Download - BOARD OF DIRECTORS · PDF fileJoanne Philpot (Chief of Service Paediatrics) Attached/ To follow . ... excel & other versions\3. public board minutes 01dec17 final mom.docx Page 3 of

$: BOARD OF DIRECTORS · PDF fileJoanne Philpot (Chief of Service Paediatrics) Attached/ To follow . ... excel & other versions\3. public board minutes 01dec17 final mom.docx Page 3 of$
BOARD OF DIRECTORS Meeting in Public

Friday, 5th January 2018, 11:40 to 14:30

Lecture Theatre, Post Graduate Medical Centre, Wexham Park Hospital, SL2 4HL

A G E N D A

Time Agenda Item Paper Action Lead 11:40 1. Welcome and Apologies for Absence

- Chairman

2.

Declarations of Interest Oral - Chairman

3. Minutes of the Previous Public Board Meeting held on 1st December 2017

Attached For Approval

Chairman

4. Action Log from Previous Meeting

Attached To Action Chairman

QUALITY 11:45 5. Ward to Board

Paediatrics Wards Jennifer Lomas (Senior Matron Paediatrics and Neonates, FPH) Lois Doel (Clinical Matron FPH, F1) Ros Rushworth (Senior Matron Paediatrics and Neonates) Amy Olley ( Associate Director Women and Children) Joanne Philpot (Chief of Service Paediatrics)

Attached/ To follow

To Note

12:25 6. Chief Executive’s Report and Quality & Performance Report

Attached To Note Chief Executive & Executive Directors

12:55 7. Quality Improvement Plan

Attached For Approval

Medical Director

13:00 8. In patient survey and action plan (6 month review)

Attached To Note Director of Nursing & Quality

FINANCE & PERFORMANCE 13:10 9. Finance Report - Month 8 Attached To Note Director of Finance

& IM&T

13:20 10. CIP Update 2017/2018

Attached To Note Directors of Operations

GOVERNANCE AND COMPLIANCE 13:30 11. Corporate Risk Assurance Framework Attached For

Assurance Chief Executive

13:35 12. Quarter 3 Board Objectives To follow To Note Chief Executive

AGENDA

1 of 201PUBLIC Board of Directors - 5th January 2018-05/01/18

13:40 13. EPRR-Annual Emergency Plan Attached To Note Directors of Operation

13:45 14. Quarterly Infection Control Report Attached For Assurance

Medical Director

13:55 15. 15.1 15.2

Board Sub-Committee Summaries Charitable Funds Committee, 5th December Quality Assurance Committee, 8th December

Attached Attached

To Follow To Note

Committee Chair Committee Chair

14:05 16. Quality Assurance Committee Terms of Reference

Attached For approval

Committee Chair

OTHER BUSINESS 14:10 17. Any Other Business Oral - All

14:15 18. Meeting Review

Oral - All

14:20 19. Questions from Members of the Public

-

14:25 20. Date of Next Meeting Friday, 2nd February 2018 Board Room, Frimley Park Hospital

-

NB: An ‘Acronym Buster’ has been included at the end of the Public Board papers pack.

AGENDA

2 of 201 PUBLIC Board of Directors - 5th January 2018-05/01/18

k:\board of directors\board meetings\2018\1. 5th jan 2018\public\word, excel & other versions\3. public board minutes 01dec17 final mom.docx Page 1 of 14

BOARD OF DIRECTORS MEETING IN PUBLIC

Friday, 1st December 2017, 11:40-14:45 Large Meeting Room, Forest Lodge, Heatherwood Hospital, Ascot, SL5 8AA

MINUTES OF MEETING

Present: Pradip Patel (PP) Chairman Andrew Morris (AVM) Chief Executive Janet King (JK) Director of HR & Corporate Services Nigel Foster (NF) Director of Finance & IM&T Duncan Burton (DB) Director of Nursing & Quality Helen Coe (HC) Director of Operations FPH Lisa Glynn (LG) Director of Operations WPH Tim Ho (TH) Medical Director Mark Escolme (ME) Non-Executive Director Dawn Kenson (DK) Non-Executive Director Ray Long (RL) Non-Executive Director Mike O’Donovan (MOD) Non-Executive Director Rob Pike (RP) Non-Executive Director Thoreya Swage (TS) Non-Executive Director John Weaver (JW) Non-Executive Director In Attendance: Nick Payne (NP) Chief of Service – ED (for item 5) Philomena Vallance (PV) Head of Nursing ED FPH (for item 5) Fiona Rodney (FR) Senior Matron ED FPH (for item 5) Michelle Youens (MY) Head of Nursing ED WPH (for item 5) Jo Hawkes (JH) Matron ED WPH (for item 5) Bruce Montgomery (BM) Freedom to Speak Up Guardian (for item 13) Jemima Harrison (JH) Litigation Manager (for item 14) Susanne Nelson-Wehrmeyer (SNW) Company Secretary Kevin Jacob (KJ) Assistant Company Secretary (minutes) 1. Welcome, Introduction and Apologies for Absence a. b.

PP welcomed everyone to the meeting which was the last one for the year. He asked the members of the Board to highlight what they felt had been the key successes for them over the last few months that had put a smile on their face. • DK – was delighted that the Trust had been successful in recruiting a new CEO. • TS –was delighted that the Trust had been successful in recruiting a new

Director of Nursing. • RL – recruitment of the new CEO, the process for which had been as robust as

he had seen in any organisation. • TH- Karen Brittain’s presentation to the Board on the Trust’s excellent

resuscitation performance. • HC -the successful integration of community health services into the Trust’s

portfolio following the transfer of the Southern Health contract. • LG -the successful redevelopment of maternity and women’s services at

Wexham Park.

3

Tab 3 Minutes of the Previous Public Board Meeting held on 1st December 2017



• JK – the granting of planning permission for the Heatherwood Hospital Redevelopment.

• RP - progress on the Heatherwood Hospital redevelopment and the establishment of the Finance Assurance Committee.

• ME – the confirmation of JK in the Deputy CEO role which meant that the Trust was well covered if there was a gap between the departure of AVM and the commencement of the new CEO.

• DB – the opportunity to bring all the ward sisters together from across the Trust for one day which had been very successful event and would be repeated on a quarterly basis.

• NF – the bringing together of different organisations. • JW – his increased knowledge and understanding of the NHS and the Trust at

Board Strategy sessions and the approval of the Heatherwood Hospital redevelopment.

• MOD – as Chair of the Organ Donation Committee he was proud that the Trust had recently been rated exceptional in some key areas

• AVM – that he would be sad to leave such wonderful people including the ED staff and the 8,500 other staff of Frimley Health who provided the best possible service and highest level of care to patients.

• SNW –that the Annual Report process was becoming more streamlined and less problematic each year.

• KJ – increased knowledge and experience of the NHS including technical terms. • PP – improvements to ED performance in a short period of time which had

reached 95% in recent weeks. This had been a great achievement. There were no apologies for absence.

2. Declarations of Interest a.

There were no declarations of interest.

3. Minutes of the Previous Meeting a.

The minutes of the previous Board meeting held in public on 3rd November 2017 were approved as a correct record subject to; • 9.p. change to “PP concluded” • 19.b. change to “there were periods of high demand” • 19.c. change to “there were many reasons” • A number of other minor typos which MOD would raise with KJ outside of the

meeting.

4. Action Log from the Previous Meeting a. b. c.

1st September 2017 - 18.e Meeting Review PP commented that work on this would be on-going into 2018. PP thanked HC for the amended CIP paper which was much more concise and set a standard for all board papers. 6th October 2017 – 11.b Corporate Risk Assurance Framework The QAC was set to undertake its deep dive into ED at its meeting on 8th December. 6th October 2017 – 14.b – Infection Control Report Hand hygiene scores to be included in the KPIs in the next infection control report.

3




d.

This action was on track for the next report. 3rd November 2017 – 11.j. MAST and Appraisal Recording and Reporting MAST and Appraisal report was to be presented to the Board in May 2018.

5. Ward to Board – Frimley Health Emergency Departments a. b.

PP introduced the ward to board: FHFT Emergency Department Chief of Service - Dr Nick Payne Head of Nursing ED FPH - Philomena Vallance Senior Matron ED FPH - Fiona Rodney Head of Nursing ED WPH - Michelle Youens Matron ED WPH - Jo Hawkes Apologies were provided from the two deputy Chiefs of Service for ED who could not attend. A comprehensive presentation was delivered by the senior staff of the Emergency Departments of Frimley Park and Wexham Park Hospitals. They highlighted the following:

• NP took over as Chief of Service for the Trust four months ago. He had been performing the same role at FPH. Since taking over, he had extended EMP services and was looking to extend nurse roles to attract more nurses. AMU was closely related to ambulatory care and ACU and he was trying to expand that service.

• Wexham had proved to be more difficult and a lot of work was needed in the next 6-9 months in advance of the new build expected in March 2019. They were bringing in ambulatory care ideas and instilling a better culture.

• The consultant rota had been revised at Wexham but was not quite as good as Frimley’s, but they had brought teams together and there was clearer and broader coverage within the department. There was more consistency with consultants being present every day and a lead consultant was present every day during weekdays with two at weekends.

• The EDU ward at Wexham had been revamped allowing ambulatory patients somewhere to sit.

• Two deputies had been appointed-Edward Behn at FPH and Ramy Saker originally from FPH had moved to WPH. Both had made an impact and worked tirelessly in their new roles.

• On the challenges, the biggest one was staffing, recruitment and retention. This was a national problem and they were looking for overseas recruits from Qatar, Pakistan, and Sri Lanka. Agency, locum and bank spend was high as a result. There were more doctors and middle grades coming in between now and February.

• There were a lot of paediatric patients coming in partly due to a new directive requiring ambulances to bring in all paediatric patients. They were now appointing paediatric consultants on both sites.

• They would like to do a rebuild of the lobby at WPH ED in an area of under-utilised space. It would be useful to have two more streaming rooms so they could access the GP service more easily. This was required to manage the winter pressures until the new ED was built.

• They needed to focus on working better together across specialties to move people away from beds and work with the community and CCGs to keep people in their own homes. This required wider input from consultants and the community and could take up to 2-3 years before seeing real impact.

• The team was very proud of EDs on both sites and with the WPH

3




c. d. e. f. g. h. i. j.

improvement they demonstrated real resilience under pressure.

PP thanked the team for the introduction and opened it up for discussion. RP had made the assumption about the consistency of definition of majors, minors and paediatrics and wondered why paediatrics numbers were higher at FPH and majors were higher at Wexham. NP had produced a report which had shown they were not the same as they were counted slightly differently on each site. There were a lot of paediatrics cases at FPH but at Wexham the same cases would go straight to the PAU and bypass ED. NP was working with Jo Philpot to develop a better model for both sites. RP asked about the consistency of growth at Frimley in majors and whether this was the same at Wexham? LG explained the majority of growth in Wexham came from Chiltern. Ambulances were up by 10.6% and there was a slight reduction from the Berkshire CCGs. STP work was more aligned in Berkshire but they were in discussions with Chiltern about the impact at the front door. JK asked about sepsis performance as both units had poor performance on delivery of antibiotics within an hour. MY indicated every patient coming in was screened and this met the 100% target. There were ring-fenced beds and colour coding for sepsis. Point of care was being used properly and they had markers for sepsis to enable targeting within an hour. At Frimley there was 100% screening and time critical patients were booked in. The Frimley challenge was about getting antibiotics within an hour. This was a national change so improvement would follow. TS asked about extended roles. NP explained there were two seniors on each site and nurse consultants. There were many people with professional healthcare backgrounds, but it was difficult to sort extra training as ED worked at a different level of intensity. They were working with HCAs and working differently on different sites with band 2s & 3s. Some of the HCAs at band 2 were really good at their roles and wanted to expand. Now there were 10 band 3s. MOD asked about the advantages of Ambulatory care. NP indicated there was an overall improvement and it was better for majors, as it would cover those coming in on a trolley. 30 to40 out of 120 major attendances for the day were now seen on either site in ambulatory care. About 30% could go straight to an assessment area from AMU. It was difficult to measure some of these things, but the benefit was felt when you come in and see there is space and people are being moved around faster. DK referenced the staff appraisal rates on the dashboards and asked how this was being tackled. It was explained that appraisals were planned in on the rota for all the staff, but it was difficult in ED as sometimes through the sheer pressure of work they did not take place. The team were keen to do appraisals properly rather than rush them. The figures for Frimley should be showing over 90%, as the numbers on paperwork presented were two months out of date. JW asked what was outside of their control that the board can help them with. The responses from the team included more educational opportunities, providing different job plans to keep staff interested, improve retention rates, the provision of social activities, improvements in environment and atmosphere. Plans to enhance flow through the department and reconfiguring MAU to enhance ambulatory care would also help. MOD asked JK whether charitable funds could be used for education and the general

3




k.

purposes fund for some of things requested. DB replied that they were being used to help support this and there had been 10 applicants for a Master’s programme. On behalf of the board, PP thanked all the ED staff for the 24/7 service they provide. Demand was constant and leadership made the biggest difference. This was a testament to NP and his team. He reminded them that the 95% target was important to patients and he was delighted that the team prioritised this. The Board NOTED the report.

6. Chief Executive’s Report and Quality & Performance Report a. b. c. d. e. f. g.

Performance - October AVM presented his report highlighting a number of key areas; Key Access Targets The four hour standard for emergency treatment was 94% for October which was the best month for over a year. Once the performance for Bracknell and Upton urgent care centres were mapped in, the Frimley system will have exceeded the 95% standard. However the first three weeks of November has seen deterioration in performance and the outturn for November for the Frimley Park and Wexham Park sites was likely to be 91.5% which was disappointing even though everyone was trying hard to meet the standard. The Trust was still on track to qualify for STF money at Q3. There has been a spike in attendances by children and generally an increase in adult attendances followed this. Everyone was focused on this but activity was relentless. AVM was more disappointed about lack of shift on the delayed transfer target of 3.5 %. The issue was around the patients who needed continuing healthcare. The Trust was nowhere near the standard of 85% of these patients being discharged from hospital and being assessed in the community. No matter what we try with CCG colleagues there has been no movement here. Any extra cash in the budget would be directed to the worse performing EDs but ideally should go into social care. C. Difficile The Trust has a target of no more than 31 cases and at the third week in November there have been a total of 30. Hand washing audits have improved to around 90% but 10% non-compliance was still not good enough. There had been a national increase in the number of cases which was a concern but some of the increase resulted due to a shortage of some of the narrow spectrum antibiotics. Next year all Trusts will be asked to reduce the E. coli infections. So far this year there have been 88 cases apportioned to FHFT. NHSI will be issuing best practice guidance on reducing E. coli in the community and in hospital. Serious Incidents As reported previously the Trust has seen a significant increase in the number of serious incidents. The safety team was putting a pack together setting the key learning’s from incidents and at the next hospital wide audit half day it is intended that Chiefs of Service will present the key findings to all the clinicians to try and avoid any repetitions of events. Sepsis This required the right intervention in the right order and there was strong compliance when it was first introduced. This has waned more recently and needed

3




h. i. j. k. l. m. n.

to improve. It is a relatively simple bundle to comply with. Compliance with the sepsis bundle improved slightly in October which was encouraging and the safety team were re-launching the compliance bundle to help lift performance back to the 90% and above. Finance NHSI would no longer allow capital to revenue transfers. This meant the trust would need to find £37 m CIP next year. The Trust was still on track to achieve the STF for Q3 but it was reliant on the CIP being delivered in full. Radiotherapy Services - Wexham Park Hospital The Trust was working in partnership with the Royal Berkshire Hospital (RBH) to provide radiotherapy at Wexham Park. The business case looked favourable. The support from Specialist Commissioning has been critical to progressing this project and Frimley Health and RBH are looking at the options to raise the capital required to build this facility. Frimley ACS Integrated Care Hubs Nationally £210m had been earmarked for the eight exemplar systems. The Trust had estimated that £20m of this would be needed for the Frimley System for the GP hubs in the north and for the Bracknell discharge to assess model especially for dementia patients. Each project needed a business case and the system is backing us to deliver changes. Discussion followed;

• MOD asked about the use of extra money to get people out of hospital and whether this was all about social care. AVM explained that social care could not afford the rates, despite places being available so the capacity was there, but not the funding. With respect to delays with continuing healthcare patients, HC indicated this was not about delays in making the assessment but finding the places. None of the social care departments had put money into creating spaces and they were now asking for 12 additional beds and for the provision of care around patients wherever they were located.

• RP on delayed transfer - one patient he had met on a ward visit had been there longer than some of nurses. HC indicated this was unfortunately not a one off event. AVM added they had approved a dedicated staff appointment to help manage private funders to move them out and they were keen to progress this. From the outset it was necessary to be clear with patients that once they were ready to go to either a nursing home of their choice or somewhere else then they needed to do this at their own cost. The Trust did not want to go down the eviction route but this may be necessary in future.

DK asked about private patient income and HC indicated that this had not recovered and some more work was being done to address this. On the Frimley site we were limited by the availability of theatre capacity. Wexham had improved and they will build on this. A deep dive was planned for CDIC. MOD referred to the performance report at page 52 which indicated that time to recruit was taking longer. JK replied they had introduced a new process for all posts and nonclinical posts which were now reviewed by the executives which may have resulted in a 2 week delay. PP asked whether this was required to manage the budgets and JK confirmed this applied to non-medical staff posts which were reviewed to potentially reduce hours and grading. MOD asked about whether elective mortality trends were adverse over time. TH

3




o. p. q.

replied that the small number in ENT skewed all the figures. This was being reviewed by Claire Stapleton and he had oversight on the rest of hospital dashboard which was going well. TS referenced page 53 which showed clinical income above plan with a high level of un-coded episodes. NF advised more agency staff had been employed to deal with the backlog and some of this work was going out to third parties to recover the position. This would not be completed till the end of the financial year. It was necessary to keep on track with the new work and estimates on a month to month basis were broadly in line with the plan. It was taking time to code from an electronic document to a paper set of notes. Documents had been sent out to scan to improve this process. JW asked whether there were better ways to undertake this work through automation. NF advised that in the longer term more information would be coded directly into the system rather than using scanned paper documents and then the system could be used to code rather than rely on manual intervention. PP set a challenge to DB on responding to customer complaints within 25 working days. Now that we had the full complement of staff, he wanted the team to do a trajectory to show how they will improve performance. He encouraged them to set an ambition and target to get this sorted as it has been less than 50% for some months now. DB indicated he would consider how best to do this. The board NOTED the report.

7. Quality Improvement Plan (QIP) a. b. c. d.

TH reported that the sepsis re-launch was on going and there had been improvement in the one hour screening requirement. He also noted that there was an increase in consultant numbers and nursing vacancies had fallen which helped the agency position. There was also now director oversight for all agency requests. There was also on-going work with EDMS to improve peoples’ working lives. MOD queried an item on page 85 on Hospital at night. TH confirmed that the policy was being enacted and needed a reboot as the two main sites were doing things a bit differently. TH added that the Wexham model was supported by a stronger consultant drive. He was expecting this to be done by the end of Q4 and the establishment of a new cross site group. RL asked about the workshop mentioned involving the CQC with Chiefs of Service. TH confirmed many of them had been on CQC inspections and this was a way of sharing knowledge. It was an opportunity to review the monthly output from their metrics which they benchmark against. A good example was flu vaccination take up. PP added the flu numbers were going in the right direction and were much improved on last year but there was still work to be done on this. The Board APPROVED the plan.

8. Finance Report - month 7 a.

NF indicated there were a number of things to highlight;

• M7 showed a £1.6m surplus pre STF which is £0.1m adverse to plan. The

3




Trust is £5.7m adverse YTD. Clinical income was better than previous months but there remained a high level of un-coded episodes at the month end. Private patient income continued to perform below plan. Pay and non-pay spend continued to be an area of concern. CIP mitigations identified at Month 04 were lagging behind required levels. Agency costs were down to £1.8m and this is within the NHSI cap but pay in total continues to be overspent.

• Everything that is done this year also improves next year’s position and would reduce the levels of savings required

• Three things from the recent budget announcement included some good news on extra capital, funding for pay beyond 1% and some extra revenues.

• There was another theme around admin costs. Nationally admin spend is 2p in every pound and is very low but more can be done to bring this down further. There was a strong hint about driving down these costs and bringing together organisations like CCGs to reduce management costs. Bringing NHSE and NHSI together would also reduce duplication

• There was some focus on protecting priority investment areas –mental health, primary care and cancer

• There were some interesting indications from NHSE and NHSI board papers. More planning guidance was expected between now and Christmas

The board NOTED the report.

9. CIP Update 17/18 a. b. c. d.

HC and LG presented the CIP report noting that;

• There was a 92.4% achievement and they were working on a forecast outturn of 93.3% or £28.5m which was an improvement on last month. This was still not enough, given there were only five more months of the year left.

• There was an improvement on Admin agency and surgery had done well. Hale ward showed significant over performance of £1.6m and this demonstrated it was easier to manage the staffing of wards on site than off site. There was an £0.5m difference between the 10 best and 10 worst performing areas.

DK asked about the consequences of exceeding the £23m agency cap. AVM explained that although there was no financial penalty we would come on to the regulator’s radar. DK also queried what was required to get non-pay under control. NF advised that this should be as well managed as everything else and would be taken back to the next set of directorate reviews. Sometimes it was about phasing. DK then asked whether all the ADs knew how to put together budgets. NF confirmed they all had a support accountant and HC and NF met everyone on a monthly basis. NF suggested it was better to look at the YTD position as the in-month variances may not be significant. RL asked about slippage and recovery and whether there was a plan which ensured mitigating actions were done. LG advised there was a list with mitigations which was regularly reviewed. AVM added the plan assumed we would meet it. HC confirmed that we usually delivered 90% of CIP but this year there was less lee-way and the mitigations had to deliver. She doubted we would get to 100% but all that can be done would be done. AVM also added that there was an assumed £2m off set which would be played into the final figures and the Trust expected getting very close to

3




e. f.

the CIP target. RP indicated there had been discussion at a recent FAC about pathology not following procurement process and given their non-pay was over by £0.5m, he queried whether they were now following the process. NF confirmed there was still work to be done on this with pathology. He went to say that pathology had not delivered savings in the first 2-3 months of the year and once they had fallen behind, it had been difficult to recover it. AVM considered that we would not be that far behind. We needed to deliver £7m, and should deliver £6m. AVM noted that pathology had also won a prize for the partnership arrangement. It had just got full accreditation which was rare. This meant that pathology could continue its business. The same model could be extended to pharmacy with the opportunity for large scale savings. The board NOTED the report.

10. Capital Programme Report 2017/2018 – Month 7 a. b. c. d.

JK presented the report noting the budget approved for capital projects (excluding medical equipment and IT) across all three sites in 2017/18 was £65.5m. There were several points to note;

• There was a difference in NF’s paper as Capital Expenditure (CapEx) for finance includes the whole of CapEx. JK’s element of this was more restricted.

• There was an £8m underspend on big schemes which had been accounted for and included a mix of backlog maintenance and new scheme slippage.

• A few projects were underspent and money was due back on the maternity and renal schemes.

• There was £200k of new projects being prioritised by the capital planning committee.

JW queried whether in considering the 10 year backlog at Wexham projects could be rescheduled to enable more projects to be completed within a year. JK responded that the document was a live one and reviewed on capital away days. The team felt saturated with work. PP commended the team as the summary list showed the huge amount of work being done and a lot of investment on infrastructure. We must be one of very few trusts that were still investing in new facilities and backlog maintenance. The board NOTED the report.

11. Corporate Risk Assurance Framework a.

PP indicated this item should be taken as read and it was noted that DK and MOD were working with the team to improve the report. The board NOTED the report.

12. Senior Information Risk Owner (SIRO) Quarterly Report a. b.

NF advised the report was self-explanatory. DK asked about the recent changes intended for data protection and wanted to

3




c.

understand the organisation’s state of readiness as she understood the fines would be significant. NF agreed there could be significant fines and confirmed there was a lot of work being done internally and nationally. He considered that in some areas health was better than in other sectors and the team was working through the implications. He assured the board the issue was being dealt with internally and there was also an IG team within the ACS. DK advised she would add the issue to the audit agenda. PP considered this was moving in the right direction and thanked the team for the great work they have done as this time last year, we were not at a good place. The board NOTED the report.

13. Speak Up Guardian Annual Report a. b. c. d.

Bruce Montgomery, Freedom To Speak Up (FTSU) Guardian updated the board with the findings of the annual report and indicated that the Freedom to Speak Up policy had been launched and after a slow start there were now 16 reports this quarter. There had been a low level of anonymous reporting and the majority of reports were concerned with unacceptable behaviour. Everyone who had made a report agreed they would report this way again. The behaviours identified were consistent with heavy workloads and a lack of skills. BM requested resources for dealing with this to identify relationship concerns and try and improve them. A discussion followed;

• TS asked about outcomes and improvements as a result of the scheme. BM confirmed that nearly every issue had been positively addressed. People were happier and the focus was on trying to ensure this was a developmental process. It was not about attributing blame but about how to treat staff.

• TS asked about the reference to fraud. BM indicated there were two recent incidents-one was investigated and nothing was found but as the complaint was anonymous the results of this could not be fed back. Another was undergoing investigation and he would feedback and share conclusions. BM confirmed to DK that RSM was being used to conduct the investigation.

• MOD asked about the training required. BM replied the focus needed to be on communication skills for senior managers and what is perceived as delivering bad news. He advised that these skills can be acquired and what was often required was a brave conversation to deal with the issues. Even senior managers with great skills, when they are under time pressure do not use these skills.

• MOD wondered when the Trust would reach the point when more generalised training was required. BM indicated this was more about individuals and not a generic approach. He had found that a lot of leadership training did not necessarily teach communications and softer skills.

• JK referenced data from the friends and family test which showed there was a decline in shop floor staff indicating FPH was a good place to work. Eleanor Shingleton-Smith had provided an update of 89 comments citing poor management. JK would follow this up for the January Top Team meeting. She considered that many of these comments would identify a lack of consideration and courtesy particularly when people were busy.

PP concluded that the board was fully supportive of this work and BM had direct access to AVM and PP. This was a time of change for the organisation and when

3




choosing the next Chief Executive, he was very mindful of choosing someone with the right people skills to ensure empathy. The Board NOTED the report.

14. Insurance Update Report a. b. c. d. e. f. g. h.

Jemima Harrison, Litigation Manager attended and presented the annual insurance report. Insurance was on the basis of a pay as you go (PAYG) scheme and due to obstetrics it was particularly expensive. The report covered many issues. She was awaiting the 2018/19 scheme contributions. JH explained that on becoming an FT in 2005 the decision was made to take on commercial cover for some of our commercial activities e.g. PPU. Commercial cover was provided by Willis who are experienced in this field as 60% of their clients are from the NHS. JW asked how PAYG worked. JH indicated that from 1990 onwards a special scheme was set up where insured parties pay in on an annual basis into a fund and any claims were paid out of this. If a trust withdrew from PAYG, you would have to pay out any future claims. The PAYG was internal to the NHS and as such removed the profit element. AVM found the increase was massive and asked whether there was any opportunity to negotiate this down. NF advised he had already had a few exchanges about the level of charges and was now awaiting a response. AVM also wondered how we compared with others. JH advised we were at the lower end last year but the discount rate had been altered and this was now not looking good. Liability costs had increased by three fold from last year and was on an upward trend. A lot of this was due to high value obstetric cases- for example one case settled at £31m. JW asked whether our premium was related to our performance. JH confirmed we benchmarked well on performance. AVM expressed concern that the premium levels may be based on turnover and if so we would be compared with the large teaching hospitals which had a different case mix. We are third largest provider for obstetrics. He considered we should push back on this as we are now two DGHs. RP asked what the percentage was in obstetrics. JH indicated this was about 50% which represented just over £10m. AVM considered the other £10-12m was compared to a teaching hospital environment. He noted the importance of obstetrics and safety in this area. If incidents could be managed down then there should be a benefit. JH confirmed this assessment as we had recently paid out £8.5m for a delayed delivery. AVM had recently met a family who probably would be successful with a claim for a £10m, as we had forgotten to do one test. DK noted that maternity looked the same as last year and this did not feel right. AVM agreed and indicated again that the basis for our premium may be turnover. PP noted that NF was challenging this and this is best left to him to follow through on. The Board NOTED the report.

3




15. Board Sub-Committee Summaries a. b. c. d. e. f. g. h.

15.1 Audit Committee, 16th November DK indicated this was a standard meeting of this committee and it had considered the limited assurance assessment of the medicines management audit. The QAC would consider this further. The Committee also received an update on progress on the policy integration project to update and review the Trust’s policies and noted that a total of 78 policies had been updated. The Committee re-emphasised the importance of the completion of the project and that each Executive Director needed to continue to drive the update of policies in their own area and complete this exercise by the end of the financial year. 15.2 Commercial & Investment Committee, 17th November ME indicated that three projects had come to board for approval. The Committee had also considered a benefits realisation on the redevelopment of the paediatric High Dependency Unit, (HDU) Wexham Park Hospital. 1. Frimley Park Hospital inpatient and diagnostic outline business case, (OBC) The Board had approved an outline business case in support of inpatient and diagnostic facilities at Frimley Park Hospital. 2. Improving the User Experience (IUE) across Frimley Health outline business

case An outline business case for the development and enhancement of the Trust’s IT infrastructure by upgrading the existing infrastructure at Frimley Park and the deployment of the same infrastructure solution at Wexham Park had been presented. This supported the move towards a paper light NHS and the trend towards greater dependence on technology. The Board had approved the outline business case. 3. Combined Heat and Power Full Business Case, (FBC) Wexham Park Hospital A full business case for the provision of new energy centre including a combined heat and power plan had been considered. The Board had approved the full business case. 15.3 Nominations Committee, 23rd November PP reported that this committee recommended the appointment of Neil Dardis as the new CEO to the NERC and CoG which met and confirmed the appointment on 29th November 2017. The board NOTED the summaries.

16. Draft Trust Membership Strategy 2017/2019 a. b.

JK introduced the strategy which had been considered and developed by the Community Engagement Group of the Council of Governors at its meetings in March and July 2017. Membership was buoyant with just under 28,000 members. Natural turnover resulted in losing around 2,000 members per year. It was considered that 15,000 was an optimal number as the membership needed to be managed. It was recognised that there should be a stratified sample and some areas and groups were under represented particularly amongst the Wexham

3




c. d.

population. The aim was to create a more meaningful membership, so it could undertake survey and other important work for the trust. PP noted that the numbers were linked to GP registrations and this was now aligned with governor representation for each constituency. JW suggested the focus should be on the quality of engagement. He noted the trust had not fully exploited social media and this could be an area of growth via the use of volunteers. The Board APPROVED the strategy.

17. Any Other Business a.

There was no other business discussed.

18. Meeting Review a.

The following comments were noted;

• DK felt the pace had been good. • JW considered the ED presentation was good. • HC thought it would be beneficial for ADs to attend ward to boards and they

could have been more structured in their presentation. • AVM would have preferred more input from others at the ward to board. • ME considered this was the most we have heard from a chief and NP had

been provided with good feedback. • PP was grateful the meeting had run ahead of time.

19. Questions from Members of the Public a.

The following questions were asked by members of the public present:

• Rod Broad, public governor, asked about whether the emergency readmissions within 30 days target was correct or was there a transfer of risk back to community? AVM replied that readmissions were pretty constant at 6+%. An internal target was set and when benchmarked this placed us within the average range with other trusts. The aim was to reduce this as much as we can.

• Rod Broad also asked about car parking as anecdotally he had heard car parking at Heatherwood was becoming more difficult. JK confirmed that hotel services had also brought this to her attention and she feared the situation would worsen as the road needed to be given up for the block 40 development. She was trying to lease some land at Ascot Racecourse to alleviate the problem which was difficult already and would worsen before it improved.

• Rod Broad also made one comment on the membership report highlighting that part of challenge was engagement, but members had been particularly helpful with the Heatherwood consultation phase and had added real value and suggested this should be publicised.

• Sarah Peacey – in relation to delayed transfers of care understood that the CCG paid for the nursing element, but the local authority paid for the care. AVM replied that social services pay for placements in nursing homes but for the group of patients falling outside of the social care remit, the health service picked this up. This covered more than just nursing – and could include some form of specialist care- community hospital or specialist rehab.

• Sarah Peacey – also asked whether the situation would improve with the

3




ACS. AVM responded that services may be more joined up and supported the principle of discharge to assess, as it was better to assess someone in a better environment than when they were at their worst in hospital.

• John Lindsay, public governor, indicated he still saw a lot of people waiting for discharge. Who was responsible for patients who were care home based but were still attending for hospital for appointments? AVM explained if someone goes to a nursing home they will still come back for care but would fall within the responsibility of social care for domestic arrangements and the CCG would pick up the costs for outpatients or inpatients. Medical care lies with the CCG.

20. Date of the Next Meeting

Friday, 5th January 2018 Lecture Theatre, PGMC, Wexham Park Hospital

These minutes of the meeting were duly approved by the Board:

Name: Pradip Patel

Signature:

Date:

3



k:\board of directors\board meetings\2018\1. 5th jan 2018\public\word, excel & other versions\4. public action log from previous meeting 1 december 2017.docx

BOARD OF DIRECTORS MEETING – PUBLIC 5th January 2018

ACTION LOG

AGREED ACTION LEAD END DATE ACTIONS COMPLETE

3rd November 2017 – 11.j. MAST and Appraisal Recording and Reporting MAST and Appraisal updated data be presented to the Board in spring 2018. JK and SNW to agree timing.

Janet King/ Susanne Nelson-

Wehrmeyer May 2018

ACTIONS IN PROGRESS 1st September 2017 - 18.e Meeting Review PP to undertake a review of board papers and work with the EDs to make the papers fit for board Pradip Patel On-going into 2018

6th October 2017 – 11.b Corporate Risk Assurance Framework Finance Assurance Committee to undertake a deep drive of the Medium Term Financial Strategy risk and the Quality Assurance Committee to undertake a deep dive of four hour A&E performance risk. Both Committees to report back to the Board. Update: Update: FAC review of Medium Terms Financial Plan risk undertaken at the 25 October meeting and reported back on November board agenda. QAC considered A&E performance on 8th December – report back to January meeting.

Rob Pike/ Mike O’Donovan 5th January 2018

6th October 2017 – 14.b – Infection Control Report Hand hygiene scores to be included in the KPI’s within the next infection control report Tim Ho 5th January 2018

ACTIONS OVERDUE

4

Tab 4 A

ction Log from P

revious Meeting

17 of 201P

UB

LIC B

oard of Directors - 5th January 2018-05/01/18

Page | 1

Report Title Ward to Board Report FPH Paediatric Ward F1 and Neonatal Unit (NNU) WPH Paediatric Ward 24 and Neonatal Unit (NNU)

Meeting Public Board

Meeting Date Friday, 5th January 2018

Agenda No. 5.

Report Type Prsentation

Prepared By A Walker, J Wyeth, V Gentry (Infection Control)

Pharmacy Department and Facilties Department

Executive Lead

FPH: Senior Matron Paediatrics and Neonates : Jennifer Lomas. Clinical Matron: Lois Doel (F1) WPH: Senior Matron Paediatrics and Neonates: Ros Rushworth. Clinical Matron: Shakeela Banno (NNU) Chief of Service: Joanne Philpot

Background

The Health and Social Care Act 2008 (Code of Practice on the Prevention and Control of infections and related guidance July 2015) states that NHS provider organisations must demonstrate that infection prevention and cleanliness are an integral part of quality assurance. Please find the report to the Board by Chief of Service and Clinical Matrons for Frimley Health Paediatric wards NB this report is presented in conjunction with the performance data provided by the Quality Team.

Issues / Actions Areas of the Infection Control Section are RAG rated for information

Recommendation Board members are asked to discuss and note this report

Appendices N/A

5

Tab 5 Ward to Board - Paediatrics Wards Cross Site


Page | 2

Wards F1 FPH NNU WX24 WXNNU MRSA bacteraemia for year

0 0 0 0

Hand Hygiene Audit Scores for quarter

100% (Ward audit) 100% (IPCN audit)




Spot check audit of alcohol hand sanitizer availability

100% 100%

Infection Control link rep attendance at quarterly forum (2017)

Attended 2/4 meetings in 2017




Clinical Lead attendance at monthly HICC (2017)

Attended 63% meetings 2017 Attended 20% meetings 2017 (Matron attended other 80%)

Consultants training at Annual Infection Control Training (2017)

IPCN records: Consultants 86% Trust Drs 100%

On MAST: Consultants 67%

Trust Drs 80% Bed Spacing (range and median) DH Estates & Facilities (2013) HBN 00-09 & 04-01: recommend clear bedspace of at least 3.6m (width) by 3.6m (depth)

Average 2.4m (range 2.1-2.9)

Average 2.11m (range 1.92 – 2.27m)

Double side rooms Average2.58 m

(range 2.5m – 2.65m) 6 bed bays

Average 2.2m (range 2.18m – 2.22 m)

Paediatric HDU Average 3.35m

(range 3.35m – 3.35m)

‘Hot room’ Average 2.06m

(range 1.7 – 2.2) depth 1.8m – 2.2m

Nursery 6 Average 1.9m

(range 1.74m – 2.06m) Depth 1.8m – 2.2m

Nursery 7 Average 1.95m

(range 1.7 – 2.2m) Depth 1.8m – 2.2m

Number of handwashing sinks per bed

Surgical and medical bays 1:5

HDU Bay 1:4 Teenage bay 1:2

(5 side-rooms 1:1)

Nursery 1 = 1:2.6 Nursery 2 = 1:3.5 (Side-room 1:1)

1:1 single rooms 1:2 in 2 bedded rooms 1:3 in 6 bedded room

1:1 in HDU

1:1 single rooms 1:4.5 in ‘Hot-room’

1:3 in Nurseries 6 and 7

Cleanliness monitoring data obtained from Facilities Dept

Wards F1 FPH NNU WX24 WX NNU National Standards for Cleanliness score (Nov17)

Nursing 94.9% Housekeeping 94.4%

Nursing 100% Housekeeping 98.8%

98.2% 100%

Antibiotic Audits obtained from Pharmacy Dept: Wards F1 FPH NNU WX24 WX NNU Was Stop/review date documented on the prescription? Was the correct Indication specified on chart? Did the prescribing Seem reasonable?

100%

86%

100%

100%

100%

100%

5



1

Neonatal Service April 2017- Nov 2017

Frimley Health

Background Location of Service: Neonatal care is provided on both the Frimley and Wexham Park sites. Each unit has Local Neonatal Unit status (LNU) (Level 2) and are part of the Kent, Surrey, Sussex and Thames Valley and Wessex Perinatal Networks respectively. Both units provide care for singletons from 27 weeks upwards and birth weight above 800g, multiple births from 28 weeks upwards and birth weight above 800g. Frimley Park and Wexham Park LNU’s provide short term ventilation for up to 48 hours. The majority of babies over 27 weeks of gestation will usually receive their full care, including short periods of intensive care, within our LNU’s. Babies expected to deliver below 27 weeks gestation &/or below 800g are transferred out in-utero to a tertiary NICU for delivery. Frimley Park and Wexham Park LNU’s may receive transfers in from other neonatal services in the Network; as per Network Pathways. Infants born outside of the pathway are resuscitated and stabilised prior to transfer to regional service. Capacity: Frimley NNU: Total of 16 cots, 2 designated intensive care, 6 High dependency and 8 special care. There are 2 designated family rooms enabling parents to ‘room in’ with their babies. Transitional care is located on the post natal ward and has 8 cots. This facility is staffed by the midwifery team and the neonatal team carry out daily ward rounds and plan the care. This allows for mother and baby to be together. Wexham NNU: Total of 21 cots, 2 designated intensive care, 3 High dependency and 16 special care. There are 4 -5 designated family rooms enabling parents to ‘room in’ with their babies. There are plans for a transitional care unit with 8 cots to open on the 22nd January 2018. Activity: Admissions April-November: Frimley NNU: total 386 equates to 10.6% of all maternities. Occupancy average from April-November 76% Wexham NNU: total 318 equates to 7.5% of all maternities. Occupancy average from April-November 72% There have been no unit closures on either site. Babies delivered outside of service specification eg. <27weeks: Frimley NNU =7 Wexham NNU=5. These pathway outsiders are reported to the network on a quarterly basis. Current redesign or service improvement initiatives:

• Frimley NNU: Capital planning bid to expand intensive care nursery as issues with space due to increase in equipment required. Floor space not adequate

5



2

when transport team retrieve and when increased amounts of equipment being used.

• Extension of pharmacy room to provide larger drug preparation area completed in May.

• New equipment purchased includes new ventilator and echocardiogram machine.

• Outreach nurses carry out 2 year neurodevelopment clinics with consultant support. This service has been provided at home on 2 occasions.

Wexham NNU:

• Upgrading uninterrupted power supply system work planned Jan 2018. • Estates plumbing work to commence in the new year as ongoing issues with

pseudomonas growth in tap water. • New transitional care unit to open in January 2018.

Themes and trends from Patient Experience 2017 There are a number of parent feedback surveys that take place in Neonates. These include the Picker Friends and Family, patient experience tracker and local peer review. Feedback comments are very positive and full of praise for staff and the care that has been received on both sites. Frimley has a facebook feedback page through the Trust and Wexham looking at implementing this. Both units are looking at Vcreate which facilitates video links between family and parents. Comments from parents: “ personalised care”, “wonderful friendly staff”, “ very informative”, “ superb care and amazing staff”, “so thankful for everything you have done” Unit Friends and Family

Scores Frimley Park 99% Wexham Park 100%

Successes Frimley NNU: Achieved Bliss Family Friendly Accreditation in July 2017 which recognises high quality family centred care. Frimley are the first LNU in the UK to achieve this and the third unit in total. A presentation ceremony took place in November and Bliss plan to return in January to video the NNU and use on their national website.

The NNU maintains joint maternity and NNU UNICEF Stage 3 Baby Friendly Initiative (BFI) status and there are plans to consider standalone Neonatal accreditation in 2018. All unit staff have undertaken BFI training.

Wexham NNU: The unit is working towards Bliss Family Friendly Accreditation. Plans are to re- audit the Bliss Baby Charter in April 2018 and contact Bliss to submit.

The NNU has achieved joint maternity and NNU UNICEF Stage 1 Baby Friendly Initiative (BFI) status and are currently working towards Stage 2. The neonatal staff will all be BFI

5



3

trained by February 2018. Both units have a neonatal outreach service which supports a smooth transition from hospital to home. The outreach teams facilitate safe early discharge and provide on going specialist care for complex babies. Formal Complaints Frimley NNU: none Wexham NNU: 2. The common theme was communication. The first complaint was the reporting of a safeguarding concern that staff had raised. The second complaint was surrounding the communication of sensitive information and terminology between parents and medical staff. Staff have been made aware of the complaints and the learning shared via unit leaflet, display board and daily briefings. Challenges

• On-going issues with Friends and Family response rates. These are being addressed by Matrons/ward managers. Getting feedback from parents in a timely fashion has proved difficult and measures included to improve this have been, checklists on discharge paperwork, senior nurse monitoring response rates, help with distribution of feedback forms from administrative staff.

• Capacity for ‘rooming in parents when acuity high on Frimley NNU.

Patient Safety

There are robust and well established clinical governance meetings which are held on a monthly basis. Incidents, risks, infection control and prevention issues are presented and discussed along with quality and training issues. There are also cross site CG meetings held 6 monthly with a plan to have a 6 monthly cross site M&M meeting.

Frimley attend joint maternity risk meetings monthly and quarterly perinatal mortality. On the Wexham site a Paediatric quality and safety meeting is held 6 monthly with representation from Paeds, general surgery, urology, plastics, ENT, orthopaedics, anaesthetics, ED and radiology. Representation is made up of Consultants, Doctors in Training, Matrons, PDNs, Pharmacy, Paeds ED and Maternity. The neonatal lead consultant and the matrons attend Network Governance meeting twice yearly. The SEC network have now combined Mortality review meetings in these forums. Frimley NNU have presented at these in November 2017.

Infection control: see report

5



4

Incidents Frimley NNU: Reported incidents for April 2017- Nov 2017 = 38 No harm: 37 Serious incidents : 2 unexpected deaths. Only 1 with duty of candour (moderate).Learning disseminated the following forums: paediatric audit, clinical governance, SEC network governance. Feedback to staff also by learning displayed on ward safety board, unit meetings, clinical governance newsletter and message of the week. Medication errors: 5 none causing harm: When appropriate, nursing staff involved in medicine errors are asked to redo the medicines management learning module and reflect on their mistakes. Prescription errors are addressed with medical staff. Successes

• Implementation in July of maternity hub daily to improve communications and escalation.

• Implementation of message of the week addressing safety issues. The key messages from patient safety are disseminated to staff.

• Situation, background, assessment, recommendation (SBAR) handover tool used. Wexham NNU: Reported incidents for April 2017- Nov 2017 = 61 Serious incidents: 0 Moderate: 1 Low 24 No harm 36 Medication errors: 7 none causing harm: When appropriate, nursing staff involved in medicine errors are asked to redo the medicines management learning module and reflect on their mistakes. Prescription errors are addressed with medical staff. Both units hold weekly psychosocial meetings to discuss safeguarding issues with the perinatal mental health and safeguarding team. Challenges Frimley NNU: Nursing handover consists of a whole team handover and then individual handover at the bedside. This leads to difficulties in achieving “team debrief’ at the end of shifts. When acuity is high space is an issue on the unit. The unit works closely with transitional care and the children’s ward when over capacity. Wexham NNU: Blood spot errors- although reduced greatly, still happen occasionally: All staff trained and given refresher training if required. 2 nurses check and sign all samples for accuracy before they are collected by screening administrator.

Cross site learning achieved by joint clinical governance and CG newsletters.

5



5

Themes and trends from Quality On a monthly basis a summary of both quality dashboards are presented at the Trust’s Quality Committee with a focus each month on one specialty. The summaries are presented at monthly Paeds Clinical Governance meetings. 2016 National Neonatal Audit Programme results published in September 2017. Measure Frimley Park Wexham Park National Average Antenatal steroids 86% 83% ** linked to

data entry access 86%

Temperature within range babies <32 weeks

69% 65% 61%

Mothers given magnesium sulphate

64% 41%** linked to data entry access

43%

Consultation with parents

96% 100% 90%

Bronchopulmonary dysplasia

14% 21% 31%

Retinopathy screening

98% 95% 94%

Mother’s milk at discharge

67% 68% 59%

Clinical follow up at 2 years of age

68% 79% 61%

The paediatric ophthalmologist now works cross site performing retinopathy screening weekly. Frimley NNU have trained a further 2 nursing staff to carry out Bayleys 2 year neurodevelopment follow up which has improved the 2 year follow up data since previous audit which was 31%. Both units have been working along with maternity on the NHS Improvement Avoidable Term Admissions into neonatal care. (ATAIN). Term admissions as a percentage of total admissions to neonatal care and a percentage of total maternities is monitored monthly on the dashboard and also by the respective perinatal networks. Both units are below national target. Cross site ATAIN meetings are held 3 monthly. The BAPM Hypoglycaemia Framework for Practice has been integrated into clinical practice and formed into a cross site guideline. Glucogel has been introduced in both NNU’s. Successes Hand Hygiene: Frimley: 100% Wexham : 99%

5



6

National Neonatal Peer Review:

Frimley NNU: the review was carried out on 17th November 2017. Feedback was very positive and there were no serious concerns from the review panel. Areas of good practice highlighted included, good teamwork, competencies up to date, available information for parents , effective infection control and overall a compact unit which was well run.

Wexham NNU: review is due in January 2018.

Cross site peer reviews take place on a monthly basis, sharing good practice and learning. Parent and staff feedback is also part of the process.

A new neonatal ophthalmology service provided by Frimley Park now provides reviews on a set day and time each week with the same ophthalmologist which enables the nursing staff to administer eye drops in preparation for examination. A clinic has also been started in Children’s clinic to follow up babies after discharge. Paediatric speech and language is now available cross site. Improved data entry on badgernet neonatal database. Challenges and Solutions Frimley NNU: babies following discharge are still returning to the neonatal unit for retinopathy screening. This places an increased strain on the nursing workload as eye drops have to be administered and the ophthalmologist requires the assistance of a nurse. We have had discussions with the paediatric ophthalmologist regarding these babies being seen in paediatric out patients. We are working together to look at this service. Major delays with IT interface between Badgernet and PAS, this has been escalated and remains on risk register.

Staffing overview A comprehensive workforce planning meeting was held within the paediatric directorate in November 2017 with an action plan. The purpose of this was to ensure service continuity by planning to implement non-medical roles and other mechanisms to address the challenges with the sustainability of the junior doctors workforce over the next 3 to 5 years. Along with looking at the number of ST4 trainees and placements the panel looked at ‘grow your own’ trainee advanced neonatal nurse practitioners to support the medical rota and doctors assistants to support the administrative side.

Both neonatal unit staffing establishments are calculated against commissioned activity based on an 80% occupancy level

Frimley NNU:

• Vacancies: Advanced Neonatal Nurse Practitioners (ANNP) x1.00 wte. Band 5 x 1.00 wte out to advert at present. Band 6 has applied for MSc funding to undertake ANNP training.

• A monthly safe staffing tool is completed and also Badgernet neonatal acuity tool. Both are reflected on the dashboard.

• The community outreach team has been increased by band (5) x 0.8 wte to support

5



7

the existing band 7.

Qualified in Speciality (QIS) nursing staff is currently 71% (BAPM requirement 70%). There are 2 members of staff due to complete the pathway in February 2018. A further 2 members of staff are undertaking the Neonatal pathway in 2018. All qualified QIS staff are NLS trained and carry an emergency neonatal bleep. The unit has 2 medical and 2 nursing NLS instructors who participate in teaching on the unit and facilitate external NLS courses. The lead consultant has just completed the Advanced Resuscitation Newborn Instructor (ARNI) course.

A Band 4 nursery nurse is undertaking the trainee associate nurse practitioner programme and is being supported by the paediatric department.

There are 2 Band 6 nurses who have undertaken introduction to counselling courses and provide additional support for parents on the unit alongside the parent support group.

There is now 7 day a week ward clerk support.

Wexham NNU:

• Vacancies: Band (5) x 3.00 wte.

• Band 8A trainee advanced nurse practitioner

• Band 8A Clinical Matron is being covered by secondment post.

• Band 6 Practice development nurse on secondment, role currently covered by other band 6 nurses.

• A monthly safe staffing tool is completed and also Badgernet neonatal acuity tool. Both are reflected on the dashboard.

Qualified in Speciality (QIS) nursing staff is currently 72% (BAPM requirement 70%). There is 1 member of staff due to complete the pathway in April 2018. All qualified QIS staff are NLS trained and carry an emergency neonatal bleep. The unit has 4 medical and 1 nursing NLS instructors who participate in teaching on the unit and facilitate external NLS courses.

When there are staff shortages on either ward, children’s ward and NNU staff support each other in covering shifts where possible. There have been episodes where cross site cover has taken place.

Challenges and Solutions:

• BAPM nursing standards require a supernumerary nurse in charge on every shift. This is not always possible if acuity high. Discussed with directorate and network, to continue with 80% occupancy establishment and flexible budget to draw on when acuity high. Ward manager and practice development Band 7’s are available to cover when acuity high.

• Recruitment to permanent Band 8 Matrons post.

5



Summary

5. Copy of M09 - FHFT - Neonatal - Oct17 (4) Page 1 of 12

RAG keySpecialty:Quality committee month: December 2017Data month: October 2016 - October 2017Chief of service: Joanne Philpot Clinical lead: J Aspel (WX) and S Jaiswal (FP)Presented by: J Philpot

Performance Change Performance Change Performance Change

Total cot occupancy 80% ↓ 52% ↓

Number of term admissions (>37 weeks) as a % of total admissions

54% ↓ 50% ↑

Number of term admissions (>37 weeks) as a % of live births

6.10% ↔ 4.70% ↓

Serious incidents requiring investigation (SIRIs)

1 ↑ 0 ↔

Incidents triggering a duty of candour response

0 ↔ 0 ↔

No. of medication errors resulting in severe harm (prescription/administration)

0 ↔ 0 ↔

Number of unexpected deaths 1 ↑ 0 ↔

Number of babies transferred out less than 27/40 gestation

0 ↔ 1 ↑

Number of babies transferred out more than 27/40 gestation

4 ↑ 1 ↔

Domain

Specialty dashboard - summaryAchieving targetBetween target and threshold (where applic)Worse than target or threshold (where applic)

Neonatal

↔ - no change

↓ or ↑ - improving performance↓ or ↑ - worsening performance

Key measures Frimley Park Hospital Heatherwood & Wexham Park HospitalsFrimley Health NHS FT

No never events. Medication errors x2 with no harm one administration and x1 missing signature. Neonatal emergency calls remain high for this month also at 16.

3 babies transferred for active cooling. HIE grade 2 (x2) and HIE grade 1( x1) . 1 unexpected death at 36+6 weeks following extensive newborn resuscitation for prolonged fetal bradycadia. X1 baby required surgery for NEC. Local audit measures 34-37 to commence from 1st November. Term admissions as total of all admissions to NNU reduced from last month. Cross site ATAIN meetings now in progress to reduce Term admission to neonatal care.

No complaints F&F 100%

100% for both ROP screening and early discharge prior to 36 weeks of age.

Key messagesFPH HWP

No infection control issues. Safe staffing throughout the month due to low acuity. Cross cover provided to Ward 24.

Improved breastmilk at discharge for eligible babies. Term admissions below national average. Audits consistently above 90% and hand hygiene at 100%.

No formal complaints and recommended FTT 100%.

ROP screening 100%.

Safe

Effective

Caring

Responsive

Well led

Appraisals and mandatory training stats improved and now > Trust target of 85%.

Activity

Intensive care activity increased 25% to 50%. High dependency activity increased 22% to 53%. Overall unit activity at 80% for month. No pathway outsiders (babies born <27 weeks) and all transfers remained within the network.

Reduced acuity, with reduced cot occupancy.

Sickness rates down from previous month. Both staff sickness and turnover within Trust targets. Staff appraisal rates remain above Trust targets, currently 95%. Successful recruitment to band 4 post. Trained Advanced neonatal Nurse Practitioner post still vacant. Workforce planning meeting held- plan to seek funding for internal candidates to undertake training 2018. Always minimum of x2 NLS trained staff on duty. % shifts staffed to toolkit lower than national average, due to staff sickness and unable to cover with bank.

Within budget for pay and non pay in September, October in arrears no data yet.

Efficiency

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

27 of 201P

UB

LIC B


02/01/2018 Safe - sites


Site FY 16/17 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD Target Threshold

FPH Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

FPHNumber of serious incidents requiring investigation (SIRIs)

2 0 0 0 0 0 2 0 0 0 0 0 0 1 1 0 0

FPHNumber of incidents triggering a duty of candour

2 0 0 0 0 0 1 0 0 1 0 0 0 0 1 0 0

FPHNumber of medication errors resulting in severe harm (prescription/administration)

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

FPHNumber of medication errors (all)(prescription/administration)

NEW 0 0 0 1 0 2 3 TBC TBC

FPHNumber of babies with extravasation injury

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 >1

FPH Neonatal emergency calls 118 11 11 16 6 9 10 6 7 19 10 5 16 16 79 TBC TBC

FPH MRSA Bacteraemia 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0FPH Hand Hygiene (NNU) 100% 100% 100% 100% 100% 100% 100% N/A 100% 100% 100% 100% 100% 100% 100% <95%

FPHAntimicrobial prescribing -Documentation of indication on drug chart *

100% in arrears =100% <80

FPHAntimicrobial prescribing - Compliance with treatment guidelines **

100% in arrears =100% <80

FPHNumber of babies with catheter associated bloodstream infection

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

FPH Registered nurse day 95% 104% 105% 99% 79% 78% 75% 69% 84% 88% 95% 81% 80% 88% 84% >=90% noneFPH Unregistered care staff day 97% 77% 97% 91% 113% 100% 106% 93% 97% 103% 77% 71% 97% 87% 89% >=90% noneFPH Registered nurse night 94% 95% 99% 103% 102% 93% 81% 83% 87% 100% 101% 93% 103% 105% 96% >=90% noneFPH Unregistered care staff night 97% 65% 93% 81% 87% 87% 135% 83% 100% 103% 94% 68% 67% 74% 84% >=90% none

Safe staffing - NNU ward

Safe

100%

100%

Incident reporting - NNU ward

Infection control - NNU ward

100%100%

100% 100% 100%

100%

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

28 of 201P

UB

LIC B


02/01/2018 Safe - sites



Safe

HWP Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

HWPNumber of serious incidents requiring investigation (SIRIs)

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

HWPNumber of incidents triggering a duty of candour

1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

HWPNo. of medication errors resulting in severe harm (prescription/administration)

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

HWPNumber of medication errors (all)(prescription/administration)

12 2 1 0 2 0 0 1 1 0 0 0 2 3 7 TBC TBC

HWPNumber of babies with extravasation injury

4 0 0 1 0 0 0 0 1 0 0 1 0 0 2 0 >1

HWP Neonatal emergency calls TBC TBC

HWP MRSA Bacteraemia 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0HWP Hand Hygiene (NNU) 96% 95% 85% 100% 100% 100% 100% 100% 95% 100% 100% 100% 100% 100% 99% 100% <95%

HWPAntimicrobial prescribing -Documentation of indication on drug chart *

100% in arrears =100% <80

HWPAntimicrobial prescribing - Compliance with treatment guidelines **

100% in arrears =100% <80

HWPNumber of babies with catheter associated bloodstream infection

0 0 0 0 0 0 0 0 0 0 0

HWP Registered nurse day 95% 94% 96% 88% 94% 97% 103% 97% 103% 104% 107% 105% 106% 90% 102% >=90% noneHWP Unregistered care staff day 86% 83% 85% 73% 96% 90% 80% 93% 90% 67% 69% 57% 73% 74% 74% >=90% noneHWP Registered nurse night 94% 90% 95% 82% 94% 95% 98% 98% 103% 101% 105% 98% 105% 86% 99% >=90% noneHWP Unregistered care staff night 91% 88% 92% 89% 95% 91% 75% 86% 90% 68% 74% 69% 71% 65% 74% >=90% none

Safe staffing - NNU

Incident reporting - NNU

100%

100%

Infection control - NNU

100% 100% 100%

100%100% 100%

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

29 of 201P

UB

LIC B


02/01/2018 Effective - M and M -sites



FPH Number of babies with Necrotizing enterocolitis (NEC) 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0

FPH Number of babies sent for therapeutic cooling 1 0 2 0 0 3 0 0 0 1 0 0 3 4 0 TBC

FPH Number of babies with diagnosis of Grade 3 Hypoxic Ischaemic Encephalopathy at discharge to home

0 0 1 0 0 2 0 0 0 1 0 0 0 1 0 >1

FPH Number of babies with pneumothorax 1 0 1 0 0 0 0 0 0 2 0 0 0 0 2 0 none

FPH Number of babies with meconium aspiration 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 none

FPH Total unexpected deaths 0 0 0 0 0 0 0 0 1 0 1 1 0 1 4 0

FPH Unexpected deaths in unit New 0 0 0 1 1 0

FPH Unexpected deaths other hospital New 1 0 0 0 1 0

HWP Number of babies with Necrotizing enterocolitis (NEC) 0 0 0 0 0 0 0 1 1 0

HWP Number of babies sent for therapeutic cooling New 1 0 0 0 1 0 TBC

HWPNumber of babies with diagnosis of Grade 3 Hypoxic Ischaemic Encephalopathy at discharge to home

New 0 0 0 0 0 0 >1

HWP Number of babies with pneumothorax 0 0 1 0 0 2 0 0 3 0 none

HWP Number of babies with meconium aspiration 0 0 2 0 0 0 0 1 3 0 none

HWP Total unexpected deaths 3 1 1 0 0 0 0 0 0 0 1 0 0 0 1 0

HWP Unexpected deaths in unit New 0 0 0 0 0

HWP Unexpected deaths other hospital New 0 0 0 0 0

Neonatal Mortality and Morbidity

Effective - Mortality

Neonatal Mortality and Morbidity

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

30 of 201P

UB

LIC B


02/01/2018 Effective - clinical perf


201610 2 3 4 5 6 7 8 9 10 11 12 13


FPH All babies <28+6 weeks have their temperature taken within the 1st hour after birth

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% >=90%

FPH Maternal steroids given if baby delivers between 24+0 and 34+6 weeks gestation

90% 69% 82% 83% 100% 100% 100% 83% 75% 83% 80% 100% 83% >=97%

FPHDocumented consultation with parents by senior member of the neonatal team within 24 hours of admission

91% 94% 97% 100% 89% 100% 100% 98% 94% 94% 90% 97% 97% >90%

FPH NNAP data completeness New 95%

FPH Receiving breast milk at discharge (babies < 33 weeks gestation at birth)

33% 60% 67% 60% 0% 33% 100% 100% 100% 71% 0% 100% 50% >60% <50%

FPHNumber of readmissions from home to neonatal unit (datasource : June Swanton)

New 1 1 7 4

FPHNumber of preterm babies admitted with hypothermia (< 36.5oC)

6 0 2 3 11

FPH Parenteral nutrition <29 weeks <1000g N/A N/A N/A 1 N/A N/A N/A 1 N/A N/A N/A 100% N/A

FPHNumber of term admissions (>37 weeks) against all admissions to Neonatal

53% 46% 60% 58% 42% 34% 55% 52% 63% 48% 45% 51% 68% 54% <=60% >70%

FPHNumber of term admission (>37 weeks) as a % of live births

5.8% 4.4% 7.9% 7.6% 4.1% 4.0% 5.9% 3.8% 8.4% 6.2% 4.1% 5.3% 6.1% 6.1% <=6% >10%

FPH Observation audit New 93% N/A

FPH Name band audit New 100% N/A

FPH Documentation audit New 91% N/A

FPH National audits New 1 N/A

Effective - Clinical performance measures

National Neonatal Audit programme (NNAP)

Mother and breastfeeding

Audit

30 day Readmission Rates

Neonatal clinical measure5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

31 of 201P

UB

LIC B




201610 2 3 4 5 6 7 8 9 10 11 12 13



HWP All babies <28+6 weeks have their temperature taken within the 1st hour after birth

100% 100% 100% 100% 100% 100% 100% 100% N/A 100% 100% 100% 100% >=90%

HWP Maternal steroids given if baby delivers between 24+0 and 34+6 weeks gestation

100% 82% 71% 83% 79% 100% 100% 100% 80% 100% 100% 92% 100% >=97%

HWPDocumented consultation with parents by senior member of the neonatal team within 24 hours of admission

100% 100% 100% 100% 93% 100% 100% 100% 100% 98% 92% 92% 100% >90%

HWP NNAP data completeness 100% 100% 100% 100% 93% 100% 100% 100% 100% 100% 100% 100% 100%

HWP Receiving breast milk at discharge (babies < 33 weeks gestation at birth)

75% 100% 100% 50% 50% 83% 50% 80% 33% 100% 80% 28% 67% >60% <50%

HWP Number of readmissions from home to neonatal unit NEW 3 6 3

HWPNumber of preterm babies admitted with hypothermia (< 36.5oC)

1 0 0 0 0 0 1 0 0 0 5 2 2 2 11

HWP Parenteral nutrition <29 weeks <1000g 1 0 2 1 3 1 0 3 10

HWP Number of term admissions (>37 weeks) against all admissions to Neonatal

38% 44% 34% 30% 38% 30% 34% 40% 37% 45% 61% 47% 45% 50% 48% <=60% >70%

HWP Number of term admission (>37 weeks) as a % of live births

4.2% 5.0% 4.3% 3.3% 6.0% 3.7% 3.8% 4.5% 3.7% 4.1% 6.8% 5.2% 5.9% 4.7% 5% <=6% >10%

HWP Observation audit 100% 100% not done 93% 100% 100% 100% 100% 100% 96% 100% 100% 100%

HWP Name band audit 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 91% 100% 100%

HWP Documentation audit 99% 92% n/a 100% 100% 92% 98% 93% not done 98% 93% 95% 90%

HWP National audits 1 1 1 1 1 1 1 1 1 1 1 1 1

National Neonatal Audit programme (NNAP)

Mother and breastfeeding

Audit

Neonatal clinical measure

30 day Readmission Rates

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

32 of 201P

UB

LIC B


02/01/2018 Caring - sites



FPH Friends and family test - inpatient survey (based on responses for NNU)

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 95% 100% 100% 99% >=90% <87%

FPH Number of complaints received 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

FPH Number of compliments received 120 10 - 19 - 8 4 2 10 2 6 9 3 8 40

HWP Friends and family test - inpatient survey (based on responses for NNU)

97% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% >=90% <87%

HWP Number of complaints received 1 0 0 0 0 0 0 0 0 0 0 2 0 0 2 0

HWP Number of compliments received 69 9 8 6 8 10 8 10 12 15 15 11 21 15 99Compliments

Friends and family test - % who would recommend this trust to friends and family if they needed similar care or treatment

Complaints

Compliments

Caring


Complaints

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

33 of 201P

UB

LIC B


02/01/2018 Responsive - sites



FPHBabies <1501g or <32+0 weeks have ROP screen in accordance with current guideline

98% 100% 100% 100% 100% 100% 80% 100% 100% 100% 100% 100% 100% 100% 100% 100%

FPH Timely discharge <36 weeks 84% 100% 100% 100% 66% 100% 100% 100% 50% 75% 83% 100% 50% 100% 80% >=60% <50%

HWPBabies <1501g or <32+0 weeks have ROP screen in accordance with current guideline

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

HWP Timely discharge <36 weeks 50% 66% 25% 25% 100% 33% 53% 45% 50% >=60% <50%

Responsive

Responsive

Responsive

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

34 of 201P

UB

LIC B


02/01/2018 Well led - sites



FH Agency spend - Doctors £000s £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0

FH Agency spend - Nursing £000s £111,874 £1,836 £1,159 £1,159 £0 £0 £0 £4,491 £0 £0 £0 £0 £0 £4,284 £8,775

FH Agency spend - Other £000s £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0 £0

FH Agency spend - Total £000s £111,874 £1,836 £1,159 £1,159 £0 £0 £0 £4,491 £0 £0 £0 £0 £0 £4,284 £8,775

FH Agency spend as % of pay bill 3.3% 0.7% 0.4% 0.4% 0.0% 0.0% 0.0% 1.7% 0.0% 0.0% 0.0% 0.0% 0.0% 1.6% 1.1% <=8% >10%

FPH % of shifts staffed to Toolkit 72.6% 29.0% 54.0% 50.0% 80.0% 70.9% 15.0% 75.8% 83.8% 69.2% 43.5% national average

FPH % of shifts with Team Leader new 12.9% 9.6% 15.3% 14.5% national average

FPH % of shifts staffed QIS to Toolkit 75.8% 58.2% 57.0% 75.8% 78.3% 82.2% 66.7% 91.0% 95.1% 96.0% 69.3% national average

FPH Nursing staff qualified in Specialty (QIS)

63.0% 63.0% 65.5% 65.5% 68.0% 68.0% 68.0% 71.0% 71.0% 71.0% 71.0% 71.0% 71.0% 70%?

FPH Turnover rate % 15.0% 14.8% 14.8% 17.5% 17.7% 20.3% 19.5% 19.1% 16.9% 12.7% 10.3% 12.8% 12.7% <=14.5% >15.0%

FPH Staff sickness rates 3.5% 5.5% 5.7% 5.2% 5.2% 3.1% 3.0% 1.7% 1.6% 0.9% 2.9% 1.9% 3.4% <2.9% >3.2%

FPH Nursing vacancies - trained (WTE) 3.42 3.42 1.62 1.01 1.01 1.78 2.00 1.71 1.71

FPH Nursing vacancies - untrained (WTE) -0.74 0.42 0.42 0.42 0.42 0.42 0.16 1.16 1.77

FPH Nursing vacancy rates - trained 2.0% 2.0% 2.0% 2.0% 2.0% 2.0% 5.7% 5.7% 5.7% 3.7% 4.1% 4.1% 5.5%

FPH Nursing vacancy rates - untrained 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.9% 2.9% 0.0%

FPH Staff appraisal rate - medical staff % NEW 100% 100% 100% 100% 100% 96% 100% >=95% <85%

FPH Staff appraisal rate - non-medical staff %

NEW 79% 91% 89% 88% 88% 100% 96% >=80% <70%

FPH Nursing appraisals 91% 88.5% 95% 95% 95% 98% 95% 86% 97% 95% >=80% <70%

FPH Mandatory training completed (consultants) %

NEW 100% 100%

FPH Mandatory training completed (all staff) %

NEW 90% 90% 88% 88% 91% >=85.0% <60.0%

FPH NLS trained % NEW 100% 100% 100% 100%

FPH % of nurses compliant with children's safeguarding training (Level 3)

NEW 96% 100% 100% 100% 100%

FPH % recommending here as a place to work

available Q1, 2, 4 >=70%Q3 >= 66%

Q1, 2, 4 <62%Q3 <62%

FPH % recommending here as a place for care

quaterly Q1, 2, 4 >=86%Q3 >=76%

Q1, 2, 4 <79%Q3 <70%

* please note this measure is benchmarked against national average : RAG: >5% below amber >10% below Red. These figures change monthly and are benchmarked against Level 2 units only.

Nursing *

75%

93%

76%

95%

Training

Friends and family test for staff - FPH only not by directorate **

Well led

Turnover, sickness

Vacancies

Agency spend - neonatal

Appraisals

76%

94%

** Friends and family test (FFT) replaced by National Staff Survey in Q3; the question is worded slightly differently “If a friend or relative needed treatment, I would be happy with the standard of care provided by this organisation”. Note the target and threshold for Q3 is based on the National Staff Survey results; Q1, 2 and 4 are based on FFT results

71%**

84%**

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

35 of 201P

UB

LIC B





Well led

HWP % of shifts staffed to Toolkit 77% 53% 65% 50% 10% 29% 36% 21% 78% 32% 47% 30% 83% national average

HWP % of shifts with Team Leader 26% 31% 40% 31% 16% 24% 26% 27% 37% 21% 16% 7% 15% national average

HWP % of shifts staffed QIS to Toolkit 77% 60% 68% 79% 69% 87% 51% 58% 93% 35% 39% 80% 96% national average

HWP Nursing staff qualified in Specialty (QIS)

70% 70% 69% 72% 72% 72% 72% 72% 72% 69% 72% 72% 72% 70%?

HWP Turnover rate % 9.9% 10.0% 10.0% 12.0% 10% 10.0% 10.6% 10% <=14.5% >15.0%

HWP Staff sickness rates 7.6% 5.5% 4.1% 8.8% 8.6% 9.2% 2.9% 1.1% <2.9% >3.2%

HWP Nursing vacancies - trained (WTE) 1.06 1.22 0.38 0.38 0.69 0.38 2.38 6.09

HWP Nursing vacancies - untrained (WTE) 0.06 0.06 0.06 0.06 0.06 1.06 1.06 1.36

HWP Nursing vacancy rates - trained 5.3% 6.4% 6.9% 6.9% 4.4% 6.5% 15.1%

HWP Nursing vacancy rates - untrained -4.1% -4.1% -4.1% 9.6% 9.6% 15.3% 13.6%

HWP Staff appraisal rate - medical staff % 100% 94% 100% 100% 100% 100% >=95% <85%

HWP Staff appraisal rate - non-medical staff %

88% 88% 86% 75% 75% 78% >=80% <70%

HWP Nursing appraisals 94% 98% 87% 83% 80% 72% 79% 75% 77% 77% 75% 75% 75% >=80% <70%

HWP Mandatory training completed (consultants) %

100% 100% 100% 100% 100% 100% 100% 100% 80% 80% 100% 100% 100%

HWP Mandatory training completed (all staff) %

100% 100% 100% 100% 100% 100% 100% 100% 67% 74% 95% 91% 88% >=85.0% <60.0%

HWP NLS trained % 70% 76% 79% 80% 80% 70% 77% 77% 77% 71% 77% 79% 79% 100%

HWP % of nurses compliant with children's safeguarding training (Level 3)

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

HWP % recommending here as a place to work

available Q1, 2, 4 >=70%Q3 >= 66%

Q1, 2, 4 <62%Q3 <62%

HWP % recommending here as a place for care

quaterly Q1, 2, 4 >=86%Q3 >=76%

Q1, 2, 4 <79%Q3 <70%

Appraisals

Training

Friends and family test for staff - HWP only not by directorate **

Turnover, sickness

Vacancies

Nursing *

60%

67%

60%

75%

68%

80%

62%

79%

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

36 of 201P

UB

LIC B


02/01/2018 Efficiency


201610 201611 201612 201613 201614 201615 201616 201617 201618 201619 201620 201621 201622


FH Budget - directorate total (cumulative) £3,844,605 £2,247,975 £2,567,301 £2,886,627 £3,205,953 £3,525,279 £3,844,605 £316,535 £632,920 £949,326 £1,265,628 £1,581,946 £1,898,369 £2,214,668

FH Actual spend - directorate total (YTD) £3,774,724 £2,231,702 £2,545,996 £2,844,171 £3,148,486 £3,472,435 £3,774,724 £287,756 £596,546 £908,134 £1,199,397 £1,506,068 £1,805,184 £2,083,039

FH Variance - directorate total (YTD) -£69,881 -£16,273 -£21,305 -£42,456 -£57,467 -£52,844 -£69,881 -£28,780 -£36,375 -£41,192 -£66,230 -£75,878 -£93,185 -£131,629 <=0

FH Pay - budget (YTD) £3,448,853 £2,017,120 £2,303,466 £2,589,813 £2,876,160 £3,162,506 £3,448,853 £282,043 £564,086 £846,129 £1,128,171 £1,410,214 £1,692,257 £1,974,300

FH Pay - actual spend (YTD) £3,353,242 £1,998,337 £2,275,245 £2,539,320 £2,806,372 £3,086,849 £3,353,242 £261,512 £528,744 £803,161 £1,064,117 £1,335,441 £1,600,153 £1,853,039

FH Pay - spend variance - (YTD) -£95,611 -£18,783 -£28,221 -£50,493 -£69,788 -£75,657 -£95,611 -£20,531 -£35,341 -£42,968 -£64,054 -£74,773 -£92,104 -£121,261 <=0

FH CIPs plan (YTD) - Paeds Mat & Gynae £780,500 £426,000 £496,833 £567,750 £638,667 £709,583 £780,500 £851,416 £83,000 £165,466 £248,000 £331,000 £414,000 £496,000

FH CIPS actual (YTD) - Paeds Mat & Gynae £662,000 £363,000 £422,667 £482,666 £542,667 £602,333 £662,000 £723,667 £73,000 £163,483 £241,000 £331,000 £414,000 £496,000

FH CIPs variance (YTD) - Paeds Mat & Gynae -£118,500 -£63,000 -£74,167 -£85,084 -£96,000 -£107,250 -£118,500 -£127,749 -£10,000 -£1,983 -£7,000 £0 £0 £0 >=0

Efficiency

Finance Spend - neonatal specialty

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

37 of 201P

UB

LIC B


02/01/2018 Activity


201610


FPH Total number of Live births 5521 471 494 421 430 424 453 437 450 462 433 429 485 461 3157

FPH Unit closure (not accepting admissions) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

FPH Community - New referrals New 13.0 10.0 13.0 9.0 45FPH Home visits New 15 41 42 35 32 165

FPH Intensive care cot occupancy 44% 42% 31% 34% 13% 42% 23% 42% 53% 27% 2% 25% 50%FPH High Dependency cot occupancy 24% 35% 30% 55% 51% 36% 35% 38% 57% 37% 31% 22% 53%FPH Special Care cot occupancy 85% 118% 95% 123% 98% 114% 58% 85% 136% 114% 102% 139% 108%FPH Total cot occupancy (16 cots) 57% 76% 62% 91% 71% 76% 66% 62% 96% 74% 64% 81% 80% <=80%

FPH Total Admissions 592 46 65 55 43 50 49 34 60 60 40 45 47 54 340FPH Labour ward 253 26 29 29 24 34 35 13 26 45 26 21 18 28 177FPH Mulberry Birth centre 4 0 1 0 1 0 0 0 0 0 1 1 0 3 5FPH Post natal ward 118 11 17 13 12 5 10 13 23 7 5 14 16 10 88FPH Transitional care 38 1 8 2 3 3 2 0 5 4 3 0 3 2 17FPH Transfers from another unit 27 1 2 5 2 4 1 5 3 4 4 3 4 7 30FPH Intensive care cot days New 15 31 46FPH High Dependency cot days New 39 99 138FPH Special Care cot days New 335 269 604FPH Home 41 5 7 6 1 4 1 3 3 0 1 6 7 4 24

FPH Ex-utero medical transfers outside network 1 0 0 0 0 0 1 0 0 1 0 0 1 0 2

FPHNumber of babies transferred out less than 27/40 gestation

2 0 2 0 0 0 0 2 2 0 1 0 0 0 5

FPHNumber of babies transferred out more than 27/40 gestation

23 2 0 6 1 1 4 0 2 5 2 0 3 4 16

FPH Surgical transfers 13 1 3 0 0 0 2 1 1 0 0 0 0 1 3FPH Cardiac transfers 5 0 1 1 0 0 2 0 0 1 1 0 0 0 2FPH Discharge home 119 12 13 13 15 15 10 3 11 10 17 16 13 17 87FPH Discharge to Social care 4 0 1 1 0 0 0 0 0 0 0 1 1 1 3FPH Discharge to Post natal Ward 91 18 14 5 1 2 10 11 9 6 2 8 13 4 53FPH Discharge to Transitional care 227 18 26 22 26 23 20 16 30 30 20 23 23 23 165

HWP Total number of Live births 4399 378 349 361 317 322 361 348 371 359 395 344 370 363 2550

HWP Unit closure (not accepting admissions) 0 0 0 0 0 0 0 0 0 0

HWP Community - New referrals 150 19 13 8 12 17 10 9 10 14 4 15 20 12 84HWP Home visits 1099 105 91 62 74 91 87 92 76 77 65 114 75 81 580

HWP Intensive care cot occupancy 55% 32% 40% 64% 40% 47% 82% 23% 95% 60% 28% 5%HWP High Dependency cot occupancy 91% 73% 67% 71% 80% 116% 82% 59% 98% 95% 76% 49%HWP Special Care cot occupancy 69% 59% 92% 117% 101% 63% 99% 79% 64% 63% 113% 59%HWP Total cot occupancy (21 cots) 78% 72% 58% 84% 105% 92% 69% 95% 71% 72% 67% 100% 52% <=80%

HWP Total Admissions 497 43 44 40 58 41 41 40 37 33 44 38 48 34 274HWP Labour ward 294 23 25 23 33 21 23 29 29 12 25 21 30 13 159HWP ISIS Birth Centre 5 3 0 0 0 0 0 0 0 0 0 0 0 0 0HWP Post natal ward 73 7 3 9 8 7 5 4 2 5 11 8 10 11 51HWP Transitional care n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0HWP Transfers from another unit 65 8 7 6 12 7 8 4 3 4 5 6 0 5 27HWP Intensive care cot days 358 14 33 20 25 36 25 28 51 14 59 37 17 3 209HWP High Dependency cot days 1002 101 82 68 62 59 74 104 76 53 91 88 68 46 526HWP Special Care cot days 5055 392 331 291 457 524 502 303 490 380 319 311 544 291 2638HWP Home New 7 4 11

HWP Ex-utero medical transfers outside network 8 0 1 0 4 0 2 0 0 0 0 2 1 0 3

HWP Number of babies transferred out less than 27/40 gestation

8 2 1 0 1 1 0 0 1 0 2 0 0 1 4

HWP Number of babies transferred out more than 27/40 gestation

2 0 1 4 5 2 1 1 14

HWP Surgical transfers 20 2 1 4 2 0 1 2 0 0 1 1 1 1 6HWP Cardiac transfers 8 2 2 2 0 0 0 1 0 0 3 0 0 0 4HWP Discharge home 303 30 29 21 27 22 28 21 21 37 23 18 31 20 171HWP Discharge to Social care 7 0 1 0 1 0 0 0 0 1 0 1 0 0 2HWP Discharge to Post natal Ward 126 14 8 9 13 9 11 16 14 10 14 10 23 10 97HWP Discharge to Transitional care n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 0

Activity

Activity

Admissions

Transfers and Discharges

Cot occupancy

Activity

Admissions

Transfers and Discharges

Cot occupancy

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

38 of 201P

UB

LIC B


1

Ward to Board Paediatric Services Apr 2017– Nov 2017

Frimley Health

Background Location of Service: The paediatric inpatient services are supported on both Frimley Park and Wexham Park sites. Both wards support high dependency, medical and surgical patients. The surgical patients on the Wexham site are cared for within a designated day surgery unit, whereas the Frimley patients are nursed within the Children’s Unit. Paediatric Assessment Units cross site support beds and cubicle facilities. Both units support Paediatric Oncology Shared Care Units (POSCU) Frimley is currently Level 1 and Wexham Level 2. Paediatric Outpatient departments and services are available on both sites alongside satellite clinics which are staffed by Frimley Health. Current redesign, service improvement initiatives and successes: Frimley:

• The ward has undergone a refurbishment which has improved facilities for both patients and families. The official opening of the new build by Sir Andrew Morris, helped by an oncology patient and was held in July 2017. This gave us the opportunity to invite and thank charities who have supported the ward refurbishments.

• A new teenage unit and purpose built oncology cubicles offering a much improved environment with larger rooms and en-suite facilities. A designated complex needs cubicle is in place.

• A New Paediatric assessment unit with cubicle facilities and a new treatment room and a designated waiting area. An infant resuscitaire has been purchased. There has been an uplift from 5 to 8 beds for GP referrals.

• A lead consultant for PAU is now in post to support the expansion and drive the service forward. Review clinics are now held weekly.

• The existing part of the ward has been redecorated to compliment the new build and supporting ‘under the sea’ theme and colours. This has also included new signs throughout the unit which improving signposting.

• New CAMHS service Monday to Friday supporting Berkshire patents. • Appointment of 2 Band 7 Specialist Mental Health nurses, based on ED and

the ward. • Evening teenage clinics commenced and well attended.

Wexham:

• There have been major clinic and ward refurbishments with much brighter and lighter environments, increased number of consulting rooms along with improved facilities for children including a separate teenage waiting area in Clinic, a designated triage room in PAU, 2 bedded older children/teenage bay and a new sensory room.

5



2

• Commissioning of a new 5 bedded HDU (PCCU) providing much improved

patient environment - more spacious, brighter and improved parent facilities • Transition into Adult Services with the first teenage outpatient week planned

during half term school holidays and some evening cardiac transition clinics • Improved access to mental health practitioners who review children and

young people in ED and the ward 7 days a week who refer to CAMHS Consultant when indicated.

• Presentation at RCPCH May 2017 re telephone access for GP s won 1st prize. • Poster at RCPCH Meeting and publication in Archives of Diseases in Children

re: Time of Intravenous antibiotics to children with suspected sepsis and neutropenia following introduction of PGD.

• Paediatric Dept awarded Training Dept of the year by Oxford Deanery • Paediatric Asthma Nursing service won the Nursing Times Respiratory Award

in Nov 2017.

Cross site: Plans to implement cross site ordering of supplies in order to improve efficiency of resources.

Areas where service is facing significant challenges in ensuring the quality of care and patient safety cross site: Staffing the middle grade doctor rota due to maternity leave, sickness and a reduction in hours; recruitment of experienced children trained nurses; access to face to face Local out of Hours CAMHS and engagement with Local Authorities in complex cases.

Themes and trends from Patient Experience 2017 There are a number of patient/parent feedback surveys that take place in paediatrics. These include the Picker Friends and Family, patient experience tracker and local peer review. National Children and Young People’s survey November 2016. Feedback comments are very positive and full of praise for staff and the care that has been received on both sites. Unit Friends and Family

Scores Frimley Park 97-100% Wexham Park 92- 100%

Comments include: Frimley: ‘Loving and caring staff’, ‘very professional’. Patient experience feedback on social media: ‘Nurses were lovely and sensitive to my child’s needs’ Patient experience tracker results good. Few comments surrounding noise at night when multiple admissions to ward, and delay in discharges with medications. Improvements made as a result of feedback include: New quiet room which supports a more appropriate environment to support patients and families. This is very effective at night. This room is also utilised as a breast feeding room for visitors. Replaced parent chairs with new wider

5



3

bed chairs with appropriate fabric as feedback suggested current day beds uncomfortable and too small. Wexham: Feedback from “well known” parents – it’s great to have a room nearby to “get some rest” “extremely helpful, caring and kind staff” “ Go beyond the call of duty”. Bedside Patient Experience Tracker: Comments include everything was very smooth, felt like my daughter was in safe hands. 100% of those surveyed have confidence in doctors. Pants and tops are handed to children and young people for their feedback which is then displayed on a washing line along with “You said We Did “actions. Frimley Health: CYP Inpatient and Day Surgery survey results from Nov 2016 published Nov 2017 : 0 in top 20%, 1 in bottom 20% and all other responses same as when compared to all other Trusts that participated. Action:

• Improve the information provided to children about what to expect on discharge from hospital.

• Senior Matron to visit Stoke Mandeville who were in top 20% for information re : discharge

• Play staff to devise generic info leaflet/booklet and to contact Well Monkey’s Helen – re : going home from hospital booklet

Challenges and solutions

• Response rates for friends and family cross site still fluctuate. Frimley installed Friends and Family kiosk however due IT issues this has been returned to manufacturers.

• Use of voluntary workers and administrative staff in distributing handouts.

• With average length of stay 1.2 days it can be a challenge to engage patients/parents to complete.

Formal Complaints Frimley: 4 Formal complaints have included parent not aware of reduced parking and meal vouchers. Parental anxiety due to concerns with communication. Communication and medication administration. Limited access to pre-operative care information. In response to information provided to ensure all staff involved with care communicate effectively and ensure parents are kept up to date and offered parents facilities on the ward. Posters have been displayed throughout the ward regarding car parking and meal vouchers. Ensure all medications are explained on discharge to parents and documented. A New F1 ward information leaflets available on the ward and in the new year we are recording a new pre-operative video which will be available on line via

5



4

the Trust web site. The play team are involved in the making of this. Wexham: 2 Formal complaints – one included lack of follow up from a specimen taken, out of date equipment being used and differing advice from doctors and nurse – closed with CEO letter and second is a complex case involving safeguarding processes with a local resolution meeting planned for Jan 2018.

Patient Safety The paediatric department has monthly clinical governance meetings where incidents and complaints are presented. There are also cross site CG meetings held 6 monthly with a plan to have a 6 monthly cross site M&M meeting. On the Wexham site a Paediatric quality and safety meeting is held 6 monthly with representation from Paeds, general surgery, urology, plastics, ENT, orthopaedics, anaesthetics, ED and radiology. Cross site risk registers are completed monthly along with dashboards and presented at clinical governance. Thames Valley and Wessex Critical care network meetings are attended by lead consultant and senior nurses. Infection control: see report Frimley: Total number of incidents reported April- Nov 2017 =101. SI= 0 Moderate= 0 Low = 20 No harm =81 There have been no Paediatric SI’s reported or incidents triggering Duty of Candour. The department has a robust incident reporting procedure for both nursing and medical staff. Medication errors total =25 none with harm. The matron or senior sister will discuss medication errors with staff members and a written reflection is completed and shared with the practice development lead. Any learning is disseminated to staff. Medication errors have been prescription errors alongside missed doses. Prescription errors have been fed back to the consultants. In some cases the staff member will retake the medicines management policy. Increased number of incidents involving potential and actual injury to staff. These are CAMHS related incidents. Engaged with staff to report any CAMHS related incidents as F1 utilised as a place of Safety. An SI was called by Surrey CCG surrounding the delayed discharge and funding of a CAMHS patient. This was attended by the paediatric safeguarding lead and the paediatric matron. Wexham: Total number of incidents reported April 2017- Nov 2017 = 115. SI = 0 Moderate =2 Low= 33 No harm = 80

5



5

2 moderates –learning – implications for follow up re- immunisation after BMT and the other awaits round table discussion, facilitated by patient safety team. Medication errors : 33 which is equivalent to 28.6 % Learning from errors is shared with nursing colleagues with support from PDN and errors are displayed against a number (only known to the individual and PDN/Consultant lead for CG and ward pharmacist) in staff room and seminar room – to encourage individual responsibility. The ward pharmacist also holds a weekly “druggle” where incidents and learning is shared.

To note : Learning from inquest April 2017 case of child who died in Dec 2012 no further recommendations made by the coroner as all actions had been implemented, embedded and had evolved since the writing of the report and action plan. Learning from SIs and RCAs Paediatric Consultants instigated and participated in a RCA and action planning for a child who died from a rare but serious condition (viral myocarditis): Learning: Improve documentation by nominating a scribe, Always involve the Adult Critical Care Consultant, Repeat a Blood Gas early to ascertain the response to treatment. This case has been used for learning – both in Paediatrics and Anaesthetics. Paediatric Consultants supported an SI in ED for a child who died from sepsis: Learning – implement Trust sepsis screening tool based on new NICE guidance and re-attendance to Paeds ED with same complaint to be seen by a senior doctor. Measure Frimley Park Wexham Park Sepsis screening 80% 100% Seen by a doctor within 2 hours

93% 100%

Seen by middle grade within 4 hours

88% 100%

Seen by consultant within 14 hours of decision to admit.

100% 100%

Successes: Cross site: Trust Paediatric Sepsis Screening and Interventions pathway implemented in Jan 2017 based on new NICE guidance. Implementation of cross site PEWS charts. VIP compliance remains a focus with improvements since introduction of new paediatric care bundles: insertion dates written on the documentation and visible at the cannula site. Part of shift safety briefing for ward areas currently. All senior staff have attended the local nurse in charge programme and have

5



6

adapted the nursing handover using safety briefings at beginning of shifts. The nursing staff also attend the x3 daily consultant- led medical handovers. Frimley: Mini sepsis audit carried out monthly by matron supported by lead consultant. Process being reviewed. Statistics on dashboard last 3 months only. Improving but still only 80%. PEWS audit 3 months currently data being collected and monthly ward sepsis data to aid application. New network age appropriate PEWS charts have been implemented

• Hand hygiene audits 100% • The safety thermometer results are 100% harm free care. • APLS – 13 trained of 14=93% trained 1 to be booked onto Frimley next

APLS in March/April 2018. Band 6 to undertake APLS instructors course in January 2018.

• PILS -7 needing update of 13= 54 % trained – the rest booked onto training-2 per course throughout 2018 raised this concern with Resus team. Unable to offer more training.

• PBLS F1 -28 trained of-43=66% % all others booked onto training Jan/Feb.

• OPD -85 % all others booked onto training. • PREVENT : F1 96% • Safeguarding Adults Level 2 –F1 -- 90% OPD 100% • Safeguarding Children level 3 F1 27 of 29=93%- OPD -- 85%

Wexham:

- New sepsis screening/pathway - Mini- audits in Feb 2017, 1 month after implementation showed 94% (17/18) which was repeated in Nov 2017 100% (14/14) compliance rate for completion of the pro-forma, with 100% compliance of completion of the sepsis screening box on the front sheet during both mini- audits. This mini- audit is conducted each month by the Senior Matron. In response to the increase in children triggering the sepsis pathway and being started on IVABs we have increased the days of the MDU is open to 5 days a week and CCNs cover 1200-1400 on Sat and Sun for ambulating IVs.

• Hand Hygiene audits conducted by IPCT ranges from 85-100 % through the year across Paediatrics

• Paeds BLS L2 2 90% (PDN facilitating local sessions to improve compliance in last 2 months), PILS/L3 = 62% with remaining 11 staff booked on SDs between Jan and Oct 2018, APLS Nursing staff = 100% with 2 APLS Instructors and 1 EPLS Instructor.

• WPH Safeguarding Children - compliance - L1 = 91%, L2 71% and L3 76% concerted and focussed effort by the safeguarding team.

• Locally Paeds – Safeguarding Adults L2 = 76%, Safeguarding Children L2 = 90%, Safeguarding Children L3 = 75%, Prevent basic awareness = 85% and Prevent WRAP = 77%

Challenges and solution Need for additional training in supporting CAMHS patient care. Berkshire CAMHS have supported training for staff in study days on Psychological Perspectives in education and primary care (PPEP). These

5



7

have been on the Wexham site and Frimley have attended. No paediatric outreach nurse in post currently at Frimley to support ambulatory cases which have significantly increased. Staff have been upskilled in outpatients. Appointed to outreach post in December 2018 and adjusted job description to reflect ambulatory care

Themes and trends from Quality On a monthly basis a summary of both quality dashboards are presented at the Trust’s Quality Committee with a focus each month on one specialty. The summaries are presented at monthly Paeds Clinical Governance meetings. Successes Frimley:

• CQUIN: Electronic discharge letters to GP’s within 24 hours, last quarter 88% (target 83%). This showed a vast improvement from July 2016 where it was 0%

• Commenced HDU data collection in October which requires further developments to implement data collection electronically. Working with critical care network on this.

• The oncology team febrile neutropenia audit 75% meeting national guidelines.

• Commencing E prescribing utilising Aria system for oncology patient chemotherapy prescribing.

Wexham:

- Working with TV & Wessex paediatric intensive care network – submitting dashboard and HDU data electronically.

- This is the second year of the joint Slough CCG and WPH paediatric asthma service – led by two CNS working with GPs and Paediatric Consultant leads and supported by an administrator. Fantastic feedback from the “asthma bus” which toured Slough secondary schools last Sept and again this September providing lots of education and practical suggestions to local young people with asthma.

This innovation has been adopted by the CYP Urgent Care Board which covers Bucks and E Berks with a plan to fund on a regular basis and visit secondary schools in all their areas with sharing of resources. Notable reduction in re- attendances of children with asthma however there are still increasing numbers of children being admitted with wheeze/asthma. This also won the Nursing Times award in the respiratory category in Oct 2017 and the team attended the awards evening at the Grosvenor hotel in London. Challenges and Solutions Implementing Transition pathways and clinics : Plan to establish the Ready, Steady, Go and Hello programme for young people into adult services – Paediatric Consultant on FP site is leading with Matron and Senior Sister from Clinics cross site. Planning teenage clinics in May half term – with CNS,

5



8

psychologist, dietician, paediatric liaison heath visitor, young minds or equivalent and careers advisors present; await confirmation from Trust physicians list of Consultants who will act as lead for medical conditions. Establishing mental health pathways and ensuring staff feel confident when looking after young people requiring early and ongoing help/support – Continue closer working with CAMHS consultants and paeds – monthly meetings, training of staff – 3 Study Days in April, May and November 2017 led by PEPP facilitators – Paeds ED, ward, nursery nurses and doctors among attendees and repeated in Nov 2017 – Feb 2018. We have seen a decrease in the use of agency RMNs since this training was implemented. Implemented risk assessment tools as per current Trust Policy and working with Emergency department to ensure safe care application following assessment. No central booking system for day surgery patients on Frimley site.

Staffing overview A comprehensive workforce planning meeting was held within the paediatric directorate in November 2017 with an action plan. The purpose of this was to ensure service continuity by planning to implement non-medical roles and other mechanisms to address the challenges with the sustainability of the junior doctors’ workforce over the next 3 to 5 years. Along with looking at the number of ST4 trainees and placements the panel looked at ‘grow your own’ trainee nurse practitioners to support the medical rota and doctor’s assistants to support the administrative side. Frimley:

• Vacancies on ward: Band 5 x 2wte. Band 2 x 1wte . Band 4 x 3.6 wte awaiting appointment.

• Vacancies in OPD: band 2 x1 wte. Successful recruitment throughout the year.

• Agency spend has fluctuated due to supporting CAMHS patients who have required long term support.

• Safe staffing data completed monthly. Twice yearly staffing acuity tool completed. Implanting training of use of equity tool via ‘Real Time’.

• Band 4 nursery nurses x 2 to have commenced nursing associate training.

• Appraisals: 88% completed. Wexham : • Vacancies on ward 24 = 6.24 wte or 16% for B6 and 5s currently. • However 4.00 B6 currently on mat leave and a further 2.00 leaving the

Trust in Jan 2018. • All adverts contain possibility of rotational posts between Paeds and

NNU locally and a plan to amend job descriptions to say explicitly when acuity is high on either site there will be an expectation that staff will

5



9

move between. • We are fully involved in the Trust’s recruitment initiatives and the

recently formed operational workforce group which will be focusing on recruitment and retention (welcome) and internationally educated nurses. 5.00 wte have started in last few months and a further 3 arriving by Feb 2018.

• Ward 24 appraisal rates improved from 45- 65 % in last 2 months • Medical staffing– no vacancies in substantive posts - with 13

Consultants, 1 Locum Consultant and 5 Specialty doctors. Vacancies at middle grade level.

Successes Frimley: Registered day shift Fill rate = Average 92% and night shift 88% 100% compliance with a minimum of 2 paediatric nurses on every shift.

• Appointed Band 7 x1 wte Senior Sister from London teaching hospital and Band 6 x1 wte paediatric outreach nurse from internal promotion.

• Appointed Band 5 x 4 wte newly qualified staff nurses who have commenced our robust paediatric preceptor ship programme which is supported cross site from October.

• We have appointed and supporting 1 x wte overseas nurse currently working as a Band 4 and supporting OSCE application.

• Clinical Educator Band 6 x 1 0.8 wte in post for one year supporting both paediatric students and also paramedic and adult student nurses who require to complete paediatric clinical placement.

• Band 4 nursery nurses x 2 to have commenced nursing associate training.

• Available training post for advanced nurse practitioner cascaded to staff. Internal applicant withdrawn.

Wexham: Registered day shift Fill rate = Average 95% and night shift 94%

• Safeguarding children team now fully established with Lead Named Nurse appointed in in April 2017 and a specialist nurse who started in Nov 2017.

• Notable success of the preceptorship programme attracting staff. A number of students and recently qualified staff have selected WPH rather than other paediatric DGHs when they know they will be on the programme which includes Acute Care Skills Days and simulation.

• Retention of some senior band 5 staff nurses who have applied for the band 6 in training posts – implemented to support staff through the transition to a senior level. We now have 5 who have successfully completed and are full B6s and a further 1 has just started mat leave. Focus on experienced B5s working through their nurse in charge competencies.

• “Grow our own” - 1 clinical support worker has completed her children’s nursing training and is working as a staff nurse on War 24 with a further 2 nursery nurses being seconded to their children’s nurse training, one will qualify Aug 2018 and Feb 2019 respectively.

5



10

• We also have started the TAP – Trainee Associate Practitioners 5.00 across Paeds and Neonates and are looking at Nursing Apprenticeships and Nursing Associate pathways.

When staff shortages the ward and NNU work well together in supporting each other. Challenges:

• A challenge has been identified around the time from recruitment to stating dates due to awaiting references and DBS clearance.

• Review and strengthen clinical leadership with a secondment opportunity for additional B7 - internal candidates – interviews in Dec 2017

• Reducing vacancy rate - continue to be involved in Trust’s recruitment initiatives - currently awaiting 3.00 wte from Philippines – no confirmed start date.

• “Grow our own” – due to changes in funding and bursaries will continue to support secondments and also plan to offer Higher Apprenticeships to our B2 and B4 - with support from PDNs and mentors will complete 2 years and reach level to complete final year of children’s nurse training. Once approved with UWL encourage our staff to apply, hopefully May 2017 with a study day a week and practical working on the Ward/PAU.

• Retention - Working with HEI to develop conversion course equivalent for adult nurses to children’s nurses.

5



02/01/2018 Summary

5. Copy of M09 - FHFT - Paediatrics - Oct 17 (2) Page 1 of 18

RAG keySpecialty:Quality committee month:Data month: Oct 2016 - Oct 2017Chief of service: Louise Wright (FPH); J Aspel / J Philpot (HWP)Presented by: Jennifer Lomas (FPH site); J Philpot (HWP)

Performance Change Performance Change Performance ChangePICU retrievals 4 watching trends 4 watching trends Time critical transfers 0 watching trends 0 watching trends Transfers out to another Hospital 7 watching trends 9 watching trends Unexpected deaths 0 ↔ 0 ↔Serious incidents requiring investigation (SIRIs)

0 ↔ 0 ↔

Incidents triggering a duty of candour response

0 ↔ 0 ↔

Number of medication incident reports

2 ↓ 4 ↑

Friends and family test - % positive responses recommending here as a place for care – Inpatients

100% (Oct) ↑ 95% (Oct) ↑

Domain

Safe

Effective

Caring

Responsive

Well Led

Frimley Park Hospital Heatherwood & Wexham Park Hospitals

Key measures Frimley Park Hospital Heatherwood & Wexham Park HospitalsFrimley Health NHS FT

Key messages

↔ - no change

↓ or ↑ - improving performance↓ or ↑ - worsening performance

Specialty dashboard - summaryAchieving targetBetween target and threshold (where applic)Worse than target or threshold (where applic)

PaediatricsDecember 2017

ActivitySignificant increase in workload in PAU. Number of ambulatory antibiotics supported in PAU increased due to reduce capacity in community. To utilise OPD to support ambulatory service.

Increase in number and length of stay for CAMHS patients and their complexity - additional workload for ward and safeguarding staff

Reduction in the DNA rate

Increased incident reporting no change in severity, however increase in medication errors both prescrption and adminsitration; work underway with both doctors and nurses to learn from errors for all

100% compliance with PEWS and interventions. Sepsis screening remains at 100%

One formal complaint - await final letter from complaints dept. Expecting improved response rate from FFT with a dedicated person handing the forms out during weekdays.FFT performance ward 92%, HWD clinic 97% and WP clinic 98%

Sustained 100% compliance with children being seen within 2 (any doctor) and 4 hrs (senior doctor) of attendance to PAU. 96% compliance with all admitted children being sb consultant within 14 hrs of admission.

Nursing vacancy rate slight decrease - 2 overseas nurse successfully completed OSCE and now registered with NMC. All new starters completed supernumerary practice, however 2.00 B6 leaving in Jan 2018.

An increase in Datix reported but only included 2 medication incidents and no harm to patient occurred. Hand hygiene audit increased. Safe staffing identified as reduced trained staff on night shift and untrained on the day. Obtained Sepsis numbers triggering but still requiring accurate data and application.

No unexpected deaths. Pews Compliance application continues at 90% but requires improvement with documentation of interventions. There is an improvement with nursing documentation but patients details required both side of notes due to EDMS and scanning of notes. Pain management can identify compliance with documentation of scoring but further interaction documentation required.

Friends and Family 100% recommendation with improved response rate but only 2 complaints received.

Reduction in the application of the Medical admission seen by mid grade within 4 hrs., however 100% maintained by consultants reviews undertaken by 14hrs.

Staff vacancies reduced with band 5 recruited preceptors in post and band 4 advert out. Staff sickness rate has reduced. Require additional PILS & ALS study days to support service needs.

Efficiency

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

49 of 201P

UB

LIC B


02/01/2018 Safe - sites


Site FY 15/16 FY 16/17 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD Target Threshold

FPH Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

FPHNumber of Serious incidents requiring investigation (SIRI)

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 >1

FPH Number of incident reports - 9 9 16 7 11 9 15 9 15 20 8 25 101

FPHNumber of incidents triggering a duty of candour

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

FPHNo. of medication errors resulting in severe harm

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 >1

FPHMedication errors reaching the patient (MERP)

1 0 0 0 0 1 0 5 3 0 0 0 2 10

FPH Cardiac arrests 0 0 0 0 0 0 0 2 0 0 0 0 0 2FPH Crash calls 0 0 0 2 0 0 0 2 0 1 0 0 0 3

FPH MRSA Bacteraemia 0 0 0 0 0 0 0 0 0 0 0 0 0 0FPH C difficile cases - attributable to trust 0 0 0 0 0 0 0 0 0 0 0 0 0 0FPH Hand Hygiene 100% 100% 100% 100% 100% 100% 100% 100% 80% 100% 100% 98% 96%

FPHAntimicrobial prescribing -Documentation of indication on drug chart *

FPHAntimicrobial prescribing - Compliance with treatment guidelines **

FPH Registered nurse day NEW NEW 90% 88% 85% 85% 90% 89% 80% 92% 86% 106% 91% 93% 93% 92% >=90% noneFPH Unregistered care staff day NEW NEW 115% 143% 135% 89% 84% 92% 88% 90% 89% 111% 111% 108% 82% 97% >=90% noneFPH Registered nurse night NEW NEW 94% 85% 86% 91% 98% 85% 75% 86% 82% 109% 91% 92% 80% 88% >=90% noneFPH Unregistered care staff night NEW NEW 130% 140% 152% 88% 86% 78% 78% 73% 75% 120% 163% 141% 108% 109% >=90% none

FPH % compliance of sepsis screening NEW No data 75% 60% 80% 80% >=90% none

FPHTotal number of patients triggering sepsis screening

NEW No data No data No data No data 98

FPH Total % Electronic discharges from F1 NEW No data No data No dataFPH Total % Electronic discharges from PAU NEW No data No data

Compliance with Sepsis Care

Discharge communication

Safe staffing - hours filled as planned - specialty

Safe

100%

Incident reporting - Paediatrics

Infection control - Paediatrics

100%

100% 100% 88%

100%

Available quarterly

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

50 of 201P

UB

LIC B


02/01/2018 Safe - sites



Safe

HWP Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

HWPNumber of Serious incidents requiring investigation (SIRI)

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 >1

HWP Number of incident reports 11 27 18 14 30 15 12 18 15 9 7 15 17 93

HWPNumber of incidents triggering a duty of candour

0 0 0 0 0 1 0 0 0 0 0 0 0 0

HWPNo. of medication errors resulting in severe harm

0 0 0 0 0 0 0 0 0 0 >1

HWPMedication errors reaching the patient (MERP)

1 0 0 3 1 2 1 4 11

HWP Cardiac arrests 0 0 0 0HWP Crash calls 0 1 0 1

HWP MRSA Bacteraemia 0 0 0 0 0 0 0HWP C difficile cases - attributable to trust 0 0 0 0 0 0 0HWP Hand Hygiene 100% 95-100% 100% 95% 100% 95% 85% 90% 95% 100% 95% 100% 95%

HWPAntimicrobial prescribing -Documentation of indication on drug chart *

HWPAntimicrobial prescribing - Compliance with treatment guidelines **

HWP Registered nurse day NEW NEW 97% 100% 94% 95% 95% 98% 96% 97% 92% 83% 92% 92% 94% 92% >=90% noneHWP Unregistered care staff day NEW NEW 82% 92% 86% 95% 88% 88% 85% 88% 90% 79% 73% 86% 100% 86% >=90% noneHWP Registered nurse night NEW NEW 94% 99% 93% 99% 96% 96% 100% 96% 91% 88% 91% 94% 95% 94% >=90% noneHWP Unregistered care staff night NEW NEW 83% 91% 86% 89% 89% 79% 100% 75% 70% 94% 75% 77% 81% 82% >=90% none

HWP % compliance of sepsis screening 100% 95% 80% 93% 94% 96% 86% 73% 91% 100% 100% 100% 100% >=90% none

HWPTotal number of patients triggering sepsis screening

1 9 2 17 761 of

sample set2 of

sample set

HWPTotal % Electronic discharges from Ward 24 (M,S,H)

87% 90% 88% 95% 98% 98% 88% 90% 91% 91% 85% 95% 96%

HWP Total % Electronic discharges from PAU 79% 71% 81% 82% 89% 83% 84% 84% 84% 82% 85% 86% 88%Note * previously known as 'Antimicrobial prescribing - Indications specified on chart'

** previously known as 'Antimicrobial prescribing - Does this treatment meet the care bundle requirements'

Available quarterly

Incident reporting - Paediatrics

Infection control - Paediatrics

86%

Discharge communication

Compliance with Sepsis Care

Safe staffing - hours filled as planned - specialty

100%

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

51 of 201P

UB

LIC B


02/01/2018 Effective - M and M -sites



FPH Number of unexpected deaths 3 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0FPH Number of expected deaths 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

HWP Number of unexpected deaths 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0HWP Number of expected deaths 1 2 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

Effective - Mortality

Mortality - specialty

Mortality - specialty

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

52 of 201P

UB

LIC B




201610 2 3 4 5 6 7 8 9 10 11 12 13


FHNumber of emergency to emergency readmissions

45 43 60 35 31 40 45 53 34 41 31 39 In arrears 243

FHReadmission rate following emergency discharge - Paediatrics

5.8% 5.1% 7.7% 5.0% 5.4% 5.0% 7.5% 6.8% 5.5% 6.7% 6.2% 5.5% In arrears 6.4%UQ <=9.7%

Med <=10.5%LQ >11.1%

FPHCompliance with documentation of initial PEWS (%)

100% 80% 100% 100% 100% 100% 100% 100% 100% 100% 90% 90% 90% 100% =<95%

FPHCompliance with documentation of PEWS interventions (%)

100% 80% 100% 100% 100% 60% 100% 90% 100% 100% 90% 90% 40% 100% =<95%

FPH% compliance with nursing documentation audit

No data No data No data 25% 40% 60% 80%

FPH % compliance with nameband audit 100% 100% 90% 100% 70% no data 90%

FPHDeliberate self harm - Review by CAMHS within 24 hours of admission and fit for discharge

100% 100% 100% 95% 95% 95% 95% 72% 95% no data no data no data no data 100% =<95%

FPH % pain management compliance 100% 100% 100% 100% 100% 80% 100% 60% 90% no data no data 80% 60% 100% =<95%

FPH Departmental (internal) 1 0 0 0 N/A 3 4 2 4 0 1 1FPH National (external) 0 0 0 0 N/A 1 1 0 2 0 0 1

FPHNumber of emergency to emergency readmissions

5 3 4 2 4 2 3 5 4 10 3 4 In arrears 29

FPHReadmission rate following emergency discharge - Paediatrics

4.7% 4.8% 5.3% 3.0% 7.1% 2.2% 4.6% 5.3% 4.9% 9.4% 5.2% 4.1% In arrears 5.8%UQ <=7.3%

Med <=7.9%LQ >8.6%

FPHMedical emergency readmissions following an elective or emergency admission

New no data no data <=5.5% >7.5%

FPHAll emergency readmissions following an elective or emergency admission

New no data no data <=5.5% >7.7%

CQC 30 day Readmission Rates



PEWS compliance

Audits

Readmission Rates - local calculation

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

53 of 201P

UB

LIC B




201610 2 3 4 5 6 7 8 9 10 11 12 13



HWP Compliance with documentation of initial PEWS (%)

99% 98% 100% 100% 94% 100% 100% 91% 100% 100% 100% 100% 100% 100% =<95%

HWP Compliance with documentation of PEWS interventions (%)

93% 93% 100% 71% 100% 89% 100% 100% 58% 100% 100% 100% 100% 100% =<95%

HWP % compliance with nursing documentation audit

100% 100% 89% 100% 90% 96% 100% 98% 100% 86% 99% 100% 100%

HWP % compliance with nameband audit 90% 90% 100% 100% 100% 100% 97% 100% 100% 80% 80% 100% 100%

HWPDeliberate self harm - Review by CAMHS within 24 hours of admission and fit for discharge

NEW no data no data no data no data no data 2 100% =<95%

HWP % pain management compliance 100% 100% 100% 100% 85% 90% 100% 100% 100% 90% 80% 100% 100% 100% =<95%

HWP Departmental (internal) 11 MINI 6 MINI 8 MINI 14 + 1 review 19 (inc. 27 MINI 4 MINI 4 MINI 10 MINI 19 MIMI 10 MINI 10 MINI In arrears

HWP National (external) 0 0CA786 paed pneumonia

BTS0 0 0 0 0 0 In arrears

HWPNumber of emergency to emergency readmissions

40 40 56 33 27 38 42 48 30 31 28 35 In arrears 214

HWPEmergency readmission rate following emergency discharge

5.9% 5.2% 8.0% 5.2% 5.2% 5.4% 7.9% 7.0% 5.6% 6.1% 6.4% 5.7% In arrears 6.5%UQ <=9.3%

Med <=10.3%LQ >11.2%

HWP Medical emergency readmissions following an elective or emergency admission

7.1% 9.4% 6.9% 8.1% 12.5% 5.1% 11.5% 6.5% 8.0% 7.8% 9.7% 5.0% 10.1% 7.9% <=5.5% >7.5%

HWP All emergency readmissions following an elective or emergency admission

5.7% 9.0% 6.3% 8.1% 10.3% 4.5% 9.5% 6.1% 6.8% 7.3% 8.2% 6.2% 9.5% 7.3% <=5.5% >7.7%

Note * excluding PAU admissions


PEWS compliance

Audits

Readmission Rates - local calculation *

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

54 of 201P

UB

LIC B


02/01/2018 Caring - sites



FPH No of compliments 5 3 2 2 9 no data no data 3 4

FPH Friends and family test - inpatient survey

100% 100% N/A 98% N/A 100% 99% 100% N/A 100% 100% 95% 100% >=97.4% <93.6%

FPH Number of complaints received 0 0 0 0 0 2 1 1 1 0 1 2 2 8FPH Number of PALS contacts 0 0 2 1 1 2 0 0 0 0 1 1 0 2

FPH Midnight Bed Occupancy 49% 67% 58% 59% 62% 62% 53% 58% 60% 66% 48% 65% 63% <=85% >=100%

HWP No of compliments 42 46 53 46 48 42 44 56 44 44 46 43 46

HWP Friends and family test - inpatient survey

100% 100% 100% 100% 97% 98% 98% 99% 100% 100% 96% 92% 95% >=97.4% <93.6%

HWP Friends and family test - HW clinics 93% 98% 97% 97% 97% 97% 98% 98% 100% 99% 98% 97% 100% >=97.4% <93.6%

HWP Friends and familty test - WX clinics 94% 100% 100% 100% 95% 95% 100% 99% 100% 99% 99% 98% 99% >=97.4% <93.6%

HWP Number of complaints received 0 0 0 0 1 1 0 0 0 0 0 1 1 2HWP Number of PALS contacts 2 4 3 4 2 1 0 3 0 2 0 0 2 7

HWP Midnight Bed Occupancy 81% 83% 79% 70% 64% 63% 66% 76% 48% 49% 50% 64% 68% <=85% >=100%

Midnight bed occupancy


Complaints - directorate

Caring


Complaints - directorate

Compliments

Compliments

Midnight bed occupancy

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

55 of 201P

UB

LIC B





FPHOP - median waiting times (days) to first OP attendance

New 47 78 74 60 53 36 35 39 68 51 72 62 79 <=55 >=84

FPHWaiting for CAMHS Assessment - Number of inpatients

New NA - 20 No data No data No data 8

FPHWaiting for CAMHS Assessment - length of stay (days)

New NA No data 7 5 25 32 18 4

FPH Number of shifts covered by RMN 30 44 35 4 33 58 55 47 11

FPH RTT Total Incomplete Waiting List New 794 775 720 638 655 651 726 687 643 573 503 538 531

FPH RTT waiting 18 weeks and over New 12 5 20 7 6 0 1 0 6 4 2 1 2

FPH RTT - % waiting within 18 weeks New 98% 99% 97% 99% 99% 100% 100% 100% 99% 99% 100% 100% 100% 92%

FPH RTT waiting 35 weeks and over New 0 0 2 0 0 0 0 0 0 0 0 0 0

FPH 2 week wait - all cancers New 100.0% 100.0% 100.0% 66.7% 100.0% 100.0% 100.0% 100.0% 90.9% 100.0% 100.0% 75.0% In arrears 93%

FPHAll children attending PAU to be seen by a doctor within 2 hours of arrival

New No data No data No data No data 100% 80%

FPHAll acute medical admissions to be seen by a paediatrician on the middle grade rota within 4 hours of admission

New 100% 100% 100% 80% 100% 100% 100% 90% 90% 100% 50% 100% 80% >80% <=80%

FPHAll acute admissions to be seen by a consultant within 14 hours of decision to admit

New 80% 60% 75% 80% 95% 100% 80% 100% 90% 100% 60% 100% 100% >80% <=80%

7-day working

Responsive

RTT

Cancer waits - children's

Waiting times

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

56 of 201P

UB

LIC B





Responsive

HWPOP - median waiting times (days) to first OP attendance

48 38 38 38 36 35 36 42 50 49 49 53 50

HWPWaiting for CAMHS Assessment - Number of inpatients

4 5 11 19 9 17 10 10 10 4 8 13 15

HWPWaiting for CAMHS Assessment - length of stay (days)

5 6 17 23 20 30 16 15 12 6

18 ( 1 pt 5 days for eating

disorder unit under section)

35

31 (1 patient, 39

days - waiting

bed)HWP Number of shifts covered by RMN 0 0 12 16 9 0 2 12 0 0 2 13 0

HWP RTT Total Incomplete Waiting List 449 524 530 553 543 575 625 533 569 632 693 683 663

HWP RTT waiting 18 weeks and over 5 3 7 1 4 7 4 4 6 6 7 6 3

RTT - % waiting within 18 weeks 99% 99% 99% 100% 99% 99% 99% 99% 99% 99% 99% 99% 100% 92%

HWP RTT waiting 35 weeks and over 0 0 0 0 0 0 2 0 0 0 0 0 0

HWPCancelled operations - Last minute cancelled operations for non-clinical reasons (% of elective admissions)

N/A N/A N/A N/A N/A N/A N/A N/A

HWP 2 week wait - all cancers 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0% 100.0% 100.0% 100.0% in arrears 93%

HWPAll children attending PAU to be seen by a doctor within 2 hours of arrival

93% 100% 901% 86% 94% 96% 100% 91% 100% 100% 100% 100% 100%

HWPAll acute medical admissions to be seen by a paediatrician on the middle grade rota within 4 hours of admission

100% 90% 86% 94% 96% 100% 100% 100% 100% 100% 100% 100% 100% >80% <=80%

HWPAll acute admissions to be seen by a consultant within 14 hours of decision to admit

98% 98% 98% 98% 89% 97% 99% 97% 95% 98% 99% 97% 96% >80% <=80%

Cancelled operations

Cancer waits - children's

7-day working

RTT

Waiting times

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

57 of 201P

UB

LIC B





FH Agency spend - Doctors £000s £409,081 £74,605 £21,945 -£3,107 £26,631 £669 -£28,302 £6,518 -£134 -£1,983 £3,040 £1,674 £163 -£2,137 £7,140FH Agency spend - Nursing £000s £500,200 £40,060 £22,658 £19,616 -£1,698 £25,986 £21,069 £5,642 £11,898 £14,651 £31,912 £25,143 £32,950 £30,188 £152,384FH Agency spend - Other £000s £4,463 £2,918 £6,044 £783 -£2,932 -£2,783 -£675 £0 £0 £0 £0 £0 £0 £0 £0FH Agency spend - Total £000s £913,744 £117,583 £50,647 £17,292 £22,001 £23,871 -£7,908 £12,160 £11,764 £12,667 £34,952 £26,817 £33,112 £28,052 £159,524FH Agency spend as % of pay bill 6.6% 9.9% 4.6% 1.6% 2.0% 2.1% -0.7% 1.1% 1.0% 1.1% 3.0% 2.4% 2.8% 2.4% 2.0% <=8.0% >10.0%

FPH Turnover rate % 17.96% 17.65% 20.93% 17.83% 17.68% 17.39% 17.20% 17.16% 16.48% 12.50% 13.26% 10.81% 11.76% <12%FPH Staff sickness rates 2.55% 3.38% 3.91% 3.75% 3.30% 3.65% 3.49% 2.90% 1.70% 2.72% 2.52% 3.60% 2.66% <2.9%

FPH Nursing Vacancies - Trained 14.9 11.73 11.93 10.29 7.88 6.63 7.7 5.57 6.57 6.58 7.06 5.26 2.91FPH Nursing Vacancies - Untrained -0.72 1.27 2.89 0.27 0.37 0.43 0.43 0.48 0.67 2.67 7.54 7.54 8.2

FPH Number of shifts filled by locum junior doctors

8 7 4 - 4 8 2 1 20 22 27 10 11

FPH WTE locum consultants (month-end snapshot)

0 1 1 - 3 2 2 1 1 1 1 1 <2

FPH % locums with competency sheet completed & shift filled by specialty

80% 80% 100% 100% 100% 80% 100% 100% 100% 100% 100% 66% 100% <=95%

FPH Number of shifts covered by unknown Locums by specialty

0 0 1 1 1 2 0 0 0 0 0 1 2 0 =>1

FPHStaff appraisal rate - medical staff (non-training grades) New New 100% 100% 100% 100% 100% 96% 100% >=95% <85%

FPHStaff appraisal rate - non-medical staff New New 79% 80% 83% 81% 81% 77% 79% >=80% <70%

FPH Consultant Led Medical Handover 100% 100% 100% 100% 100% 100% 100% 100% 100% 85% 83% 95% >80% <=80%

FPH % of shifts with at least two paediatric trained nurses

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% <=90%

FPH % of nurses trained in paediatric life support

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% >=90% <=82%

FPH Mandatory training completed (consultants) %

95% 100% 95% >=85.0% <60.0%

FPH Mandatory training completed (all staff) %

95% 95% 95% 95% 95% 95% 95% 79% 79% 82% 76% 81% >=85.0% <60.0%

FPH % recommending here as a place to work

in arrears Q1, 2, 4 >=70%Q3 >= 66%

Q1, 2, 4 <62%Q3 <62%

FPH % recommending here as a place for care

in arrearsQ1, 2, 4 >=86%

Q3 >=76%Q1, 2, 4 <79%

Q3 <70%

Well led

Turnover, sickness - Paediatrics

Vacancies - Paediatrics

Appraisals - directorate

Agency spend - Paediatrics

Training - directorate

Competent medical cover available

71%* 76%

Locums

76%

Competent nursing staff available

Friends and family test for staff - FPH as a whole

75%

93%84%* 95% 94%

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

58 of 201P

UB

LIC B





Well led

HWP Turnover rate % 15.45% 15.64% 16.13% 14.52% 17.39% 17.27% 16.67% 15.38% 16.06% 15.38% 14.39% <12%

HWP Staff sickness rates 4.69% 4.47% 1.53% 0.93% 3.90% 2.47% 1.95% 3.89% 4.66% 4.42% 4.20% <2.9%

HWP Nursing Vacancies - Trained 16% 17% 16% 17% 18% 17% 16%HWP Nursing Vacancies - Untrained 4% 4% 4% 4% 4% 4% 4%

HWP Number of shifts filled by locum junior doctors

HWP WTE locum consultants (month-end snapshot)

<2

HWP % locums with competency sheet completed & shift filled by specialty

100% <=95%

HWP Number of shifts covered by unknown Locums by specialty

0 =>1

HWPStaff appraisal rate - medical staff (non-training grades) New New 100% 100% 100% >=95% <85%

HWPStaff appraisal rate - non-medical staff New New 45% 60% 65% >=80% <70%

HWP Consultant Led Medical Handover 100% 100% 100% 100% 100% 100% 100% 100% >80% <=80%

HWP % of shifts with at least two paediatric trained nurses

100% 100% 100% 100% 100% 100% 100% 100% 100% <=90%

HWP % of nurses trained in paediatric life support

90% 100% 100% 90% 90% 66% 66% 73% 91% 85% 81% 82% 82% >=90% <=82%

HWP Mandatory training completed (consultants) %

100% 100% 100% 100% 100% 100% 100% 100% 80% 80% 100% 100% 100% >=85.0% <60.0%

HWP Mandatory training completed (all staff) %

65% 71% 69% 75% 69% >=85.0% <60.0%

HWP % recommending here as a place to work

in arrears Q1, 2, 4 >=70%Q3 >= 66%

Q1, 2, 4 <62%Q3 <62%

HWP % recommending here as a place for care

in arrearsQ1, 2, 4 >=86%

Q3 >=76%Q1, 2, 4 <79%

Q3 <70%

60% 68% 62%

Locums

Competent medical cover available

Appraisals - directorate

Vacancies - Paediatrics

Turnover, sickness - Paediatrics

75% 80% 79%

* Friends and family test (FFT) replaced by National Staff Survey in Q3; the question is worded slightly differently “If a friend or relative needed treatment, I would be happy with the standard of care provided by this organisation”. Note the target and threshold for Q3 is based on the National Staff Survey results; Q1, 2 and 4 are based on FFT results

Competent nursing staff available

Training - directorate

Friends and family test for staff - HWP as a whole

60% *

67% *

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

59 of 201P

UB

LIC B




201610 201611 201612 201613 201614 201615 201616 201617 201618 201619 201620 201621 201622


FH Budget - directorate total (cumulative) £16,261,160 £9,512,053 £10,873,815 £12,216,840 £13,564,947 £14,913,053 £16,261,160 £1,327,591 £2,654,163 £3,981,170 £5,318,983 £6,606,154 £7,926,837 £9,251,067

FH Actual spend - directorate total (YTD) £15,489,240 £9,352,572 £10,608,209 £11,746,141 £12,912,142 £14,175,761 £15,489,240 £1,297,290 £2,637,967 £3,913,926 £5,250,347 £6,460,085 £7,769,791 £9,092,727

FH Variance - directorate total (YTD) £771,920 £159,481 £265,606 £470,699 £652,805 £737,293 £771,920 £30,301 £16,196 £67,244 £68,636 £146,069 £157,047 £158,339 >0

FH Pay - budget (YTD) £14,128,579 £8,274,004 £9,456,719 £10,624,684 £11,792,649 £12,960,614 £14,128,579 £1,177,591 £2,355,183 £3,532,774 £4,700,079 £5,875,099 £7,050,119 £8,225,139

FH Pay - actual spend (YTD) £13,852,728 £8,301,058 £9,409,635 £10,499,403 £11,608,224 £12,751,631 £13,852,728 £1,146,014 £2,280,636 £3,416,340 £4,582,785 £5,704,791 £6,878,662 £8,060,608

FH Pay - spend variance - (YTD) £275,851 -£27,054 £47,084 £125,281 £184,425 £117,404 £275,851 £31,577 £74,546 £116,434 £117,295 £170,308 £171,457 £164,531 >0

FH CIPs plan (YTD) - Paeds Mat & Gynae £851,416 £426,000 £496,833 £567,750 £638,667 £709,583 £780,500 £851,416 £83,000 £165,466 £248,000 £331,000 £414,000 £496,000

FH CIPS actual (YTD) - Paeds Mat & Gynae £723,667 £363,000 £422,667 £482,666 £542,667 £602,333 £662,000 £723,667 £73,000 £163,483 £241,000 £331,000 £414,000 £496,000

FH CIPs variance (YTD) - Paeds Mat & Gynae -£127,749 -£63,000 -£74,167 -£85,084 -£96,000 -£107,250 -£118,500 -£127,749 -£10,000 -£1,983 -£7,000 £0 £0 £0 >0

FH Did not attend (DNA) rate % 7.6% 7.3% 7.7% 8.7% 6.5% 6.6% 6.2% 6.6% 8.3% 7.4% 8.2% 8.7% 7.5% 7.6% UQ <=5.7%Med <=7.0%

LQ >8.4%

FH Outpatient new to follow-up ratio 1.43 1.39 1.34 1.24 1.18 1.24 1.35 1.36 1.36 1.40 1.34 1.27 1.17 1.32 UQ <=1.00Med <=1.38

LQ >2.06

FH Outpatient clinic session utilisation 71.8% 79.0% 78.0% 81.9% 77.0% 76.4% 68.8% 78.4% 77.6% 74.2% 70.9% 78.8% 80.8% 76%

FH Booking Efficiency 48.7% 47.3% 43.9% 52.6% 40.7% 42.3% 43.2% 53.1% 73.4% 49.5% 47.3% 44.8% 44.8% 50% >=95% <85%

FH No OP clinics cancelled by hospital < 6 weeks (for avoidable reasons)

8 18 10 8 6 9 15 8 9 7 4 4 5 52

FH No Patients cancelled by hop with < 6 wks notice for avoidable reasons

FH% OP clinics cancelled by hospital with < 6 wks notice for avoidable reasons out of all scheduled clinics

2.0% 4.1% 2.7% 2.1% 1.6% 2.1% 4.2% 2.0% 2.2% 1.8% 1.0% 1.0% 1.2% 1.9% <=5% >8%

FH Non-elective Average LOS 0.77 0.82 0.91 0.95 0.86 0.74 0.77 1.12 0.87 0.96 0.79 0.96 0.89 0.92 UQ <=3.23Med <=3.65

LQ >4.29

FH Elective Average LOS 0.63 1.16 1.15 1.57 1.87 0.75 3.07 4.00 0.70 1.48 0.90 2.59 0.58 1.91 UQ <=2.40Med <=3.12

LQ >3.67

Efficiency

Finance Spend - Paediatrics

Outpatients

Outpatient utilisation - specialty

Average length of stay

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

60 of 201P

UB

LIC B




201610 201611 201612 201613 201614 201615 201616 201617 201618 201619 201620 201621 201622


Efficiency

FPH Did not attend (DNA) rate % 8.4% 7.6% 9.4% 10.7% 8.1% 6.8% 6.8% 7.5% 9.5% 9.1% 8.4% 9.2% 8.0% 8.4% UQ <=9.3%Med <=11.4%

LQ >13.6%

FPH Outpatient new to follow-up ratio 0.94 1.01 0.91 0.89 0.88 0.98 1.05 1.14 1.22 1.09 1.17 1.09 1.06 1.12 UQ <=0.90Med <=1.21

LQ >1.87

FPH Number of patients waiting for overdue follow up appointments

FPH Outpatient clinic session utilisation 67.6% 75.3% 75.6% 76.9% 71.1% 73.6% 65.9% 75.5% 77.0% 74.6% 68.9% 75.1% 80.0% 74%

FPH Booking Efficiency 70.8% 80.5% 77.5% 75.7% 74.4% 77.3% 77.9% 77.6% 78.0% 75.8% 73.9% 69.2% 71.3% 75% >=95% <85%

FPH No OP clinics cancelled by hospital < 6 weeks (for avoidable reasons)

4 17 7 7 4 6 13 5 5 6 3 3 4 39

FPH No Patients cancelled by hop with < 6 wks notice for avoidable reasons

FPH% OP clinics cancelled by hospital with < 6 wks notice for avoidable reasons out of all scheduled clinics

1.4% 5.7% 2.7% 2.6% 1.6% 2.0% 5.3% 1.8% 1.8% 2.2% 1.1% 1.2% 1.4% 2.1% <=5% >8%

FPH Non-elective Average LOS 1.00 1.26 1.39 1.42 1.36 1.32 1.33 1.31 1.40 1.36 1.38 1.91 1.15 1.37 UQ <=0.98Med <=1.26

LQ >1.67

FPH Elective Average LOS 0.50 1.00 0.00 1.50 1.25 2.00 0.00 3.33 1.00 3.00 1.00 2.20 UQ <=1.20Med <=1.96

LQ >3.41

Outpatient utilisation

Outpatients


5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

61 of 201P

UB

LIC B




201610 201611 201612 201613 201614 201615 201616 201617 201618 201619 201620 201621 201622


Efficiency

HWP Did not attend (DNA) rate % 7.2% 7.1% 6.5% 7.5% 5.6% 6.5% 5.8% 6.1% 7.5% 6.3% 8.0% 8.3% 7.0% 0.07 UQ <=5.7%Med <=7.0%

LQ >9.0%

HWP Outpatient new to follow-up ratio 1.85 1.69 1.75 1.49 1.38 1.42 1.58 1.53 1.46 1.63 1.48 1.40 1.26 1.47 UQ <=1.00Med <=1.38

LQ >2.06

HWP Number of patients waiting for overdue follow up appointments

HWP OP Medical - new to follow-up ratios 2.0 1.7 1.9 1.7 1.8 1.8 1.9 1.7 2.1 1.8 2.1 1.9 1.8 <1.8 2

HWP OP Medical - cancellation rates 8.6% 8.6% 9.0% 6.5% 8.6% 8.7% 8.9% 8.7% 10.3% 9.5% 11.7% 10.7% 9.4%

HWP OP Medical - did not attend (DNA) rates %

10.6% 10.1% 10.8% 10.7% 9.0% 10.5% 11.9% 10.1% 9.6% 9.6% 14.8% 11.2% 9.4% <9% 10%

HWP OP Surgical new to follow-up ratios 0.5 0.5 0.7 0.6 0.4 0.4 0.5 0.5 0.7 0.5 0.5 0.5 0.4 <1.8 2

HWP OP Surgical - cancellation rates 7.7% 7.3% 6.2% 4.7% 6.7% 5.3% 2.6% 4.2% 11.4% 8.3% 7.3% 9.6% 11.3%

HWP OP Surgical - did not attend (DNA) rates %

8.0% 7.3% 9.6% 12.2% 10.1% 8.4% 9.2% 8.5% 8.6% 7.7% 10.3% 7.6% 7.7% <9% 10%

HWP Outpatient clinic session utilisation - Wexham

85% 89% 85% 93% 91% 90% 80% 91% 84% 79% 78% 88% 85% 84%

HWP Outpatient clinic session utilisation - Heatherwood

63% 74% 72% 94% 83% 45% 56% 50% 59% 39% 64% 75% 68% 59%

HWP Booking Efficiency 38% 34% 30% 41% 29% 29% 29% 40% 69% 36% 34% 35% 32% 37% >=95% <85%

HWP No OP clinics cancelled by hospital < 6 weeks (for avoidable reasons)

4 1 3 1 2 3 2 3 4 1 1 1 1 13

HWP No Patients cancelled by hop with < 6 wks notice for avoidable reasons

HWP% OP clinics cancelled by hospital with < 6 wks notice for avoidable reasons out of all scheduled clinics

3.3% 0.7% 2.6% 0.8% 1.7% 2.3% 1.9% 2.4% 3.4% 0.9% 0.8% 0.8% 0.8% 1.5% <=5% >8%

HWP Average length of stay - non-elective 0.72 0.77 0.85 0.87 0.79 0.65 0.68 1.09 0.76 0.87 0.69 0.79 0.80 0.8 UQ <=3.37Med <=3.78

LQ >4.33

HWP Average length of stay - elective 0.64 1.16 1.17 1.57 1.92 0.75 3.16 4.00 0.78 1.23 0.89 2.55 0.55 1.9 UQ <=2.54Med <=3.18

LQ >4.01

Average length of stay - Specialty

Outpatients

Outpatient utilisation - specialty

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

62 of 201P

UB

LIC B


02/01/2018 Activity


201610

Site FY 16/17 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 YTD

FHTotal number of OP referrals (from all sources; to all clinicians)

1,052 1,396 1,167 1,414 1,264 1,415 1,131 1,351 1,306 1,235 1,055 1,102 1,478 8,658

FH Number of OP new/first attendances 1,040 1,266 1,076 1,256 1,287 1,414 1,036 1,301 1,241 1,148 1,067 1,117 1,330 8,240

FH Number of OP follow-up attendances 1,487 1,761 1,440 1,552 1,517 1,749 1,404 1,776 1,686 1,602 1,433 1,424 1,568 10,893

FH Total number of OP attendances 2,527 3,027 2,516 2,808 2,804 3,163 2,440 3,077 2,927 2,750 2,500 2,541 2,898 19,133

FH Number of non-elective inpatient discharges 852 965 928 796 701 882 685 939 725 727 551 811 1,054 5,492

FH Number of elective inpatient discharges 41 51 55 49 54 40 27 15 10 25 39 22 12 150

FPHTotal number of OP referrals (from all sources; to all clinicians)

5709 421 482 408 484 434 525 461 491 487 441 394 323 534 3,131

FPH Number of OP new/first attendances 6111 478 557 531 523 524 593 441 550 534 503 470 448 621 3,567

FPH Number of OP follow-up attendances 6243 450 561 485 463 463 581 463 628 652 550 550 487 638 3,968

FPH Total number of OP attendances 12354 928 1,118 1,016 986 987 1,174 904 1,178 1,186 1,053 1,020 935 1,259 7,535

Activity

Outpatients - Specialty


Inpatients - Specialty

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

63 of 201P

UB

LIC B


02/01/2018 Activity


201610


Activity

FPH Number of non-elective inpatient discharges 1356 145 103 114 110 95 119 96 121 124 137 82 123 232 915

FPH Number of elective inpatient discharges 16 2 2 1 2 4 0 2 0 1 3 1 2 1 10

FPH Medical Paediatric admissions 2131 226 222 215 207 157 191 165 190 190 218 144 218 284 1,409

FPH All other specialities admissions 1303 122 126 80 93 88 121 89 139 133 113 119 128 153 874

FPH Admissions up to 10 days New 0 1 0 0 1 1 1 1 1 1 2 1 2 9

FPH Admissions over 10 days - 2 years New 129 136 135 121 86 107 107 99 100 106 94 132 175 813

FPH Admissions over 2 - 15 years New 211 193 145 161 150 196 138 215 200 204 158 204 253 1372

FPH Admissions 16 - 18 years 136 8 14 14 13 15 5 8 10 6 7 7 12 7 57

FPH High Dependency - HDU Occupied Bed Days New 0

FPH High Dependency - HDU Episodes of Care New 0

FPH Retrievals to PICU 19 1 0 1 4 5 1 3 0 3 1 1 3 4 15

FPH Time critical transfer 6 0 0 0 0 1 0 0 0 0 0 0 0 0 0

FPH Transfers in from another Hospital 19 2 0 3 4 2 2 4 2 2 1 1 2 0 12

FPH Transfers out to another Hospital 60 5 2 9 8 3 9 5 4 5 8 5 5 7 39

FPH Surgical Transfers 14 3 - 0 2 1 1 - - 2 2 0 2 1 7

FPHNumber of CAHMS patients admitted over 72 hours

6 0 1 0 0 1 1 1 1 4 1 1 3 2 13

FPH Paediatric Assessment Unit (PAU) 2769 262 267 286 272 270 289 240 261 272 295 288 289 415 2,060

FPH Number on Ambulatory IV Antibiotics 479 - 62 42 38 39 41 43 57 77 66 86 71 103 503

FPH Ward attenders 1032 63 97 97 80 99 83 72 113 115 73 109 92 73 647

FPH Oncology patients attending 217 - 25 25 25 - 25 20 25 23 25 24 25 22 164


Paediatric Assessment Unit

5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

64 of 201P

UB

LIC B


02/01/2018 Activity


201610


Activity

HWPTotal number of OP referrals (from all sources; to all clinicians)

5624 631 914 759 930 830 890 670 860 819 794 661 779 944 5,527

HWP Number of OP new/first attendances 5407 562 709 545 733 763 821 595 751 707 645 597 669 709 4,673

HWP Number of OP follow-up attendances 9405 1,037 1,200 955 1,089 1,054 1,168 941 1,148 1,034 1,052 883 937 930 6,925

HWP Total number of OP attendances 14812 1,599 1,909 1,500 1,822 1,817 1,989 1,536 1,899 1,741 1,697 1,480 1,606 1,639 11,598

HWP OP Medical - New 5007 367 478 360 504 457 531 326 497 406 413 317 454 480 2893

HWP OP Medical - Follow up 9192 744 830 679 856 808 931 630 860 869 754 668 856 849 5486

HWP OP Medical - total number of attendances 14199 1111 1308 1039 1360 1265 1462 956 1357 1275 1167 984 1285 1329 8353

HWP OP Surgical Specialties- New 400 22 43 38 28 43 40 19 41 29 47 31 43 21 231

HWP OP Surgical Specialties - Follow up 213 11 22 25 17 19 16 10 19 19 25 17 22 8 120

HWPOP Surgical Specialties - total number of attendances

613 33 65 63 45 62 56 29 60 48 72 48 65 29 351

HWP OP Visiting Consultants Medical 122 8 9 7 9 0 8 7 9 0 10 8 7 0 41

HWP OP Visiting Consultants Surgical 147 16 19 0 13 9 9 0 8 10 15 7 9 14 63

HWP Urgent Review Clinic Attendances 398 51 43 37 0 0 0 0 0 0 0 0 0 0 0

HWP Nurse led blood clinic 1189 97 97 83 74 113 94 108 106 114 121 100 81 109 739

HWP Nurse led dressing clinic 754 65 59 58 65 57 63 69 68 37 59 55 44 51 383

HWP Outreach - CCN Actvity 4578 341 412 328 355 397 457 360 379 342 372 293 258 269 2273

HWP Outreach - ANP Activity 3179 250 371 290 254 263 198 256 236 237 191 162 144 142 1368


5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

65 of 201P

UB

LIC B


02/01/2018 Activity


201610


Activity

HWP Number of non-elective inpatient discharges 707 862 814 686 606 763 589 818 589 818 600 590 469 4,577

HWP Number of elective inpatient discharges 39 49 54 47 50 40 25 15 25 15 9 22 39 140

HWP All Paediatric Spells 4871 440 452 446 436 401 317 382 423 377 395 348 394 450 2769

HWP Admissions up to 10 days 25 5 3 2 2 0 0 3 0 1 4 1 3 2 14

HWP Admissions over 10 days - 2 years 1149 119 131 138 94 85 105 90 80 89 88 93 79 122 641

HWP Admissions over 2 - 15 years 3431 309 287 273 282 208 283 268 322 265 283 233 294 298 1963

HWP Admissions 16 -18 years 265 19 25 23 23 23 27 21 21 22 20 21 19 28 152

HWPAll Medical - Destination Ward 24 (incl via PAU)

2695 250 267 296 258 188 232 204 225 205 203 165 222 236 1460

HWPElective Medical -Destination Ward 24 (incl via PAU)

226 10 25 27 19 22 12 13 10 17 11 11 3 8 73

HWPAll Medical - Direct Admissions to Ward 24 (not via PAU)

744 51 56 81 82 43 72 48 66 55 64 50 60 48 391

HWP High Dependency - HDU Occupied Bed Days 832 64 111 114 98 93 87 135 107 80 76 69 100 95 662

HWP High Dependency - HDU Episodes of Care 449 34 68 60 56 50 45 39 67 57 34 36 47 42 322

HWP All Surgical spells 2176 202 179 140 143 129 183 178 198 172 192 183 172 214 1309

HWP Surgical Non-elective spells 773 63 53 46 59 39 69 82 94 90 95 79 56 88 584

HWP Retrievals to PICU 21 3 2 4 1 2 1 2 1 1 2 0 1 4 11

HWP Time critical transfers 2 0 1 0 0 0 0 0 0 0 1 0 1 0 2

HWP Transfers in from another Hospital New 0 1 1 3 0 1 0 2 2 2 1 0 2 9

HWP Transfers out to another Hospital 66 8 5 10 8 5 3 7 10 11 11 6 7 9 61

HWP Surgical Transfers New 3 of the 7 2 of the 6 2 of the 7 3 of the 9 0

HWPNumber of CAHMS patients admitted over 72 hours

New 2 3 2 7

HWPPaediatric Assessment Unit (PAU) attendance

8982 910 957 902 771 660 854 737 861 596 562 544 696 812 4808

HWP PAU Attenders, GP Emergency Ref 2362 228 253 224 202 193 263 173 251 191 165 138 198 227 1343HWP PAU Attenders, A&E Dept 3503 348 412 387 300 249 322 266 348 224 221 175 268 289 1791HWP PAU Attenders, Other Emergency 889 74 88 85 83 53 83 98 119 84 88 96 103 145 733HWP Number on Ambulatory IV Antibiotics 894 89 98 119 81 71 67 85 62 49 53 10 28 22 309

HWPGP Drop-in Blood Clinic Attendances - Number of children having blood tests (WN420)

2996 178 227 183 267 302 302 289 246 255 218 248 247 293 1796

HWP Oncology patients attending New 14 16 13 10 18 20 20 15 14 25 26 20 24 144

Paediatric Assessment Unit


5

Tab 5 W

ard to Board - P

aediatrics Wards C

ross Site

66 of 201P

UB

LIC B


Budget £ Actual £ Variance £1,512,882 1,472,900 39,982-

1,810,538 1,894,526 83,988

Year to Date (M8)

1820 F1 Paediatrics Fph

7464 Paeds Ward 24 Wph

5



Page | 1

Report Title

Chief Executive’s Report

Meeting

Board of Directors - Public

Meeting Date

Friday 5th January 2018

Agenda No.

6.

Report Type

To Note

Prepared By

Andrew Morris, Chief Executive Officer

Executive Lead


Performance Overview

Performance April - November For November the trend of continuing to deliver the 18 week referral to treatment standard, 62 day cancer treatment pathway and 6 week maximum wait for diagnosis was maintained. On clostridium difficile the Trust has had 31 cases which is the target for the financial year. The spike in c diffs in October dented the otherwise strong performance on prevention however none of the cases had the same ribotyping and there has been a lift nationally in the number of cases reported. Hand washing compliance is above 90% and there is stronger compliance with the antibiotic policy. There was 1 MRSA case identified on the Frimley site which takes the total to 3 this year, however this case is currently under appeal following the request for third party apportionment. On 4hrs the performance of the Trust was 91.2% for the month and 92.7% for the first two months of the quarter. On a System basis with the performance of the urgent care centres at Bracknell Maidenhead and Upton mapped in the performance was in excess of 93%. However for the first 20 days in December performance dipped to 85% Trust wide. This was due to bad weather and significant difficulties in staffing the two EDs at senior doctor level for the night and weekend shifts which resulted in very high numbers of patients waiting more than 4 hrs for treatment. The number of breaches as a result of lack of beds accounted for about 35%. In order to claim the £1.5m STF for quarter three the System needs to achieve a minimum of 92.86% and with the deterioration in performance of the Trust in December this will be a close call. On delayed transfers of care the Trust has 5.6% if it’s 1100 adult bed stock blocked with patients waiting to move home or into another care setting. The target for the winter is 3.5%. This is denting the 4hr performance. So far this year there have been 7 never events and 6 have resulted in a low level of harm and 1 has been rated as moderate. Each has had action plans to identify

6

Tab 6 Chief Executive's Report and Quality & Performance Report


Page | 2

measures to avoid a repetition of events and the audit half day is being used to communicate the actions that directorates need to take to ensure that the learning from these incidents is maximised. The ED department at Frimley has reaudited its compliance with the sepsis bundle and performance had improved to best quartile performance for 6 of the 7 elements of the the bundle. The take up of the flu vaccine is at 67% which is a improvement of almost 100% on last year and the Trust should achieve the target of 70% by 31st December. This is an important elements of the Trust’s winter plan. The roll out of the electronic referral process for GP continues to increase with the expectation that by the end of the financial year all referrals will be transmitted electronically. Activity is 2% down for GP referrals and 1% down for emergency admissions compared to April to November 16. ED attendances are on plan and elective activity is 1% down for the same period. This in marked contrast with the rest of this decade when activity had increased year on year.

Finance

Financial performance For November the Trust was showing surplus of £800k which was £500k behind plan. Income was up along with private patient activity. However pay and non pay spend exceeded plan which was disappointing but agency spend was maintained within the NHSI cap even though the spend on medical locums is still high. The continuous improvement programme delivery was at 93.5% for the month and is still projected to deliver around 92% of the £30m target. The Executive Directors are confident that the additional mitigation schemes will bridge the gap on the CIP shortfall by the year end and the Trust should be able to achieve the full STF of £12m for delivering the financial plan and hopefully £6m for 4 hrs although quarters 3 and 4 - £3m remain at risk.

Issues/ Points to Note

Winter pressures funding As part of the Chancellor’s announcement to boost NHS funding by £350m for this winter the Trust has received £1.9m to help fund the additional costs associated with pressures in quarters 3 and 4. The Trust has put a series of measures in place such as extending the opening times of the ambulatory care units, further enhancing staffing in ED, additional consultant ward rounds at weekends and maintaining 18 weeks performance all at extra cost. This is therefore a welcomed boost however this allocation has been made on condition that the financial control total is increased by £1.9m and while it improves the bottom line the added benefit will be marginal as it has to be deployed to increase the £22m target surplus by £1.9m. The allocation is also subject to 4 hr performance not falling below 91.48% for Q4 as a System. The System also received £650k for a new discharge to assess scheme. This has been developed with the support of social care directors and relies on making use of empty nursing home capacity to receive patients who are medically fit for discharge from hospital. The assessment process to determine a patient’s ongoing needs will be

6



Page | 3

made out of hospital and patients would then move on to their preferred destination. This capacity could free up 30 to 40 hospital beds in Q4. This funding does not impact adversely on the Trust’s financial control total. New Emergency Dept - Wexham Park The construction work proceeds at pace and the contractor will have completed the steel framework for 4 floors by early January. To mark this point of the construction there will be a topping out ceremony in early January. Frimley Accountable Care System As part of the Chancellor’s announcement in November on extra capital funding for NHS and fledgling accountable care systems, the Frimley System will (subject to the final sign off of business cases by NHSE) receive £28m to establish the integrated community hubs mainly for the Wexham Park catchment although some this funding will used to support new facilities in Surrey Heath and Fleet. In addition a further £3m has been earmarked for a discharge to assess facility in Bracknell which is an example of the NHS and Social Care working differently to improve services to patients. This facility when built will provide much needed additional capacity for older people and people with dementia. Also the NHSE and NHSI will be working together develop a new framework to performance manage health and care systems via a single annual operating plan and a financial control total for 2018/19. This will apply to the Frimley Health and Care System if it gains accreditation by the two regulators in February 2018. CQC - Local System Review The CQC will be undertaking a System review in March 2018 of the social care service offered by Hampshire County Council. The review will be similar to one carried out in Bracknell Forest and will focus on the coordination of health and social care across the county. Armed Forces Covenant The Trust has signed up to the Armed Forces covenant which ensures that Service Personnel receive the same health services as other citizens in the area where they live. It recognises the moral obligation to members of the Armed Forces and their families and establishes how they should be treated. Special consideration should be given by the NHS in some cases, especially for those who have given the most such as the injured or bereaved. The Trust has a strong relationship with the Armed Forces which goes back to 1995 with the establishment of the Ministry of Defence Hospital Unit. Berkshire and Surrey Pathology Services The Berkshire and Surrey Pathology Service has secured a new major contract for the provision of a pathology services in the Hillingdon area. The partnership involving Ashford and St Peters, Royal Surrey County Hospital, Royal Berks Hospital and Frimley Health is one of the most successful networks in the NHS. The partnership has successfully integrated Wexham Park and Royal Berks in 2017 and is now fully accredited by UKAS with the exception of biochemistry at RBH which will be inspected in February. Given the success of this particular partnership the CEOs are keen to establish a similar arrangement to network Pharmacy services across the four Trusts.

6



Page | 4

Recommendation

The Board is asked to note the Report.

6



Quality and performance report November 2017

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

72 of 201P

UB

LIC B


Quality and performance report – November 2017 Frimley Health NHS Foundation Trust – Board of Directors Page 2

Contents

Safe Effective Caring Responsive Efficiency / Finance

This report covers the period from November 2016 to allow comparison with historic performance.

However, the key messages and targets relate to November 2017 for the financial year 2017/18

Page Page

Contents 2 Appendix A 36

Chief executive’s overview 3 Methodologies for calculating the measures 37

CQC rating and single oversight framework 7 Glossary 39

Key messages by exception 8

Domains 14

Safe 14

Effective 19

Caring 22

Responsive 24

Well-led (workforce) 27

Well-led (efficiency) 29

Well-led (finance) 30

Benchmarking RAG key

Benchmarking 31 Achieving target

Activity Between target and threshold (where applicable)

Activity 33 Worse than target or threshold (where applicable)

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

73 of 201P

UB

LIC B



Chief executive’s overview (1)


Performance overview

For November the trend of continuing to deliver the 18-week referral to treatment standard, 62-day cancer treatment

pathway and 6-week maximum wait for diagnostic test was maintained. On Clostridium difficile the trust has had 31

cases which is the target for the financial year. The spike in C.diff cases in October dented the otherwise strong

performance on prevention, however none of the cases had the same ribotyping and there has been a lift nationally in

the number of cases reported. Hand washing compliance is above 90% and there is stronger compliance with the

antibiotic policy. There was one MRSA case identified on the FPH site, which takes the total to three this year;

however this case is currently under appeal following the request for third party apportionment.

On the four hour A&E target the trust was 91.2% for the month and 92.7% for the first two months of the quarter. On a

system basis with the performance of the urgent care centres at Bracknell, Maidenhead and Upton mapped in, the

performance was in excess of 93%. However for the first 20 days in December performance dipped to 85% trust-wide.

This was due to bad weather and significant difficulties in staffing the two emergency departments (ED) at senior

doctor level for the night and weekend shifts, which resulted in very high numbers of patients waiting more than four

hours for treatment. The number of breaches as a result of a lack of beds accounted for about 35%. In order to claim

the £1.5m sustainability and transformation fund (STF) for quarter three the system needs to achieve a minimum of

92.86% and with the deterioration in performance of the trust in December this will be a close call.

On delayed transfers of care the trust has 5.6% of its 1100 adult bed stock blocked with patients waiting to move home

or into another care setting. The target for the winter is 3.5%. This is denting the four hour A&E performance.

So far this year there have been seven never events and six have resulted in a low level of harm and one has been

rated as moderate. Each has had action plans to identify measures to avoid a repetition of events and the audit half

day is being used to communicate the actions that directorates need to take to ensure that the learning from these

incidents is maximised.

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

74 of 201P

UB

LIC B





Performance overview (continued)

The ED department at Frimley has re-audited its compliance with the sepsis bundle and performance has improved to

the best quartile performance for six out of the seven elements of the bundle.

The take-up of the „flu vaccine is at 67% which is an improvement of almost 100% on last year and the trust should

achieve the target of 70% by 31st December. This is an important element of the trust‟s winter plan.

The roll out of the electronic referral process for GPs continues to increase, with the expectation that by the end of the

financial year all referrals will be transmitted electronically.

Activity is 2% down for GP referrals and 1% down for emergency admissions compared to April to November 2016. ED

attendances are on plan and elective activity is 1% down for the same period. This is in marked contrast with the rest

of this decade when activity has increased year on year.

Financial performance

For November the trust was showing a surplus of £800k which was £500k behind plan. Income was up along with

private patient activity. However pay and non-pay spend exceeded the plan which was disappointing, but agency

spend was maintained within the NHS Improvement cap even though the spend on medical locums is still high. The

continuous improvement programme (CIP) delivery was at 93.5% for the month and is still projected to deliver around

92% of the £30m target. The executive directors are confident that the additional mitigation schemes will bridge the

gap on the CIP shortfall by the year-end and the trust should be able to achieve the full STF (sustainability and

transformation fund) of £12m for delivering the financial plan and hopefully £6m for four-hour A&E target, although

quarters 3 and 4 (worth £3m) remain at risk.

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

75 of 201P

UB

LIC B





Issues / points to note

Winter pressures funding

As part of the Chancellor‟s announcement to boost NHS funding by £350m for this winter the trust has received £1.9m to help

fund the additional costs associated with pressures in quarters 3 and 4. The trust has put a series of measures in place, such as

extending the opening times of the ambulatory care units, further enhancing staffing in ED, additional consultant ward rounds at

weekends and maintaining 18-weeks performance, all at extra cost. This is therefore a welcomed boost, however this allocation

has been made on condition that the financial control total is increased by £1.9m and while it improves the bottom line the added

benefit will be marginal as it has to be deployed to increase the £22m target surplus by £1.9m. The allocation is also subject to

performance against the four hour A&E standard not falling below 91.48% for Q4 as a system.

The system also received £650k for a new discharge-to-assess scheme. This has been developed with the support of social

care directors and relies on making use of empty nursing home capacity to receive patients who are medically fit for discharge

from hospital. The assessment process to determine a patient‟s on-going needs will be made out of hospital and patients would

then move on to their preferred destination. This capacity could free up 30 to 40 hospital beds in quarter 4. This funding does

not impact adversely on the trust‟s financial control total.

New Emergency Dept - Wexham Park Hospital

The construction work proceeds at pace and the contractor will have completed the steel framework for four floors by early

January. To mark this point of the construction there will be a topping out ceremony in early January.

Frimley Accountable Care System

As part of the Chancellor‟s announcement in November on extra capital funding for NHS and fledgling accountable care

systems, the Frimley System will (subject to the final sign off of business cases by NHS England) receive £28m to establish the

integrated community hubs mainly for the Wexham Park catchment, although some of this funding will be used to support new

facilities in Surrey Heath and Fleet. In addition, a further £3m has been earmarked for a discharge-to-assess facility in

Bracknell, which is an example of the NHS and Social Care working differently to improve services to patients. This facility,

when built, will provide much needed additional capacity for older people and people with dementia.

Also the NHSE and NHSI will be working together to develop a new framework to performance manage health and care systems

via a single annual operating plan and a financial control total for 2018/19. This will apply to the Frimley Health and Care

System if it gains accreditation by the two regulators in February 2018.

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

76 of 201P

UB

LIC B





Issues / points to note (continued)

CQC - Local System Review

The Care Quality Commission (CQC) will be undertaking a System review in March 2018 of the social care service

offered by Hampshire County Council. The review will be similar to one carried out in Bracknell Forest and will focus

on the coordination of health and social care across the county.

Armed Forces Covenant

The trust has signed up to the Armed Forces covenant which ensures that service personnel receive the same health

services as other citizens in the area where they live. It recognises the moral obligation to members of the Armed

Forces and their families and establishes how they should be treated. Special consideration should be given by the

NHS in some cases, especially for those who have given the most, such as the injured or bereaved. The trust has a

strong relationship with the Armed Forces, which goes back to 1995 with the establishment of the Ministry of Defence

Hospital Unit.

Berkshire and Surrey Pathology Services

The Berkshire and Surrey Pathology Service has secured a new major contract for the provision of a pathology

service in the Hillingdon area. The partnership, involving Ashford and St Peters, Royal Surrey County Hospital, Royal

Berkshire Hospital and Frimley Health, is one of the most successful networks in the NHS. The partnership has

successfully integrated Wexham Park and Royal Berkshire (RBH) in 2017 and is now fully accredited by UKAS with

the exception of biochemistry at RBH, which will be inspected in February. Given the success of this particular

partnership, the CEOs are keen to establish a similar arrangement to network Pharmacy services across the four

trusts.

Recommendation

The Board is asked to note the Report

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

77 of 201P

UB

LIC B



CQC overall rating & NHSI single oversight framework

Year to Date (Month 08) Forecast Outturn

Plan Actual Target Threshold Plan Actual Target Threshold

NHS Improvement’s score for financial performance

Use of resources score (1 - 4) 1 1 1 2 1 1 1 2


Care Quality Commission (CQC) overall rating

Frimley Park Hospital September 2014 Outstanding

Wexham Park Hospital February 2016 Good

Heatherwood Hospital May 2014 Good

Well-led Activity

15/16 16/17 Nov-16 Dec Q3 Jan-17 Feb Mar Q4 Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov-17 YTD Target Threshold

NHS Improvement (NHSI) – overall segment score

Segment score New 2 1 2 2 2 in arrears 1 2

Operational performance

A&E maximum waiting

time of 4 hours 94.7% 91.6% 91.3% 88.7% 84.7% 91.2% 91.4% 92.3% 90.2% 91.3% 91.5% 90.4% 90.7% 94.2% 91.4% 95% None

Maximum time of 18

weeks from point of

referral to treatment

(RTT) − patients on an

incomplete pathway

93.3% 92.6% 93.4% 92.2% 92.8% 92.5% 92.2% 92.5% 92.4% 92.2% 93.2% 92.8% 92.8% 92.9% 92.3% 92.0% 92.4% 92.2% 92.5% >=92% None

Maximum 62-day wait

for first treatment from

urgent GP referral for all

suspected cancers

88.7% 89.9% 90.3% 92.6% 89.7% 87.9% 89.0% 91.0% 89.3% 90.2% 92.6% 92.8% 91.9% 95.7% 94.5% 93.2% 94.2% 94.0% in

arrears >=85% None

Maximum 6-week wait

for diagnostic

procedures

0.8% 0.4% 0.4% 0.3% 0.3% 2.3% 0.8% 0.4% 1.2% 0.7% 0.4% 0.4% 0.5% 0.4% 0.4% 0.3% 0.4% 0.3% 0.2% <=1.0% None

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

78 of 201P

UB

LIC B



Key messages – by exception (1)

Safe Effective Caring Responsive Efficiency / Finance Well-led Activity

Domain Key points Action taken

Safe

Never events

There have been two Never Events reported, one on

each site

Never events

These are subject to a full root cause analysis and key actions identified

Serious incidents requiring investigation (SIRI)

There are ten Serious Incidents requiring investigation

reported for November. There were seven for the FPH

site which include falls with significant injury, a grade 3

pressure ulcer and two unexpected deaths. There have

been three reported for the WPH site. These were a

fall with significant injury, one unexpected death as a

result of a treatment delay and the third was a never

event relating to wrong site surgery

Serious incidents requiring investigation (SIRI)

These continue to be reviewed as part of the SIRI process and key

learning is identified. There is an extensive action plan in place for the

deteriorating patient work stream with the introduction of electronic

observations being prioritised as an IT priority

C difficile rate

There were 3 cases in November – one at WPH and

two at FPH

C difficile rate

The root cause of the cases was antibiotic treatment required for the

patient‟s underlying condition. As there has been a second case in the

FPH stroke unit within 28 days the sample is being sent for testing at the

reference lab to confirm any cross infection.

MRSA

FPH identified 1 case in November 2017 on ward G5

MRSA

This case is currently under appeal following the request for Third Party

apportionment (as the infection was identified 32 hours into the

admission and was not as a result of healthcare provided by the trust)

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

79 of 201P

UB

LIC B






Effective

Stroke - % of patients receiving a swallow screen within 4

hours of arrival

There are on-going gaps within the stroke coordinator team,

due to sickness and a vacancy

Delayed referrals are also a contributing factor

Stroke - % of patients receiving a swallow screen within 4 hours

of arrival

Interviews were held last week and the team hope to fill the

vacancy from February 2018. Ward nurses that have undertaken

the swallow screen training will be assessed by end of the year so

that they can support the stroke coordinators

Contributing factors are discussed at the Clinical Governance

Committee when breaches are reviewed

T&O - % fractured neck of femur patients going to theatre

within 36 hours

Performance has dropped in October on both sites. Delays in

getting patients to theatre were caused by capacity issues

and surgeon availability

T&O - % fractured neck of femur patients going to theatre within

36 hours

Discussions are on-going about surgeon availability and the

consultant mix

Obs - Caesarean section rate (planned & unscheduled)

Overall Lower Segment Caesarean Section (LSCS) rate

28.9% for October (Frimley Park 28.2% & Wexham Park

29.7%) . Year to date 30.1%. Overall emergency LSCS rate

13.4% (Frimley Park 12.4% & Wexham Park 14.7%)

Obs - Caesarean section rate (planned & unscheduled)

Emergency LSCS rates are closely monitored on both sites. The

year-to-date emergency rate is 13.9%

The “Saving Babies Lives” project is in progress; new guidance on

reduced fetal movements has seen an increase on the induction of

labour rate although this may not have impacted on the LSCS rate

Audit of induction of labour continues.

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

80 of 201P

UB

LIC B






Caring

Complaints answered within 25 working days

Number of complaints re-opened

There were 80 complaints received in November. We have

seen an increase at HWP and a decrease at FPH however

this is not outside the trust‟s target against activity

There were 11 reopened complaints for November (five of

the reopened complaints are historic and several months post

response)

Complaints answered within 25 working days

Number of complaints re-opened

Review and breakdown of the complaints at HWP has not

identified any areas of concerns or key themes

There continues to be an improved response time to

complaints. The team has had additional resources put in

place at the end of October which has had a positive impact

on the response rates and turnaround

Local survey: noise at night

68% of patients were bothered by noise at night from other

patients

Patient Experience inpatient bedside surveys have improved

across the board in November with our patients reporting a

positive experience of care within our hospitals

Local survey: noise at night

The Patient Experience team are working with key wards to

promote the reduction of noise at night.

There is continued work at ward level to create local action

plans to address key patient feedback and to increase the

number of local PET surveys

Maternity friends and family experience for months giving

birth

There were 93.6% positive responses from women giving

birth at the trust against a target of 99.0%. FPH is at 95.1%

and HWP at 89.3%, which is its lowest since August

Maternity friends and family experience for months giving

birth

A low response rate at FPH is affecting the overall

result. The matrons have an action plan to increase the

response rate. The build is due to be completed at

Wexham soon, but the interim arrangements are having an

impact on mothers‟ experience

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

81 of 201P

UB

LIC B






Responsive

Emergency Department - % admitted or discharged

within 4 hours

At HWP performance dipped compared to the previous

month. However there is still a sustained improvement

in performance compared to year to date average

At FPH, performance is at 91.8% and there have been

challenges with capacity and demand. There were

issues with bed availability and waiting times out-of-

hours.

Emergency Department - % admitted or discharged within 4 hours

Work is on-going to improve medical staffing levels (including more

senior decision making presence) in ED against a background of

high vacancy rates

Sustaining performance consistently is underpinned by changes in

the acute medicine model introducing frailty, winter plans which

include system wide work and an intense focus on use of the

SAFER bundle. This aims to reduce length of stay and improve

flow through the wards to support 4 hour performance

FPH continue to improve staffing levels out of hours and the

recruitment of middle grade doctors remains the top priority. FPH

staff are working alongside GP out-of-hours services to support

during peak evening and weekend activity. Nursing staffing in being

reviewed to facilitate improved patient flow during the day. New

pathways have been implemented to facilitate direct admissions to

the Paediatric Assessment Unit (PAU)

Delayed transfers of care (DTOC)

5.6% of bed days were lost due to delays in

discharging or transferring patients (6.3% at FPH and

4.9% at HWP) against the target of 3.5%. This was

an improvement on the previous month when it was

6.3%

Many of these are caused by delays in assessments

and placements of continuing healthcare patients

The trust is a long way from meeting the standard of

85% of patients being discharged from hospital and

assessed in the community

There is an on-going domiciliary care capacity crisis

in Buckinghamshire and Berkshire

IRIS model in HWP has opened, whilst the numbers

on the medically stable list reduced, the capacity did

not

Delayed transfers of care (DTOC)

The extended opening of ambulatory care continues to have a

positive effect

The Frailty unit is being re-launched to support patient care, right

time and place using an in-reach approach

On-going internal therapy work-ups – data suggests that beds are

lost during this phase of the patient journey

Delayed patients are being discussed with partners in regular calls

Implementation of daily updates via email to improve

communication between FPH discharge team and Continuing

Health Care (CHC) team

Highlighted Senior decision making and SAFER is being reviewed

Twice weekly stranded calls (Red calls) are held to proactively

manage the medically stable list

The IMPACT team is coming; waiting for a date from

Buckinghamshire Healthcare

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

82 of 201P

UB

LIC B






Well-led

(Workforce)

Staff turnover

Due to the short deadline there has been a delay in

reporting this figure. However, there is evidence that

turnover has decreased with an average of 31 nurse

leavers per month so far in 2017 compared to 34 in 2016

Time to recruit

Time to hire remains above target, however, this has

decreased since last month. Particular delays appear to

occur within the authorisation process and at shortlisting

Strong performance in regards to nurse recruitment

activity, with 154 nurses recruited in Aug-Oct 17 and the

overall trust vacancy rate decreasing to 15%

Between Jan – Oct 2017 the trust has recruited 43

consultants and 49 „middle grade‟ doctors; this is a 15%

increase on last year

Time to recruit

Work is ongoing to revise the recruitment process to

reduce wastage; reducing the number of adverts;

streamlining shortlisting and holding standardised

assessment centres where suitable (i.e. nursing posts)

Non-medical appraisals

Appraisal rates still remain below target. Appraisal status

is also included on the MAST training system for staff and

managers easily identify where appraisals are due.

Non-medical appraisals

Monthly appraisal compliance reports are being run by

the workforce information team; HR Business Partners

and the Learning & Organisational Development team are

using this information to target areas of concern

Agency rate

A 50% decrease in medical locum spend has been

achieved at FPH (from £564kpm to £280pm) since the

centralisation of bank services in August. There has

been both a reduction of rates and a decrease in usage.

Agency rate

There are plans to take over bookings at Wexham Park

where similar savings should be achievable

Well-led

(Efficiency) No exceptions to report

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

83 of 201P

UB

LIC B




Domain Key points Risks

Well-led

(Finance)

In month 08 the trust is £0.5 behind plan at £0.8m surplus (excluding sustainability and transformation funding (STF)) and £6.3m

behind YTD. Prior months exceptional items and STF mean bottom line in month and YTD is in surplus but this hides the underlying

run rate issue on expenditure. CIP mitigations are still lagging. The year end forecast assumes delivery of control totals based on a

better income month and being able to identify additional mitigations to offset some of the in month variance and anticipating reliance

on further non-recurrent exceptional gains.

Income

Clinical income is above plan but there remains a very high level of

uncoded episodes again this month (£18m). Other income including

EDMS and Education has also performed well this month and is £0.5m

better than plan

Income forecasts need to align as soon as possible

to commissioner forecasts to reduce year end

forecasting risk

Expenditure

Operational spend YTD is £6m over plan of £405m (excluding

Integration) due mainly to high pay costs (medical agency and ad-hoc

sessions). In month £1.9m overspent due mainly to non-pay variances

including EDMS £0.5m (matched by income), Farnham Rents £344k, IT

Maintenance £182k

Underlying costs significantly higher than plan

CIP mitigations need constant emphasis and

attention

Net surplus/ deficit

The trust is £6.3m adverse YTD against its set budget

One-off exceptional items mean the trust is showing a positive variance

on the bottom line

STF achieved £1.9m for M08 because of the one-off benefits booked in

Month 03

CIP mitigations still lagging and must be recovered


6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

84 of 201P

UB

LIC B



Safe - Key measures (1)


15/16 16/17 Nov-16 Dec Jan-17 Feb Mar Apr May Jun Jul Aug Sep Oct Nov-17 YTD Target Threshold

Infection control

Clostridium difficile * 41 33 4 2 4 2 2 3 1 5 4 6 3 6 3 31 None None

Clostridium difficile due to lapses in care 13 4 1 0 0 0 0 0 0 1 0 4 2 0 0 7 <=31 None

Clostridium Difficile - infection rate per

100,000 bed days 14.09 5.45 10.91 6.04 5.45 8.45 2.73 14.09 10.91 16.36 8.45 16.36 8.45 <=7.60 >10.40

MRSA Bacteraemia 2 2 0 0 0 0 1 0 0 1 0 1 0 0 1 3 0 None

Escherichia coli (E. coli) bacteraemia

bloodstream infection (BSI) rate New New

Hand hygiene compliance 85% 86% 86% 90% 91% >=90% <75%

Medication errors resulting in harm

Low 56 22 2 1 1 4 1 2 0 2 2 1 0 1 in arrears 8 None

Moderate * 4 8 0 0 1 0 1 1 1 0 0 0 1 0 in arrears 3 <=42 None

Severe * 0 0 0 0 0 0 0 0 0 0 0 0 0 0 in arrears 0 0 None

Pressure ulcer incidence

Hospital acquired - grade 2 * 143 169 18 18 21 16 21 20 18 21 17 14 14 10 in arrears 114 <=216 None

Hospital acquired - grade 3 * 6 5 0 0 2 1 1 0 2 0 1 0 1 0 in arrears 4 <=12 None

Hospital acquired - grade 4 * 0 0 0 0 0 0 0 0 0 0 0 0 0 0 in arrears 0 0 None

Community acquired - lapses in care 1 0 0 0 0 1 1 in arrears 3 TBC TBC

Incident reporting

Never events 6 4 0 0 1 0 0 1 0 1 1 1 1 0 2 7 0 None

Serious incidents requiring investigation

(SIRI) (total trust including Fleet) * ** 73 70 5 8 11 3 7 4 11 12 7 14 14 10 10 82 <=90 >96

Fleet community services SIRIs 1 0 0 1 0 1 1 0 4 TBC TBC

Potential under-reporting of patient safety

incidents (definition TBC) 30.7 33.96 TBC TBC

NHS England/NHS Improvement Patient

Safety Alerts outstanding 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 None

Incidents triggering a duty of candour

response New 96 6 12 12 6 9 10 13 8 13 13 13 15 in arrears 85 TBC TBC

Failure to notify of a suspected or actual

reportable patient safety incident New 0 0 0 0 0 0 0 0 0 0 0 0 0 in arrears 0 0 None

Falls resulting in significant injury

Number of falls * 28 20 0 1 4 1 2 1 3 3 2 1 3 1 3 17 <=37 None

Number of falls per 1000 bed days 0.06 0.04 0.00 0.02 0.09 0.03 0.05 0.03 0.07 0.08 0.05 0.03 0.07 0.02 0.08 0.05 TBC

Safe staffing - hours filled as planned

Registered nurse day 92% 95% 93% 92% 90% 89% 88% 91% 90% 90% 88% 89% 91% 94% 90% >=90% None

Unregistered care staff day 96% 96% 94% 98% 95% 95% 95% 98% 98% 98% 95% 96% 95% 95% 96% >=90% None

Registered nurse night 96% 98% 97% 98% 96% 94% 94% 96% 96% 96% 94% 95% 95% 96% 95% >=90% None

Unregistered care staff night 100% 99% 98% 100% 97% 96% 96% 99% 99% 99% 98% 99% 97% 99% 99% >=90% None

* monthly targets are as follows: TBC

** retrospective data for Fleet community services to be added to create a new trust total for SIRIs. Fleet community services were transferred under FHFT from January 2017

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

85 of 201P

UB

LIC B



Safe - Key measures (2)



VTE (venous thromboembolism) risk assessment

Admitted adult patients who have been

risk assessed for VTE 98% 97% 98% 97% 98% 98% 98% 98% 98% 97% 98% 97% 97% 97% in arrears 98% >=95% None

Delivering a 7-day service

Emergency admissions reviewed by a

consultant within 14 hours of admission New 95% Bi-annual audit TBC

Access to diagnostics * New 100% Bi-annual audit TBC

Access to consultant-directed

interventions * New 100% Bi-annual audit TBC

Twice daily consultant reviews for high

acuity areas * New 100% Bi-annual audit TBC

Sepsis CQUIN - Timely identification of Sepsis in emergency department (ED) and acute inpatient settings

The percentage of patients screened for

sepsis in ED 66% 94% 96% 88% 96% 96% 94% 96% 88% 100% 100% 100% 96% in arrears 96% >=90% None

The percentage of acute inpatients

screened for sepsis New 61% 68% 70% 66% 66% 66% 42% 42% 34% 28% 30% 44% in arrears 35% >=90% None

Sepsis CQUIN – Timely treatment of Sepsis in emergency department (ED) and acute inpatient settings

The percentage of patients who met

criteria were administered intravenous

antibiotics within 1 hour of arrival in ED

New 83% 77% 87% 90% 70% 80% 38% 85% 75% 71% 73% in arrears

76% >=90% None

The percentage of patients who met

criteria were administered intravenous

antibiotics within 1 hour of arrival on the

ward

New 68% 70% 70% 67% 87% 87% 63% 57% 63% 50% 63% in arrears

54% >=90% None

Sepsis CQUIN – Antibiotic Review

% of antibiotic prescriptions for patients

diagnosed with sepsis that were

documented and reviewed by a clinician

within 72 hours

82% in arrears

Q1 >=25%

Q2 >=50%

Q3 >=75%

Q4 >=90%

Reduction in antibiotic consumption per

1,000 admissions

4828

baseline in arrears TBC

Reduction in total consumption of

carbapenem per 1,000 admissions TBC

Reduction in total consumption of

piperacillin-tazobactam per 1,000

admissions

TBC

* Audit data to be treated with caution due to loose national definitions and the use of questions that were open to interpretation

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

86 of 201P

UB

LIC B



Safe – Other CQUINS 2017/18 (1)

15/16 16/17 Apr-17 May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan-18 Feb Mar-18 Q4 YTD Target Threshold

Improving Staff Health and Wellbeing

Staff Survey Question : Does

your organisation take positive

action on Health and Wellbeing

33% Improvement plans to be in place

Staff

survey

for 2017

to go live

Improvement plans to be in place

Staff

survey

due to be

reported

Review for

2018

requirement

>35% None

Staff Survey Question : In the

last 12months have you

experienced musculoskeletal

problems (negative response

measured)

76% Improvement plans to be in place Improvement plans to be in place >78% None

Staff Survey Question : During

the last 12 months have you

felt unwell as a result of work

related stress (negative

response measured)

69% Improvement plans to be in place Improvement plans to be in place >71% None

Healthy Food – changes to food and drink provision

Percentage of drink lines

stocked that are sugar-free New Due Due Due Due >=70% None

Percentage of confectionary

and sweets stocked that do

not exceed 250 calories

New Due Due Due Due >=60% None

Percentage of pre-packed

sandwiches and other savoury

pre-packed meals that contain

less than 400 calories

New Due Due Due Due >=60% None

Improving the uptake of ‘flu vaccinations for Frontline Clinical Staff

Cumulative uptake of „flu

vaccination by frontline staff 38.5% Launch of „flu campaign Launch of „flu campaign Due Due Due Due Due Due >70% None

NHS e-Referral System (e-RS)

% of referrals to first outpatient

services able to be received

through e-RS

New Due Due Due Due Q2 >=80%

Q3 >=90%

Q4 =100%

None

Appointment slot issue (ASI)

reduction New 30% 30% 25% 25% 28% 28% 18% 25% 21% 16%

<=4% by

Q4 None


6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

87 of 201P

UB

LIC B



Safe - Other CQUINS 2017/18 (2)

15/16 16/17 Apr-17 May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan-18 Feb Mar-18 Q4 YTD Target Threshold

Advice and Guidance

Advice and Guidance

Services to be in place for

services agreed with CCG

and be operational to cover

at least 35% of total GP

referrals

New

Agree specialities,

trajectories, timetable and

implementation plan

Advice and guidance services

to be operational from Jan-18

>=35% by

Jan-18 None

Provide asynchronous

responses within 2 working

days

New

Agree local quality

standard for provision of

responses

>=80% None

Supporting Safe Proactive Discharge

Increase the number of

patients discharged to usual

place of residence

(applicable to patients aged

65yrs and above)

New

Map and streamline existing discharge pathways

across acute, community and NHS care home

settings – roll out protocols in partnership across

local whole systems. Deliver and agree with

commissioners a plan, baseline and trajectories to

reflect impact of local initiatives agreed

Q3, Q4 2.5%

point increase

None

Implement Emergency Care

Data Set (ECDS) New

Demonstrate credible

planning to evidence that

the ECDS can be

collected and returned

from 01/10/2017

Return data

weekly and ensure

95% of patients

have valid chief

complaint and

diagnosis

Q3 >=95%

None

Improving services for people with mental health needs

Reduce by 20% the number

of attendances to emergency

department (ED) for those

within a selected cohort of

frequent attenders

New

Identify and agree cohort. Review and develop care

plan for each person with the patient and other

relevant care organisations

20% reduction

in ED

attendances

within selected

cohort

None

Improve Mental Health need

coding data New

Conduct internal audit of

ED mental Health Coding.

Agree data quality

improvement plan

Review progress against

data quality improvement

plan and confirm systems

are in place to ensure ED

HES data submissions are

correct

None None


6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

88 of 201P

UB

LIC B



Safe – CQUINS – key messages


Area Key points Action taken

Sepsis and

antimicrobial

resistance (AMR)

Sepsis

Q2 CQUIN requirements partially met.

Inpatient screening and Antibiotics within 1 hour of trigger time

remains a challenge

Anti-microbial resistance (AMR)

Review of antibiotics within 72 hours

CQUIN target met for Q2, but antimicrobial stewardship will need

to improve across a number of specialties

Training has been increased for all staff

New sepsis bundle launched across all sites

Performance has been discussed at all key clinical meetings

All clinical leaders aware of the need to improve recognition,

escalation and timely treatment of sepsis and will work with their

teams to ensure this message is shared

AMR Q2 data shared with Consultants

Health and

Wellbeing

Staff survey – the improvement plan is in place

Healthy food – On track to achieve Q4 targets

„Flu vaccination – excellent progress with vaccination campaign,

as of 7.12.17 66.38% of frontline staff vaccinated across the trust

Numerous Health and Wellbeing initiatives are in place to support

staff in terms of physical and mental health; all are advertised on

the intranet

„Flu vaccination – Peer vaccination programme continues. Areas

with low uptake will be visited to „myth bust‟ and ensure staff

working a nights/weekends have sufficient opportunity to be

vaccinated.

NHS

e-Referrals

Q2 CQUIN requirement met

On target for November ASI trajectory reduction of 5%

Excellent collaboration between provider and CCGs

Success of project to date has initiated a plan to commence a

collaborative with other providers/CCG‟s to pull plans together and

provide a consistent message to GP‟s across a wider geography.

Internal and External e-Referrals meetings embedded and

implementation plans are in place

Advice and

Guidance

Q2 CQUIN requirement met

Specialities are taking up A&G in line with e-Referral roll out where

A&G is felt to be of benefit.

The project will be managed via the e-Referrals project group

Supporting

Proactive and

Safe Discharge

Q2 requirements met

Site specific workstreams set up under the umbrella of the Urgent

Care Board to deliver the 7 pillars

Emergency Care Data Set (ECDS) – both WPH and FPH

Emergency Departments now live

• Improved monitoring systems for patient flow in place

• Clinically fit list utilised daily to enable community teams to „pull‟

patients from hospital to home

• IRIS due to be launched on WPH site 11.12.17

Improving

Mental Health

Q2 CQUIN requirement met.

Significant challenge in getting patient cohort on the FPH site to

engage and consent to care/management plans with some of

cohort moving out of area.

BHFT really engaged and working well with WPH ED Team and

patient cohort

Governance arrangements implemented

Cohort agreed and attendance trackers in place

CCGs asked to contact NHSE as CQUIN requires consent for

management plans to be in place whereas RCEM guidelines

recommend patient engagement and consent should be sought but

is not an absolute, as management plans are key to supporting

patients in seeking right care in the right place.

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

89 of 201P

UB

LIC B



Effective - Mortality and morbidity – key measures & messages


In-hospital mortality and summary hospital-level mortality indicator (SHMI)

KEY: Higher than expected Within expected range : 90 - 110 (overall and non-elective)

70 - 130 (elective) Lower than expected

Well-led Activity

Key messages


Mortality

SHMI trust wide is as or below expected

Elective SHMI at HWP remains high

Training in next quarter will support reviewing clinicians

All elective deaths are reviewed by the M&M or

SI process as appropriate, there is no single

theme.

Potentially

avoidable deaths These are published quarterly. Q2 will be published in December

All are investigated by the SI process. Themes of

learning will be circulated in the Q2 safety report

15/16 16/17 Oct-16 Nov Dec Jan-17 Feb Mar Apr May Jun Jul-17 Aug Sep Oct-17 YTD Target Threshold

Potentially avoidable deaths

Total deaths reviewed New 262 309 292 259 None

Deeper review New 71 71 69 56 None

Total number of deaths

considered to have been

potentially avoidable where

RCP score <=3 (definitely,

strong evidence or probably

avoidable)

New 4 2 2 in

arrears TBC

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

90 of 201P

UB

LIC B



Effective – CRAB morbidity – key measures & messages


Key messages


CRAB data

Medical triggers are improving on both sites. The coded data is now

accurate up to October. Therefore this reduction is likely to be

indicative of real improvement

Overall mortality and complications for surgery are as or below

expected. There has been a rise in O/E ratio above 1.25 for surgical

complications on the Frimley site which is currently being investigated

Continued surveillance approaching winter

The result of this examination will be reported in

February 2018

*The final data point may be subject to change due to late reported data

Medical

practice

trigger

trends *

Surgical

complications *

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

91 of 201P

UB

LIC B






Stroke *

% of patients admitted directly

to the stroke unit in 4 hours 66% 72% 82% 68% 55% 83% 80% 83% 76% 78% 81% 77% 70% 84% 76% 78% >=80% <72%

% of patients scanned within 1

hour of arrival 58% 64% 71% 63% 69% 71% 71% 67% 76% 65% 55% 58% 66% 62% 60% 64% >=50% <45%

% of patients receiving a

swallow screen within 4 hours

of arrival 75% 81% 89% 63% 84% 87% 86% 81% 80% 81% 77% 84% 80% 79% 76% 80% >=90% <80%

Cardiology

% of eligible patients receive

treatment; call to balloon within

150 minutes

93% 92% 96% 86% 90% 90% 66% 96% 95% 100% 94% 84% 96% 96% in arrears 94% >=85% <80%

Trauma and orthopaedics

% fractured neck of femur

patients meeting best practice

criteria

87% 83% 83% 74% 77% 82% 74% 52% 75% 69% 75% 66% 66% 62% in arrears 66% >=65% <55%

% fractured neck of femur

patients going to theatre within

36 hours

87% 89% 85% 90% 90% 86% 71% 77% 90% 77% 83% 93% 69% in arrears 80% >=90% <80%

Critical care

Critical care non-clinical

transfers out of the trust New 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 None

Theatres

Compliance with the WHO

surgical safety checklist New 99% 99% 99% 98% 98% 98% 98% 98% 99% 99% 99% 100% 99% 99% 99% >=95% <90%

Obstetrics

Caesarean section rate

(planned & unscheduled) 26% 26.9% 27% 32% 28% 27% 29% 27% 29% 30% 27% 26% 27% 29% 29% 28% <=25% >27%

Emergency C-section rate New 14% 15.2% 17.1% 13.9% 13.1% 15.9% 13.4% 14.7% 15.2% 14.2% 13.5% 13.8% 13.5% 14.3% 14.1% <=14.0% >15.0%

Still births over 24 weeks New 41 2 4 4 4 6 4 1 3 2 3 1 4 3 21 None None

Emergency readmissions

Emergency re-admissions

within 30 days following an

elective or emergency spell

7.0% 6.9% 6.7% 7.1% 6.5% 7.2% 6.5% 7.1% 7.2% 6.9% 6.9% 7.0% 7.2% 6.2% in arrears 6.9% <=6.8% None

* Stroke data is for FPH only as the unit at Wexham Park was decommissioned during 2016/17

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

92 of 201P

UB

LIC B



Caring - Key measures (1)



Local Surveys *

1. Overall did you feel you were treated with

respect and dignity while you were in this

ward? 96% 96% 97% 96% 97% 96% 97% 97% 97% 98% 96% 97% 97% 96% 96% 97% >=95% <90%

2. Do you have confidence and trust in the

doctors treating you? 92% 93% 93% 91% 92% 93% 93% 93% 93% 95% 92% 94% 91% 92% 94% 93% >=95% <90%

3. Were you bothered by noise at night from

hospital staff? (percentage of patients saying

no) 87% 87% 87% 88% 90% 86% 87% 85% 88% 87% 89% 88% 88% 86% 87% 87% >=90% <80%

4. Were you ever bothered by noise at night

from other patients? (percentage of patients

saying no) 69% 66% 65% 59% 65% 63% 69% 77% 70% 73% 72% 67% 69% 69% 68% 70% >=80% <70%

5. If you needed it, did you get enough help

from staff with eating and drinking? 88% 90% 93% 92% 90% 88% 92% 92% 90% 95% 90% 95% 91% 85% 88% 91% >=90% <80%

6. Have you and your family or carers been

involved enough in discussing your discharge

from hospital? 70% 82% 84% 85% 77% 83% 86% 84% 85% 88% 84% 84% 82% 83% 86% 84% >=80% <70%

7. Were you involved as much as you wanted

to be in decisions about your care and

treatment? **** New 92% 91% 92% 91% 92% 92% 86% 87% 90% 84% 88% 83% 83% 85% 86% >=90% <80%

8. Within the first couple of days of admission

did a member of staff ask you about your

home situation? New 83% 82% 86% 83% 86% 86% 84% 87% 86% 88% 88% 89% 86% 89% 87% >=80% <70%

9. Did nurses talk in front of you as if you

weren‟t there? (percentage of patients saying

no) New New 89% 92% 94% 92% 95% 93% 92% 93% 93% >=95% <85%

10. Beforehand, did a member of staff explain

the risks and benefits of the operation or

procedure in a way you could understand? New New 86% 94% 93% 98% 95% 88% 90% 90% 92% >=95% <90%

Complaints

Number of complaints received ** *** 765 920 82 64 75 71 49 63 70 80 75 93 88 78 80 627 <=77 >88

Number of complaints per 100 patient contacts 0.00 0.07 0.07 0.07 0.08 0.07 0.04 0.06 0.06 0.07 0.07 0.09 0.08 0.07 0.07 0.07 <=0.07 >0.09

% of complaints answered within 25 working

days 60% 37% 29% 46% 33% 29% 8% 47% 64% 55% 48% 42% 47% 40%

in

arrears 49% >85% <70%

Number of complaints re-opened 71 97 8 10 5 11 9 2 12 11 11 13 12 9 11 81 <=8 >9

* Note all targets and thresholds have been reviewed and made more challenging for 2017/18, but have been applied retrospectively to 2016/17 as well

** provisional data for the reporting month

*** Annual targets are as follows: Number of complaints (923)

**** Note – this question last year was “Did the doctors clearly explain the treatment plan?”

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

93 of 201P

UB

LIC B



Caring - Key measures (2)



Patient Friends and Family Scores - What % would recommend this trust to friends and family if they needed similar care or treatment?

Emergency department - % positive 91.1% 91.0% 89.2% 91.5% 92.4% 93.1% 94.2% 94.5% 94.0% 91.3% 92.3% 92.9% 94.2% 93.5% 93.4% >=94.4% <89.1%

Outpatients - % positive 95.9% 96.3% 96.5% 95.5% 95.6% 96.4% 95.6% 96.2% 97.1% 96.5% 96.1% 97.0% 96.9% 97.0% 96.6% >=96.8% <94.6%

Inpatients - % positive 97.4% 97.5% 97.2% 97.1% 97.4% 97.6% 98.0% 97.7% 97.5% 97.3% 97.9% 97.3% 97.6% 98.0% 97.7% >=97.7% <96.4%

Maternity - % positive (of those

giving birth here) 96.7% 97.5% 95.3% 95.1% 95.3% 95.6% 97.5% 95.4% 98.4% 97.5% 94.3% 95.4% 96.3% 93.6% 96.4% >=99.0% <97.9%

Community - % positive 98.8% 98.6% 100% 100% 90.9% 100% 93.9% 100% 96.4% >=98.3% <97.0%

CQC inpatient survey

Overall satisfaction out of 10 (Q72) 8.30 8.30 >=8.40 <7.99

Mixed sex accommodation breaches

Mixed sex accommodation breaches 6 0 0 6 0 0 0 0 0 0 6 7 5 0 18 0 None

Dementia care - % of all admitted patients (75+) who :

Have been screened for Dementia

(within 72 hours) 95% 97% 96% 97% 99% 99% 99% 99% 100% 99% 100% 99% 99% in arrears 99% >=90% None

Scored positively on the dementia

screening tool that then received a

dementia diagnostic assessment

(within 72 hours)

97% 89% 97% 96% 96% 100% 100% 100% 100% 100% 100% 100% 100% in arrears 100% >=90% None

Received a dementia diagnostic

assessment with a “positive‟ or

“inconclusive‟ outcome that were

then referred for further diagnostic

advice/follow up (within 72 hours)

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% in arrears 100% >=90% None

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

94 of 201P

UB

LIC B



Responsive - Key measures



Diagnostics

Diagnostics waiting 6

weeks and over 87 49 42 27 224 87 49 76 40 40 44 48 29 32 26 None

% waiting 6 weeks and over

for a diagnostic procedure 0.8% 0.4% 0.4% 0.3% 2.3% 0.8% 0.4% 0.7% 0.4% 0.4% 0.4% 0.4% 0.3% 0.3% 0.2% <=1.0% None

Referral to treatment (RTT)

% waiting within 18 weeks 93.3% 92.6% 93.4% 92.2% 92.5% 92.2% 92.5% 92.2% 93.2% 92.8% 92.9% 92.3% 92.0% 92.2% 92.5% >=92.0% None

Incomplete

waiting list

Total 35470 36093 34879 34787 34430 35470 36093 36097 36694 36772 36587 37031 37315 36780 34912

Admitted 8145 7727 9182 8485 8294 8145 7727 7976 7904 8099 8407 8364 8633 8715 8762

Non-admitted 27325 28366 25697 26302 26136 27325 28366 28121 28790 28673 28180 28667 28682 28065 26150

Waiting 18 weeks and over

(backlog) 2775 2715 2288 2697 2582 2775 2715 2812 2489 2729 2692 2833 2985 2855 2608

Waiting 35 weeks and over 160 149 132 164 153 160 149 136 136 156 141 124 126 148 121

Waiting 52 weeks and over 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 None

Cancelled operations

Last minute cancelled

operations for non-clinical

reasons (% of elective

admissions)

0.9% 0.9% 0.9% 1.3% 1.1% 0.9% 0.7% 0.8% 0.8% 0.9% 1.2% 0.8% 0.7% 1.0% in arrears 0.9% <=0.8% >1.2%

% of cancelled patients

admitted within 28 days 93.3% 91.5% 92.3% 94.9% 92.5% 96.8% 79.2% 100% 95.0% 88.9% 91.0% 96.2% 100% 98.6% in arrears 95.2% 100% <90%

Delayed transfers of care

% of bed days lost due to

delays 3.5% 4.4% 4.8% 3.9% 4.7% 5.5% 6.5% 5.7% 6.3% 5.6% 5.4% <=3.5% >4.0%

Number of patients delayed

at the end of each month 305 395 63 53 72 60 65 55 53 66 64 74 89 84 62 547

Emergency department

% admitted or discharged

within 4 hours 94.7% 91.6% 91.3% 88.7% 84.7% 91.2% 91.4% 92.3% 90.2% 91.3% 91.5% 90.4% 90.7% 94.2% 91.4% >=95.0% None

% of all ambulance

handovers taking longer

than 60 mins?

0.8% 1.2% 1.1% 1.3% 2.1% 0.5% 0.3% 0.1% 0.5% 0.2% 0.5% 0.4% 0.4% 0.1% in arrears 0.3% <=1.0% >2.0%

Number of patients

spending >12 hours from

decision to admit to

admission

12 4 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 None

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

95 of 201P

UB

LIC B



Responsive – Cancer – Key measures


Nov-16 Dec Q3 Jan-17 Feb Mar Q4 Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov-17 Target

Cancer

2 week waits – urgent

GP referrals 96.2% 96.3% 95.9% 95.6% 97.9% 96.8% 96.8% 95.6% 96.4% 96.4% 96.2% 96.8% 95.6% 95.5% 96.0% 96.5% in arrears >=93%

2 week waits - Breast

symptomatic referrals 95.8% 96.8% 96.8% 97.2% 97.1% 97.0% 97.1% 95.8% 96.2% 95.7% 95.9% 97.5% 95.1% 96.9% 96.5% 94.7% in arrears >=93%

31 day wait for first

treatment 100% 99.5% 99.7% 98.5% 100% 100% 99.5% 98.9% 99.2% 97.8% 98.6% 99.6% 100% 100% 99.9% 99.3% in arrears >=96%

31 day wait

for second or

subsequent

treatment

Surgery 100% 100% 100% 100% 100% 100% 100% 100% 100% 96.9% 98.8% 100% 100% 100% 100% 96.6% in arrears >=94%

Anti-

cancer

drugs 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98.2% 99.3% 100% in arrears >=98%

62 day wait for first

treatment 90.3% 92.6% 89.7% 87.9% 89.0% 91.0% 89.3% 90.2% 92.6% 92.8% 91.9% 95.7% 94.5% 93.2% 93.3% 94.0% in arrears >=85%

62 day wait for

screening patients 100% 100% 100% 95.9% 100% 100% 98.2% 100% 97.0% 97.1% 97.8% 94.2% 100% 98.1% 97.5% 100% in arrears >=90%

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

96 of 201P

UB

LIC B



Responsive – Cancer 62-day waits standard by tumour group


Nov-16 Dec Q3 Jan-17 Feb Mar Q4 Apr May Jun Q1 Jul Aug Sep Q2 Oct Nov-17 Target

Brain/CNS NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

in

arrears >=85%

Breast 100% 100% 100.0%

(77.5/77.5) 100% 100% 100%

100%

(65/65) 94.1% 100% 89.4%

94.7%

(62.5/66)

100.0

% 100% 100%

100.0%

(78/78) 100%

Childrens NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Gynaecological 83.3% 50.0% 78.3%

(9/11.5) 75.0% 100% 88.9%

91.3%

(10.5/11.5) 77.8% 88.9% 100%

86.4%

(9.5/11) 75.0% 100% 100%

89.3%

(12.5/14) 87.5%

Haematological 85.7% 100% 83.6%

(23/27.5) 75.0% 76.5% 100%

81.8%

(13.5/16.5) 90.9% 100% 100%

96.6%

(28.5/29.5)

100.0

% 75.0% 100%

92.3%

(12/13) 85.7%

Head & Neck 100% 66.7% 76.9%

(5/6.5) 100% 100% 81.8%

88.2%

(7.5/8.5) 100% 75.0% 100%

93.3%

(7/7.5)

100.0

% 60.0% 77.8%

81.0%

(8.5/10.5) 80.0%

Lower GI 100% 79.2% 93.0%

(33/35.5) 100% 100% 89.2%

95.1%

(39/41) 90.9% 84.6% 100%

92.1%

(35/38) 93.3% 93.3% 90.0%

92.0%

(34.5/37.5) 90%

Lung 75.0% 90.0% 74.2%

(11.5/15.5) 75.0% 100% 72.7%

82.6%

(19/23) 75.0% 86.7% 86.7%

84.2%

(16/19) 88.9% 100% 76.5%

86.5%

(16/18.5) 100%

Sarcomas 0.0% NA 25.0%

(0.5/2) 66.7% 100% 100%

83.3%

(2.5/3) 100% NA 100%

100%

(1.5/1.5)

100.0

% 100% NA

100%

(1/1) 100%

Skin 100% 91.9% 97.1%

(68/70) 96.4% 100% 96.9%

97.6%

(82/84) 100% 92.3% 100%

96.9%

(63.5/65.5)

100.0

% 97.6% 100%

99.0%

(97.5/98.5) 95.7%

Upper GI 50.0% 87.5% 81.8%

(13.5/16.5) 66.7% 100% 100%

81.6%

(15.5/19) 66.7% 81.8% 90.9%

80.7%

(23/28.5) 85.7% 80.0% 100%

86.0%

(18.5/21.5) 92.3%

Urological 82.4% 95.2% 83.3%

(80/96) 84.0% 75.9% 82.6%

80.5%

(93/115.5) 88.0% 94.7% 87.5%

90.5%

(86/95) 96.6% 94.7% 87.1%

92.4%

(73/79) 92.5%

Other 100% 100% 100.0%

(5/5) 0.0% 100% 0.0%

20.0%

(0.5/2.5) 100% NA 0.0%

66.7%

(1/1.5)

100.0

% 0.0% NA

25.0%

(0.5/2) 50%

Total 90.3% 92.6% 89.7%

(325.5/361.5) 87.9% 89.0% 91.0%

89.3%

(345.5/386.5) 90.2% 92.6% 92.8%

91.9%

(332/361.5) 95.7% 94.5% 93.2%

94.2%

(351/372.5) 94%

Cancer – 62-day referral to treatment standard – over 104 day waiters

Number of

patients waiting

over 104 days 11 10 7 5 3 3 3 2 2 3 2 4 2

% of patients

waiting over 104

days 0.6% 0.7% 0.5% 0.3% 0.2% 0.2% 0.2% 0.1% 0.1% 0.2% 0.1% 0.3% 0.1% 0%

Half numbers are where a patient has been referred here for treatment from another provider or vice versa; the patient is shared between providers

The additional figures provided for the quarters are the number of patients treated within the 62-day standard out of the total number of patients treated for that tumour group

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

97 of 201P

UB

LIC B



Well-led – Workforce Key measures (1)

Safe Effective Caring Responsive Well-led Efficiency / Finance Activity


Staff numbers

Staff in post FTE 90182 93395 7839 7831 7921 8003 8011 8062 8081 8066 8038 8079 8121 8113 8138 None

Vacancy FTE 11539 10096 757 797 801 609 649 706 779 867 819 922 983 890 904 None

Starters FTE 1189 1564 97 81 225 192 94 118 87 71 115 85 129 111 101 None

Leavers FTE 1135 1197 75 103 95 87 132 102 80 101 111 102 102 116 75 None

Turnover

Turnover rate % 14.8% 14.6% 14.5% 14.7% 14.4% 14.6% 15.0% 15.1% 15.7% 15.1% 14.9% 14.8% 15.0% 15.0% 15.1% N/A <=14.5% >15.0%

Nursing turnover rate % 16.9% 14.6% 14.4% 14.4% 14.0% 14.3% 14.3% 14.6% 15.1% 15.0% 14.9% 14.8% 15.0% 14.1% 13.9% N/A <=15.0% >16.0%

Executive team turnover (definition

TBC) New 0 1 0 0 1 0 0 0 0 2 None

Time to recruit

Time to recruit from date vacancy

created to date of unconditional

offer (days) New 53.9 47.6 50 52.6 64.1 48.7 50.5 53.4 55.5 52.7 48.7 52.2 58.4 51.3 <=40 >50

Vacancy

Vacancy rate - total % 11.9% 10.2% 9.2% 9.7% 9.8% 7.4% 8.8% 8.5% 9.3% 10.2% 9.7% 10.8% 11.4% 10.9% 10.5% <=11.5% >13.0%

Vacancy rate – doctors % * New New <=5.0% by Q3 >5.5%

Vacancy rate – nurses % New 15.4% 13.9% 13.9% 15.8% 15.3% 14.3% 14.0% 15.7% 17.1% 18.0% 17.7% 17.7% 15.5% 15.0% <=14.5% by Q3 >15.5%

Agency spend

Agency spend as % of pay bill 9.9% 7.7% 7.2% 8.0% 8.4% 7.3% 6.3% 5.6% 5.7% 5.9% 6.0% 5.3% 6.0% 5.2% 4.8% <=8.0% >10.0%

Agency spend – total (£000s) ** 40705 30473 2397 2626 2830 2483 2137 1886 1917 2036 2012 1789 2042 1764 1658 15104 <=1917 >2013

Agency - doctors (£000s) *** 17375 12656 995 1113 1333 1052 557 911 794 1018 958 792 1068 836 778 7155 <=898 >988

Agency - nurses (£000s) 13534 8490 617 556 724 582 619 604 465 406 485 492 550 524 452 3978 None

Agency - other (£000s) 9796 9327 785 957 773 849 961 371 658 612 569 505 424 404 428 3971 None

Sickness

Sickness absence rate % 3.0% 2.9% 2.9% 3.2% 3.3% 3.0% 2.8% 2.9% 3.0% 2.9% 2.8% 2.9% 3.1% 3.1% 3.1% <=2.9% >3.2%

* On-going reviews with finance are being undertaken to ensure the establishments reflect the actual position trust-wide; data will be available as soon as possible

** The agency spend total is a control target based on an annual total target of £23m or £1.917m per month

*** Agency spend for doctors – the target is based on an overall reduction in spend of £1.88m for 2017/18

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

98 of 201P

UB

LIC B



Well-led – Workforce Key measures (2)


Appraisal rates

Appraisal (non-medical) % * N/A N/A 79% 48.4% 48.8% 55.3% 54.8% 56.2% 56.9% 58.2% 61.8% 60.7% 61.6% 60.6% N/A >=80.0% <70.0%

Appraisal (medical) % N/A N/A 97.7% 97.4% 96.9% 97.2% 98.3% 98.6% 98.1% 97.2% 97.2% 98.1% 98.4% 96.9% 95.6% N/A >=95.0% <85.0%

Training

Statutory and mandatory

training % ** N/A N/A 52.9% 55.0% 62.3% 64.2% 66.7% 68.2% 68.9% 73.7% 72.8% 73.3% 76.5% 77.7% N/A >=85.0% <60.0%

Friends & family test for staff

% recommending here as a

place to work N/A N/A 67% *** 71% 73% 69% in arrears

Q1, 2, 4

>=70%

Q3 >= 66%

Q1, 2, 4 <62%

Q3 <62%

% recommending here as a

place for care N/A N/A 77% *** 88% 89% 88% in arrears

Q1, 2, 4

>=86%

Q3 >=76%

Q1, 2, 4 <79%

Q3 <70%

NHS staff survey

NHS staff survey -

engagement score

(definition TBC)

New 3.91 3.91 >=3.87 <3.79

* The data up to December 2016 has been taken from the staff friends and family test, where a question has been added to assess appraisals undertaken in the previous 12 months; data

after this is sourced from the electronic staff record (ESR)

** Work continues to standardise the electronic staff record (ESR) trust-wide from which this data is taken

*** Friends and family test (FFT) replaced by National Staff Survey in Q3; the question is worded slightly differently “If a friend or relative needed treatment, I would be happy with the

standard of care provided by this organisation”. Note the target and threshold for Q3 is based on the National Staff Survey results; Q1, 2 and 4 are based on FFT results


6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

99 of 201P

UB

LIC B



Well-led – Efficiency Key measures



Outpatients

Did not attend (DNA)

rates 6.5% 6.8% 6.9% 7.8% 7.3% 6.5% 6.3% 6.5% 6.7% 7.2% 7.3% 7.3% 7.3% 6.9% 6.9% 7.0% <=7.6% >10.2%

Outpatient new to

follow-up ratios 2.16 2.03 2.03 2.05 2.00 1.98 2.04 2.00 2.03 2.04 1.93 1.97 2.02 1.92 1.94 1.98 <=2.41 >3.59


Elective length of stay 2.53 2.53 2.53 2.53 2.47 2.58 2.50 2.69 2.96 2.55 2.67 3.11 2.85 2.61 2.42 2.73 <=2.77 >3.59

Non-elective length of

stay 4.10 4.05 3.96 4.01 4.20 4.28 4.19 4.25 4.10 4.13 3.97 3.96 4.01 4.04 3.82 4.03 <=3.91 >5.05

Day case rate

% day cases of all

electives 81% 81% 82% 81% 83% 82% 81% 81% 82% 82% 82% 82% 83% 83% 83% 82% >=80% <70%

Theatre utilisation

Intra-session theatre

utilisation rate 73% 73% 74% 73% 73% 74% 73% 74% 73% 74% 73% 71% 74% 74% 74% 73% >=85% <70%

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

100 of 201P

UB

LIC B



Well-led - Finance Key measures


Year to Date (Month 08) Forecast Outturn

Plan £m Actual £m Variance £m Target Threshold Plan £m Actual £m Variance £m Target Threshold

Income 435.5 436.9 1.4 See EBITDA 658.3 657.7 (0.6) See EBITDA

Expenditure 402.6 403.4 (0.8) See EBITDA 604.1 603.0 1.1 See EBITDA

EBITDA (income

less expenditure) 32.9 33.5 0.6 0.0 (0.2) 54.2 54.7 0.5 0.0 (0.25)

Financing costs 20.7 20.5 0.2 0.0 (0.2) 31.4 31.7 (0.3) 0.0 (0.25)

Net / surplus

deficit 12.2 13.0 0.8 0.0 (0.2) 22.8 23.0 0.2 0.0 (0.25)

CIPs 20.5 18.3 (2.3) 0.0 (1.0) 30.5 28.7 (1.8) 0.0 (1.0)

Cash balance 72.0 84.6 12.6 0.0 (3.5) * 67.1 86.9 19.8 0.0 (6.0) *

Capital

expenditure 58.6 32.0 (26.6) 0.0 (1.0) ** 96.9 80.0 (16.9) 0.0 (0.5)

Figures in brackets indicate an adverse position

* Cash balance - threshold is cumulative at £0.5m per month , given material variances are correlated to STF payments

** Capital expenditure – timing differences / slippage in-month can mean the month threshold is lower than for the forecast

Well-led Activity

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

101 of 201P

UB

LIC B



Benchmarking – selected measures (1)

Safe Effective Caring Responsive Efficiency / Finance Activity

Safe Effective

Caring

NOTE – for each graph, the position furthest to the left is the best performing trust

Data periods: VTE = Q2 2017/18; SHMI = Sept 2016 – Aug 2017; ED FFT, Inpatient FFT, Maternity FFT

(friends & family test) = Oct 2017; Dementia = Q2 2017/18

Well-led

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

102 of 201P

UB

LIC B



Benchmarking – selected measures (2)

Responsive

Workforce

NOTE – for each graph, the position furthest to the left is the best performing trust

Data periods: A&E (4 hour target) = Nov 2017; RTT (incomplete pathways) = Oct 2017; Diagnostic test waits = Oct 2017; Cancer = Q2 2017/18; Staff FFT

(friends & family test) = Q2 2017/18; Staff turnover = Sep 2017


6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

103 of 201P

UB

LIC B



Activity


15/16 16/17 Nov-16 Dec Jan-17 Feb Mar Apr May Jun Jul Aug Sep Oct Nov-17 YTD YTD %

change

GP and general dental practitioner referrals to all outpatients

NHS North East Hants and

Farnham 40777 42415 3573 2954 3414 3175 4023 2970 3593 3791 3526 3441 3320 3541 3483 27665 -4%

NHS Slough 37444 41494 3637 3253 3577 3232 3871 3246 3768 3693 3717 3626 3570 3582 3236 28438 3%

NHS Windsor, Ascot and

Maidenhead 31293 33292 2880 2586 2899 2702 3065 2426 2875 2927 2853 2780 2786 2753 2650 22050 0%

NHS Bracknell and Ascot 19019 19567 1673 1335 1663 1686 1764 1454 1638 1602 1747 1734 1725 1796 1690 13386 2%

NHS Surrey Heath 17106 17534 1515 1172 1264 1208 1513 1202 1435 1426 1406 1410 1332 1350 1265 10826 -13%

NHS Chiltern 13931 14542 1261 1095 1204 1161 1429 1116 1259 1201 1236 1230 1247 1226 1240 9755 1%

Other CCG's 15846 16417 1377 1073 1373 1303 1432 1239 1410 1466 1304 1274 1257 1372 1303 10625 -5%

Total GP/GDP referrals 175416 185261 15916 13468 15394 14467 17097 13653 15978 16106 15789 15495 15237 15620 14867 122745 -2%

% change on previous year 8% -1% 6% -6% 7% -14% 4% -1% 7% 1% -4% 1% -7%

Outpatient attendances

New attendances 276653 294862 26578 21791 25018 23192 26715 22145 25820 25889 25188 24534 24141 26385 26534 200636 1%

Follow-up attendances 598902 598138 53825 44624 50011 45813 54607 44337 52503 52879 48574 48365 48764 50770 51446 397638 -1%

Total OP attendances 875555 893000 80403 66415 75029 69005 81322 66482 78323 78768 73762 72899 72905 77155 77980 598274 0%

% change on previous year 5% -3% 5% -5% 14% -8% 7% 3% 4% -3% -7% 3% -3%

Emergency department (ED) attendances

ED attendances (total) 230609 237509 19752 19713 19458 17357 20403 19209 21147 20339 20686 19251 19468 20149 19811 160060 0%

% change on previous year 3% 4% -1% -7% -2% 2% 2% 2% -4% -1% -3% -1% 0%

Non-elective admissions

Non-elective admissions (total) 104023 109236 9475 9425 9072 8014 9322 8522 9312 8883 9230 8734 9104 9262 9537 72584 -1%

% change on previous year 9% 4% 0% -7% -1% -2% 1% -4% -3% 1% -2% -2% 1%

Elective admissions

Daycase 64340 67810 6188 5030 5855 5407 6024 4862 5920 5587 5474 5340 5346 5840 6213 44582 -2%

Overnight 15567 15413 1363 1143 1221 1199 1411 1124 1306 1245 1184 1164 1128 1221 1264 9636 -8%

Regular day attenders 15820 15897 1477 1176 1377 1250 1537 1322 1525 1516 1424 1434 1313 1376 1422 11332 7%

Total elective admissions 95727 99120 9028 7349 8453 7856 8972 7308 8751 8348 8082 7938 7787 8437 8899 65550 -1%

% change on previous year 14% -2% 6% -3% 13% -11% 11% 1% 0% -2% -10% 2% -1%

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

104 of 201P

UB

LIC B



Activity - ED attendances and emergency admissions (FPH)


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

change


NHS North East Hampshire &

Farnham 51725 4383 4110 4253 3678 4469 4244 4650 4518 4695 4190 4306 4361 4359 35323 0%

NHS Surrey Heath 25195 2105 2100 2035 1860 2087 2044 2243 2203 2185 2124 2108 2077 2094 17078 0%

NHS Bracknell & Ascot 19325 1675 1569 1650 1362 1727 1523 1701 1728 1689 1536 1674 1778 1733 13362 3%

Other 18406 1534 1561 1442 1357 1558 1513 1619 1657 1811 1600 1627 1675 1594 13096 5%

Total 114651 9697 9340 9380 8257 9841 9324 10213 10106 10380 9450 9715 9891 9780 78859 1%

% change on previous year 3% 2% 0% -8% -3% 3% 4% 5% -1% -1% -1% 0% 1%

Emergency department (ED) attendances - by priority

Majors 52496 4271 4428 4547 3860 4389 4177 4486 4399 4712 4433 4336 4354 4244 35141 0%

Resuscitation 8211 713 729 720 592 583 643 624 629 686 721 672 705 767 5447 -3%

Paeds 28424 2232 2175 2139 2003 2415 2555 2744 2785 2671 2632 2548 2376 2246 20557 4%

Minors 24989 2436 1975 1898 1768 2416 1878 2306 2236 2255 1604 2120 2388 2464 17251 2%

Not recorded 531 45 33 76 34 38 71 53 57 56 60 39 68 59 463 36%

Emergency admissions

NHS North East Hampshire &

Farnham 18191 1521 1578 1558 1328 1520 1328 1475 1535 1619 1501 1503 1586 1588 12135 -1%

NHS Surrey Heath 8696 712 764 760 603 721 692 731 715 737 691 751 691 740 5748 -2%

NHS Bracknell & Ascot 7541 627 600 672 480 661 580 629 639 672 610 673 732 760 5295 3%

Other 7078 561 640 571 553 644 550 611 576 674 584 556 569 561 4681 0%

Total 41506 3421 3582 3561 2964 3546 3150 3446 3465 3702 3386 3483 3578 3649 27859 0%

% change on previous year 0% 1% 1% -13% -8% -8% -2% -1% 2% 4% -1% 0% 7%

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

105 of 201P

UB

LIC B



Activity - ED attendances and emergency admissions (HWP)


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

change


NHS Slough 51,401 4,320 4,272 4,275 3,770 4,508 4,066 4,527 4,205 4,272 3,917 4,008 4,389 4,213 33,606 -2%

NHS Windsor, Ascot &

Maidenhead 27,077 2,220 2,256 2,243 2,080 2,284 2,091 2,377 2,239 2,119 2,060 2,109 2,221 2,188 17,411 -4%

NHS Chiltern 28,348 2,346 2,422 2,417 2,186 2,545 2,305 2,491 2,344 2,405 2,346 2,431 2,372 2,471 19,169 3%

NHS Bracknell & Ascot 1,730 132 139 154 103 119 153 142 138 134 109 157 153 139 1,126 -7%

Other 14,302 1,037 1,284 989 960 1,106 1,270 1,397 1,305 1,376 1,369 1,048 1,123 1,035 9,923 -3%

Total 122,858 10,055 10,373 10,078 9,099 10562 9,885 10,934 10,231 10,306 9,801 9,753 10,258 10,046 81,214 -2%

% change on previous year 3% 5% -1% -6% -2% 1% 0% -1% -7% -2% -4% -2% 1%

Emergency department (ED) attendances - by priority

Majors 63624 5352 5443 5616 5242 5795 5366 5987 5644 5698 5734 5677 5843 5649 45598 9%

Resuscitation Included in Majors

Minors 30616 2232 2424 2227 1832 2051 2225 2296 2255 2274 2313 1819 1896 1850 16928 -28%

Paeds 28618 2471 2506 2235 2025 2716 2294 2651 2332 2334 1754 2257 2519 2547 18688 11%

Emergency admissions

NHS Slough 16,845 1,578 1,489 1,409 1,232 1,462 1,364 1,515 1,355 1,397 1,263 1,400 1,422 1,525 11,250 1%

NHS Windsor, Ascot &

Maidenhead 12,570 1,186 1,097 1,022 1,001 1,067 931 1,096 984 944 986 990 1,045 1,086 8,059 -3%

NHS Chiltern 11,594 1,089 1,082 1,020 920 1,069 945 1,015 928 944 982 1,026 938 1,104 7,884 6%

NHS Bracknell & Ascot 909 82 69 81 65 76 68 96 64 68 46 76 85 67 571 -7%

Other 3,125 264 288 236 205 246 260 286 287 279 293 258 257 262 2,180 -11%

Total 45,043 4,199 4,025 3,768 3,423 3,920 3,568 4,008 3,618 3,632 3,570 3,750 3,747 4,044 29,944 0%

% change on previous year 21% 9% 3% 1% 6% 5% 11% -1% -5% 2% -1% -5% -4%

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

106 of 201P

UB

LIC B



Appendix A – Methodologies & glossary

Appendix A


6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

107 of 201P

UB

LIC B



Appendix A – Methodologies for calculating the measures

Measure name Numerator Denominator

Length of stay Total number of bed days occupied

Excludes private patients

Excludes daycases

Based on admission method, split

between elective (from a waiting

list) and non-elective admissions

(includes emergencies and

obstetrics)

Total number of discharges in the

period

Expressed as a proportion

Measure is consistent with

that reported on HED

(benchmarking service)

Readmissions Emergency readmissions to any

specialty following an elective or

non-elective spell

Readmission length of stay must be

at least 1 day ie an overnight stay

Readmission occurs within 30 days

of previous discharge

Total number of discharges

(completed spells) in the period prior

to the last 30 days


that used by CQC

Daycase % Total number of admitted spells

where the intended management

was daycase, they were admitted

electively (off a waiting list) and

their spell length of stay was 0 days

Total number of elective spells

(admitted off a waiting list) Expressed as a percentage


6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

108 of 201P

UB

LIC B



Appendix A – Methodologies for calculating the measures

Measure name Numerator Denominator

Outpatient new

to follow-up

ratio

Number of follow-up outpatient

attendances for all referrals and all

appointment types (consultant and

non-consultant led). Includes ward

attenders and private patients

Number of new outpatient

attendances

Expressed as a ratio where

one new attendance results

in “n” follow-up attendances




Outpatient

DNA rates

Number of outpatient appointments

where the patient did not attend.

Includes all referrals and all

appointment types (consultant and

non-consultant led). Includes

private patients

Number of outpatient attendances

plus the number of appointments

where the patient did not attend

Expressed as a percentage




Falls resulting

in significant

injury (rate per

1000 beddays)

Falls recorded on Datix resulting in

moderate or severe harm or death

Total number of occupied beddays

(including daycases)

Divided by 1000

Expressed as a rate


6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

109 of 201P

UB

LIC B



Appendix A - Glossary

Term Meaning

CCG Clinical Commissioning Group

CIP Cost Improvement Plan or Programme

CoSRR

Continuity of Services Risk Rating As from 1st October 2013 Monitor‟s new Risk Assessment Framework replaced the old Compliance Framework. Part of

the change saw the Financial Risk Rating (FRR) being replace by the Continuity of Services Risk Rating. This measure is

designed to describe the risk of a provider failing to carry on as a going concern. The scale is rated from 1 to 4 with 4

being „No evident concerns‟ and 1 being „Significant Risk‟

CQUIN Commissioning for quality and innovation

CRAB CRAB (Copeland‟s Risk Adjusted Barometer) is based on the POSSUM scoring system

EBITDA Earnings before interest, tax, depreciation and amortization

FHFT Frimley Health NHS Foundation Trust

FPH Frimley Park Hospital

HW Heatherwood Hospital

HWP Heatherwood and Wexham Park Hospitals

POSSUM Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity

WX Wexham Park Hospital

YTD Year-to-date


6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

110 of 201P

UB

LIC B


Frimley Health NHS FT Board of Directors Page 40

[Copyright information needs to go here]

Xxxxxxxxxxxxxxxxxxxxx

150315-230733-KN-UK

6

Tab 6 C

hief Executive's R

eport and Quality &

Perform

ance Report

111 of 201P

UB

LIC B


Page | 1

Report Title

Frimley Health NHS Foundation Trust Quality Improvement Plan as at October 2017

Meeting

Board of Directors

Meeting Date

January 2018

Agenda No.

7.

Report Type

To advise the Board of Directors on the progress against the Frimley Health NHS Foundation Quality Improvement Plan

Prepared By

Debbie Barrow Governance Manager

Executive Lead

Dr Timothy Ho Medical Director

Executive Summary

Attached is the Frimley Health Quality Improvement Plan which was reviewed and agreed at the meeting of the Trustwide Quality Committee in November 2017 The Quality Improvement Plan describes the key quality and patient safety risks identified for Frimley Health and the actions that are being taken to mitigate those risks, current work streams in progress and further work required. Progress against the Improvement Plan is monitored on a monthly basis by the Frimley Health Quality Committee.

Background

The Trust Quality Committee coordinates and monitors the implementation of the responsive actions being taken by the organisation in relation to quality and provides assurance to the Board that the quality agenda is being embedded in line with the quality strategy, and that performance is measured and monitored.

Issues / Actions

• The Trust has recently held a CQC Workshop where the Chiefs of Service, Associate Directors and members of the nursing teams were asked to consider the the key strengths and risks/weaknesses for the organisation against the 5 CQC domains (safe, effective, caring, responsive & well-led).

• The risks/weaknesses identified are to be reviewed against the Trust Quality Improvement Plan to ensure that these have been recognised and appropriate actions being taken

Recommendation

The Board of Directors is asked to review the progress against the action plan, to agree the priority areas of concern and trajectories for achieving compliance

Appendices

Quality Improvement Plan December 2017

7

Tab 7 Quality Improvement Plan


FRIMLEY HEALTH NHS FOUNDATION TRUST

Quality Improvement Plan

as at December 2017

Ragging Key:

Achieved/on target/progress

made

In progress but some challenges

Significant difficulty, poor

progress

Action achieved, closed

Page 1

7

Tab 7 Q

uality Improvem

ent Plan

113 of 201P

UB

LIC B


Site

Recommendation &

Current Risk Rating Actions

Target

Completion

Date

Director

Lead(s) Manager

Monitoring

Committee Actions / Current Status

Frimley

Health

Recruitment & Retention

Continue to improve staffing

recruitment and retention

The Trust has put in place a robust

recruitment plan and this is

monitored regularly by Directors

and reported monthly to the Board.

The Trust will continue to actively

recruit and retain staff using all

tools and resources possible. National undersupply of qualified clinical

staff is resulting in high vacancy rates

and over reliance on agency staff.

Specific risks in the following

occupations:

*Band 5 Staff Nurses (General)

*Theatre nurses & ODP's

*Paediatric Nurses

*Sonographers

*Radiographers

Medical Roles:

1. Paediatrics – middle grade

2. Anaesthetics – middle grade

3. Trauma and orthopaedics – junior and

middle grade

4. Acute medicine – junior, middle grade

and consultant

5. Care of the Elderly – junior, middle

grade and consultant

6. Respiratory Consultant

7. Urology Consultant

8. Dermatology Consultant

8. ED - junior and middle grade

Q4 17/18 Director of

HR &

Corporate

Services /

Director of

Nursing

Deputy

Director of

Nursing

(WPH) /

Assistant

Director of

Resourcing

Workforce

Committee

November update: Overall nursing vacancy rate has fallen (from

14.7% to 11.6%) in the last couple of months due to high number of

students recruited in September and October. We are also seeing

the number of nurses from the Philippines (70 still in the pipeline)

starting with the trust increasing, which will further reduce

vacancies going forward. Between Jan - Oct 2017 we have recruited

43 consultants (25 at FP and 18 at WP) and 49 trust/middle grade

doctors (31 at FP and 18 at HWP) a 15% increase compared to the

same time last year. There has been a focus in recent months to

appoint to positions currently being filled by high cost locums in

specialties such as Gastroenterology and Dermatology so to reduce

agency spend. Following a discussion at the Board in September the

Trust has produced a corporate retention plan and will be engaging

with management and clinical teams to develop this plan further.

December update: Nursing: • Strong performance in regards to

nurse recruitment activity (154 nurses recruited in three months

(Aug-Oct 17)) with the overall Trust vacancy rate decreasing from

14.9% in July to 11.2% (15.9% at HWP and 7.2% at FP) in October. •

Also evidence that turnover has decreased with an average of 31

nurse leavers per month so far in 2017 compared to 34 in 2016. •

We are also now starting to see a steady flow of Philippine

candidates starting with the Trust. 68 remain in the pipeline and we

expect an average of 10 to start each month • A further trip to the

Philippines has been booked for May/June with Drake and we are

also exploring skype interviews from Australia and New Zealand

with them • There are changes to the way that we are inducting

internal nurses from December with a new ‘boot-camp approach’

being adopted. International nurses will only

Quality Committee Quality Improvement Plan

as at December 2017

7

Tab 7 Q

uality Improvem

ent Plan

114 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


be able to start on one Friday of each month and will have at least 4

weeks extensive training (at Apollo ward at Heather wood) so

support completion of OSCE before they start on the wards

Doctors

* Between Jan - Oct 2017 we have recruited 43 consultants (25 at

FP and 18 at WP) and 49 trust/middle grade doctors (31 at FP and

18 at HWP) a 15% increase compared to the same time last year.

We are also working with a new recruitment agency (MSI) to recruit

ED/middle consultants from Qatar. So far from Qatar we have 2

Specialty Doctors starting in ED FPH in Dec 2017 and 2 Specialty

docs in ED WPH in January.

Retention:

Since the board update in October we have completed the

following:

• Sent out detailed data from the exit questionnaires and 100 day

survey to management and clinical teams

• Produce a draft retention action plan (draft attached will be

discussed at next Workforce Committee) – many of these actions

are now underway but we need to prioritise and review resource

requirements

• Held a stakeholder event with ward sisters to discuss local issues

and gain feedback on action plan and what can be done locally7

Tab 7 Q

uality Improvem

ent Plan

115 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Frimley

Health

E D M S

Consider the size and

organisation of paper health

records

This will remain an ongoing

piece of work until such time

as all of the records become

electronic as part of the EDMS

project. Until that time we are

continuing to split records

each month to meet the size

requirement.

EDMS programme over the next 2

years within pilot specialities due to

go live in June 2016


Ops (WPH)

Head of

Nursing and

General

Manager

Outpatients

OPD HCG 24/07/2017 - All clusters now live and project is in closedown. The

revised scanning strategy means that the Trust will be operating

with a mix of paper (legacy) and digital (day forward) records for

the forseable future. Outstanding issues to be addressed re:

consent and speicality specific proformas

September update: The Trust is not planning on digitising all legacy

records beyond those required for space saving benefits. Legacy

notes will remain available on demand or at the request of the

clinician. All current and future activity documentation is now being

digitised

October update: This space saving should be achieved my mid 2018

at the latest where we will revert to scanning current episode

information only. The Programme Board has approved the

preparation of an internal scanning hub to provide a service tailored

exclusively to the needs of the Trust, which may influence the

comments referenced above. Trust has an ambition to implement

the use of electronic forms with the Evolve application to reduce

spend on externally printed stationary and scanning costs. Current

focus on OPD forms.

December update: We continue to shelf clear at Frimley and

Heatherwood to free the space. eForm work is also progressing

with the first forms now live. Availability of forms will increase and

therefore the amount of original paper notes will decrease. The

programme Board is exploring all options to ensure the digitisation

of records happens as quickly and safely as possible.

7

Tab 7 Q

uality Improvem

ent Plan

116 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Frimley

Health

Medical Staffing Out of Hours

/ Use of Agency

To ensure early identification of

potential gaps in medical

staffing cover out of hours and

minimise the use of agency

staff

Each speciality to review medical

staffing model and make

recommendations to mitigate

forthcoming expected gaps in junior

doctor rota

Q3 17/18 Medical

Director

Deputy

Medical

Directors FPH

& WPH

Workforce Committee sub-group will brief all Directorates in early

April regardng the need for a Workforce Plan template to be

completed, including likely need for changes in the future.

Directorates to present their Workforce Plan at the meeting in

September

Spend being moniored by Speciality

Speciality meetings considering vision for workforce

Rotas changed

HCAs and non clinical support staff being used in surgery

New Temporary Workforce approval process for all medical bank &

agency staff developed by HR/Deputy Medical Directors/Directors

of Operations. Introduced at beginning of October, email from CEO

to all AD's & CoS to launch new process

7

Tab 7 Q

uality Improvem

ent Plan

117 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Frimley

Health

Deteriorating Patient:

To ensure all clinical staff have

the right skills & tools to

recognise & deliver timely

treatment to the deteriorating

patient

Learning from SIs and M&M

Reviews to be incoporated into

training programmes

Ongoing Medical

Director

Lead Nurse

for

Deteriorating

Patient

Resuscitation

Committee

Continues to be a theme arising from Morbidity & Mortaility

reviews and serious incidents - November update: ONGOING

March update: Learning from SIs is shared and disseminated via

Directorates and incorporated into ongoing training programs

including November update: ALERT AND ESCALATE

In depth review of recent cluster of SIs relating to deteriorating

patient to be undertaken. Learning from avoidable deaths - led by

Trust lead for Mortality & Morbidity, report to Board in October 17

Marked improvement in Cardiac Arrest Audit, FHFT now at 30.60%

against national average of 20% patients that survive a cardiac

arrest in hospital and go home

November update: Introduction of Adult Deteriorating patient study

day with assessment called ESCALATE (october 2017) DONE

New plan for improving compliance with mandatory training for

resuscitation being developed. November update: ONGOING BUT

ACTIONED.

December update: Resus team now part of Patient Safety team.

Improvement in compliance in Resus training stats, Adult Level 1

66% against target of 85%. Focus over next 6 weeks targetting

compliance with Paediatric Resus training.

2 Band 7 posts approved and staff seconded

Electronic observations to be a priority as part of IT Strategy

Observational review of compliance

with Hospital at Night arrangements

to be undertaken regarding

implementation and effectiveness

of night-time handover

Q2 17/18 March update: Deputy Medical Director and Chief of Serivce for

Medicine currently to undertake an Observational audit

Medical & Deputy Medical Directors to attend clinical handover to

observe compliance and agree further actions. November update:

No change

7

Tab 7 Q

uality Improvem

ent Plan

118 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Frimley

Health

Sepsis

To implement the new NICE

guidelines for recognition and

Management of Sepsis (NG51)

Monitor compliance of the Sepsis

Screening Tool through quarterly

audits

Ongoing Medical

Director

Head of

Patient Safety

Sepsis

Committee

On HWPH site compliance remains a challenge, weekly ward audits

undertaken by the matrons which has improved compliance plus 2

sepsis study days with a 3rd planned 29/6.

Both sites have well embedded and attended monthly sepsis

meetings and all wards have nominated sepsis champions. June

update: Quarterly audits continue, training and education in place.

July update: Sepsis bundle distributed cross-site July 17. To be

attached to obs equipment to promote screening

Audit findings shared at Quality Committee & nursing forums

September update: To review Sepsis bundle and update in line with

new Sepsis Guidelines launched September 17

October update: NICE guidelines have been released. Advanced

Nurse Practitioner for Critical Care to attend national meeting w/c

2/10 to see a national tool is released. If not then agreement of a

revised tool will occur. In the meantime, strong message to clinical

matrons regarding screening and 2 sessions for the FY1 is being

provided by the Consultant Lead. Aim to ratify new bundle by the

end of October and implement in November.

Business case for 2 x Band 7 Deteroiorating Patient lead for each

site to cover AKI & Sepsis approved

Sepsis bundle being agreed, launch date 27/11/17

December update: The bundle was agreed at the Quality

Committee in November and launched across Frimley Health on

27th November. Audit of compliance will continue. The 2 band 7

posts will be advertised once signed off by finance.

7

Tab 7 Q

uality Improvem

ent Plan

119 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Frimley

Health

Do Not Attempt Resuscitation

To ensure there is evidence

that DNAR decisions have been

appropriately discussed & and

are displayed in the medical

records (at the front)

To review new national guidance

(ReSPECT)

Q4 17/18 Medical

Director

Lead Nurse

for

Deteriorating

Patient

Resuscitation

Committee

Dr Kelvin Wright now Consultant lead for DNAR.

▪ National Guidance (Respect) currently under review, to be rolled

out as part of the End of Life care planning

June Update: First ReSPECT workshop held in May. Cross-site

DNACPR policy at June HEB.

Frimley Health DNACPR policy ratified at HEB. CRoss ite DNACPR

form currently under consultation November update: Ongoing new

form out for consultation. To be audited in Q4. December update:

Resus team now part of Patient Safety team

8. Improvement in compliance in Resus training stats, Adult Level 1

66% against target of 85%.

Frimley Park Emergency Pressure

To ensure quality of patient

care through patient flow

Ongoing Director of

Operations

AD for

Medicine

Unscheduled

Care

November update: ambulatory care now open 7 days a week and

activity levels being monitored. Business case completed with NEHF

for GP(s) to work on frailty unit. Successful recruitment to middle

grade rota in ED and new starters will be joining the team between

now and Feb 18.

December 2017: additional ambulance line handover nurses to be

rostered, ESI streaming continues, paediatric emergency flow being

reviewed in light of high attendances and higher acuity currently

presenting

WPH Emergency Pressure

To ensure quality of patient

care through patient flow

Ambulatory Care majors streaming commenced in ED January 2017.

▪ ESI started 20/04/17.

▪ New medical model launched in ED March 2017.

▪ The Urgent Care Steering Group has been re-launched

August 2017 - GP works on G6 acute frailty unit every Friday to

encourage discharge and liaison with primary care

August 2017 - Joined acute frailty network & has been successful in

securing short term national funding

December 2017: GPs to be employed in Frailty Unit are being

recruited, frailty identification tool in place for emergency

attendances and admissions, ERS@H now working weekends in ED

to facilitate discharges

To reduce avoidable admissions

through Ambulatory Care pathways

and review the threshold for

admission by implementing a

dynamic response from primary

care, social care and community

services to support pts at home.

7

Tab 7 Q

uality Improvem

ent Plan

120 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Frimley

Health

Discharge planning is a

Transformation Workstream

supported by the Project

Management Office (PMO),

currently developing prioritised

action plan with ‘quick’ wins and

long term actions to be taken


Nursing /

Director of

Operations

Transformation

Group

Heads of

Nursing

June update: IRIS 'huddle' twice a week in place for NEH&F ICTs to

share information on 'known' patients to facilitate early discharge

planning. Work underway to engage with Berks & Surrey SPA.

Training on electronic systems completed for NEH teams. An IG

solution is required for Berks/Surrey teams

2 Deputy Directors of Nursing will be leading discharge groups on

both sites with focus on delayed discharges and transfers to

community teams

Discharge Groups established on both sites.

November update: Safer Discharge Bundle being implemented as

first priority In regards to the discharge planning workstream –

SAFER Workshop is being held on 3rd November.

December update: Further workshop focusing on review &

management of stranded patients held in November, changes made

in delay reasons list, with a plan to be able to pull a medically fit list

from Real time.

To review the management of

private funding for nursing home

care and support families who are

privately funded


Operations

Matron -

Patient Access

Urgent Care

Board

Funding has been agreed by CCG and lead in post

but being used by CCG for other purposes. Director of Ops resolved

Social worker to manage and work with private funders to reduce

delays & expedite decision making, evoking CHOICE protocol where

appropriate

Nursing homes to participate have yet to be identified

June update:

Funding has ceased for this post . Work underway to identify a way

forward. Job Description written for new position of Private funding

discharge co-ordinator. KPI’s and metrics being collated with

options being explored for new position

Trusted assessors scheme in place to reduce emergency admissions

and discharge back to care homes

November update: Trusted assessors scheme is on-going with

additional homes being added. Private funders JD has been written.

December update: JD Currently being banded Trusted assessor

meeting to held 30/11 to review current process and feedback from

all involved.

Discharge Planning

To ensure there is a robust

discharge planning process in

place to reduce patients’ length

of stay, pressure on hospital

beds and patient readmission

7

Tab 7 Q

uality Improvem

ent Plan

121 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Observational review of compliance

with Hospital at Night arrangements

to be undertaken regarding

implementation and effectiveness

of night-time handover

Q3 17/18 Medical /

Nursing

Directors

WPH Deputy

MD

Quality

Committee

Different levels of maturity on each site, more embedded at

Wexham Park Hospital

Discussed at Critical Care Delivery Group and all Chiefs of Service

asked to support attendance at night-time handover to ensure

patient safety and priorities are aligned throughout the night

Medical Director & Deputy Medical Director on FPH site to liaise

with Chief Registrar to format a plan moving forward

June update: FPH Chief Registrar had several meetings with ICU,

currently H@N at FPH meeting involves medical team and NNP. Site

and bed managers attend briefly to give update. Surgery do not

attend, ICU attend workload permitting.

October update: Obs & gynae WPH day to night + night to day

handover trialling Safety SBAR model

Meetings arranged with key stakeholders to discuss handover

process between day to night in order to identify how handover can

add value for all participants.

November update: WPH obs and gynae new safety sbar handovers

to be re-auditted in jan, interim feedback positive.

Review weekend handover

plans/documents to identify

consistent approach

Q3 17/18 Su2S Matron Quality

Committee

July-17 multiple audits and QI projects being run by junior doctors

from different specialities to create clearer weekend handovers

plans from specialities. Learning from each project to be brought

together to create a single consistent approach.

December update: John Seymour contacted re:review and

standardisation of current documents used across medical

directorate.

Frimley

Health

Clinical Handover

To ensure consistency in both

medical and nursing handover

arrangements & ownership

7

Tab 7 Q

uality Improvem

ent Plan

122 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Frimley

Health

Consent / Local Safety

Standards for Interventional

Procedures

To ensure appropriate checking

processes are in place for

patients undergoing invasive

procedures undertaken outside

of Theatres

Recommendations to be considered

from national guidance NHS

England Patient Safety Alert re:

Supporting the introduction of the

National Safety Standards for

Invasive Procedures published,

actions to be taken by September

2016 (progress with

implementation)

Sep-16 (The

Trust will be

expected to

demonstrate

progress

made with

implementat

ion by 14th

Sept. The

deadline for

developmen

t of all

LocSSIPs is

still to be

confirmed

by NHS

England)

Medical

Director /

Director of

Nursing

Deputy

Medical

Director (FPH)

Quality

Committee

July - theatres and maternity LocSSIPs are completed and being

actioned with new WHO forms being implemeted.Vascular access

LocSSIP is in second draft stages and being sent out for comment.

Intentionally retained product pathway is currently being reviewed

as to how to encorporate the documentation within the patient

notes. Paediatric pregnancy testing is being developed by the pre-

op matrons in conjunction with the paediatric wards. Cross site

development of the emergency department LocSSIPs is underway

and the resus team are working on a flashcard for use in emergency

invasive procedures.

October update: To undertake audit of compliance with WHO

surgical safety checklist for interventional procedures undertaken

outside of the Theatre environment

7

Tab 7 Q

uality Improvem

ent Plan

123 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Review consent documentation and

procedures & implement new

process

Q3 17/18 Consent Policy

&

Implementation

Group

October update: Awaiting proofs of Obs & Gynae consent forms,

volumes agreed for each procedure. Communications gone out to

Obs & Gynae staff regarding forms. Excellent engagement from

COS & HON. Meeting with contacts at WPH to discuss introducing

forms. Orthopaedic procedures; Hallux valgus, THR, tennis elbow

and TKR; engagement with 3 consultants on these procedures.

November update: Electronic consent ; further discussion with

Medical Director regarding e-Consent, on-going investigations

regarding options. Consent Policy; Exiting policy is currently being

reviewed and revised. Plan to create a Trust Wide policy. Obs &

Gynae; 6 consent forms, first proofs approved, advised OK to print

waiting for delivery! Next step is to roll out at Wexham with

support from COS and Head of Midwifery. Orthopaedics; first draft

of procedure specific consent forms for TKR, THR & Knee scopes

with Consultant for review. Fantastic engagement from Obs &

Gynae and some Orthopods.Struggling with engagement for

Urology at Wexham December update: Electronic Consent: e-

consent discussions and investigations continue. Consent audit to

commence December. Obs & Gynae; Consent forms now in use.

Excellent engagement with Wexham, minor adjustments to be

made to the forms, but first drafts available shortly. Orthopaedics;

Second draft of procedure specific consent forms for Total Knee

Replacement, Total Hip Replacement and Knee scopes with

Consultant for review. Challenges around engaging with Urology at

Wexham escalated. New, procedure specific consent form for

Orthodontics at Wexham rolled out. New, procedure specific

consent form for Endoscopy ready for ratification by Consent

Committee.

7

Tab 7 Q

uality Improvem

ent Plan

124 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Review current patient information

with particular focus on risks and

benefits to support the consent

process for high priority

Q3 17/18 Consent &

Implementation

Group

The guidance for developing and managing information leaflets is

currently being reviewed and will be ratified via the Trust Consent

Committee.

April update: Obs & Gynae leaflets for top 5 procedures currently

being updated in line with current guidance, as part of phase one.

June update: Gynae have set up at tracking system for monitoring,

reviewing and updating patient information. All Gynae PIL will be

looked at in due course.

Both Chairs of Consent Groups via Deputy Medical Directors to

explain actions being taken

September update: Obs & Gynae consent forms on order.

Orthopedic procedures identified and work has commenced on

formatting prepolulated consent forms. PIL has been gathered for

review. Meeting with Urology at Wexham to discuss procedures for

review. October update: PIL for; Hallux valgus, total hip

replacement, tennis elbow and total knee replacement under

review.

November update: Gyane Patient Information Group continues to

review and update PIL. Review of Orthopaedic PIL on-going. Funding

for Knee and Hip information packs previously in circulation has

now ceased due to cost. Alternatives options to be explored.

December update: Review of Orthopaedic PIL on-going 7

Tab 7 Q

uality Improvem

ent Plan

125 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Frimley

Health

Cancer Pathways

To improve the number of

patients treated within the 62

day cancer target and to

reduce the number of patients

whose diagnosis and treatment

takes longer than 104 days

To improve cancer patient

experience and rationalise

referral pathways

Ensure appropriate

videoconferencing facilities are in

place

Q3 17/18 Directors of

Operations

CIO Cancer Board

Executive Board

Trust Board

Request made again to Informatics. August update: business case

in development by IT. Top Team have not agreed funding, issues

continue to arise March update: Top Team approved the outfit of 4

rooms in Dec 16. Currently out to procurement at this time

Plan in place, currently out to tender.

October update: Implementation of the 4 rooms approved in phase

1 to start Oct and will take about 6-8 weeks to complete the work.

(dependent on furniture orders, room set up, that are outside IT

control).

November update: Installation schedule underway.

December update: Delays occurred in finalising the contract which

is due to be signed off imminently. An initial kick off meeting will

take place with the Video Conferencing (VC) supplier within 10 days

of the contract being signed and the activity of work will be planned

out to deliver VC starting in January 2018.

7

Tab 7 Q

uality Improvem

ent Plan

126 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Frimley

Health

Management of Patients with

Mental Health Issues &

Learning Disabilities

To review with mental health

colleagues the increase in

number and complexity of

patients with with mental

health needs

The Trust should ensure that staff

have clarity around accountability

and Duty of Care when managing

patients sectioned under the MHA

including the use of restraint


Nursing

Deputy

Director of

Nursing FPH

Specialist Simulation training to be provided for key stakeholders

including security team

Awareness

Meeting held with MAYBO to discuss how to provide security staff

with next level restraint training

Maybo proposal for simulation training to be sustained through

train-the-trainer

Rapid Tranquilisation Policy in draft

Consultant Psychiatrist now delivering Rapid Tranqulisation training

and Broadmoor training

Maybo Level II training undertaken by all Security staff on both sites

'Managing Challenging Behaviour' incidents roles & responsibilities

in-house awareness video being developed

On-line roll out anticipated end June 17, dependent on SIM suite

availability

June update:

In-house training video filming has commenced. Paediatric scenario

roll out expected by end of July. Delay caused by availability of SIM

suite & clinicians

Paediatric senario filming completed.

The Trust should ensure that any

patient detained under section 2 of

the MHA with a high risk of

absconding, self-harm and previous

suicidal attempts must be escalated

and addressed by the senior nursing

staff if a RMN or a 1:1 specialist

cannot be provided. All patients

requiring 1:1 supervision should

receive a daily assessment of their

requirement and priority for 1:1care


Nursing

Assoc Director

for Site

Management

All patients sectioned under the Mental Health Act are now

highlighted & discussed at the Bed Management Meetings

Policy approved at Nursing & Midwifery Board, now at

implementation stage

Policy to be reviewed in August 17

Discussions with Commissioners & Mental Health providers around

Paediatric Mental Health pathway

Adults ongoing

CAMHS commissioning issues being addressed with Berkshire

Healthcare

Education video under development

7

Tab 7 Q

uality Improvem

ent Plan

127 of 201P

UB

LIC B


Site

Recommendation &


Target

Completion

Date

Director

Lead(s) Manager

Monitoring


Frimley

Health

Seven Day Services

To ensure that all specialities

meet the 4 key clinical

standards required as being

'must do' by 2020 in terms of

providing a 7-day service

including:

* patients wait no longer than

14 hours to initial consultant

review

* patients get access to

diagnostic tests with a 24-hour

turnaround time, for urgent

requests (12 hours) and for

critical patients, one hour

* patients get access to

speciality, consultant directed

interventions

* patients with high-

dependency care needs receive

twice-daily speciality

consultant review, and those

patients admitted to hospital in

an emergency will experience

daily consultant-drected ward

rounds

From last national audit of 7-day

services the Trust benchamarked

well against peers & nationally but

below target, actions to be taken

include:

*Audit findings to be analyzed by

site to see where key issues lie

*To review and improve access to

diagnostics at WPH, i.e

echocardiography and MRI out of

hours

*To reinforce the requirement to

Document name & seniority of

clinician to provide around who is

reviewing patient and when

Q3 17/18 Medical

Director

Deputy

Medical

Directors FPH

& WPH

Quality

Committee

March update: We have raised awareness of standards and are

using a poster pull-up to endorse these.

▪ National audit now underway.

Overall achieved better than national average for most indicators

Directors of Ops to review audit findings and develop gap analysis

November update: September audit now underway, results will be

shared when published.Sept

December update: Audit completed internal analysis underway.

Results will be sent to the Deputy Medical Directors for review once

analysed.

7

Tab 7 Q

uality Improvem

ent Plan

128 of 201P

UB

LIC B


Page | 1

Report Title

National Adult Inpatient Survey 2016 Review and Action Plan Update

Meeting

Public Board

Meeting Date

5th January 2018

Agenda No.

8.

Report Type

For information

Prepared By

Angela Ballard, Head of Patient Experience

Executive Lead

Duncan Burton, Director of Nursing

Executive Summary

Patient experience is a key priority for all NHS organisations whether they are delivering care or monitoring the effectiveness of that care. Working together to improve patient experience is a priority for Frimley Health NHS Foundation Trust. The Trust recognises feedback from all sources is key in the design and delivery of care.

Background

Patient Experience in its entirety is monitored through the bimonthly Patient Experience Forum, with changes being led by the directorates making improvements directly to frontline care. This report details performance against the National Adult Inpatient Survey 2016, Emergency Department Survey 2016 and the Children and Young Adult Survey 2016 and changes in practice as one part of the patient experience overview.

Issues / Actions

Issues •The Trust is measured as “about the same” as all other Trusts in England in the inpatient national survey

• The Trust made improvement in a number of questions compared to 2014 National Childrens and Young Peoples survey

• The Trust measured “about the same” as other Trust in the national Emergency Survey 2016

Actions • Directorates have developed local action plans to achieve the Trust’s ambition of delivering outstanding patient experience by 2020

Information/ Recommendation

• Preliminary 2017 National Inpatient Survey Results will be available in January

2018 • Implementation of a new aligned Patient Experience and Quality & Clinical Audit

IT Solution will take place in early 2018

Appendices

Nil

8

Tab 8 In patient survey and action plan (6 month review)


Page | 2

1.0 Background The Care Quality Commission (CQC) use surveys to find out what people think of the NHS healthcare services that they use. The results help assess NHS performance. The CQC use them for regulatory activities such as registration, monitoring ongoing compliance and reviews. The Adult Inpatient Survey takes place on an annual basis. This survey looked at the experiences of 77,850 people who received care at an NHS hospital in July 2016 and the results were published on 31st May 2017. The survey included patients aged 16 years or older, who had at least one overnight stay but excluded patients whose treatment related to maternity or, patients admitted for planned termination of pregnancy, day case patients, and private patients (non-NHS). The National Emergency Department and Children and Young People’s Survey results were published in October 2017 and take place every 2 years and were last undertaken in 2014. The CQC National Maternity Survey 2017 will be published on the CQC in January 2018 and this survey will now run on an annual from 2018. These results show how trusts performed on individual questions in the survey. The technique used to analyse these results allows the CQC to identify which trusts they can confidently say performed 'better', 'worse' or 'about the same' when compared with other trusts. 2.0 Frimley Health Results Between August 2016 and January 2017, a questionnaire was sent to 1,250 recent inpatients at each of the trust sites. Responses were received from 562 patients at Frimley Health NHS Foundation Trust. The results which can be found here http://www.cqc.org.uk/provider/RDU/survey/3 demonstrate that in all areas Frimley Health was “about the same” when compared to other Trusts The National Children and Young Peoples Inpatient/Day case Survey 2016 had a 32% response rate with 764 parents/children responding to the questionnaire and the results were significantly better than they were in 2014. The National Emergency Survey which was undertaken in September 2016 sent 1,250 questionnaires Responses were received from 358 patients across the Trust. The results demonstrated that Frimley health was about the same when compared to other Trusts. Results available online All data and further reports are available via our online reporting system and can be found here http://www.cqc.org.uk/provider/RDU/survey/3 In order for the Trust to understand the results further an additional 1250 patients were surveyed and the results have allowed the clinical teams to develop action plans based on the information. Improvement themes were identified such as discharge, communication and consent. These triangulate with other patient experience data such as themes from Complaints and PALs and the Friends and Family Test qualitative feedback. 3.0 Ambition The long term ambition is for Frimley Health to deliver outstanding patient experience and ensure that our patients report that we perform “better” than other Trusts for at least 10 of the questions by 2020. The next survey was undertaken in July 2017 and the Trust will get the preliminary results in early 2018.

8



http://www.cqc.org.uk/provider/RDU/survey/3

http://www.cqc.org.uk/provider/RDU/survey/3

Page | 3

4.0 Action to Date The local results were shared with the Executives, Associate Directors, Chiefs of Service and Heads of Nursing. Each directorate has developed an action plan that consists of short and longer term objectives. These are monitored formally via the Patient Experience Forum. It should also be noted that actions to improve patient experience across the Trust have been on-going subsequent to the July 2016 survey. The team have introduced monthly review of the real-time data with the Heads of Nursing and quarterly ward reviews. 4.1 General Overarching Actions Update

•Results shared with directorate ADs/CoS/HON, meetings offered with Patient Experience Team to support analysis and action planning

•Article in Inform in June •Discussed at Nursing & Midwifery Board and weekly HON meetings

•Request for item to be added to Clinical Governance meeting agendas

•Workshop planned for January 2018 to present and review the 2017 results.

Raising Awareness

•Review of all realtime survey questions and updated from April 2017

•Monthly ward dashboards review of realtime results and quarterly ward meetings

•Implementaion of the agreed business case for the alignment of a single provider for the realtime patient experience survey across all sites

Realtime Results not reflective of national survey results

•Consent audit results and the patient survey results at consent workstream committees on both sites. The consent lead is writing to all the chiefs of service and has offered to do a presentation for the specialists.

Consent

8



Page | 4

4.2 Examples of General Overarching & Directorate Action Plan Updates October 2017 Directorate Improvement Theme Action Completed General Surgery & Urology

Consent/Communication • New emergency pathway patient information leaflets in place at FPH

• Shared with WPH June 2017 • Overarching – Consent group

implemented at WPH. FPH enhanced and refocused at FPH

Discharge • All staff in Short Stay Surgical Unit at FPH wearing “Ask Me about your Discharge” badges

• Medication Launch planned for telephone follow up service for emergency laparotomy patients post discharge

Pharmacy Discharge • Medicines Information helpline offered at FPH – additional copies of information leaflets ordered. Exploring resources to extend helpline to HWP patients

Communication • In progress with review of pain patient information leaflet for side effects to look out for

Gynaecology Noise at Night • Availability of eye masks and ear plugs reviewed and offered during the night time medication round.

Theatres & Anaesthetics

Communication • Escalation policy for overnight patients and admission criteria for review with Director of Operations (HWP)

Improving Mealtime Experience

• Ward kitchen installation completed July 2017

Trauma & Orthopaedics

Discharge • T&O discharge advice process approved at Clinical Governance – leaflet in place

• Get up and Go national leaflets in place

Communication • Involving patients in bedside handover and encouraging discussion of any concerns revisited with ward staff by Matron

• “My Hip Fracture Care 12 questions to ask” widely used and given to patients and their families by Orthogeriatrician on first review

General Medicine Discharge • Implementation of the discharge pack in August 2017 across medicine

• The introduction of a business card for any question/queries post discharge.

Noise at Night • Audit of availability of eye masks and ear plugs undertaken at FPH – actions taken to address issues

• Mobile phone and TVs turned off at set times to promote quiet nights

Generic Food • New food service changed and Protected Mealtimes embedded at HWP sites

• Implemented traffic light system for

8



Page | 5

food trays at HWP to ensure patients requiring assistance at mealtimes are easily identifiable and reviewed during peer review

Volunteers • Launched policy for Volunteers • Role profiles aimed at meeting the

needs of the Trust to improve patient and staff experience.

• Introduced pharmacy runners to reduce waiting times for medications on discharge. Evaluation at WPH has shown a reduction in the waiting time for drugs. The average pre-volunteer for collection was 68 minutes, whereas with the volunteers it drops to 44 minutes.

• Chaplaincy volunteers have been developed to provide emotional support and recently has seen the development of a mindfulness volunteer at FPH

• Work on Volunteer Strategy is in progress with support of NHS Elect

End of Life Care (EOLC) • “No one dies alone” volunteer project development and volunteers have been recruited

• First Trust EOLC conference took place in September 2016

• Change in line management of Bereavement Services WPH by Lead Chaplain to ensure seamless process for families and carers

• Work is continuing with integrated community teams at FPH

• EOLC dashboard development to be monitored through Quality Committee

• Established a Trust wide sign to respect privacy and dignity at end of life of a purple lily to be placed on the outside of the door or curtain

Discharge • Cross site Discharge Policy developed • Implementation of SAFER discharge

bundle • Integrated Referral and Information

Service (IRIS) Models of Care – implement on both sites

• Strategy Discharge group implement on both sites lead by the deputy directors of nursing

• Pharmacy prescribers implemented in areas with high patient turnover with more in training

• Paediatric trained nurse appointed to assist with complex discharges from Ward 24 WPH

• Discharge teams implement to support individual wards at WXPH

8



Page | 6

Emergency Department

Improve communication and waiting times

• The HWP ED introduced a paging system in September 2017

• A new waiting time board which is updated every 30 mins to raise awareness for patient attending the ED implemented July 2017

• Review of the ED reception at HWP to remove the glass panels in order to improve communication undertaken in Oct 2017

• Review of the streaming process implemented in Oct 2017 to improve communication and inform patient of waiting times on booking into the department.

5.0 For information/recommendation Implementation of the New Patient Experience and Quality & Clinical Audit IT Solution will be

implemented by the new supplier in early 2018 which will provide consolidation and alignment of the system and processes across the Trust.

There will be a Trust Wide workshop in early January 2018 to review the 2017 National Inpatient survey results

8



1

Report Title

Month 08 Finance Report to The Board of Directors

Date of Meeting Friday, 5th January 2018 – (to be completed by Company Secretariat) Agenda Number

9.

Report type To receive assurance on the current and forecast financial position of the Trust

Prepared by Edward John (Director of Operational Finance) / Hugh Cronshey (Assoc. Dir of Finance)

Executive Lead Nigel Foster (Director of Finance)

Executive Summary Month 08 shows a £0.8m surplus pre STF which is £0.5m adverse to plan. The Trust is at £6.3m adverse YTD*. There has been a significant improvement in clinical income compared to prior months. Private patient income has also improved slightly. Pay and non-pay spend continue, as ever, to be an area of concern. CIP mitigations identified at Month 04 are lagging behind required levels. Agency and bank costs are stable and within the NHSI cap but pay in total continues to be overspent and not reducing to required levels. The exceptional items booked in M03 of £5.4m plus the inclusion of type 3 A&E activity mean the STF finance element is achieved and for NHSI reporting purposes the Trust appears ahead of plan YTD*. CIP is at 93.5% delivery (89% YTD). The year end I&E forecast has been set to original NHSI plan based on a better income month and being able to identify additional mitigations to offset some of the in month variance and an expectation that the Trust will be forced to rely on further non-recurrent exceptional gains. * For reporting to NHSI a break-even ytd position is reported. This is because the original plan submitted in December 2016 had a level of unidentified CIPs that were prudently phased to be back ended but have since been identified and re-phased in budgets.

Background The Trust had set a budget of £22.8m surplus for 2017/18 against which this report is monitored. This surplus plan includes £18.6m of STF; £22.6m of DH support inc £6m of Cap-to-Rev, and assumes delivery of £30.5m of cost reduction CIP. The plan is to generate a surplus of £4.2m before STF. This report provides financial performance information in relation to the achievement of both the control total and key dependent indicators including CIP, Cash and Capital.

Issues and Options Cost containment is not delivering at expected levels and the underlying position is significantly behind plan (£5.6m ytd) The 2017/18 plan is also supported with significant non-recurrent deficit support of £16.6m plus capital to revenue transfer of £6m and one-off balance sheet adjustments of £5.4m.

Recommendation The Board is asked to note the month 8 financial position

Appendices Finance and Commercial Board Report: Note – all variance are reported against budgets and not original NHSI Plan.

9

Tab 9 F

inance Report - M

onth 8

135 of 201P

UB

LIC B


2

Finance & Commercial Board Report Financial Performance November 2017

9

Tab 9 F

inance Report - M

onth 8

136 of 201P

UB

LIC B


3

• The pre STF position is behind plan by £0.5m in month • A pre STF deficit YTD of £4.3m (£6.3m adverse) • Clinical income is £0.9m above plan: Uncoded spells dropped to £18m • Other income: Better in month but not significantly and PPU still behind YTD • Pay and non-pay are overspent by £1.9m in month - Agency and bank costs are in line with prior months - Farnham rents and EDMS high overspent items in non-pay • M08 STF of £1.9m accrued because of ytd position (due to stock adj M03) • Capex behind plan by £26m YTD and cash healthy at £85m • CIP was £2.5m 93% delivered (£18.3m 89% YTD)

M08 / year end at a glance

Underlying Position and forecast • I&E Forecast for the year is held to plan due to income improvement • Underlying position is still around £5-6m worse than budgeted plan • Control total still dependent on reducing cost base which is currently HIGH RISK • The A&E element of STF is assumed achievable due to type 3 activity

9

Tab 9 F

inance Report - M

onth 8

137 of 201P

UB

LIC B


4

Summary In M08 the Trust is £0.5 behind plan at £0.8m surplus (exc STF) and £6.3m behind YTD. Prior months exceptional items and STF mean bottom line in month and ytd is in surplus but this hides the underlying run rate issue on expenditure. CIP mitigations are still lagging. The year end forecast assumes delivery of control totals based on a better income month and being able to identify additional mitigations to offset some of the in month variance and anticipating reliance on further non-recurrent exceptional gains.

Area Key points Risks / Issues

Income • Clinical income is above plan but there remains a very high level of uncoded

episodes again this month (£18m). Other income including EDMS and Education has also performed well this month £0.5m better than plan.

• Income forecasts need to aligned asap to commissioner forecasts to reduce year end forecasting risk

Expenditure • Operational spend YTD is £6m over plan of £405m (excl. Integration) due mainly to

high pay costs (medical agency and a-hoc sessions). In month £1.9m overspent due mainly to non-pay variances inc EDMS £0.5m (matched by income), Farnham Rents £344k, IT Maintenance £182k

• Underlying costs significantly higher than plan

• CIP mitigations need constant emphasis and attention

Net surplus/ deficit

• The Trust is £6.3m adverse YTD against its set budget • one-off exceptional items mean the Trust is showing a positive variance on the

bottom line • STF achieved £1.9m for M08 because of the one-off benefits booked in Month 03

• CIP mitigations still lagging and must be recovered

CIPs • In month £2.5m delivery against a plan of £2.7m or 93% (YTD £18.3m 89%) • CIP is critical to the delivery of the

financial plan – mitigations need to be critically examined again

Cash balance • Cash closed at £84.6m a positive variance to plan of £12.6m due mainly to STF

payments received and Heatherwood Hospital capex slippage; forecast held at £86.9m or £19.8m above plan.

• None

Capital expenditure

• In month £5.3m behind plan of £9.4m (YTD £26.6m behind). Forecast is for a £16.9m underspend which is due to slippage on Heatherwood Hospital.

• None

9

Tab 9 F

inance Report - M

onth 8

138 of 201P

UB

LIC B


Income & Expenditure - Month 08 and Year to Date – Summary

5

Key messages: STF: The Trust failed to achieve the M08 control total and only just met the year-to-date target. However, unless there is a significant improvement in the financial position in M09 or other non-recurrent items are incorporated, the trust will not achieve the Q3 control total and will lose the £5.6m of STF for that qtr. Operating Income: Clinical income from Commissioners is £0.9m over plan, this reflects a strong in month performance. However, there is still some uncertainty, given the backlog of un-coded activity. The remainder of the over-performance is due to the release of income to cover high EDMS costs in month (£0.4m).

Operating Expenditure: The overspend of £1.9m is split between £0.6m on pay and £1.2m on non-pay. Both categories of are a deterioration from last month and are suggestive of an upward trend, most noticeably on non-pay, although pay-costs are their highest level for this financial year. Forecast: The forecast as at M08 has been held to plan however given the in-month performance, the recovery challenge has become harder and the risk of non-achievement of the financial target is that much greater. Please note: The phasing of the internal plan differs from the APR submitted to NHSI. This is largely due to the profile of the CIP plans and the profile of the budgets held in reserves.

Plan Actual Variance Plan Actual Variance Plan Actual Variance£m £m £m £m £m £m £m £m £m

Income 54.0 55.3 1.3 421.7 421.3 (0.4) 634.3 633.7 (0.6)Expenditure (50.0) (52.0) (1.9) (399.0) (405.1) (6.0) (598.7) (603.0) (4.2)Trust Financing (2.6) (2.6) 0.1 (20.7) (20.5) 0.2 (31.4) (31.7) (0.3)Net Revenue Surplus / (Deficit) 1.3 0.8 (0.5) 2.0 (4.3) (6.3) 4.2 (1.0) (5.2)

Exceptional Items 0.0 0.0 0.0 0.0 5.4 5.4 0.0 5.4 5.4Net Position 1.3 0.8 (0.5) 2.0 1.2 (0.8) 4.2 4.5 0.2

STF Funding 1.9 1.9 0.0 10.2 10.2 0.0 18.6 18.6 0.0Integration Funding 0.5 0.5 0.1 3.6 3.7 0.1 5.4 5.4 0.0Integration Costs (0.5) (0.5) (0.1) (3.6) (3.7) (0.1) (5.4) (5.4) 0.0Net Revenue Surplus / (Deficit) after one-off items

3.2 2.7 (0.5) 12.2 11.4 (0.8) 22.8 23.1 0.2

Frimley HealthCurrent Month Year to Date Full Year Out-turn

9

Tab 9 F

inance Report - M

onth 8

139 of 201P

UB

LIC B


Income & Expenditure - YTD month high level variances

6

Theme Key IssuesVariance M8

YTD £mIncomeCCG/NHSE Income Pass Through Drugs & Devices, Uncoded Activity at average prices 1.5Clinical Income Delayed commisioner funding for Clinical Schemes (Frality, Ambulatory Care) (0.1)Non CCG Income Private Patient, Overseas, RTA, Pharmacy Repackaging Unit (1.8)Corporate Income Car Park, Accomodation, EDMS Project, Catering (0.1)Total Income (0.5)PayMedical Pay Agency and Locum Costs above substantive Vacancy (2.9)Nursing & Ancillary Nursing underspends offset through HCA overspends (2.1)Prof/Tech & Scientific Agency Cover above vacancies (1.0)

Admin & Management Vacancies not all covered through bank/Agency3.0

Total Pay (3.1)Non PayDrugs Lower overall issues, mostly PbR Excluded, Higher FP10s 2.0Clinical Supplies Theatre items, some maintenance contracts (1.9)Other Non Pay Mostly Corporate Areas (Rates, Ulitilities, Maintenance, IM&T, ) (2.9)Total Non Pay (2.7)

Total Before Exceptional Items (6.2)

Excpetional Items Stocktake, Donated Assets 5.4STF Central Strategic Transformation Funding 0.0

Grand Total (0.8)

9

Tab 9 F

inance Report - M

onth 8

140 of 201P

UB

LIC B


7

Forecasted Outturn Refreshed:

As at M08, the Directorate forecast deteriorated £0.5m.

This is due to a worse than expected performance in month and the

recurrent impact on the rest of the financial year

Most of the mitigations identified in earlier months have been incorporated into the bottom up forecasts. But due to the deterioration in the financial forecast, the challenge over the remainder of the year has risen to £2.7m. This assumes that spend on WLI can outturn £0.5m below the forecast.

Sum of Annual Bud

Month 08 Likely Variance

Change from M07

1PAY 401,179 408,782 7,684 6142NON 233,906 230,334 (6,186) 1,1553INC (657,828) (657,321) 3,272 (1,092)TOTINT (78) 59 337 (123)Grand Total (22,820) (18,146) 4,674 553

MitigationsAdditional Stock (1,500) (1,500)WLI Restraint (500)Additional Mitigations Required (2,674) (2,674)Total (22,820) (22,820) 500

Year End Forecast (£000s)

9

Tab 9 F

inance Report - M

onth 8

141 of 201P

UB

LIC B


Expenditure Trend – Excluding Integration & Stock Adjustment

8

Non-Pay: This month has seen the highest recorded non-pay cost this financial year and is £1,150k higher than the previous month. The bulk of this increase is in non-clinical costs although some of this is non-recurrent and offset by income.

Pay: Pay costs have increased by £150k from the previous month and is the highest monthly cost this financial year. This increase is driven by employed staff costs rather than temporary staffing.

9

Tab 9 F

inance Report - M

onth 8

142 of 201P

UB

LIC B


9

I&E Month 08 – Subjective Analysis – Adj. to show impact of Exceptional Items Income: Clinical income from NHS commissioners was £0.9m over the in-month plan. Private Patients income showed an improved position in month and met its income target. The over-recovery on Other Operating Income relates to the release of EDMS funding, which offsets expenditure below. Pay: As noted already, pay costs this month were the highest in the financial year. The greatest increase being in nursing and across both sites and is £0.3m higher in month, when compared to the average for M01-M07 Agency costs are lower again for the second month running, bank costs are higher, however.

Non Pay: Non-pay costs continue to overspend and whilst some of this is related to patient activity, the biggest area of overspend is in Premises and Fixed Plant. Half of the overspend on that area of spend relates to EDMS and is offset by income. The rest of the in-month variances relate to continued overspend in off-site rental and the cost of IT maintenance contracts.

I&E by Subjective Heading Mth Bud £m

Month Act £m

Mth Var £m

YTD Bud £

YTD Act £

YTD Var £

IncomeIncome From Activities (48.93) (49.76) (0.83) (382.18) (382.14) 0.04Other Operating Income (5.09) (5.59) (0.50) (39.69) (39.27) 0.42Income Total (54.02) (55.35) (1.33) (421.87) (421.41) 0.46PayMedical And Dental 8.88 8.70 (0.18) 70.87 68.52 (2.35)Nursing & Midwifery 10.41 9.99 (0.41) 82.65 77.29 (5.36)HCAs & Other Support Staff 4.01 4.41 0.40 32.26 36.14 3.88AHPs, Prof, Scientific & Technical 4.37 4.23 (0.15) 34.89 33.02 2.37Agency Staff External 0.54 1.84 1.29 4.13 16.08 11.95Other Staff 5.17 4.81 (0.36) 41.82 38.65 (7.42)Pay Total 33.39 33.98 0.60 266.62 269.69 3.07Non-PayClinical Service And Supplies 9.60 9.90 0.30 77.55 77.39 (0.16)General Supplies And Services 0.79 0.87 0.08 6.42 5.91 (0.50)Premises & Fixed Plant 5.15 6.15 0.99 41.31 43.52 2.21Other Non Pay 3.74 3.65 (0.09) 27.98 29.16 1.17Non-Pay Total 19.29 20.57 1.28 153.25 155.98 2.72

Underlying Net Position (1.34) (0.79) 0.55 (1.99) 4.26 6.25Exceptional ItemsIncome from Donated Asset 0.00 0.00 0.00 0.00 (0.71) (0.71)Stock Adjustment (0.00) 0.00 0.00 (0.00) (4.73) (4.73)Net Impact of Exceptional Items (0.00) 0.00 0.00 (0.00) (5.44) (5.44)

Grand Total (1.34) (0.79) 0.55 (1.99) (1.18) 0.82STF Funding (1.86) (1.86) 0.00 (10.23) (10.23) (0.00)Net of STF (3.20) (2.65) 0.55 (12.23) (11.41) 0.82

9

Tab 9 F

inance Report - M

onth 8

143 of 201P

UB

LIC B


Notes: In this analysis adverse variances are shown as a positive number The budget shown in this schedule is the Trust’s internal plan. The exceptional items are recorded within CCG income and financing costs

Income & Expenditure Month 08 – Directorate Positions

10

The bulk of the overspend is in the clinical areas, although the YTD % variance has worsened for the Coporate areas from M07.

I&E by DirectorateYTD Bud

£mYTD Act

£mYTD Var

£mYTD Bud

£mYTD Act

£mYTD Var

£mYTD Bud

£mYTD Act

£mYTD Var

£mYTD Plan

YTD Total

YTD Var % Var

Directorate: ClinicalMedicine: Frimley 39.1 40.0 0.8 21.5 21.6 0.1 (1.1) (1.1) 0.0 59.54 60.47 0.93 1.56%Medicine: Wexham 36.6 38.2 1.7 15.4 15.6 0.1 (1.4) (1.1) 0.3 50.58 52.67 2.09 4.13%Orthopaedics & Plastics 15.0 15.6 0.5 7.7 7.2 (0.5) 0.0 (0.0) (0.0) 22.74 22.76 0.02 0.09%Paeds, Maternity & Gynae 32.0 32.2 0.2 3.8 4.0 0.2 (0.3) (0.5) (0.2) 35.49 35.72 0.23 0.65%Pathology 12.5 13.2 0.7 9.1 9.8 0.7 (3.4) (3.5) (0.1) 18.16 19.44 1.28 7.07%Private Patients 3.9 3.7 (0.2) 1.2 1.2 0.0 (7.3) (6.6) 0.7 (2.23) (1.71) 0.52 -23.38%Radiology 9.6 9.7 0.1 6.2 6.8 0.6 (0.3) (0.3) 0.1 15.46 16.23 0.77 4.95%Surgery 25.7 25.0 (0.7) 8.5 9.3 0.8 (0.8) (0.7) 0.1 33.43 33.63 0.20 0.59%Theatres, Crit Care & Anaes 30.6 31.6 1.1 8.3 8.2 (0.0) (0.1) (0.1) (0.0) 38.75 39.78 1.03 2.66%

Clinical Total 204.9 209.2 4.3 81.6 83.6 2.0 (14.6) (13.8) 0.8 271.92 279.0 7.07 2.60%Directorate: CorporateDirector of Integration 1.1 2.6 1.5 2.5 1.1 (1.4) (3.6) (3.7) (0.1) 0.00 0.00Finance & Strategy 9.3 9.2 (0.1) 3.6 5.2 1.6 (0.2) (1.4) (1.2) 12.67 12.94 0.27 2.11%HR & Corporate Services 17.8 17.8 (0.0) 16.5 16.9 0.4 (6.8) (5.7) 1.2 27.44 28.98 1.54 5.61%Medical Director 0.6 0.6 (0.0) 0.9 0.7 (0.3) (1.5) (1.3) 0.2 0.02 (0.08) (0.09) -569.84%Nursing & Quality 3.8 3.9 0.1 1.4 1.5 0.1 (1.3) (1.5) (0.2) 3.90 3.86 (0.04) -1.08%Operations: Frimley 16.1 16.4 0.2 4.6 4.7 0.1 (1.2) (1.1) 0.1 19.61 19.99 0.38 1.93%Operations: Wexham 10.5 10.2 (0.3) 5.0 5.0 0.0 (4.3) (3.7) 0.5 11.25 11.52 0.28 2.47%

Corporate Total 59.3 60.6 1.3 34.5 35.0 0.5 (18.9) (18.4) 0.5 74.90 77.2 2.33 3.11%

CCG Income and financing cost 3.6 2.5 (1.1) 39.6 33.7 (5.9) (402.2) (403.8) (1.6) (359.04) (367.6) (8.58) 2.39%

Grand Total 267.8 272.3 4.5 155.7 152.3 (3.4) (435.7) (436.0) (0.3) (12.23) (11.4) 0.82 -6.67%

Pay Non Pay TOTAL inc Income

9

Tab 9 F

inance Report - M

onth 8

144 of 201P

UB

LIC B


Total Trust Bank Expenditure (Excl. Integration funded spend)

Bank Costs continue to rise compared to the Q4 Average last year.

Bank costs have risen slightly in the month. The new rate for B6 & 7 has been implemented and in the first month has had little impact on fill rates. However, the savings it has generated has been modest. This will continue to be monitored.

11

Hospital Bank2016/17 Q4

Ave ra g e M06 M07 M08

FPH Admin 101,911 114,423 72,867 109,036AHP 22,455 31,269 29,307 24,853Ancillary 509,561 406,061 383,206 423,763Nursing 521,993 508,512 513,568 519,915Prof Tech & Scientific 65,318 96,025 112,138 111,272

FPH 1,221,238 1,156,291 1,111,086 1,188,838WPH Admin 6,701 32,035 47,384 57,983

AHP 17,040 62,569 60,556 51,100Ancillary 267,839 373,154 254,841 290,695Nursing 540,065 588,551 651,428 578,122Prof Tech & Scientific 8,433 8,363 9,538 9,348

WPH 840,078 1,064,672 1,023,747 987,249

Total 2,061,316 2,220,963 2,134,833 2,176,087

9

Tab 9 F

inance Report - M

onth 8

145 of 201P

UB

LIC B


Total Trust Agency Expenditure (Excl. Integration funded spend)

Agency Costs have reduced £200k from M06

Agency costs have reduced for the second month running and are at the lowest level for this financial year. Agency staff make up 5% of the total pay costs in the month, which is almost 1% lower than the M01-M06 average.

12

Hospital Agency 2016/17 Q4

Ave ra g e M06 M07 M08FPH Medical 564,574 284,387 239,212 258,957

Nursing 239,956 196,788 170,853 137,504Prof Tech & Scientific 125,480 55,519 42,524 44,039AHP 166,390 74,323 117,281 109,709Admin 136,964 26,989 6,561 41,904Ancillary 6,493 5,186 648 1,460MOD Agency 0 0 60 0Other Staff 0

FPH 1,239,856 643,194 577,139 593,573WPH Medical 401,237 748,660 608,791 533,339

Nursing 398,465 355,127 352,530 314,430Prof Tech & Scientific 121,280 129,953 106,114 186,448AHP 196,174 47,010 87,599 51,491Admin 106,570 54,985 43,956 37,266Ancillary 1,977 5,195 2,101 -1,801MOD Agency 1 0 0 0Other Staff

WPH 1,225,703 1,340,930 1,201,092 1,121,173

Total 2,465,560 1,984,124 1,778,230 1,714,746

9

Tab 9 F

inance Report - M

onth 8

146 of 201P

UB

LIC B


The graph shows the forecasted spend based on a rolling 3 month run rate. The decrease in M08 has meant the forecast is to remain within the NHSI cap on agency.

Total Trust Agency Expenditure Trend

13

9

Tab 9 F

inance Report - M

onth 8

147 of 201P

UB

LIC B


Trust Overview – 2017/18 Total Savings Programme

All values in £000 14

The monthly position has improved to 93.5% in month. The YTD position continues to increase from 87.9% to 89 % achievement. The forecast position has further improved to 94% as mitigations and improved performance recorded. The CIP gap is now forecast at just under £2m by year end.

9

Tab 9 F

inance Report - M

onth 8

148 of 201P

UB

LIC B


CIP Recovery Actions to date

15

The CIP underperformance reported at M04 has been mitigated by a mix of new

mitigations and an improvement in the original

plans

9

Tab 9 F

inance Report - M

onth 8

149 of 201P

UB

LIC B


16

Cash Position Month 8

Key messages: - The cash balance for month 8 finished at £84.6m, a decrease of £4.3m from M7 against a planned decrease of £3.3m - The in month cash movement remained close to plan as movements in trade and other receivables, and trade and other payables offset one another, and the in month slippage in capital programme was offset by a fall in deferred income - The in year cash movement is now £5.0m ahead of plan, as demonstrated in the table below, and year to date cash position £12.6m above plan - The year-end position remains forecast to finish £19.8m above plan at £86.9m due to the brought forward variance of £7.7m slippage in capital programme of £16.9m offset by the impact in the change of inventory treatment (£4.7m)

Plan Actual Variance Plan Actual Variance Plan Forecast Variance£m £m £m £m £m £m £m £m £m

Net Cash Increase / (Decrease) -3.3 -4.3 -1.0 -7.0 -2.1 5.0 -11.9 0.3 12.2

Cash Brought Forward 75.3 88.9 13.6 79.0 86.7 7.7 79.0 86.7 7.7Cash Carried Forward 72.0 84.6 12.6 72.0 84.6 12.6 67.1 86.9 19.8

FRIMLEY HEALTHCurrent Month Year to Date Full Year

Analysis of Year to Date Variance £mSurplus of £11.4m ahead of NHSI plan by £0.3m 0.3Capital expenditure slippage to programme 27.9Forecast PDC funding of £4.6m not drawn down (4.6)Unplanned increase in inventories and receipt of donated assets (5.4)Net working capital position due to fall in deferred income (11.0)Other movements in provisions, financial liabilities and non-cash items (2.2)

5.0

9

Tab 9 F

inance Report - M

onth 8

150 of 201P

UB

LIC B


Capital Month 8

17

Month 8: - Capital expenditure for month 8 was in line with average for the year as £4.1m but this still remains £5.3m behind plan in month - The Heatherwood redevelopment (£2.8m) and Wexham EDAR scheme (£0.8m) continue to be the largest contributors to this underspend due to the delayed planning process and expenditure profile timing differences respectively Year to Date: - YTD expenditure of £32.0m now £26.6m behind plan - Of this; £24.2m can be accounted for by the estates schemes, £1.6m IM&T and £0.8m medical equipment although the latter two are anticipated to recover later in the year Full Year: - The full year forecast of £80.0m, £16.9m under plan of £96.9m, has been retained for this reporting period however this will be subject to further review in month 9 with a likely further downwards revision to follow

£'m Month Plan Month Actual Diff YTD Plan YTD Actual Diff FY PlanFY

Forecast Diff

HWPH

Heatherwood 2.90 0.09 2.81 13.60 0.95 12.65 26.08 9.18 16.90

Wexham - EDAR 2.45 1.66 0.79 13.68 8.10 5.57 23.75 24.00 (0.25)

Wexham - Women's Services 0.25 0.40 (0.15) 5.37 5.01 0.36 5.37 6.28 (0.91)

Wexham - Estate 1.41 0.95 0.45 11.40 7.31 4.09 16.80 18.34 (1.55)

Information technology 0.25 0.11 0.14 1.70 1.94 (0.24) 3.03 3.03 0.00

Medical equipment 0.27 (0.04) 0.30 2.15 1.36 0.79 3.23 3.23 0.00

HWPH total 7.53 3.18 4.35 47.90 24.67 23.22 78.26 64.07 14.19

FPH

Estate 1.23 0.45 0.77 5.95 4.43 1.52 11.05 8.35 2.71

Medical Equipment 0.13 0.28 (0.15) 1.00 0.97 0.03 1.50 1.50 0.00

Information Technology 0.32 0.16 0.16 2.27 1.38 0.89 3.85 3.85 0.00

FPH total 1.67 0.89 0.78 9.22 6.79 2.43 16.40 13.69 2.71

Integration capital 0.23 0.03 0.19 1.50 0.56 0.94 2.27 2.27 0.00

Frimley Health Total 9.42 4.10 5.33 58.61 32.02 26.59 96.94 80.04 16.90

9

Tab 9 F

inance Report - M

onth 8

151 of 201P

UB

LIC B


18

Frimley Health total assets employed £421m. Items to note: • The combined assets across all 3 sites fell by £4m to £503m, £1m behind plan. • Non-current assets of £342m behind plan by £34m primarily due to the b/fwd impact of the 16/17 site valuation and enhanced by the slippage in capital programme • Net current assets remain high, and rose a further £5m above plan in month to a ytd position £24m above plan • Slight decrease in trade and other receivables offset by a similar fall in trade and other payables however deferred income fell by £5m in month having increased in the previous period following as the income for high value Q3 invoices raised in M7 is recognised • Equity and reserves increased by £2m in month to £421m due to the net surplus in month

September Actual £m

October Actual £m

November Actual £m

November Plan £m

November Actual £m

Assets, Non-Current Intangible Assets 4.647 4.718 4.842 1.400 3.442Property, Plant and Equipment 331.447 334.664 337.010 374.580 (37.570)

Assets, Non-Current, total 336.094 339.382 341.852 375.980 (34.128)

Assets, Current Inventories 7.886 7.936 7.878 3.500 4.378Trade and Other Receivables, Current 57.700 70.906 69.062 52.800 16.262Cash and Cash Equivalents (excluding overdrafts) 96.855 88.878 84.593 71.954 12.639

Assets, Current, total 162.441 167.720 161.533 128.254 33.279

TOTAL ASSETS 498.535 507.102 503.385 504.234 (0.849)

Liabilities, Current Trade and Other Payables, Current (61.608) (64.030) (62.217) (60.433) (1.784)Deferred Income, Current (19.474) (22.260) (17.721) (9.750) (7.971)Borrowings, Current (0.287) (0.287) (0.287) (0.200) (0.087)Provisions, Current (0.280) (0.259) (0.259) (0.400) 0.141

Liabilities, Current, total (81.649) (86.836) (80.484) (70.783) (9.701)

NET CURRENT ASSETS (LIABILITIES) 80.792 80.884 81.049 57.471 23.578

Liabilities, Non-Current Provisions, Non-Current (0.051) (0.051) (0.051) (0.400) 0.349Borrowings, Non-Current (1.607) (1.584) (1.567) (2.000) 0.433

Liabilities, Non-Current, total (1.658) (1.635) (1.618) (2.400) 0.782

TOTAL ASSETS EMPLOYED 415.228 418.631 421.283 431.051 (9.768)

Taxpayers' and Others' EquityTaxpayers Equity

Public dividend capital 243.125 243.126 243.126 247.762 (4.636)Income and expenditure reserve 60.714 64.115 66.768 59.989 6.779

Taxpayers' equity, total 303.839 307.241 309.894 307.751 2.143Other Reserves

Revaluation Reserve 111.389 111.389 111.389 123.300 (11.911)

Total Equity & Reserves 415.228 418.630 421.283 431.051 (9.768)

Balance Sheet M8

9

Tab 9 F

inance Report - M

onth 8

152 of 201P

UB

LIC B


Page | 1

Report Title 2017/18 CIP Summary – Month 08



Agenda No. 10.

Report Type To note

Prepared By Hugh Cronshey, Associate Director of Finance

Executive Lead

Helen Coe, Director of Operations, FPH Lisa Glynn, Director of Operations, HWPH

Executive Summary

Performance of CIP schemes are given in the attached paper. 1. CIP Programme Performance Month 8

• At the close of month 8, the Trust delivered £18.3m against the plan of £20.5m, which is an adverse variance of -£2.2m and a delivery of 89%. This is slightly better month but remains broadly in line with ytd average run rate delivery.

• The main areas of underperformance remain in the following areas:

- ED medical staffing across both sites - BSPS savings resulting from the incorporation of RBH into the

Partnership - Theatre schemes relating to Premium staffing, Pain Service redesign

and non-pay reductions

2. Forecasted Outturn

• The forecasted outturn has again been refreshed for M08 and shows a £0.3m improvement to £28.7m or 94% which reflects the CIP mitigations identified in M04 as well as continued improvement in some areas.

10

Tab 10 CIP Update 2017/18


Page | 2

Background

Annual Savings Programme

• The Trust’s combined CIP and synergy target for 2017/18 is £30.5m. • YTD delivery to the end of M08 is 89% of the phased plan

Issues / Actions

• The Trust continues to work on delivering both the core CIP schemes and

address the mitigