may extend invitations to other personnel with the relevant skills, experience or expertise as necessary to deal with the business on the agenda or to support the delivery of particular programmes of work.
3.8 A quorum shall be three members, one who must be the Chair or Vice-Chair and one who must be Chief Finance and Commercial Officer or Associate Director of HR and Organisational Development.
4. Administration of Meetings 4.1 A minimum of 10 meetings shall be held each year, usually taking place on a monthly
basis. An annual schedule of proposed dates will be prepared in advance. Extraordinary meetings may be called at the request of the Chair.
4.2 The Company Secretary and/or Chief Finance and Commercial Officer, supported by HR, will produce the agenda and all necessary papers. Subject to availability, the agenda and any supporting papers will be distributed no less than three working days prior to a meeting, wherever possible.
4.3 In agreement with the Chair or Vice-Chair, if an item needs to be raised on the day,
this will be covered under Any Other Business, subject to there being available time. 4.4 The minutes of each meeting shall be formally recorded. 5. Review 5.1 These terms of reference must be reviewed at least on an annual basis, or more
frequently in the event of significant political, organisational, staff or policy changes. Date Issued: 25 November 2015 Review Date: 25 November 2016
WORKFORCE COMMITTEE
Minutes of the Workforce Committee held on 13 November 2015 at Yeovil District Hospital
Present: Mark Saxton [Chair] Non-Executive Director Maurice Dunster Non-Executive Director Mark Appleby Associate Director of HR and Organisational Development Tim Newman Chief Finance & Commercial Officer In Attendance: Jade Renville Company Secretary
Action 1
1.1
WELCOME & APOLOGIES Following its establishment by the Board on 21 October 2015, Mark Saxton welcomed everyone to the inaugural meeting of the Workforce Committee, for which it was agreed he would act as Chair.
2 2.1
DECLARATIONS OF INTEREST There were no declarations of interest relating to items on the agenda.
3 3.1
3.2
3.3
3.4
TERMS OF REFERENCE Mark Appleby tabled the draft Terms of Reference, which had been based on those for other committees of the Board and informed by NHS Provider’s Foundations of Good Governance. Following thorough review by the Committee, Jade Renville agreed to circulate a revised draft based on their comments, the key points of which were: • The focus of the Committee should be to advise the Board on the
strategic, transformational workforce agenda, with its secondary role being to review transactional, operational HR performance.
• Meetings would generally be held monthly over two hours.
• Membership would comprise two non-executive directors (one who would act as Chair), the Chief Finance and Commercial Officer and the Associate Director of HR and Organisational Development, along with a number of attendees from HR and members of the executive leadership team. One governor would be invited as an observer to the Committee.
4 4.1
4.2
WORKFORCE PERFORMANCE REPORT AND HR DASHBOARD The Committee reviewed the operational HR performance report which had been received by the Board on 21 October 2015, from which it was noted that: • Along with nursing staff and HCAs, the numbers of admin and
clerical FTEs had increased. While it was acknowledged that this was likely a result of delivering the Trust’s strategic work programmes, it was agreed a more detailed breakdown of the roles would be presented at the next meeting of the Committee.
MA
2 | P a g e
4.3
4.4
4.5
4.6
4.7 4.8 4.9
• Despite an increase in contracted staff, there are also more temporary staff being used compared with the same period last year. While it was recognised that the nursing recruitment plan is seeking to address this issue in part, it was agreed there should be a breakdown of vacancies by department to enable the Committee to scrutinise other areas of pressure and any emerging trends. It was also agreed that bank vacancies should be captured separately to the other data. In terms of nursing recruitment and vacancy levels, it would be important for the information and finance teams to present consistent, standardised data and it was acknowledged that the quality of the data is now a primary area of focus.
• It was agreed that the “workforce comparison to 2014”, slide should
be annotated to show the reasons for significant differences compared to the previous year and include an explanation of what staff groups are captured within each category, such as additional clinical services. If possible, it would also be helpful to include benchmark data of other trusts.
• In terms of staff turnover and leavers, there had been an increasing
trend. Mark Appleby said there had been a number of retirements but Mark Saxton pinpointed that there had been more resignations and asked about the mechanisms for obtaining feedback. Mark Appleby responded that YDH is getting better at exit interviews and capturing this information. It was agreed that going forwards, the Workforce Committee should receive details of the key trends showing why people decide to leave.
From review of the operational HR performance report, it was agreed that at its next meeting the Committee would give specific focus to the following areas: • Vacancy data and recruitment plans. • Turnover, leavers and the reasons why staff decide to leave. • Non-attendance at work (sickness absence rates).
5 5.1
ITEMS RAISED BY THE BOARD The Workforce Committee noted the areas raised by the Board. It was agreed that at the next meeting, Ali Morris, Head of Organisational Development and Recruitment, would be asked to give an update on the actions arising from the internal audit / counter fraud reports into HR. The other areas would be picked-up in the terms of reference and reviewed by the Committee as part of its standing responsibilities.
AM
6 6.1
ANY OTHER BUSINESS There was no further business to discuss.
7 7.1
DATES AND TIMES OF FUTURE MEETINGS Jade Renville agreed to set the future meeting dates of the Workforce Committee, which would ideally take place on the same day as the Financial Resilience and Commercial Committee, where possible. The next meeting would take place on 22 December 2015, 10:30 – 12:30, in the Boardroom, Level 1, YDH.
JR
3 | P a g e
7.2
7.3 7.4
7.5
7.6
The format of the next meeting was agreed as followed: • Review of operational HR performance. • Consideration of the three areas of focus identified above [item 4.7,
4.8, 4.9 refers]. • Adoption of the “People Plan” with an update on progress with its
implementation since the Board seminar on 30 September 2015. At a future meeting, it was agreed there may need to be a review of ESR data quality.
APPENDIX 3 BOARD OF DIRECTORS
25 NOVEMBER 2015
Report to: Board of Directors Report from: Paul Mears Subject: Symphony Update Date: 25 November 2015 This is a regular monthly report updating the Board on progress with the Symphony Programme in South Somerset. South Somerset was selected in March 2015 as one of 29 sites nationally to become Vanguard sites for the development of new care models and new ways of working. Programme Board and Working Groups The programme continues to progress well. The main workstream highlights are as follows: Complex Care At the recent Complex Care Away day the objective was to agree the approach to the setting up and recruitment for hubs 2 and 3. The approach was agreed with recognition that some changes would be required due to the geographic locations being remote from the hospital and to begin to move towards a unified model incorporating both complex care and enhanced primary care. These will be captured in an enhancement roadmap. The options appraisal for the next hubs’ geographical locations is due to be completed and presented by the end of week beginning 16 November 2015. Enhanced Primary Care (EPC) EPC continues to progress ahead of schedule and the wave 2 roll out is gathering momentum. So far two practices have been visited as part of this process. Three further practices will be visited in the next two weeks. Health Coach interviewing has progressed with 33 interviews and 8 candidates have gone through to the next stage. The first wave of health coaching training for hub staff and existing health coaches has been completed. An Interim Project Manager has been brought on board – Matthew Butt. Joint Venture (JV) A meeting was held in London with NHS England and Monitor on 23 October 2015. The outcome of the meeting highlighted the need for further engagement regarding the organisational structure being proposed.
This has resulted in further engagement with Bevan Brittan who are preparing a ‘Heads of Terms’ document that will provide rationale for the proposed JV structure as well as supporting evidence as to how the proposed structure will operate. It is the intention to engage further with NHS England in early December to present the ‘Heads of Terms’ principles. To support this activity KPMG has been engaged to provide a taxation opinion to support the JV operational proposal. A ‘kick off’ meeting has defined the scope of the activity and KPMG has committed to provide a draft for discussion by the first week of December. National Vanguard Programme As lead Vanguard for organisational forms, we have been offered additional resource to ensure that the learning is shared with other sites. The national team is working closely with us to identify and work through the key issues. Bi-weekly calls are now set up to discuss general updates and to seek the support of NHS England where required. In addition bi-weekly calls will commence in December to address specific challenges associated with the development of the JV. During this period the programme submitted a financial update to NHS England. The update was a joint submittal with the CCG and both forecast to be on plan with expenditure for this current financial year.
APPENDIX 4 BOARD OF DIRECTORS
25 NOVEMBER 2015
Report to: Board of Directors Report from: Jason Maclellan Subject: SmartCare Electronic Health Record (TrakCare) Update Date: 25 November 2015 Summary The aim of this monthly highlight report is provide the Board with an update on progress and to provide assurance on the actions and controls in place to ensure successful implementation of the SmartCare electronic health record system (TrakCare). Executive Summary The programme status for Nov remains at AMBER. Plan summary In the last update there was a target to complete detailed re-planning 23 October. This wasn’t achieved due to a lack of progress on the TrakCare build complete milestone which is a key dependency on the critical path of the programme. Following the Programme Board this week there was an increased commitment to achieve this by 27 November. Significant progress towards this goal has been made over the last week so I am confident this will be achieved. The go-live date is still to be confirmed. The Intersystems Programme Board has indicated that our preferred date in Spring 2016 cannot be supported due to proximity to the North Devon implementation. The next available implementation window is the end of May 2016. Discussions are on-going but this needs to be resolved by mid December to avoid operational issues around resource planning. Good progress is being made in the following areas:
• Clinic build – tracking to be 90% complete by late December. Four specialities now at 100% and testing has commenced in the first specialty.
• Data migration and Integration – detailed planning has been completed and we
continue to track on schedule.
• Maternity – the majority of scope has now delivered and there are only minor items outstanding.
Pharmacy is still challenging although good progress has been made
• Collaboration between trusts to ensure a single consolidated and agreed list of gaps and requirements.
• Senior support within Intersystems. • ISC programme team members are in Australia to collaborate with the product
delivery team.
• Forecast is that must have requirements will be completed by end January. • Early April go-live is not achievable based on this date. • The end of May could be achievable subject to planning so based on the go-live
decision it may be possible to re-align the phase 1 deliverables. • The alternative will be to continue with a pharmacy release de-coupled from the
phase 1 implementation. In order to minimise the impact of the delays to phase 1 and to protect our benefits realisation schedule we have agreed to identify areas where phase 2 work can start prior to phase 1 completion. Key areas which would benefit from this approach would be order comms, ePrescribing and medicines administration, clinical decision support and active clinical notes. We agreed that would be define terms of reference for these working parties and identify the resource requirements on both sides so this activity can be planned. Resource Teresa Coombes has been appointed to the role of Transformation Manager for the programme. This is an excellent addition to the team and is in line with the previously stated goals to have more operational experience within the programme team and to move away from a dependency on contract resource, building a legacy of knowledge and experience in the trust. A replacement healthcare architect from the supplier has still not been provided so this will be escalated. Holiday and sickness contributed to a significant shortfall in application specialist resource from the supplier being available on site. This has impacted our ability to move forward in firming up requirements and solutions in key areas and contributed to the delay in completing the detailed implementation plan. Budget Still underspent to date however the potential for a May go-live means there will be pressure on the budget. We are forecasting the need to extend our existing HP contract for 3 months which will be an adverse variance to the benefits profile. Smartcare collaborative There is a move to increase collaboration between the trusts starting with a session on 30 November. At this session opportunities to collaborate more will be identified with a view to reducing unnecessary duplication of work and increase pace. Key Risks & Issues
• On-going uncertainty over go-live date • Confirmation that pharmacy solution will be fit for purpose won’t be possible until late
January/early February. • If April go-live date is confirmed then there is a risk around resource contention.
1
YDH │Operating and Finance Performance Overview Month 7 – October 2015
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 Aug 15
97.12
October Number
of Deaths
57
Mortality Rates
0
20
40
60
80
100
120
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
Hospital Standardised Mortality Ratio (HSMR)*
Monthly data 6 month moving average
0
20
40
60
80
100
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
Actual number of deaths *
Monthly data 6 month moving average
RAG Status: Significantly better than national average, Within expected range, Significantly higher than national average.
4
Safe [2]
Patient Falls and Pressure Ulcers
Patient Falls
83 (88 in October 14)
Pressure Ulcers
13 (13 in October 14)
0
20
40
60
80
100
120
140
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
Patient falls
Monthly data 6 month moving average
0
5
10
15
20
25
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
Pressure ulcers +2
Monthly data 6 month moving average
5
Safe [3]
C.Difficile and MRSA cases
October C.Diff
0 (1 in October 14)
October MRSA
0 (0 in October 14)
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
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
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 6, of these 2
were due to Lapses in Care.
6
Effective [1]
Additional Notes
SSNAP Published figures for Q3 Oct-Dec14:
National Average 4hr to Stroke Unit : 56.9%
National Average 90% Stay on Stroke Unit: 82.2%
TIA High Risk patients seen within 24hrs in October = 85.7%
(Target = 80%)
90% Stay on Stroke
Unit
70% (Target: 80%)
Admission Direct
within 4hrs
44% (Target: 90%)
CT Scan in 1hr
50% (Target: 50%)
October 15
Stroke Services
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
4Hr Direct Admission
4Hr Direct Admission Target
0%
10%
20%
30%
40%
50%
60%
70%
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
Achievement 1HrCTScan
7
Effective [2]
Additional Notes
Best Practice achievement in Financial Year 14/15 : 37.5%
The new Orthopaedic Geriatrician started 1st September.
Best Practice
Achievement
45.5% (Target: 60%)
YTD AvLoS Direct admission:
Trauma ward
13.4 days (vs 14.6 days Other wards)
October 15
Fractured Neck of Femur Services
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
Average Length of Stay - #NOF patients
Trauma Ward Admission Other Admissions
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Operatedon within 36
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
8
Delayed Discharges
0
10
20
30
40
50
60
70
Number of Inpatients Medically Fit for Discharge
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)
08/2015 09/2015 10/2015
October 15
Lost Bed Days
638 (1035 Oct 14)
In Month Bed Cost
£150,568 (£244,260 Oct 14)
Additional Notes
The number of lost beddays is on an increasing trend, mainly
due to increasing delays in Further non acute NHS Care,
Residential Homes, Nursing Homes, and also Care Packages
within the patient’s own home.
Overall, the number of lost beddays compared to the same
time last year has reduced by 38%.
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]
9
DNA - Outpatients
Overall DNA Rate
7.5%
1st Appointment Rate
5.5% FU Appointment Rate
8.2%
Effective [4]
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
DNA Rate
Overall DNA rate First DNA rate Follow up DNA rate
Additional Notes
Published National DNA rates for Q4 14/15 were 8.02%.
(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
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
Tho
usa
nd
s
DNA Cost
RAG Status: Less than 5%, 5-7%, Over 7%.
October 15
10
0 5 10 15 20 25 30 35 40
Consultant/Clinican Unavailable
Insufficient Session Time
Urgent Case took Priority
No Beds Available
THEATRE / OUTPATIENT STAFF SHORTAGE
NO ANAESTHETIST AVAILABLE
Hospital Non Clinical On the Day Cancellations of Elective Operations - October 15
Cancelled Operations
On the Day Non-
Clinical Reasons
48 (18 - Oct 14)
Rebooked within 28
Day Target
42
Total Cancelled due
to Lack of Beds
52
October 15
Additional Notes
The figure for Total Cancelled due to Lack of Beds includes
cancellations with more than 1 day notice given.
6 on the Day Non-Clinical Cancellations were originally booked
within 28 days, however have been subsequently cancelled for
a second time due to lack of Beds.
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 10 20 30 40 50 60 70 80 90
Consultant/Clinican Unavailable
Insufficient Session Time
Urgent Case took Priority
No Beds Available
Administrative Reasons
Requires Alternative Session/Specialty
Equipment Failure/Unavailable
THEATRE / OUTPATIENT STAFF SHORTAGE
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
1:2.2
6 Month Rolling
Average
1:2.2
Additional Notes
NHS Better Care, Better Value 14/15 Q4 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
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
New:Follow Ratio
New:Follow Ratio 6 month moving average
October 15
0123456789
0100020003000400050006000700080009000
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
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
RTT Completed Pathways - Non admitted
Monthly data RTT target 6 Month Moving Average
Responsive [1]
Admitted Stops
77.1% (Target: 90%)
Non-Admitted Stops
92.7% (Target: 95%)
Total Incompletes
91.4% (Target: 92%)
Additional Notes
Following on from the recent letter from Simon Stevens
outlining proposed changes in RTT Wait times, the
Incomplete Pathways targets for RTT will remain and
from October onwards the penalties to the Trust will be
£300 for every incomplete pathway over the 18 weeks
target.
RTT Pathways
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
RTT Incomplete Pathways
Monthly data RTT target 6 Month Moving Average
Admitted
Incompletes
81.4% (Target: 92%)
Non-Admitted
Incompletes
94.7% (Target: 92%)
13
0
100
200
300
400
500
>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
399
Non-Admitted Patients
over 18 Weeks
340
Patients over 26
Weeks
250
Patients over 52
Weeks
0
October 15
RTT Incomplete Pathways
01,0002,0003,0004,0005,0006,0007,0008,0009,000
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
RTT Incomplete Pathways with All Stops
RTT Incomplete Pathways RTT incomplete pathways > 18 weeks
Number of Stops
14
Responsive [3]
Additional Notes
The Diagnostics waits position was below target in October,
primarily due to current capacity issues within the Endoscopy
service. The Operational team has completed an action plan to
address the backlog and recover the position. This recovery
expected to enable the trust to achieve its overall Diagnostic
Waits position.
Overall Diagnostic 6
Week Waits %
96.7% (99.3% - Oct 14)
Imaging 6 Week
Waits %
99.8% (99.1% - Oct 14)
Physiological
Measurement Waits %
99.7% (99.5% -Oct 14)
Endoscopy 6 Week
Waits %
89.0% (99.7% - Oct 14)
October 15
Diagnostic Waits
0 10 20 30 40 50 60 70
October 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
Mar
-15
Ap
r-1
5
May
-15
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
Diagnostic 6 Week Waits %
Diagnostic 6 Week Waits % Target
15
Responsive [4]
Inpatient & Day Case
Waiting List
2211 (+25.4% vs last FY)
Outpatient GP/DP
Waiting List
3151 (+4.6% vs last FY)
Notes
The IP/DC waiting list has increased to 2211 which can
be attributed to the number of Cancelled Operations
over the last few weeks.
Oct 15
Inpatient and Outpatient Waiters
0
500
1000
1500
2000
2500
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
IP/DC Waiting List
1500
2000
2500
3000
3500
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
OP Waiting List
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
Avg A&E Attendances per Day
Avg A&E attendances per day Avg ambulance arrivals per day
Avg Emergency Admissions Per Day
88%
90%
92%
94%
96%
98%
100%
Apr
-12
Jun-
12
Aug
-12
Oct
-12
De
c-12
Feb-
13
Apr
-13
Jun-
13
Aug
-13
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
A&E 4 hour performance - All Attendances
Monthly data 6 month moving average
Responsive [5] ED Attendances
A&E Performance
92.03% (95.2% Oct 14)
Average A&E
Attendances per day
126.8 (125.9 Oct 14)
Average Ambulance
Arrivals per day
41.8 (41.4 Oct 14)
Additional Notes
A&E activity over the two month period August and September
was down by 0.7% vs last year (-57 attendances).
YTD attendances (26,990) vs last FY YTD (28,163).
Average Emergency Admissions excludes Paediatrics and
Maternity.
Average Breaches
per Day
10 (6 Oct 14)
October 15
Average Emergency
Admissions per day
48.8 (48.5 Oct 14)
17
Responsive [6]
Admission Avoidance
Additional Notes
The introduction of FOPAS and the introduction of AAU
services has resulted in both an increase in zero length of stay
admissions and an decrease in the percentage of patients
admitted to wards from AAU.
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
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
October 15
0 LOS % vs LY
31.3% (23.5% - Oct 14)
% Admitted to Wards
from AAU (CDU)
52.4% (53.9% - Oct 14)
0
100
200
300
400
500
600
700
800
40.0%
45.0%
50.0%
55.0%
60.0%
65.0%
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-1
4
Jan
-15
Feb
-15
Ma
r-1
5
Ap
r-1
5
Ma
y-1
5
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
% of Patients Admitted to Wards from CDU/AEC
Change in CDU CDU & AEC Admission % Linear (CDU & AEC Admission %)
18
Responsive [7]
30 Minute Handover
Target
99.2% (99.7% Oct 14)
YTD Fines
£6200 (£8400 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
£0 £1,000 £2,000 £3,000 £4,000 £5,000 £6,000 £7,000
Am
bu
lan
ce
han
do
vers
-
Fin
es
Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15
19
Cancer 2 Week Wait Draft Data
2 Week Suspected
Cancer
93.7% (Target 93%)
2 Week Breast
94.1%
(Target 93%)
Additional Notes
Draft Data for October indicates that the trust has achieved
the 2 Week Wait Suspected Cancer and the 2 Week Breast
Cancer Targets.
October 15
Responsive [8]
0
20
40
60
80
100
0
100
200
300
400
500
600
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
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%
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
2 Week Cancer Targets
2WW Suspected Cancer 2WW Breast
20
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
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
62 Day Treatment Standard
Achievement % 6 Month Rolling % Target %
Cancer 31 and 62 Day Targets Draft Data
Additional Notes
Draft Data for October indicates that the trust achieved all
Cancer 31 Day Targets.
The breach of the 62 day Treatment Screening target was due
to Patient Choice.
The Trust is submitting the weekly 62 day Standard Treatment
Cancer PTL to Monitor to enable them to track our weekly
performance against this Target.
31 Day Treatment First
98.6% (Target 96%)
31 Day Treatment
Subsequent Drugs
100% (Target 98%)
31 Day Treatment
Subsequent Surgery
100% (Target 94%)
62 Day Treatment
Screening
75% (Target 90%)
62 Day Treatment
Standard
85.0% (Target 85%)
62 Day Treatment
Upgrades
100% (Target 90%)
Responsive [9]
85.0%
87.0%
89.0%
91.0%
93.0%
95.0%
97.0%
99.0%
101.0%
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
31 Day Treatment First
Achievement % Target % 6 month rolling %
21
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%.
All 62 day Urgent GP Referral pathways have achieved
the monthly target of 85% this year to date.
Responsive [10]
0
5
10
15
20
Sep-15
September - Number of 62 Day Patients Seen
Skin Urology Breast Lower GI Upper GI Haematology Gynaecology Lung Head and Neck Brain Sarcoma Other
Cancer SiteYTD
14/15
YTD
15/16
Brain 0 0 0 100% 1 0 0 0 0 100% 1 (0)
Breast 95.5% 55.5 (2.5) 100% 2 100% 6 100% 9 100% 11 100% 5 80% 5 (1) 83% 6 (1) 95.5% 44 (2)
Gynaecology 80.0% 12.5 (2.5) 100% 2 100% 3 80% 3 (0.5) 100% 2 100% 1 100% 1.5 0 95.8% 12 (0.5)
Haematology 64.3% 7 (2.5) 100% 1 0.0% 1 (1) 66.7% 3 (1) 50% 2 (1) 100% 2 100% 2 0.0% 1 (1) 65.2% 11.5 (4)
Head and Neck 0% 2.5 (2.5) 0.0% 1 (0.5) 100% 2 33.3% 2 (1) 50% 1 (0.5) 0 0% 1 (1) 0 45.5% 5.5 (3)
Lower GI 75.9% 27 (6.5) 100% 3 36.4% 6 (3.5) 100% 1 60% 5 (2) 100% 5 66.7% 7.5 (2.5) 100% 1 71.4% 28 (8)
Lung 70.8% 12 (3.5) 100% 5 81.8% 6 (1) 88.9% 5 (0.5) 50% 1 (0.5) 55.6% 5 (2.5) 100% 1 80.0% 5 (1) 81% 26 (5)
Sarcoma 100% 1 100% 1 0 0 0 0 0 0 100% 0.5 (0)
Skin 99.2% 123 (1) 100% 10 100% 17 90% 10 (1) 100% 17 93% 14 (2) 94.6% 18.5 (1) 100% 12 97.0% 98.5 (3)
Upper GI 73.9% 11.5 (3) 100% 2 100% 3 80% 5 (1) 66.7% 3 (1) 50% 2 (1) 75% 6 (1.5) 100% 2 80% 22.5 (4.5)
Urology 90.8% 49 (4.5) 96.3% 14 (0.5) 95.2% 11 (0.5) 88% 13 (1.5) 94.7% 10 (0.5) 92% 7 (0.5) 91.7% 12 (1) 77% 13 (3) 90% 77.5 (7.5)
Other 0 100% 1 0 0 100% 1 0 0 0 100% 2 (0)
All 90.5% 301 (28.5) 97.5% 40 (1) 88.6% 53 (6) 87.0% 50 (6.5) 89.5% 53 (5.5) 88.8% 40 (6) 85.3% 54.5 (8) 85.0% 40 (6) 88.6% 329 (37.5)
Sept-15 %
Referrals &
(Breaches)
Aug-15 %
Referrals &
(Breaches)
Number of
Referrals
(Breaches)
15/16 YTD
Number of
Referrals
(Breaches)
14/15 YTD
Apr-15 - %
Referrals &
(Breaches)
May-15 %
Referrals &
(Breaches)
Jun-15 %
Referrals &
(Breaches)
Jul-15 %
Referrals &
(Breaches)
Oct-15 %
Referrals &
(Breaches)
22
Responsive [11]
Elective Admissions
1,800 (1,782 Oct 14)
Non-Elective Admissions
1,686 (1,734 Oct 14)
Elective LOS
2.7 Days (-0.8 vs Oct 14)
Non-Elective LOS
5.2 Days (+0.3 vs Oct 14)
Additional Notes
Following the peak in elective length of stay in January, the
elective length of stay has dropped back within range of
previous levels.
October 15
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
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
Average Length of Stay (Days)
LOS Elective LOS Non Elective
23
Friends and Family Test Caring [1]
A&E
2.3% (16.8% Oct 14)
Inpatients
14.4% (35.4% Oct 14)
Maternity
8.4% (26.3% Oct 14)
Overall Rate
7.8% (22.4% Oct 14)
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.
We are expecting to see an increase in response rates over
the next few months.
October 15
64.9%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%
26.3%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%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
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
Friends and Family Test Inpatient / ED / Maternity Response to 'extremely
likely' and 'likely' to recommend YDH
% Extremely Likely % Likely
813 814 735 576 462 451 601 705 694 758 890 699 878414
3641 34803239 3380
3119 28083202 2990 3190
4071
56455433 5432
5300
0%
5%
10%
15%
20%
25%
0
1000
2000
3000
4000
5000
6000
7000
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
Friends and Family Test % of Inpatient / ED / Maternity Responses
No of Respondants No of eligible Patients % of responses
Outpatients
44 Responses
(n/a Oct 14)
24
Monitor
Target PeriodFY
14/15Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Q1 Q2
RTT 18 week RTT admitted wait - All specialties 90% M 88.6% 74.3% 77.0% 72.4% 79.6% 79.7% 75.8% 77.1% 76.3% 78.2%
RTT 18 week RTT non-admitted wait - All specialties 95% M 95.6% 92.7% 93.8% 94.2% 93.0% 91.8% 92.7% 91.1% 93.1% 92.5%
RTT 18 week RTT Incomplete pathways - All Specialties 92% M 93.9% 89.6% 89.8% 89.5% 89.3% 89.4% 88.9% 91.4% 89.4% 89.2%
A&E A&E Clinical Quality: Total time of 4 hours in A&E 95% M 95.2% 95.5% 95.8% 95.0% 97.6% 95.3% 95.4% 92.0% 95.7% 96.1%
Cancer Max waiting time of 2 weeks from urgent suspect cancer GP referral to first outpatient appt 93% Q 92.6% 91.2% 92.6% 91.3% 93.6% 89.9% 91.3% 93.7% 92.0% 91.7%
Cancer Max waiting time of 2 weeks for symptomatic breast patients (cancer not initially suspected) 93% Q 92.96% 94.8% 88.9% 84.9% 84.2% 88.1% 90.5% 94.1% 89.4% 89.6%
Cancer Max waiting time of 31 days from diagnosis to first treatment for all cancers 96% Q 98.1% 97.8% 98.6% 100% 100% 98.8% 97.6% 98.6% 98.8% 98.8%
Cancer Max waiting time of 31 days for subsequent DRUG treatments for all cancers 98% Q 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Cancer Max waiting time of 31 days for subsequent SURGICAL treatments for all cancers 94% Q 95.9% 100% 90.9% 100% 100% 100% 100% 100% 99.0% 98%
Cancer Max waiting time of 62 days from urgent GP referral to first treatment for all cancers 85% Q 88.2% 97.5% 88.6% 87.0% 89.5% 88.8% 88.1% 85.0% 89.1% 90.5%
Cancer Max waiting time of 62 days from consultant screening service referral for all cancers 90% Q 93% 100% 100% 100% 100% 100% 85.7% 75.0% 94.1% 100%
Safety C.Diff year on year reduction (lapses in care only) 8 pa Q 3 0 1 0 1 0 0 0 1 0
Indicators
Well Led
25
YDH │Workforce Well Led - Staffing Month 7 – October 2015
26
Well Led [1]
Additional Notes
Total FTE has increased by 211 FTE compared to October
2014.
Total FTE
2,048 (Oct 14 – 1836)
October 15
Contracted & Temporary FTE
0
50
100
150
200
250
300
1,600
1,650
1,700
1,750
1,800
1,850
1,900
Ap
r-1
2
Jul-
12
Oct
-12
Jan
-13
Ap
r-1
3
Jul-
13
Oct
-13
Jan
-14
Ap
r-1
4
Jul-
14
Oct
-14
Jan
-15
Ap
r-1
5
Jul-
15
Oct
-15
Contracted Vs Temp FTE
Contracted FTE Temp Worked FTE
0 200 400 600 800
Additional Clinical…
Additional Prof…
Admin & Clerical
Allied Health…
Ancillary
Estates
Medical & Dental
Nursing & Midwifery Reg
Senior Managers
HCA's
Contracted & Temporary FTE - 3 Year Trend
Oct-13 Oct-14 Oct-15
27
Well Led [2]
Additional Notes
Contracted FTE has increased by 165 FTE compared to October
2014.
The vacancy percentage for September 15 is 9% * compared to
8% in October 2014.
* Vacancies calculated as budgeted FTE less contracted FTE.
Contracted FTE
1856
(Oct 14 – 1691)
October 15
Contracted FTE
0 100 200 300 400 500 600
Additional Clinical Services
Additional Prof Scientific &…
Admin & Clerical
Allied Health Professionals
Ancillary
Estates
Medical & Dental
Nursing & Midwifery Reg
Senior Managers
HCA's
Contracted FTE - 3 Year Trend
Oct-13 Oct-14 Oct-15
1,500
1,550
1,600
1,650
1,700
1,750
1,800
1,850
1,900
Ap
r-1
2
Jul-
12
Oct
-12
Jan
-13
Ap
r-1
3
Jul-
13
Oct
-13
Jan
-14
Ap
r-1
4
Jul-
14
Oct
-14
Jan
-15
Ap
r-1
5
Jul-
15
Oct
-15
Contracted FTE
Contracted FTE Rolling 6 mth avg FTE
28
Well Led [3]
Additional Notes
Temporary FTE has increased by 47 FTE compared to October
2014.
The increase in temporary nursing staff is due to covering
vacancies and is being addressed by the Nursing Recruitment
Plan.
Total FTE
192
(Oct 14 – 145 )
October 15
Temporary FTE
0
50
100
150
200
250
Ap
r-1
2
Jul-
12
Oct
-12
Jan
-13
Ap
r-1
3
Jul-
13
Oct
-13
Jan
-14
Ap
r-1
4
Jul-
14
Oct
-14
Jan
-15
Ap
r-1
5
Jul-
15
Oct
-15
Temporary FTE
Temp Worked FTE Rolling 6 mth avg FTE
0 10 20 30 40 50 60 70 80 90 100
Additional Clinical…
Additional Prof…
Admin & Clerical
Allied Health…
Ancillary
Estates
Medical & Dental
Nursing & Midwifery Reg
Senior Managers
HCA's
Temporary FTE - 3 Year Trend
Oct-13 Oct-14 Oct-15
29
Recruitment Position – October 2015 Overview
Total starters 34
Total leavers 11
Offers
Medical non-training 15
Medical training 3
Nursing (band 5 only) 8
Other clinical 21
Corporate 33
Total 80
Vacancies in Progress*
Medical non-training -16
Medical training -1
Nursing (band 5 only) -21
Other clinical -36
Corporate -86
Total -199
Bank Vacancies in Progress*
Clinical -26
Non-clinical -20
Total -46
* Includes vacancies the Recruitment Team are
actively working on from Director authorisation
to pre-employment checks complete.
30
Nursing Vacancies Forecast net vacancy/over established closing monthly position Vacancy = negative, over establishment = positive
14 19
21
31
22
8 8 8
-60
-50
-40
-30
-20
-10
0
10
20
30
Plan Actual and projected
Leavers assumed to be 4 per month based on
YTD average
Number of starters
Total Jan’15 - Dec’16
=168
Recruitment in advance of new ward opening, 15
wte increase in required nursing establishment
8
12 4
31
Recruitment Position – October 2015
Notes
• Staff Nurse Campaign – 3 more nurses started in September, and we have 22 more starting in November.
The majority of these are from the EU. This will bring the total recruited since January to 120. 10 nurse pin
numbers are still awaited for some starters, 2 from May cohort, 3 from July, and 10 from September) and we
are chasing this as much as possible, but are dependent on the NMC administration process.
• Since January, staff nurse leavers have been 37 compared to plan of 66, joiners have been 120 compared to
plan of 109.
• Medical Campaign – 9 of 12 SHO vacancies, 13 of 15 Middle Grade vacancies, and 8 of 14 Consultant
vacancies are on track to be filled.
• We have had very positive developments regarding offers and candidate interest:
• Consultant in ED - offer accepted. Another candidate visiting on 10 December.
• Consultant Physician in Respiratory Medicine – candidate visiting on 27 November
• Consultant Stroke Physician - offer accepted, starting on 1 December
• Consultant Radiologist - started 5 November
• Specialty Doctor in ED - started 5 November
• Specialty Doctor in Anaesthetics - four offers accepted, three starting early December and one in
March 2016.
• Recruitment Fairs - We attended the University of Birmingham nursing fair in October, and the Acute and
General Medicine Conference in November to increase awareness of YDH and market us to potential
candidates. Both fairs were extremely positive with excellent feedback about our new stand and materials.
We obtained a good number of contacts, which have been followed up – with two potential doctor and one
nurse very interested. We learned a great deal and are planning for a number of other fairs in 2016.
32
Well Led [4]
Workforce Comparison to 2014
Skills GroupsContracted
FTE
Temporary
FTETotal FTE
Temporary
%
Contracted
FTE
Temporary
FTETotal FTE
Temporary
%
Additional Clinical Services 41 2 44 5% 50 1 51 2%
Additional Prof Scientific & Technical 50 - 50 0% 45 4 49 9%
Admin & Clerical 351 17 368 5% 406 32 438 7%
Allied Health Professionals 87 2 89 2% 99 4 103 4%
Ancillary 137 40 177 22% 155 32 186 17%
Estates 20 - 20 0% 21 - 21 0%
Medical & Dental 216 19 235 8% 223 19 243 8%
Nursing & Midwifery Reg 503 36 539 7% 535 71 606 12%
Senior Managers 70 0 70 0% 88 - 88 0%
HCA's 216 29 245 12% 233 29 262 11%
Total 1,691 145 1,836 8% 1,856 192 2,048 9%
Oct-15Oct-14
33
Well Led [5]
Staff Turnover
Percentage
13.5%
(Oct 14 – 14.5%)
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
Ap
r-1
2
Jul-
12
Oct
-12
Jan
-13
Ap
r-1
3
Jul-
13
Oct
-13
Jan
-14
Ap
r-1
4
Jul-
14
Oct
-14
Jan
-15
Ap
r-1
5
Jul-
15
Oct
-15
Staff Turnover
Actual Target Lower Limit Target Upper Limit
34
0 20 40 60 80 100 120
Other/Not Known
Relocation
Work Life Balance
Lack of Opportunities
To undertake further…
Promotion
Health
Incompatible Working…
Child Dependants
Better Reward Package
Adult Dependants
Rolling Year Leavers - Resignations
Well Led [6]
Additional Notes
The main skills group of the leavers in October 15 were
Medical and Dental, Nursing & Midwifery and Admin &
Clerical.
October 15 Leavers
0 50 100 150 200 250
Resignation
End of…
Retirement
Redundancy
Dismissal
Death in…
Transfer
Rolling Year Leavers by Reason
Number of Leavers
16
(Oct 14 – 32)
0 20 40 60 80
Additional Clinical Services
Additional Prof Sci & Tech
Admin & Clerical
Allied Health Professionals
Ancillary
Estates
Medical & Dental
Nursing & Midwifery Reg
Senior Managers
Unregistered Nurses
YTD Leavers by Skills Group
35
Well Led [7]
Additional Notes
Sickness is reported one month in arrears.
The rolling 12 month sickness percentage is 3.3%.
The number of employees on Long Term Sickness (>28 Days)
July 15 – 42
Aug 15 – 30
Sept 15 – 29
Percentage
2.9%
(Sept 14 – 3.0%)
September 15
Sickness
0.0%0.5%1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%
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
Sickness Absence vs Target
Total for YDH Target
0% 1% 2% 3% 4% 5% 6% 7% 8%
Additional Clinical Services
Additional Prof Scientific &…
Admin & Clerical
Allied Health Professionals
Ancillary
Estates
Medical & Dental
Nursing & Midwifery Reg
Senior Managers
HCA's
Sickness Absence by Skills Group
Jul-15 Aug-15 Sep-15
36
Well Led [8]
Additional Notes
The percentage of staff up to date with their Mandatory
Training has increased to 89%, against a target of 90%.
Compliance
Percentage
89%
(Oct 14 – 81%)
October 15
Mandatory Training
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Ap
r-1
2
Jul-
12
Oct
-12
Jan
-13
Ap
r-1
3
Jul-
13
Oct
-13
Jan
-14
Ap
r-1
4
Jul-
14
Oct
-14
Jan
-15
Ap
r-1
5
Jul-
15
Oct
-15
Mandatory Training Compliance vs Target
Total for YDH Target
0% 20% 40% 60% 80% 100%
Additional Clinical Services
Additional Prof Scientific…
Admin & Clerical
Allied Health Professionals
Ancillary
Estates
Medical & Dental
Nursing & Midwifery Reg
Senior Managers
HCA's
Mandatory Training by Skills Group - % Compliant
Aug-15 Sep-15 Oct-15
37
Well Led [9]
Additional Notes
The percentage of staff remaining in date for their Annual
Appraisal increased to 80% in Sept 15 against a target of 90%.
Compliance
Percentage
80%
(Oct 14 – 79%)
October 15
Appraisals
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Ap
r-1
2
Jul-
12
Oct
-12
Jan
-13
Ap
r-1
3
Jul-
13
Oct
-13
Jan
-14
Ap
r-1
4
Jul-
14
Oct
-14
Jan
-15
Ap
r-1
5
Jul-
15
Oct
-15
Appraisal Compliance vs Target
Total for YDH Target
0% 20% 40% 60% 80% 100%
Additional Clinical Services
Additional Prof Scientific…
Admin & Clerical
Allied Health Professionals
Ancillary
Estates
Medical & Dental
Nursing & Midwifery Reg
Senior Managers
HCA's
Annual Appraisal by Skills Group - % Compliant
Aug-15 Sep-15 Oct-15
38
Well Led [10]
Workforce Assurance
Workforce
Contracted FTE 1985 50 45 406 99 155 21 223 535 88 233 1856 1691
Vacancy Rate 10% -7% 17% 1% 10% 15% 9% 16% 12% 15% -3% 9% 8%
Turnover
Turnover * 10% - 15% TBC TBC TBC TBC TBC TBC TBC TBC TBC TBC 14% 15%
Sickness Absence
Sickness Absence (Sept-15) 3.0% 1.1% 2.6% 3.2% 1.2% 4.1% 0.6% 0.7% 3.0% 2.7% 5.1% 2.9% 3.0%
Sickness Absence (Rolling Yr) 3.0% 2.6% 1.7% 3.1% 1.5% 5.2% 1.9% 0.7% 3.6% 0.9% 6.3% 3.3% 3.4%
Performance Compliance
Mandatory Training 90% 84% 92% 89% 91% 86% 96% 91% 90% 96% 88% 89% 81%
Appraisal 90% 76% 90% 86% 73% 76% 89% 91% 74% 70% 85% 80% 79%
Trustwide
Senior
ManagersHCA'sOct-15 Target
Nursing &
Midwifery Oct-15 Oct-14
Additional
Clinical
Services
Add'l Prof
Scientific &
Technical
Admin &
Clerical
Allied
Health
Professional
Medical
& DentalAncillary Estates
39
Well Led [11]
Workforce Assurance
Trauma & Orthopaedics 23 17 23% 38 35 8% 93% 22% 4.6% 56% 90% 94% 4 0 0
Elective Ward 14 13 7% 26 26 -2% 103% 13% 7.7% 100% 90% 95% 1 0 0
Surgery & Gynae Ward 17 13 19% 28 29 -2% 101% 34% 2.3% 94% 88% 100% 4 0 0
Kingston Wing 13 12 6% 31 31 2% 101% 12% 2.9% 81% 84% 96% 0 0 0
ICU 45 38 16% 46 38 17% 99% 17% 0.7% 66% 86% 67% 2 0 0
Gynae, Breast and MFFD 17 9 45% 32 26 19% 100% 3% 5.2% 82% 92% 91% 1 0 0
Midwifery 56 54 3% 74 72 3% 89% 14% 8.0% 85% 94% 97% 1 1 0
EAU 22 21 4% 37 41 -11% 101% 18% 0.8% 67% 88% 83% 4 0 0
Ward 8A - Medicine 17 11 33% 28 25 12% 100% 27% 9.2% 53% 69% 90% 2 0 0
Stroke & Elderley Care 15 10 32% 30 26 12% 101% 25% 4.7% 76% 96% 96% 4 0 0
Ward 9A - Medicine 19 19 0% 31 34 -9% 103% 31% 3.6% 94% 93% 85% 1 0 0
Ward 9B - Medicine 17 12 30% 28 24 17% 103% 52% 2.4% 81% 90% 100% 3 0 0
Ward 10 16 16 1% 20 21 -5% 100% 15% 10.5% 83% 88% 97% 0 0 0
CCU 18 19 -5% 18 19 -5% 101% 30% 1.9% 57% 80% 92% 0 0 0
SCBU 11 10 14% 17 15 13% 98% 19% 1.0% 50% 89% N/A 0 0 0
Total Vacancies 319 277 13%
Elec
tive
Car
e
Turnover
%
Sickness
Absence %
Urg
ent
Car
e
Oct-15
Registered Nursing All Staff
Budgeted
FTE
Contracted
FTE Pals Complaints GrievancesFFT *
Mandatory
Training %
Appraisal
%
Vacancy
Rate %
Budgeted
FTE
Contracted
FTE
Vacancy
Rate %
Average
Fill Rate %
YDH │Financial Performance Month 7 – October 2015
Executive Summary Business as usual (BAU) excluding transformation. All variances reported are for YDH BAU budget of £18.4m deficit. Monitor set a revised target of £17.1m with additional £0.4m (£17.5m total) subject to consultancy expenditure approval
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
£10.4m
YTD
deficit
£0.02 m YTD
favourable vs
budget
£1.3m in
month
deficit Trend in month surplus / deficit
Executive Summary In month October 2015 BAU breakeven to budget. Whole trust including transformation breakeven to budget in month.
(8) (16)
(57)
(3)
(66)
84
67
(1,315) (1,314)
(1,450)
(1,400)
(1,350)
(1,300)
(1,250)
(1,200)
(1,150)
(1,100)
Underspend
Overspend
Includes £70k adverse
donated asset income timing
variance (£420k YTD) expect
to reverse by year end. 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
Nursing overspent by £106k
Executive Summary – Year to date summary BAU budget Year to date £10.4m deficit; £0.02m favourable to budget
1
2
3
4
Income
Expenditure
Capital
Cash
-Income is £245k (0.35%) adverse to budget.
Clinical income is £83k favourable, private patients is break even and
RTA income £122k adverse.
Other income £205k adverse, £420k adverse timing on donated
asset income offset by additional contract and education income.
-Expenditure is £10k (0.0%) favourable to budget.
Pay is £249k adverse, £794k overspend on nursing staff is offset by
underspends in medical, admin and other staff groups.
Non pay is £238k favourable, lower expenditure on consumable
items mainly in theatres and underspend on drugs offset by less
additional income.
-Capital is £3,116k (49%) underspent against plan.
The main variances are due to the purchase of medical and radiology
equipment taking place later than planned, and timing variance on
costs for the modular ward construction, SCBU and TrakCare.
-Cash at 31st October is £8m.
This is above plan and continues to be monitored weekly. Vanguard
income has now been received increasing the cash position above
plan
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 £83k favourable & £84k in month favourable variance.
1 2 3 4
6,492 6,492
1,179 1,179
303 303
469 545
462 302
4,000
5,000
6,000
7,000
8,000
9,000
10,000
Other High Cost Drugs
Specialised Commissioning Dorset CCG
Somerset CCG
October 2015
Actual
£8.91m
October 2015
Budget
£8.82m
7,750
7,950
8,150
8,350
8,550
8,750
8,950
9,150
9,350
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
• In month less income was received for high cost
pass through drugs is due to lower expenditure.
• Specialised Commissioning contract in line with
budget in month, Somerset and Dorset CCG
contract in line with budget YTD.
Other includes- Overseas patients, Local Authority, Military, Public
Health & NCA
1.2 | Non NHS clinical income - 1.3 | Other non clinical income Adverse variance in month £24k, adverse by £327k YTD
1 2 3 4
1,174 1,190
16
44
200
179
900
1,000
1,100
1,200
1,300
1,400
1,500
Private Patients Other Non NHS Clinical Income
Other Non Clinical Income
October 2015
Actual
£1.39m
October 2015
Budget
£1.41m
£’0
00
1,000
1,050
1,100
1,150
1,200
1,250
1,300
1,350
1,400
1,450
1,500
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
• £21k favourable in month on private patients,
breakeven year to date. Compared to prior year this is
£98k favourable (8%) YTD, and £41k favourable in
month. Kingston Wing £366k contribution YTD.
• £29k adverse Other Non NHS Clinical Income due to
Injury Cost Recovery Scheme, variable income stream
YTD £91k lower than prior year, mandated bad debt
percentage increase.
• Other Non Clinical Income £16k adverse in month,
£70k timing variance on donated asset income offset
by additional education income for apprentices.
(150)
(100)
(50)
0
50
2.1 | Pay expenditure & temporary staffing Pay YTD is £249k overspent & £57k in month, additional costs for nursing partially offset by underspend on other staff groups..
1 2 3 4
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
£57k Adv
Notes
• Nursing pay is overspent due to additional agency staff shifts and the hospital was in
escalation areas for the majority of October
• Ancillary are overspent in pharmacy and radiology due to sickness and vacancy cover.
£’0
00
2.1 | Pay expenditure & temporary staffing Nursing Staff - £106k overspent in month, £794k YTD
1 2 3 4
100
150
200
250
300
350
1,400
1,600
1,800
2,000
2,200
2,400
2,600
2,800
Agency Actual Bank Actual Substantive Actual
Agency Premium Budget Bank Budget Substantive Budget
Prior Month Budget Average Occupied Bed Days
Notes
• Agency shifts and expenditure decreased in month, partly offset by an increase in substantive and bank
expenditure.
• Day theatre beds were open as an escalation area for 29 days in October. Costs incurred to staff the unit for these
days equate to approx. £93k.
• Registered nursing agency expenditure as a % of total registered nursing expenditure was 12.5% for October. The
plan submitted to monitor for October was 11.4% with the target for Q3 and Q4 at 8%.
£’0
00
2.1 | Pay expenditure & temporary staffing Medical Staff Analysis - £15k overspent in month, £199k underspent YTD. Agency spend in month £243k, YTD £1,683k.
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 mainly due increased contracted
payroll costs. The corresponding reduction in agency and additional payroll
payments is not as great as expected as some late claims were received.
Total pay costs are £21k higher than prior month.
Elective Care in month spend is for backfill of vacancies across Middle Grade
and SHO posts in Surgery, Gynae and Anaesthetics.
Urgent Care in month spend is for backfill of vacancies across Consultant,
Middle Grades and SHO posts in Radiology, ED, FOPAS, Medicine and
Acute Physicians
In monthYear to
dateIn month
Year to
date
Respiratory Consultant 23 239 9% 14%
Care of the Elderly Consultant 26 220 11% 13%
Stroke Consultant 33 200 14% 12%
Radiology Consultant 26 41 11% 2%
Elective Care 58 350 24% 21%
Other Urgent Care 76 624 31% 37%
Other Corporate 2 8 1% 0%
Totals 244 1682
Expenditure (£'000s) % of expenditure
1 2 3 4 2.2 | Drugs £3k overspent in month; £227k underspent YTD, this is partially offset by reduced income for high cost pass through drugs.
-
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 – Oct £7.69m has been spent on drugs and £4.7m of income received to directly pay for high cost items.
• In month the net drugs position is £80k adverse, YTD £157k adverse to budget. This is due to reduced income for
high cost drugs included in the block contract with Somerset CCG.
• Specialised Commissioning drugs has reduced income, under the contract the Trust only receives income to cover
70% of drug costs above plan.
£’0
00
1,665 1,677
1,955 2,545
1,083 841
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Cancer Drugs FundSpecialised CommisioningSomerset & Dorset CCG
October
2015 Actual
£4.70m
October 2015
Budget
£5.06m
YTD High Cost Drugs Income
£’0
00
1 2 3 4 2.3 | Other non pay expenditure Overspent by £66k in month, underspent by £11k YTD.
(31)
24
(59)
(70)
(60)
(50)
(40)
(30)
(20)
(10)
0
10
20
30
ConsumableM&SE
High CostConsumable
Other NonPay
Variance to
Budget in Month
£66k Adv
750
1,250
1,750
2,250
2,750
3,250
3,750
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 £31k in month, £55k underspent YTD. Underspend in
private patients, central stores partially offset by additional expenditure on pathology
related to activity and radiology for a service offset by lower pay.
• High cost consumables are underspend by £24k in month, £535k YTD, favourable
variance for RTT costs incurred in other non pay payment to another provider,
underspend in orthopaedics theatres.
• Other non pay is overspent by £59k in month, additional RTT costs for patients
transferred to Shepton Mallet Treatment centre offset by underspend in high cost
consumables. Set up costs for nursing accommodation including first month rental
(£200k YTD) £93k of income offset by £93k of rent and subsistence expenses.
£’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 £253k achieved against plan of £256k. YTD £1,513k achieved against plan of £1,531k.
1 2 3 4 £’0
00
Project
Actual
Recurrent
Acutal Non
Recurrent
Total
Achieved Plan Variance Recurrent
Non
Recurren Total
Procurement 31 0 31 22 9 230 0 230
1% Items 56 36 92 95 (3) 0 1,102 1,102
Facilities 12 0 12 13 (1) 57 100 157
Corporate 21 0 21 8 13 100 0 100
Energy 8 0 8 10 (3) 125 0 125
Commercial 18 0 18 9 10 104 0 104
CNST 5 0 5 5 0 63 0 63
Non Pay Inflation 31 0 31 31 0 362 0 362
Hospital Effectiveness 0 0 0 25 (25) 0 300 300
Urgent Care 37 0 37 37 0 386 0 386
Total 220 36 256 256 (0) 1,426 1,502 2,929
In Month Annual Plan
2.5 | Transformation Budget £0k breakeven in month; £0k breakeven YTD.
0
100
200
300
400
500
600
700
800
Planned Income & Expenditure Actual Expenditure Actual income
1 2 3 4
Notes
• Costs incurred year to date include extended FOPAS service pay costs. Project teams and
external support to facilitate implementation.
• In month was breakeven, YTD to 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
426
1,420
1,846
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
Pay Non Pay Income
£’0
00
YTD
Expenditure
£1.85m
YTD
Income
£1.85m
3.1 | Capital Underspent by £306k in month, YTD £3,116k underspent
1 2 3 4
0
500
1000
1500
2000
2500
3000
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 is underspent due to SCBU
works and fire alarm project now scheduled later in
the year.
• Medical equipment scheduled to be purchased later
this year.
• Radiology equipment now being funded via a lease
agreement.
• IT equipment expenditure for baby tagging system
completed earlier than planned.
• New ward, projected progressing with works started
on the roof, with planned completion by December/
January .
£’0
00
Capital Expenditure In Month Year to Date
Actual Variance Actual Variance
Operational Capital Spend
Total General Site Capex 209 367 884 1,283
Medical Equipment 29 46 144 685
Radiology 3 72 61 239
IT Upgrad / Replacement 5 19 48 30
IT / Developments 4 (4) 87 (37)
Major Developments
Energy Project 0 0 143 127
New Ward 564 (214) 994 506
Front Entrance 2 (2) 12 (12)
IT - Smartcare 166 10 873 253
Donated Schemes in Year 0 12 46 41
Total 982 306 3,292 3,116
4.2 | Cash Inflow in month was £3,656k, cash balance at 31st October; £8,045k
1 2 3 4 £’0
00
Notes
• At end of October 2015 cash balance was £6,753k 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.
• £3.6m of Milestone income has been received in October
• Due to the cash position being greater than plan no additional loan support is being drawn down
for November.
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 £24.3m to
cover revenue and
capital.
4.2 | Balance Sheet 1 2 3 4
Notes
• Current assets have remained
constant with Vanguard milestone
income invoiced in month 6 now
being received.
• Borrowing >1yr have increased due
to the drawdown of the loan from
the Department of Health.
Sep 15 Oct 15 Mvt In Mth
Non Current Assets 52,630 53,156 526
Current Assets
Stock 1,989 2,066 77
NHS Trade Debtors 4,729 968 (3,761)
Non NHS Trade Debtors 630 804 174
Accrued Income 1,756 2,183 427
Prepaid Contracts 1,493 1,295 (198)
Cash in Hand and at Bank 4,389 8,045 3,656
Total Current assets 14,986 15,361 375
Current Liabilities
Trade Creditors (1,290) (1,833) (543)
Other Creditors (2,936) (2,911) 25
PDC Dividend Creditor (3) (94) (91)
Capital Creditor (1,145) (1,824) (679)
Accruals (9,772) (10,576) (804)
Borrowings <1yr (115) (115) 0
Deferred Income (9,917) (9,658) 259
Current Liabilities (25,178) (27,011) (1,833)
Net Current Assets (10,192) (11,650) (1,458)
Total Assets less Current Liabilities 42,438 41,506 (932)
Trade and other Payables >1yr (11) 0 11
Borrowings> 1yr (5,348) (5,741) (393)
Provisions >1yr (1,028) (1,028) 0
Net Assets employed 36,051 34,737 (1,314)
Financed by:
I&E Reserve Current year (9,132) (10,446) (1,314)
Public Dividend Capital 41,823 41,823 0
I&E Reserve Previous year (4,638) (4,638) 0
Revaluation Reserve 7,998 7,998 0
Total Financed 36,051 34,737 (1,314)
Summary Statement of Comprehensive Income For business as usual operations – excluding transformation.
1 2 3 4
Financial Summary
£000's Aug-15 Sep-15 Actual
Variance to
Budget % var Actual
Variance
to
Budget % var
Annual
Budget
2015/16
Income
Clinical Income 8,355 8,570 8,905 84 (0.9%) 59,663 83 (0.1%) 103,258
Non NHS Clinical Income 197 281 216 (8) 3.5% 1,582 (122) 7.7% 2,891
Other Income 1,153 1,178 1,174 (16) 1.4% 8,087 (205) 2.5% 13,946
Total Income 9,704 10,029 10,295 60 (0.6%) 69,332 (245) 0.4% 120,095
Pay
Registered Nursing (2,074) (2,190) (2,056) (22) (1.1%) (14,766) (339) (2.3%) (25,178)
Unregistered Nursing (525) (527) (559) (84) (15.0%) (3,845) (455) (11.8%) (5,891)
Medical Staff (2,358) (2,344) (2,365) (15) (0.6%) (16,182) 201 1.2% (27,808)
Estates, Admin & Clerical (1,277) (1,301) (1,289) 65 5.0% (8,950) 344 3.8% (16,095)
Pay - Scientific, Therapeutic & Technical (680) (629) (661) 16 2.4% (4,458) 169 3.8% (8,022)
Pay - Ancillary (366) (368) (359) (18) (4.9%) (2,546) (167) (6.6%) (4,135)
Total Pay Expenditure (7,280) (7,360) (7,290) (57) (0.8%) (50,747) (249) (0.5%) (87,129)
Non Pay
Drugs (956) (1,094) (1,210) (3) (0.2%) (7,685) 227 3.0% (13,929)
Consumable M&SE (640) (735) (658) (31) (4.8%) (4,665) 55 1.2% (8,179)
High Cost M&SE (169) (192) (265) 24 9.0% (1,490) 535 35.9% (3,471)
Other (1,838) (1,921) (1,778) (55) (3.1%) (12,411) (559) (4.5%) (20,275)
Total Non Pay Expenditure (3,605) (3,942) (3,912) (66) (1.7%) (26,252) 259 1.0% (45,855)
EBITDA (1,181) (1,273) (906) (63) (6.9%) (7,666) (235) (3.1%) (12,889)
Other Technical (423) (260) (408) 63 15.5% (2,779) 407 14.6% (5,542)
Surplus / (Deficit) (1,603) (1,533) (1,314) 0 (10,446) 172 (18,431)
Prior Months Actuals In Month - Oct 15 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 Aug-15 Sep-15 Actual
Variance to
Budget % var Actual
Variance
to
Budget % var
Annual
Budget
2015/16
Income
Clinical Income 8,845 8,950 9,198 (208) 2.3% 61,360 (1,441) 2.3% 109,729
Non NHS Clinical Income 197 281 216 (8) 3.5% 1,582 (122) 7.7% 2,891
Other Income 1,153 1,328 1,174 (16) 1.4% 8,237 (55) 0.7% 13,946
Total Income 10,194 10,559 10,588 (232) 2.2% 71,178 (1,618) 2.3% 126,566
Pay
Registered Nursing (2,084) (2,198) (2,065) 36 1.7% (14,808) (97) (0.7%) (25,893)
Unregistered Nursing (527) (529) (561) (85) (15.2%) (3,859) (469) (12.1%) (5,891)
Medical Staff (2,362) (2,361) (2,375) 63 2.7% (16,240) 570 3.5% (28,761)
Estates, Admin & Clerical (1,324) (1,361) (1,345) 133 9.9% (9,260) 759 8.2% (17,462)
Pay - Scientific, Therapeutic & Technical (680) (629) (661) 45 6.8% (4,460) 278 6.2% (8,336)
Pay - Ancillary (366) (368) (359) (18) (4.9%) (2,546) (167) (6.6%) (4,135)
Total Pay Expenditure (7,342) (7,445) (7,366) 174 2.4% (51,173) 873 1.7% (90,479)
Non Pay
Drugs (956) (1,094) (1,210) (3) (0.2%) (7,685) 227 3.0% (13,929)
Consumable M&SE (640) (735) (658) (31) (4.8%) (4,665) 55 1.2% (8,179)
High Cost M&SE (169) (192) (265) 24 9.0% (1,490) 535 35.9% (3,471)
Other (2,266) (2,257) (1,996) 5 0.3% (13,831) (307) (2.2%) (23,396)
Total Non Pay Expenditure (4,032) (4,278) (4,129) (5) (0.1%) (27,672) 510 1.8% (48,976)
EBITDA (1,180) (1,163) (906) (63) (6.9%) (7,666) (235) (3.1%) (12,889)
Other Technical (423) (260) (408) 63 15.5% (2,779) 407 14.6% (5,542)
Surplus / (Deficit) (1,603) (1,424) (1,314) 0 (10,446) 172 (18,431)
Prior Months Actuals In Month - Oct -15 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 10%.
• Paediatric income is phased to grow at the end of the year, so would expect it to make a positive contribution by
year end. Rheumatology apportionments still being investigated.
5.1 | Service Line Reporting Elective Care SLR YTD contribution by specialty
Notes
• The above shows several large contributions in Ophthalmology, Orthopaedics and Surgical specialties.
• The latter two are making a small contribution relative to the respective size of the specialties (in terms of
revenue).
• Gynaecology apportionments being revised, potentially explaining the relatively high profitability of obstetrics.
Appendix: 6 REPORT TO: Board of Directors REPORT BY: Clinical Research Unit PRESENTED BY: Dr Tim Scull, Medical Director TITLE: Clinical Research Unit Annual Report and Operational Capability
Document DATE: November 2015 What is this item about and what is the Board asked to do? The enclosed annual report details the Research and Development department’s performance and future direction. The NIHR and Comprehensive Network require a report detailing performance including key performance indicators. The Board is asked to receive and note the annual report. The operational capability document provides a Board level approved operational framework which sets out how the organisation plans to meet its research related responsibilities/ requirements as stated in the Research Governance Framework and Clinical Trials Regulations. The statement also provides researchers with an operational overview of resources available to support research. The Board is asked to approve the information within the document on an annual basis. Are there legal, financial, procedural, workforce implications and/or legislative requirements? • Legally? Yes - the document is required by the NIHR/DoH for Research Governance. • Financially? Yes- the document publicises our research achievements which will bring
income into the Trust. • Regarding Workforce? Having a high performing research department will enhance
staff recruitment. The research staff are funded by the NIHR on the number of studies hosted and number of patients recruited.
Is this paper clear for release under the Freedom of Information Act 2000? Yes What are the next steps/future actions? Information about the Research Support Service and the required documents is available via the NIHR website as well as from the Research Manager. The document includes information relating to research governance and areas of expertise. This ensures that research is conducted within strict ethical and regulatory frameworks in disease areas pertinent to the population with study oversight from an experienced clinician.
Links to the Trust’s strategic objectives and/or priorities: The document includes information relating to research performance ensuring a safe and robust service. The paper highlights key achievements advertising the Trusts capabilities. The paper provides information on research activity and performance detailing future direction in line with Trust’s plan. The document provides information which will advertise the achievements of the Trust continuing to maintain the reputation of providing high quality care. Links to the Board Assurance Framework/Corporate Risk Register (if applicable): N/A Reference to CQC domains: safe, effective, well-led, responsive Report history: Last presented to the Board - October 2014
Page 1 of 8
Clinical Research Unit Annual Report 2014-15
Clinical Research Unit Annual Performance Report 2014 - 2015 Dr Stephen Gore, R&D Director Mrs Joanna Allison, Clinical Research Unit Manager/Lead Nurse
Executive Summary The NIHR Clinical Research Network recruited more than 620,000 patients to clinical research studies last year.
During the year the NIHR hit a recruitment milestone of more than three million patients recruited to clinical research studies in the last six years. Nearly 96,000 of these patients were recruited to commercial contract studies. NIHR, Annual Report 14-15
The Trust’s Clinical Research Unit in 2014 -15 had continued to over perform and recruited over 729 patients into studies contributing to the national achievement. Despite a reduction in core infrastructure funding, the department received funding/income amounting to more than £790 000.
This report will document the research activity, governance arrangements and finance for the year as well as highlighting key achievements.
Our Key achievements in 2014-2015
• Participated in the Clinical Research Network -South West Peninsular (CRN: SWP) Patient Experience Questionnaire which achieved a 75% response rate and demonstrated patient satisfaction when participating in studies.
• Received funding and sponsored an innovative pilot study called VERRDICT examining volatile biomarkers in patients undergoing colorectal surgery.
• Journal articles published in Annuals of Surgery, Gut, Colorectal disease and Techniques in Coloproctology by Chief investigator of the STARRCAT trial
• Reduction in time taken to approve studies locally - all studies approved within 15 days (local network target).
• Doubled the number of commercial industry studies hosted by the Trust. • Secured funding for a cross county post shared with Musgrove Park Hospital that has
improved the radiotherapy pathway for trial patients from Yeovil going to Taunton for their treatment.
Future strategy in 2015 - 2016
• To increase the number of Life science industry studies by 15%. • To provide a broad portfolio of studies which appeal to the majority of patients. • To raise the profile of research in Yeovil by developing a new website that provides
information for patients and staff. • To join with Somerset Partnership Trust and Musgrove Park Hospital Trust to form a
collaboration to ensure patients can be offered opportunities to participate in dementia research and encourage different ways of working in view of the Vanguard project.
• To continue to meet new 70 day target for first patient at site to consent into each study.
• To develop research in new disease areas such as Ophthalmology, Gynaecology and Dementia.
• To work closely with Network PCPIE lead to engage more patients into research • To build on areas of growth such as orthopaedics, dermatology, diabetes, surgery • Work with the South West Pen research network to increase opportunities to participate in research. • To develop innovative research proposals with key staff and apply for funding.
Research Activity and Recruitment
The majority of the Trust research activity continues to be the recruitment of patients into multi-centre externally funded non-commercial clinical studies that are adopted on to the (NIHR) Portfolio. There have been approximately 120 NIHR research studies active in the Trust at any point over the last year and 35 new studies were opened within year. These cover the common disease areas such as cancer, stroke, cardiovascular disease, gastroenterology, orthopaedics and paediatrics. The breadth of the Trust portfolio covers research into the genetics of disease, new and novel drug combinations and surgical intervention as well as lifestyle factors.
Recruitment target Based on previous activity data, the network set an overall recruitment target for the Trust of 650 patients for the year. The Trust reached a total of 729 patients who participated in a variety of band 1, 2 and 3 studies. Figure 1 illustrates the actual recruitment in relation to the overall target. The target for 2015-2016 has been set at 650 patients due to the fact that there are less studies recruiting large numbers of patients available due to the move towards targeted therapies and personalised medicine
Figure 1 demonstrates target versus actual recruitment over the year
Figure 2 demonstrates the yearly increase into recruitment
Clinical Research Portfolio
Oncology The national oncology trial portfolio continues to see a reduction in the number of large RCTs due to therapy becoming targeted. However during this year we have opened a number of Phase 2 studies within oncology and this has given our patients wider access to novel treatments. Recruitment into our urology, upper GI and colorectal portfolio has increased and our breast portfolio continues to recruit well with engagement from the surgical, specialist nurse and oncology teams.
Figure 3: Recruitment by Cancer Site Portfolio for YDH for 2014-15
Medical/Surgical Clinical Trials Portfolio The Medical/Surgical research portfolio comprises of a wide range of trials in many disease areas as demonstrated in Figure 4. Examples of achievement are mentioned below. • Stroke
Over the last year the Trust has recruited 158 patients into studies on the NIHR Stroke portfolio which is an achievement for a smaller site. Dr Khalid Rashed is passionate about stroke research and leads the team in conducting high quality studies within this speciality. Despite concern over the stroke service, the team have recruited into complex, multidisciplinary studies. The research team recruited 60 patients into the AVERT study and received a Silver Club Recruiter trophy for their recruitment that was presented at a National conference. The study requires standard versus early physiotherapy intervention and requires physiotherapist, OTs and the ward team to work closely together and this has been internationally acknowledged. The team have also recruited well into the hyper acute stroke study ENCHANTED that examines differing doses of thrombolysis and rapid blood pressure lowering methods after stroke. This highlighted that there were differences in the way blood pressure after stroke was managed within the Trust and by working closely with the medical team and the consultant stroke nurse a guideline for managing blood pressure after stroke is being developed.
• Surgery
Mr Nader Francis was the chief investigator for the VERRDICT study which recruited 14 patients. This pilot study conducted here at Yeovil enabled collaboration with a commercial company and university sites to look at novel biomarkers in colorectal surgery patients. The pilot project was a proof of principal study to see if a breath test to collect the biomarkers was acceptable to patients. This proved to be very acceptable to patients as all patients approached for the study entered and a further multicentre study is planned once grant funding is secured. The ROCCS study is another surgical study which continued to recruit well looking at patients having a reversal of stoma with randomisation into either normal closure or mesh placement that may prevent future hernia formation.
Orthopaedic Research Portfolio With complex study design and the need for involvement from OTs, physios, theatres and outpatient staff, the portfolio has been challenging but highly successful. The team recruited 201 patients into the Fracture Free observational study that aims to improve our understanding of the causes and consequences of fractures in patients by capturing and analyzing patient data. This enabled the Trust to be the highest recruiter into orthopaedic studies within the CRN :SWP region.
Figure 4 Total Number of Patients Recruited into Medical Trials by Site April 2013 - April 2014
Research Management and Governance All research continues to be managed centrally in the Trust by the Clinical Research Unit with Dr Steve Gore as Director of Clinical Research. 98% of activity is NIHR adopted multi-centre clinical trials. These are mainly non-commercial/ academic and charity funded research with the exception of one externally funded research grant. The remaining Trust portfolio comprises of studies being funded by the Pharmaceutical Industry. Over the year, the number of industry studies has steadily increased to 11.
Key Performance Indicators
KPI description
RAG rating Activity
Complete approvals process in 30 days from date of submission of SSI
100% of studies now approved within 30 days
To increase commercial study portfolio by 15%
Number of commercial portfolio studies increased to 5 studies
Complaints Incidents and Adverse Event Reporting There were no written complaints from research patients in 2014/15. Several cards and letters of thanks were received from patients and carers.
There have been a small number of research related minor incidents and near misses that have been reported through the Trust Safeguard system for incident reporting. The majority of these have involved pharmacy and dispensing issues and issues surrounding the working environment in one of the offices.
The Research Department is, however, aware of the overriding need for patient safety and pharmacovigilance will always remain the top priority.
Consumer Involvement and Awareness The department took part in the CRN: SWP Patient Experience Questionnaire in November 2014. This achieved a 75% response rate (102 given out and 77 returned) and the aim of the questionnaire was to evaluate and understand patients’ experience in being involved in research studies and inform local delivery. It aimed to identify the positive aspects of participation, and develop a greater understanding of the potential barriers to participation to enable us to plan effective recruitment strategies. Some of the key results were that 99% of patients felt they were strongly valued when participating in a trial and 88% would recommend taking part in research to a friend or relative. Some of the most powerful data to come out of the survey was quotes from the patients such as “Staff were amazing, totally supportive, knowledgeable, professional but personable in their approach” and “Having the opportunity to be at the forward front of medical advances” and from one oncology patient “There is nothing better than to be alive and see my children become adults - I am so lucky. I thank god (well science really) for my trial drug and that some scientist thought to create it.”
The majority of the clinical trial work undertaken by the Trust has user involvement built in at the protocol design stage through to the format and wording of the patient information sheets and consent forms. Each of the research grant proposals have worked with local peer support groups to elicit ideas on study design, documentation and dissemination.
Each year, ‘International Clinical Trials Day’ which is held in May, is an opportunity to showcase the research activity within the Trust. The 2014 day was led nationally and within the Trust included a stand detailing studies and processes, articles in the local and national press, posters and most importantly patients were encouraged to ask their clinical teams what studies are running. The theme of the 2014 day was ‘it’s OK to ask’ so aimed to encourage patients to talk to their clinicians about any research going on in their area.
Research publications The STARRCAT pilot study that was sponsored by the Trust was well-accepted by patients and there have been 5 publications in international journals following this study.The results from the study has led to the development of a new bespoke tool for evaluation of laparoscopic rectal cancer surgery. This assessment tool will be further validated in a larger study and a grant has been submitted to proceed with the follow up study.There is mounting evidence of the benefits that laparoscopic rectal cancer surgery can offer to patients in terms of reduced complications and faster recovery from surgery. This assessment tool will be useful to help guide training of surgeons wishing to perform this surgery, and ensure that these techniques are introduced in a safe manner.
Research Finance
Infrastructure funding
Yeovil Hospital received a funding allocation from the South West Peninsular Research Network broadly based on accrual and complexity of research studies in progress. The budget is ring fenced for research and is supported by a designated Trust Finance Assistant.
The baseline budget allocation for 2014 -15 has seen a decrease of 7% as the South West Peninsular Research Network did not meet their patient recruitment target. This was largely a result of a flat national trials portfolio and because the network did not perform.
Grant Income to the Trust The Colorectal Therapies Healthcare Technology Cooperative awarded Mr Nader Francis £5000 from the Impact Acceleration Award Funding to conduct the “VERDDICT” study. This funding was supplied to work in partnership with Bedfont Scientific Plc who provided matched funding, to deliver the study with the Trust acting as the study sponsor. .
Research Capability Funding (RCF)
The Trust was awarded £36,022 for 2014-15 from the DH primarily to support research staff activity either during or between grants, thus enabling an ongoing research programme. A proportion of this has supported grant writing activity and the research team ongoing professional development.
Pharmaceutical Industry Income
All pharmaceutical funded studies hosted by the Trust are costed via the national costing template. In 2014 -15, there have been 5 industry studies recruiting and 6 in follow up in the Trust and although though they tend to be run to a higher standard than academic studies and are labour intensive, they do provide an important source of external income.
Summary of Finances for Research and Development Department 14-15 R & D Financial SummaryFinancial Report for the Period ended 31st March 2015
Annual Budget YTD Budget YTD Actual Variance NotesAdv / (Fav)
£'s £'s £'s £'sExpenditureR & D Pay 551,796 551,796 543,377 (8,419)R & D Non Pay 26,288 26,288 17,579 (8,709)Allocated to other departments 89,145 89,145 89,145 0Overheads 102,748 102,748 102,748 0
769,977 769,977 752,849 (17,128)
IncomeNIHR FSF - 30466 (32,100) (32,100) (36,022) (3,922) Research & Capability FundingClinical Trials - 30291 (75,750) (75,750) (87,546) (11,796)South West Peninsula Network (623,373) (623,373) (702,953) (79,580)Other (14,038) (14,038) (2,729) 11,309Total Income (745,261) (745,261) (829,250) (83,989)
R&D & Clinical Trials SummaryTotal Expenditure 769,977 769,977 752,849 (17,128)Total Income (745,261) (745,261) (829,250) (83,989)(Surplus) / Deficit 24,716 24,716 (76,401) (101,117)
STARRCAT Financial SummaryFinancial Report for the Period ended 31st March 2015
Annual Budget YTD Budget YTD Actual VarianceAdv / (Fav)
£'s £'s £'s £'sExpenditureR & D Pay 23,206 23,206 18,952 (4,254)R & D Non Pay 28,019 28,019 (6,345) (34,364)Allocated to other departments 6,134 6,134 6,134 0 1PA for Mr Nader Francis
57,359 57,359 18,741 (38,618)
IncomeSTARRCAT - 30225 (49,391) (49,391) (60,782) (11,391)Total Income (49,391) (49,391) (60,782) (11,391)
RfPB Grant - STARRCAT SummaryTotal Expenditure 57,359 57,359 18,741 (38,618)Total Income (49,391) (49,391) (60,782) (11,391)(Surplus) / Deficit 7,968 7,968 (42,041) (50,009)
TOTAL R&D (Surplus) / Deficit 32,684 32,684 (118,442) (151,126)
NIHR Guideline B01
R&D Operational Capability Statement
Version History
Version number Valid from Valid to Date approved Approved by Updated by
RDOCS 002 29/06/2012 29/06/2013 11/07/2012 BoD Barbara Williams-Yesson
RDOCS 003 29/06/2013 30/06/2014 Barbara Williams-Yesson
RDOCS 004 30/06/2014 30/06/2015 BoD Barbara Williams-Yesson
RDOCS 005 01/07/2015 30/06/2016 Joanna Allison
Contents
Organisation R&D Management Arrangements
Organisation Study Capabilities
Organisation Services
Organisation R&D Interests
Organisation R&D Planning and Investments
Organisation R&D Standard Operating Procedures Register
Planned and Actual Studies Register
Other Information
Organisation R&D Management Arrangements
Information on key contacts
Name of Organisation
R&D Lead / Director (with responsibility for reporting
on R&D to the Organisation Board)
Name:
Address:
Contact Number:
Contact Email:
Other relevant information:
Role:
Name:
Contact Number:
Contact Email:
Role:
Name:
Contact Number:
Contact Email:
Role:
Name:
Contact Number:
Contact Email:
Add further contacts by selecting and then copying the five Excel rows (ie whole rows) above for Contact, role, name, number and email.
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Mrs Joanna Allison
01935 384615
Senior Research Nurse
R&D Office details:
Clinical research unit
, Level 4, Yeovil District Hospital, Higher Kingston, Yeovil, Somerset BA21 4AT
01935 384559
Contact 2:
Key Contact Details e.g. Research Governance Lead, NHS Permissions Signatory contact details
Contact 1:
Organisation DetailsYeovil District Hospital NHS Foundation Trust
Dr Stephen Gore, Research & Development Director: Dr Tim Scull, Medical Director Responsible for reporting to Board
Clinical Research Unit Manager
01935 384559
Research facillitator
Mrs Nicola Marks
01935 384559
Contact 3:
Mrs Kerry Rennie
Page 1 of 8
Information on staffing of the R&D Office
R&D Office Roles
(e.g. Governance, Contracts, etc)
Whole Time
Equivalent
R&D Director 0.1
clinical research Unit manager 0.8
Research facillitator 1
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Then select a row in the table and 'insert copied cells'. (Please do not select and copy individual cells or groups of cells as this does not preserve formatting.)
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Information on reporting structure in organisation (include information on any relevant committees, for example, a Clinical Research Board / Research Committee / Steering Committee.)
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Information on Research Networks supporting/working with the Organisation.
Information on how the Organisation works with the Comprehensive Local Research Network (CLRN), Primary Care Research Network (PCRN), Topic Specific Clinical Research Networks (TCRN).
Research Networks
Research Network (name/location)
NIHR Clinical Research Network: South West
Peninsula
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Information on collaborations and partnerships for research activity (e.g. Biomedical Research Centre/Unit, Other NHS Organisations, Higher Education Institutes, Industry)
Current Collaborations / Partnerships
Organisation Name
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Reporting Structures
Contact NumberDetails of Collaboration / Partnership (eg Contact Name Email address
Role/relationship of the Research Network eg host Organisation
Comments
indicate if shared/joint/week days in office etc
All staff work at Yeovil District Hospital
R&D Team
The Trust Clinical research Unit Manager reports to the R&D Director who chairs the quarterly R&D Executive Group. he R&D Director reports to the Medical Director who in return reports to the Hospital Management Team and
the Board of Directors. A report is submitted annually to the Board of Directors detaining activity and includes Key Performance Indicators.
Yeovil Hospital receives research funding to support portfolio activity
Page 2 of 8
Page 3 of 8
Organisation Study Capabilities
Information on the types of studies that can be supported by the Organisation to the relevant regulatory standards
CTIMPs
(indicate Phases)
Clinical Trial of a
Medical Device
Other Clinical
Studies
Human Tissue:
Tissue Samples
Studies
Study Administering
Questionnaires
Qualitative Study
As Sponsoring Organisation P
As Participating Organisation P P P P P P
As Participant Identification Centre P P P P P P
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Which licences does the organisation hold which may be relevant to research?
Licence Name
Example: Human Tissue Authority Licence
HTA licence
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PCT ONLY: Information on the practices which are able to conduct research
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OTHER
Number/notes on General Practitioner (GP) Practices
Licence Details Licence End Date (if applicable)Licence Start Date (if applicable)
Organisation Licences
Types of Studies Organisation has capabilities in (please tick applicable)
Licence for use of tissue - does not extend to storage for future research
Page 4 of 8
Organisation Services
Information on key clinical services contacts and facilities/equipment which may be used in studies for supporting R&D governance decisions across the organisation.
Service Department Contact Name within
Service Department
Contact number
Pathology Dr David James 01935 384298
Radiology Dr Cenydd Thomas 01935 384928
Pharmacy Mr Jon Standing 01935 384513
Clinical Investigations Ms Ashley Davidson 7789006860
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Information on key management contacts for supporting R&D governance decisions across the organisation.
Department Contact Name within
Service Department
Contact number
Archiving Joanna Allison
Clinical Research
Unit Manager
01935 384615
Contracts Joanna Allison
Clinical research
Unit Manager
01935 384615
Data management support Joanna Allison
Clinical Research
Unit Manager
01935 384615
Finance Fiona Timmins 01935 384526
Information Technology Jason Maclellan,
Chief Information
Officer
7427683596
Human Resources Mark Appleby 01935 384830
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Contact email
Clinical Service Departments
Histopathology, Haematology, Chemical
Details of any internal agreement
templates
and other [email protected]
Specialist facilities that may be provided
(eg number/type of scanners)
Contact email
Echo, ECG, Lung function
Aseptic service
MRI / CT/bone scan and Xray service
Pharmacy service
Named Archivist within R&D, governed by
Archiving SOP
Specialist services that may be provided
Centralised Research Department for all
aspects of research and data management
Designated finance accountant for
Support from Chief Information Officer and
team
Human Resource advice and support
The Trust supports the use of the Model
Clinical Trials agreement (CTA)
Management Support e.g. Finance, Legal Services, Archiving
Details of any internal agreement
templates
and other [email protected]
Page 5 of 8
Organisation R&D Interests
Information on the areas of research interest to the Organisation
Area of Interest
Orthopaedics
Diabetes
Gastroenterology
Heamatology Malignant conditions Dr Belinda Austen [email protected] 01935 384559
Cancer
Surgery
Stroke
Dementia
Paediatrics
Critical Care
Dermatology
Care of the Elderly Chronic disease, falls, dementia Dr Khalid Rashed [email protected] 01935 384344
Oral and dental Children and adults Ms Helen Griffith [email protected] 01935 384333
Cancer Acute oncology, colorectal and lung Dr Matt Sephton [email protected] 01935 384336
Emergency Medicine Emergency departement Dr Katalin Fernando [email protected] 01935 384388
Opthalmology All opthamology conditions Mr Paritosh Shah [email protected] 01823 344309
Gynacology Endometriosis Mr Ahmir Shah [email protected] 01935 384347
Cardiology
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Information on Local / National Specialty group membership within the Organisation which has been shared with the CLRN
National / Local Specialty Group Contact Name Contact Number
Local Mr Nader Francis 19354244
Local Mr Nader Francis
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Organisation R&D Planning and Investments
Area of Investment (e.g. Facilities, Training,
Recruitment, Equipment etc.)
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Contact Email Details
Dr Alex Bickerton [email protected]
Common Childhood ailments
Knee, Hip , shoulder and ankle surgery Mr Ben Lankester [email protected]
Colorectal
Contact Email
Dr Paul Heaton
Organisation R&D Areas of Interest
Young adult and adult diabetes
Contact Name Contact Number
Specialty Area (if only specific areas within Specialty Group Membership (Local and National)
[email protected] oncology
Indicative dates
Planned Investment
Description of Planned Investment Value of Investment
Dr Steve Gore [email protected] 01935 384877
01935 384559
colorectal surgery Mr Nader Francis [email protected] 01935 384244
01935 384559
breast and urology Dr Geoff Sparrow [email protected] 01935 384559
Inflammatory Bowel Disease & carcinomas
Acute Stroke Service Dr Khalid Rashed [email protected] 01935 384344
[email protected] 01935 384344In-patient Care Dr Khalid Rashed
[email protected] 01935 384559
Malignant, non-malignant Dr Rachel Wachsmuth [email protected] 01935 384559
Medical cardiology Dr Andrew Broadley [email protected] 01935 384556
Intensive care Dr Jeremy Reid [email protected] 01935 384246
Page 6 of 8
Organisation R&D Standard Operating Procedures Register
Standard Operating Procedures
SOP Ref Number Valid to
The Organisation will work to the NIHR Research
Support Services Framework and those SOPs for both
Participating and Sponsoring research
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Information on the processes used for managing Research Passports
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Information on the agreed Escalation Process to be used when R&D governance issues cannot be resolved through normal processes
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SOP Details
Indicate what processes are used for managing Research Passports
SOP Title Valid from
Escalation Process
From the R&D Director to the R&D Executive Group and/ or Clinical Governance then refer as appropriate to Medical Director and to the Hospital Management Team or Board
These are issued and managed by the Clinical Research Unit in accordance with current guidance
Page 7 of 8
Planned and Actual Studies Register
The Organisation should maintain or have access to a current list of planned and actual studies which its staff lead or collaborate in.
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Other Information
For example, where can information be found about the publications and other outcomes of research which key staff led or collaborated in?
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Information available on the Trust Internet pages which is currently being updated.
Other Information (relevant to the capability of the Organisation)
The Trust Clinical Research Unit maintains an up dated list of all research activity and staff involved across the organisation.
Comments
Page 8 of 8
mg/lth10.1 November 2015
Board of Directors Meeting November 2015
Director of Nursing Report
Monthly Report of Nurse/Midwifery Staffing Levels
1 October 2015 - 31 October 2015
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 Returns
mg/lth10.1 November 2015
Recruitment e-Rostering Bank and Agency usage Monitor nursing agency rules Unfilled Shifts Unify Return
Day Night Day Night
War
d na
me
Registered midwives/nurses Care Staff Registered
midwives/nurses Care Staff
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 959 959 1212 1218.5 775 775 600 600 100.0% 100.5% 100.0% 100.0%
KW 713 741.5 657.5 656.5 713 713 333.5 333.5 104.0% 99.8% 100.0% 100.0%
6A 1421.5 1421.5 1381.5 1381.5 1069.5 780.5 678.5 667 100.0% 100.0% 73.0% 98.3%
6B 1069.5 1137 1466.5 1466.5 713 747.5 566 577.5 106.3% 100.0% 104.8% 102.0%
7A 1286.5 1337.5 944.5 925 713 713 713 713 104.0% 97.9% 100.0% 100.0%
EAU 1426 1456.5 1561.5 1555 1058 1069.5 701.5 723.5 102.1% 99.6% 101.1% 103.1%
8A 1069.5 1070.5 1282.5 1264 713 713 713 713 100.1% 98.6% 100.0% 100.0%
8B 1302 1335 1295.5 1301 713 713 713 724.5 102.5% 100.4% 100.0% 101.6%
9A 1426 1485 866.5 872 713 747.5 713 713 104.1% 100.6% 104.8% 100.0%
9B 1069.5 1128.5 1187 1192.5 713 747.5 701.5 701.5 105.5% 100.5% 104.8% 100.0%
10 1069.5 1097.5 356.5 333.5 1012 1012 0 0 102.6% 93.5% 100.0% -
ICU 2340 2316 119 119 2242.5 2242.5 0 0 99.0% 100.0% 100.0% -
CCU 1395 1414.5 0 5.5 883.5 883.5 0 0 101.4% - 100.0% -
Freya 2857.5 2542.5 997.5 787.5 1953 1816.5 651 630 89.0% 78.9% 93.0% 96.8%
SCBU 930 930 465 465 294.5 283 294.5 271.5 100.0% 100.0% 96.1% 92.2%
Recruitment Registered Nurses: The ongoing recruitment drive for registered nurses continues with rolling fortnightly interviews and successful candidates being offered positons on the day; candidates are both UK and EU of origin. The following graph indicates our current recruitment position and going forward as of 5 November 2015:
mg/lth10.1 November 2015
The closing position includes the numbers required for the Winter Escalation Ward. NB: It should be noted this is only accurate on the day it is calculated due to the fluidity of recruitment. e-Rostering e-Rostering continues to be modified and updated to ensure meaningful reports are available on the system. Bank and Agency Usage The following table indicates the number of bank / agency used during October 2015:
Ward
WA
RD
10
9A
9B
8A
8B
AC
CU
7A
EAU
6A
6B
ICU
KW
MFF
D /
GYN
AE
MA
TER
NIT
Y
SCB
U
TOTA
L
Registered Bank 11 5 10 20 25 1 8 18 10 9 34 10 32 105 22 320
Unregistered Bank 1 1 2 18 15 2 3 0 3 13 1 12 0 11 3 85
Total Bank 12 6 12 38 40 3 11 18 13 22 35 22 32 116 25 405
Registered Agency 15 20 43 51 38 2 28 47 31 73 0 17 61 0 11 437
Unregistered Agency 1 9 30 19 34 1 12 12 6 26 0 14 11 0 1 176
Total Agency 16 29 73 70 72 3 40 59 37 99 0 31 72 0 12 613
TOTAL Bank & Agency 28 35 85 108 112 6 51 77 50 121 35 53 104 116 37 1018
mg/lth10.1 November 2015
The tighter controls on managing bank and agency booking continued during October resulting in the following changes as indicated in the table below (excluding escalation and those areas currently excluded from the Safer Staffing report).
September October Reduction Increase Registered Bank 260 320 60 Unregistered Bank 227 85 142 Registered Agency 567 437 130 Unregistered Agency
175 176 1
TOTAL 1229 1018 272 1 Monitor, Nursing Agency Rules We have requested the use of seven off framework agencies but have had no response to date from Monitor regarding the applications. We were using 100% framework agencies from the 19 October until Saturday 31 October 2015 when we had to use off framework shifts in order to maintain the safe provision of clinical care. In order to try and reduce non-framework agency usage the introduction of a bank incentive scheme has been agreed that is within the proposed Monitor price caps and will run until January 2016. There will also be the re-instatement of overtime rates for all nursing staff to entice our workforce to work more shifts on the bank and to work overtime and thus reducing agency spend. Unfilled Shifts
10
9A
9B
8A
8B
7A
EA
U
6A
6B
CC
U
ICU
KW
JW
Frey
a
SC
BU
Tota
l
Using Professional Judgement
Registered 6 1 2 2 1 1 8 1 1 62 2 87
Unregistered 3 7 1 3 1 9 3 11 5 1 8 7 59
Nurses Not Available
Registered 1 1 1 1 4 56 64
Unregistered 2 3 1 4 1 28 2 41
TOTAL 12 7 3 8 3 11 5 23 6 2 68 8 9 84 2 251
The high number of unfilled shifts of Ward 6A and ICU using professional judgement are all activity related. Freya constantly has a high number of shifts not covered due to unavailability of staff. They have recently recruited a high number of newly qualified midwives to mitigate this in the future. RECOMMENDATIONS The Board of Directors is asked to note the information contained in this summary report and the actions currently in place.
Appendix: 8 REPORT TO: Board of Directors REPORT BY: Jade Renville, Company Secretary PRESENTED BY: Jade Renville, Company Secretary Peter Wyman, Chairman TITLE: DRAFT Fit and Proper Persons Policy and Procedures
DATE: 25 November 2015 What is this item about and what is the Board asked to do? New regulations came into effect for NHS bodies on 27 November 2014 requiring directors to be fit and proper persons (Regulation 5). The enclosed policy and procedures sets out in one place the process which is followed by YDH to ensure that its directors are fit and proper in accordance with the regulations. The Board is asked to APPROVE the Fit and Proper Persons Policy and Procedures. Are there legal, financial, procedural, workforce implications and/or legislative requirements? Regulation 5 – See Above. Is this paper clear for release under the Freedom of Information Act 2000? Yes What are the next steps/future actions? • Fit and Proper Persons Policy and Procedures to be formatted within new branded
corporate style. • Annual declarations are to be collected from those existing in post. • Pre-employment checks (including the fit and proper requirements) will continue to take
place as part of business as usual activities. Links to the Trust’s strategic objectives and/or priorities: Care for our population. Links to the Board Assurance Framework/Corporate Risk Register (if applicable): N/A Reference to CQC domains: Safe, effective, well-led, responsive. Report history: Discussion at the Board of Directors on 17 December 2014 [Minute 1-167/14 Refers].
Fit and Proper Persons Policy and Procedures
Version 1.0 DRAFT Approved By Date Approved Author Company Secretary Name of Responsible Committee / Group Board of Directors Date Issued Review Date Relevant Staff Groups All directors whether executive, non-executive,
permanent, interim, deputy or assistant/associate directors, and irrespective of directors' Board voting rights.
Equality Impact Assessment Completed Yes
TABLE OF CONTENTS
1. Introduction 1.1 New regulations came into effect for NHS bodies on 27 November 2014 (Document Reference
A) requiring directors to be fit and proper persons (Regulation 5), and trusts to implement a duty of candour when dealing with complaints (Regulation 20). These Regulations, and the fundamental standards of care, were revised and brought into force more widely for all care providers, less partnerships, from 1 April 2015 (Reference B).
1.2 Regulation 5 establishes a statutory requirement governing the appointing of or having in
place individuals as directors, or performing the functions of, or functions equivalent or similar to, the functions of a director (Regulation 5(2)).
1.3 Directors must satisfy all the requirements set out in Regulation 5(3) and be declared fit and
proper persons. Individuals must be: of good character, have the necessary qualifications, competence, skills and experience for their role, have the appropriate level of physical and mental fitness, have not been party to any serious misconduct or mismanagement in the course of carrying on a regulated activity, and not be deemed unfit under Schedule 4, Part 2 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. Providers must also ensure that certain information regarding the individuals is available Regulation provisions to the CQC.
2. Purpose 2.1 The purpose of the Regulation is to ensure that all Board level and director appointments at
NHS bodies carrying on a regulated activity are held responsible for the overall quality and safety of the care provided, for making sure the care meets the existing regulations and effective requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and that providers and directors can be held to account. Services must be safe, effective, caring, responsive, and well-led.
2.2 The aim of this document is to provide the policy and procedures by which YDH will support its
commitment to the fit and proper person requirements. The Trust will not permit any individual to hold the post of director who does not meet the standards required to be approved as a fit and proper person, either on appointment or through changing circumstances.
3. Application 3.1 The Care Quality Commission (CQC) has fully integrated the fit and proper person
requirements (FPPR) into their regulatory registration and inspection framework. YDH must demonstrate that it is meeting these requirements in order to continue to deliver regulated services, or to vary its registration with the CQC should it wish to do so.
3.2 The FPPR applies to all directors whether executive, non-executive, permanent, interim,
deputy or assistant/associate directors, and irrespective of directors' Board voting rights. The requirement does not apply to the Council of Governors. Although it is for YDH to determine which individuals fall within its scope, the CQC will take a view on how effectively YDH has discharged its responsibility.
3.3 The CQC will check and monitor the extent to which YDH meets the requirements:
• At the point of registration; • During an inspection under the 'well-led' question, the CQC will confirm that the Trust has
undertaken appropriate checks and satisfied itself that on appointment, and subsequently, all new and existing directors meet the requirements; and
• On receipt of concerning information regarding directors, it will be logged by the CQC as an enquiry and processed in line with their procedures in line with safeguarding/whistleblowing protocols.
3.4 The CQC assesses the fitness of health service providers by focusing on the fitness of the
nominated individuals. It will consider whether YDH has taken the appropriate steps to ensure that individuals are:
• Of good character; • Have the necessary qualifications, competence, skills and experience for their role; • Have the appropriate level of physical and mental fitness; and • Have not been party to any serious misconduct or mismanagement in the course of
carrying on a regulated activity, and are not deemed unfit under the Regulation provisions.
4. Key Document Reference 4.1 This policy should be read in conjunction with the following:
A. Regulation 5 Fit and Proper Persons: Directors and Regulation 20 Duty of Candour,
Guidance for NHS Bodies, Care Quality Commission November 2014. B. Guidance for Providers on Meeting the Regulations, Health and Social Care Act 2008
(Regulated Activities) Regulations 2014 (Part 3) (as amended), Care Quality Commission (Registration) Regulations 2009 (Part 4) (as amended), Care Quality Commission February 2015.
C. Regulation 5 Fit and Proper Persons: Directors, Information for NHS Bodies, Care Quality Commission March 2015.
D. Regulation 5 Fit and Proper Persons: Directors, Information for providers of Adult Social Care, Primary Medical and Dental Care, and independent Healthcare, Care Quality Commission March 2015.
E. NHS Employment Check Standards revised July 2013. • YDH HR Policy Manual (including policies for for maintaining high professional standards,
capability, disciplinary and raising concerns).
5. Process and Responsibilities 5.1 It is the overall responsibility of the Chair of the Trust to discharge the FPPR, to ensure all
directors meet the fitness test and not the unfit criteria, and to declare to the CQC that the Trust complies with the requirements of Regulation 5.
5.2 YDH has a responsibility to implement the following on a continuing basis:
• Provide the evidence that appropriate systems and processes are in place to ensure that
all new and existing directors are and continue to be fit and proper persons, and do not meet any of the unfitness criteria set out in Schedule 4 part 2 of the regulations;
• Make every reasonable effort to assure itself about the suitability of an individual by all means available;
• Make specified information available to the CQC upon request. • Be aware of the various guidelines available, and to have implemented procedures in line
with this best practice; • Inform the regulator where a director no longer meets the requirement and is registered
with a health or social care professional regulator, and take action to ensure the position is held by someone meeting the requirement.
5.3 An overview of the process is set out at Appendix 1. 5.4 The checklist for assessing individuals (at appointment) as fit and proper is attached at
Appendix 2. 5.5 Candidate declaration of fitness forms are attached at Appendix 3 and 4 (A is used where
YDH is undertaking a DBS check (previously CRB), B is for where no such check is required). 5.6 The declaration form for those already in post is included at Appendix 5 (which should be
completed annually). Full checks as described at Appendix 2 will be carried out, in addition to the annual declaration, every three years.
5.7 Activity described at Appendix 2, 3 and 4 will be undertaken by the Trust’s HR team. The annual declarations (Appendix 5) will be collected annually by the Company Secretary.
5.8 If an individual who holds an office or position no longer meets the requirements, YDH will take such action as is necessary and proportionate to ensure that the office or position is held by someone who does meet the requirements. The Trust may suspend individuals during investigations into whether the requirements are met, or if at any stage the Trust becomes aware of information which may mean an individual is not a fit and proper person. The issues will be addressed on a case by case basis in line with the Trust’s HR manual. Where the individual is a health care professional, YDH will inform the regulator/professional body in question. Interim measures may be required to minimise the risk to people who use the services.
6 Review 6.1 This policy will be reviewed in 3 years as set out in Policy for the Management of Procedural
Documents, or more frequently in the event of a major change to the law or any other circumstances which has an impact on the procedural document in question, at which point a review will take place as soon as reasonably practicable.
APPENDIX 1 – FIT & PROPER DIRECTORS PROCESS OVERVIEW
Check 1: Person is of good character as defined under Part 2 Schedule 4
Is individual to be a director?
Proof of ID including a photograph Criminal Record Certificate Enhanced criminal record certificate Evidence of conduct in employment Verification of end of previous employment Documentary evidence of qualifications Full employment history and gaps Information about relevant physical or mental conditions
Fit and Proper Person Test Requirement
Is individual to be performing the function of, or functions similar to those of a director?
No Regulation 5 does
not apply
Yes
No
Does individual satisfy all Regulation
5 Paragraph 3 requirements?
Yes
Check 2: Person possesses the qualifications, competence, skills, and experience necessary for the post
Check 3: Person is sufficiently healthy after reasonable adjustments are made to perform the intrinsic tasks of the post
Check 4: Person has not been responsible for, privy to, contributed to, or facilitated serious misconduct or mismanagement whilst carrying out regulated activity
Check 5: Person is not deemed unfit to hold the position on the grounds of unfitness under Part 1 Schedule 4
Have all requirements been met?
Individual cannot be appointed or remain
in post unless requirements are
reasonably resolved
Yes No Is person being
recruited?
Is person in post?
No
Yes Can all requirements be corrected?
No
If health care professional, social
worker, or other professional registered
with health care or social care regulator, then inform regulator
Yes
Individual continues in post or takes up post
Yes
Make the information required under
Schedule 3 or other enactment available to
the CQC
Ensure personnel files are complete including self-cert, references, checks, registration
APPENDIX 2 Fit and Proper Person Check – Pre-Employment Checklist
Procedural Checks 1 and 4: Good Character, and Misconduct or Mismanagement No Check and Evidence Required Date Obtained HR Initials 1. Signed Declaration of Fitness from candidate (Form A or B, according to whether DBS checks required) 2. DBS checks - as appropriate to the post - in line with NHS Employment Check Standards. 3. Undertake police check/certificate of good character – only needed if individual has spent 6 months or more
outside the UK in the last 5 years before application.
4. Where post requires the individual to be a registered health professional – check professional body’s register for:
• Confirmation that individual is registered to carry out the proposed role • Details of any limitation on their registration that might affect the duties proposed • Details of any current or previous fitness to practice proceedings/professional disciplinary proceedings.
5. Search of CQC records: http://www.cqc.org.uk/ • Check if any provider for whom the individual has worked has had registration suspended/cancelled due
to failings in care in the last 5 years (or longer if available) • Check the involvement of the individual or any providers in previous inspections (Investigate further if
inspection rating is ‘requires improvement’, or ‘inadequate’).
6. Search for involvement of individual or providers in serious care issues/investigations. Check the following websites:
• Public Inquiry Reports - http://www.nationalarchives.gov.uk/webarchive/inquiries-inquests-royal-commissions.htm#
• Serious Case Reviews - http://www.nspcc.org.uk/preventing-abuse/child-protection-system/england/serious-case-reviews/
• Homicide investigations for mental health trusts (if employed previously by mental health trust) - http://www.england.nhs.uk/publications/invest-reports/
7. Review Parliamentary and Health Service Ombudsman reports relating to providers to identify whether these give rise to further lines of enquiry regarding the individual: http://www.ombudsman.org.uk/
Procedural Check 2: Qualifications, Competence, Skills and Experience No Check and Evidence Required Date Obtained HR Initials 8. A full employment history, together with a satisfactory written explanation of any gaps in employment in line
with NHS Employment Check Standards.
For new appointees coming to the NHS for the first time, validate a minimum of 3 years’ continuous employment and training).
9. Two references - one of which must be most recent employer, in line with NHS Employment Check Standards 10. Academic and professional qualifications check - checked against job description/person specification - in line
with NHS Employment Check Standards
Procedural Check 3: Health No Check and Evidence Required Date Obtained HR Initials 11. Occupational health clearance in line with NHS Employment Check Standards Procedural Checks 4: Misconduct or Mismanagement See Procedural Check 1 above. Procedural Check 5: Grounds of Unfitness No Check and Evidence Required Date Obtained HR Initials 12. Check Register of Insolvent Companies for any company for whom the individual had a previous/current
director role, that have become insolvent: http://wck2.companieshouse.gov.uk//wcframe?name=accessCompanyInfo
13. Check Disqualified Directors Register to identify whether individual has been disqualified through a court order/by an undertaking of the Insolvency Service from being a director of a company or a member of an LLP: http://wck2.companieshouse.gov.uk//wcframe?name=accessCompanyInfo, and; https://www.insolvencydirect.bis.gov.uk/IESdatabase/viewdirectorsummary-new.asp (lists directors the Insolvency Service got disqualified in the last 3 months), and; Contact The Insolvency Service for details of directors who got disqualified more than 3 months ago: [email protected]
14. Check the Individual Insolvency Register to identify whether the individual is insolvent: https://www.insolvencydirect.bis.gov.uk/eiir/
15. Check Register of Judgments to review details of County Court judgments, and credit refusals: http://www.trustonline.org.uk/ (Small fee charged for doing so.)
16. Check Bankruptcy or Debt Relief Restrictions Register: https://www.insolvencydirect.bis.gov.uk/IESdatabase/viewbrobrusummary-new.asp
17. If individual has worked for an organisation regulated by the Financial Conduct Authority (FCA), check
Financial Service Register: https://register.fca.org.uk/ 18. If individual has worked in a consumer credit business check the business name on the Consumer Credit
Register: http://fca-consumer-credit-interim.force.com/CS_RegisterSearchPageNew
Additional Checks: No Check and Evidence Required Date Obtained HR Initials 19. Proof of identity (including recent photograph) in line with NHS Employment Check Standards 20. Confirmation of right to work in the UK in line with NHS Employment Check Standards
Fit and Proper Persons Check
Candidate Declaration of Fitness Form (A) The position for which you have applied is subject to Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This regulation requires that Yeovil District Hospital NHS Foundation Trust must not appoint, or have in place, a) an individual as a director of the Trust, or b) performing the functions of, or functions equivalent or similar to the functions of, such a director, without being satisfied that the individual is a fit and proper person to hold such a position. The position you have applied for has been identified as being an 'eligible position’ under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 [the Exceptions Order] and, in certain circumstances, the Police Act 1997. As such, it meets the eligibility criteria for a standard or an enhanced disclosure to be requested through the Disclosure and Barring Service (DBS). Both standard and enhanced DBS disclosure certificates contain information about any convictions, cautions (including reprimands and final warnings) which are not 'protected' as defined by the Rehabilitation of Offenders Act 1974 (Exceptions Order) 1975 (as amended) - see highlighted note in the section below. Enhanced disclosures may also include other relevant police information where this is deemed relevant to the position you are applying for. Where the position has, in addition, been identified as a regulated activity under the Safeguarding Vulnerable Groups Act (2006) (as amended by the Protection of Freedom's Act 2012) an enhanced DBS disclosure will include information which is held on the Children's and/or Adults barred list(s), as applicable to the position. Please be aware that the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013 (S.I. 2013/1198) made amendment to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 to provide that certain spent convictions and cautions will become protected when specific conditions are met. Protected convictions and cautions will not be disclosed in a DBS check, and employers cannot ask for information about protected convictions or cautions, or take these into account when considering you for appointment. Before you complete this form please read guidance and criteria for the filtering of these convictions and cautions which can be found on the Disclosure and Barring Service website at: www.gov.uk/government/disclosure-and-barring-service Consequently, before you can be considered for appointment with the Trust we need to be satisfied of your suitability for the position, therefore you are asked to complete following declaration. Yeovil District Hospital Foundation Trust aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity, marriage or civil partnership. We undertake not to discriminate unfairly against applicants on the basis of criminal conviction or other such information declared.
APPENDIX 3
11
Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that we believe may have a bearing on your suitability for the position. If we do not raise this information with you, this is because we do not believe that it should be taken into account. In that event you still remain free, should you wish, to discuss the matter with the recruiting manager. As part of assessing your application, we will only take into account criminal records and other information declared which is relevant to the position being applied for. The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud.
Please ensure that you read the Guidance Notes for Applicants that accompanied your application form carefully before completing this declaration form. They provide you with further and more detailed information about how your application will be processed, the persons to whom it will be disclosed and the checks that will be done to verify the information provided.
Please answer all of the following questions in this form. If you answer ‘yes’ to any of the questions, please provide full details in the space indicated. Please also use the space below to provide any other information that may have a bearing on your suitability for the position for which you are applying. You may continue on a separate sheet if necessary, and you may attach supplementary comments should you wish to do so. Answering ‘yes’ to any of the questions below will not necessarily bar you from an appointment within the NHS; this will depend on the relevance of the information you provide in respect of the nature of the position for which you are applying, and the particular circumstances. 1. Are you currently bound over, or do you have any convictions or cautions (including warnings and reprimands) which are not deemed 'protected' under the amendment to the Exceptions Order 1975*, issued by a Court or Court-Martial in the United Kingdom or in any other country?
No Yes
If YES, please include details of the order binding you over and/or the nature of the offence, the penalty, sentence or order of the Court, and the date and place of the Court hearing. *Please note that you do not need to tell us about convictions, cautions, warnings or reprimands which are deemed 'protected' under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 as amended by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2013 - see applicant notes above. You also are not required to tell us about parking offences.
12
2. Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of?
No Yes
If YES, please include details of the nature of the offence with which you are charged, date on which you were charged, and details of any on-going proceedings by a prosecuting body. You are reminded that, if you are appointed, you have a continued responsibility to inform us immediately where you are charged with any new offence, criminal conviction or fitness to practise proceedings in the United Kingdom or in any other country that might arise in the future. You do not need to tell us if you are charged with a parking offence. 3. Are you aware of any current investigation being undertaken by the NHS Counter Fraud and Security Management Services (NHS CFSMS) following allegations made against you?
No Yes If YES, please include details of the nature of the allegations made against you, and if known to you, any action to be taken against you by NHS Counter Fraud and Security Management Services (NHS CFSMS).
4. Have you been investigated by the Police, NHS CFSMS or any other Investigatory Body resulting in a current or past conviction or dismissal from your employment or volunteering position?
No Yes If YES, please include details of the nature of the allegations made against you, and if known to you, any action to be taken against you by the Investigatory Body. Investigatory bodies include: Local Authorities, Customs and Excise, Immigration, Passport Agency, Inland Revenue, Department of Trade and Industry, Department of Work and Pensions, Security Agencies, Financial Service Authority. This list is not exhaustive and you must declare any investigation conducted by an Investigatory Body. 5. Have you ever been dismissed by reason of misconduct from any employment, volunteering, office or other position previously held by you?
No Yes If YES, please include details of the employment, office or position held, the date that you were dismissed and the nature of allegations of misconduct made against you.
13
6. Have you ever been disqualified from the practise of a profession, or required to practise subject to specified limitations following fitness to practise proceedings, by a regulatory or licensing body in the United Kingdom or in any other country?
No Yes If YES, please include details of the nature of the disqualification, limitation or restriction, the date, and the name and address of the licensing or regulatory body concerned. 7. Are you currently or have you ever been the subject of any investigation or fitness to practise proceedings by any licensing or regulatory body in the United Kingdom or in any other country?
No Yes If YES, please include details of the reason given for the investigation and/or proceedings undertaken, the date, details of any limitation or restriction to which you are currently subject, and the name and address of the licensing or regulatory body concerned. 8. Are you subject to any other prohibition, limitation, or restriction that means we are unable to consider you for the position for which you are applying?
No Yes
If YES, please include details. 9. Are there any other matters that may be relevant to the position being applied for which might cause your reliability or suitability for employment to be called into question?
No Yes If YES, please include details. Please note that you are not required to disclose a protected conviction or caution as defined by the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 as amended by the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) (England and Wales) Order 2013 or any circumstances ancillary to that protected conviction or caution - as outlined within the applicant notes above. If you have answered 'yes' to any of the questions above, please use the space on the next page to provide details.
14
If you have answered ‘yes’ to any of the questions above, please use this space to provide details. Please indicate clearly the number(s) of the question that you are answering. You may continue on a separate sheet if necessary and may attach supplementary comments should you wish to do so.
15
DECLARATION IMPORTANT The Data Protection Act 1998 requires us to advise you that we will be processing your personal data. Processing includes: holding, obtaining, recording, using, sharing and deleting information. The Data Protection Act 1998 defines ‘sensitive personal data’ as racial or ethnic origin, political opinions, religious or other beliefs, trade union membership, physical or mental health, sexual life, criminal offences, criminal convictions, criminal proceedings, disposal or sentence. Where you are applying for a position which involves regulated activity, this will also include any barring decisions made by the Disclosure and Barring Service (DBS) against the Children’s or Adults barred lists under the terms of the Safeguarding Vulnerable Groups Act 2006 (as amended by the Protection of Freedom's Act 2012). The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud. Once a decision has been made concerning your appointment, Yeovil District Hospital NHS Foundation Trust will not retain this declaration form any longer than necessary (see further details in Guidance Notes for Applicants which was provided with your application form). This declaration will be kept securely and in confidence. Access to this information will be restricted to designated persons within the organisation who are authorised to view it as a necessary part of their work. In signing the declaration on this form, you are explicitly consenting for the data you provide to be processed in the manner described above. I have read the Guidance Notes for Applicants that accompanied my application form, and I consent to the information provided in this declaration form being used by Yeovil District Hospital NHS Foundation Trust for the purpose of assessing my application, and for enquiries in relation to the prevention and detection of fraud. I confirm that the information that I have provided in this declaration form is correct and complete. I understand and accept that if I knowingly withhold information, or provide false or misleading information, this may result in my application being rejected, or if I am appointed, in my dismissal, and I may be liable to prosecution. Please sign and date this form. Name: Signature: Post: Department: Date: Please complete and return this form in a separate envelope marked 'confidential' to: Recruitment Team, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT If you wish to withdraw your consent at any time after completing this declaration form or you have any enquiries relating to information required in this form, please contact the Recruitment Team on 01935 384586.
Fit and Proper Persons Check
Candidate Declaration of Fitness Form (B) The position for which you have applied is subject to Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This regulation requires that Yeovil District Hospital NHS Foundation Trust must not appoint, or have in place, a) an individual as a director of the Trust, or b) performing the functions of, or functions equivalent or similar to the functions of, such a director, without being satisfied that the individual is a fit and proper person to hold such a position. Consequently, before you can be considered for appointment with the Trust we need to be satisfied of your suitability for the position, therefore you are asked to complete following declaration. Yeovil District Hospital Foundation Trust aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of ethnicity, disability, age, gender or gender re-assignment, religion or belief, sexual orientation, pregnancy or maternity, marriage or civil partnership. We undertake not to discriminate unfairly against applicants on the basis of criminal conviction or other information declared. Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that we believe may have a bearing on your suitability for the position. If we do not raise this information with you, this is because we do not believe that it should be taken into account. In that event you still remain free, should you wish, to discuss the matter with the recruiting manager. As part of assessing your application, we will only take into account relevant criminal record and other information declared which is relevant to the position being applied for. The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud. Please answer all of the following questions. If you answer ‘yes’ to any of the questions, please provide full details in the space indicated. Please also use the space below to provide any other information that may have a bearing on your suitability for the position for which you are applying. You may continue on a separate sheet if necessary, and you may attach supplementary comments should you wish to do so. The position for which you have applied is regarded as non exempt from the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (the Exceptions Order). This means that you are required to declare all current ‘unspent’ criminal convictions or cautions (including reprimands and final warnings). You are not required to disclose convictions or cautions which have become ‘spent’. Answering ‘yes’ to any of the questions below will not necessarily bar you from an appointment within the NHS. This will depend on the relevance of the information you provide in respect of the nature of the position for which you are applying, and the particular circumstances.
APPENDIX 4
1. Are you currently bound over or do you have any current ‘unspent’ convictions or cautions (including reprimands or warnings) that have been issued by a Court or Court-Martial in the United Kingdom or in any other country?
No Yes
If YES, please include details of the order binding you over and/or the nature of the offence, the penalty, sentence or order of the Court, and the date and place of the Court hearing. You do not need to tell us about parking offences.
2. Have you been charged with any offence in the United Kingdom or in any other country that has not yet been disposed of?
No Yes
If YES, please include details of the nature of the offence with which you are charged, date on which you were charged, and details of any on-going proceedings by a prosecuting body. You are reminded that if you are appointed, you are required as part of your contractual arrangements with our organisation to inform us immediately where you are charged of any new conviction (including warnings, cautions, reprimands), or fitness to practise proceedings in the United Kingdom or in any other country that might arise in the future while you are in our employment or are undertaking an activity on behalf of our organisation. You do not need to tell us if you are charged with a parking offence.
3. Are you aware of any current investigations being undertaken by the NHS Counter Fraud and Security Management Service (NHS CFSMS) following allegations made against you?
No Yes
If YES, please include details of the nature of the allegations made against you, and if known to you, any action to be taken against you by the NHS CFSMS.
4. Have you been investigated by the Police, NHS CFSMS or any other Investigatory Body resulting in a current conviction or dismissal from your employment or volunteering position?
No Yes
If YES, please include details of the nature of the allegations made against you, and if known to you, any action to be taken against you by the Investigatory Body. Investigatory bodies include Local Authorities, Customs and Excise, Immigration, Passport Agency, Inland Revenue, Department of Trade and Industry, Department of Work and Pensions, Security Agencies, Financial Service Authority. This list is not exhaustive, and you must declare any investigation conducted by an Investigatory Body.
5. Have you been responsible for, privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity?
No Yes
If YES, please provide full details of the serious misconduct/mismanagement. This must include details of the employment, office or position held, the date you were dismissed and the nature of allegations of serious misconduct/,mismanagement made against you.
6. Have you ever been dismissed by reason of misconduct from any employment,
volunteering, office or other position previously held by you?
No Yes If YES, please provide full details of the misconduct. This must include details of the employment, office or position held, the date you were dismissed and the nature of allegations of misconduct made against you.
7. Have you ever been disqualified from the practise of a profession, or required to practise subject to specified limitations following fitness to practise proceedings, by a regulatory or licensing body in the United Kingdom or in any other country?
No Yes
If YES, please include details of the nature of the disqualification, limitation or restriction, the date, and the name and address of the licensing or regulatory body concerned.
8. Are you currently the subject of any investigation or fitness to practise proceedings by any licensing or regulatory body in the United Kingdom or in any other country?
No Yes
If YES, please include details of the reason given for the investigation and/or proceedings undertaken, the date, details of any limitation or restriction to which you are currently subject, and the name and address of the licensing or regulatory body concerned.
9. Are you an individual:
• who has been adjudged bankrupt or whose estate has been sequestrated and (in either
case) has not been discharged; or • who has made a composition or arrangement with, or granted a trust deed for, his
creditors and has not been discharged in respect of it; or • who within the preceding five years has been convicted in the British Islands of any
offence and a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him; or
• who is subject to an unexpired disqualification order made under the Company Directors’ Disqualification Act 1986.
No Yes
If YES, please provide full details.
10. Are you a body corporate, or a body corporate with a parent body corporate: • where one or more of the Directors of the body corporate or of its parent body corporate
is an unfit person under the provisions of sub-paragraph (a) of this paragraph, or • in relation to which a voluntary arrangement is proposed under section 1 of the
Insolvency Act 1986, or • which has a receiver (including an administrative receiver within the meaning of section
29(2) of the 1986 Act) appointed for the whole or any material part of its assets or undertaking, or
• which has an administrator appointed to manage its affairs, business and property in accordance with Schedule B1 to the 1986 Act, or
• which passes any resolution for winding up, or • which becomes subject to an order of a Court for winding up.
No Yes If YES, please provide full details.
11. Are you currently subject to any other prohibition, limitation, or restriction that means we are unable to consider you for the position for which you are applying?
No Yes
If YES, please provide full details.
12. Do you know of any other matters in your background which might cause your reliability or suitability for employment or volunteering role to be called into question?
No Yes
If YES, please include details. Please note that you are not required to disclose information about convictions, cautions (including reprimands and final warnings) which are deemed as spent under the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 - as outlined in the applicant notes above. If you have answered ‘yes’ to any of the questions above, please use this space to provide details. Please indicate clearly the number(s) of the question that you are answering. You may continue on a separate sheet if necessary and may attach supplementary comments should you wish to do so.
DECLARATION IMPORTANT The Data Protection Act 1998 requires us to advise you that we will be processing your personal data. Processing includes: holding, obtaining, recording, using, sharing and deleting information. The Data Protection Act 1998 defines ‘sensitive personal data’ as racial or ethnic origin, political opinions, religious or other beliefs, trade union membership, physical or mental health, sexual life, criminal offences, criminal convictions, criminal proceedings, disposal or sentence. The information that you provide in this declaration form will be processed in accordance with the Data Protection Act 1998. It will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the prevention and detection of fraud. Once a decision has been made concerning your appointment, Yeovil District Hospital NHS Foundation Trust will not retain this declaration form any longer than is necessary (see further details in ‘Guidance Notes for Applicants’). This declaration will be kept securely and in confidence. Access to this information will be restricted to designated persons within the organisation who are authorised to view it as a necessary part of their work. In signing the declaration on this form, you are explicitly consenting for the data you provide to be processed in the manner described above. I have read the ‘Guidance Notes for Applicants’ that accompanied my application form, and I consent to the information provided in this declaration form being used by Yeovil District Hospital NHS Foundation Trust for the purpose of assessing my application, and for enquiries in relation to the prevention and detection of fraud. I confirm that the information that I have provided in this declaration form is correct and complete. I understand and accept that if I knowingly withhold information, or provide false or misleading information, this may result in my application being rejected, or if I am appointed, in my dismissal, and I may be liable to prosecution. Please sign and date this form. Name:
Signature:
Post:
Department:
Date:
Please complete and return this form in a separate envelope marked 'confidential' to: Recruitment Team, Yeovil District Hospital NHS Foundation Trust, Higher Kingston, Yeovil, Somerset, BA21 4AT If you wish to withdraw your consent at any time after completing this declaration form or you have any enquiries relating to information required in this form, please contact the Recruitment Team on 01935 384586.
APPENDIX 5
FIT AND PROPER PERSONS TEST DECLARATION
(Annual Declaration for Directors in Post) The position you hold is subject to Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This regulation requires that Yeovil District Hospital NHS Foundation Trust must not appoint, or have in place, a) an individual as a director of the Trust, or b) performing the functions of, or functions equivalent or similar to the functions of, such a director, without being satisfied that the individual is a fit and proper person to hold such a position. You are therefore asked to complete the following declaration to satisfy the Trust of your continued suitability for the position. We will discuss with you any information declared by you that we believe may have a bearing on your continued suitability for the position. If we do not raise this information with you, this is because we do not believe that it should be taken into account. In that event you still remain free, should you wish, to discuss the matter with the Company Secretary in the first instance. Answering ‘yes’ to any of the questions below will not necessarily bar you from continued service with Yeovil District Hospital NHS Foundation Trust. This will depend on the relevance of the information you provide and the particular circumstances. However, your employment/office may be ended if the Trust is not satisfied with the information/explanation provided. I hereby confirm that I am not: a) an individual
i. who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged; or
ii. who has made a composition or arrangement with, or granted a trust deed for, his creditors and has not been discharged in respect of it; or
iii. who within the preceding five years has been convicted in the British Islands of any offence and a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him; or
iv. who is subject to an unexpired disqualification order made under the Company Directors’ Disqualification Act 1986; or
b) a body corporate, or a body corporate with a parent body corporate:
i. where one or more of the Directors of the body corporate or of its parent body corporate is an unfit person under the provisions of sub-paragraph (a) of this paragraph, or
ii. in relation to which a voluntary arrangement is proposed under section 1 of the Insolvency Act 1986, or
iii. which has a receiver (including an administrative receiver within the meaning of section 29(2) of the 1986 Act) appointed for the whole or any material part of its assets or undertaking, or
iv. which has an administrator appointed to manage its affairs, business and property in accordance with Schedule B1 to the 1986 Act, or
v. which passes any resolution for winding up, or vi. which becomes subject to an order of a Court for winding up.
I confirm that the information that I have provided in this declaration form is correct and complete. I understand and accept that if I knowingly withhold information, or provide false or misleading information, this may result in my dismissal, and I may be liable to prosecution.
Name:
Signature:
Date: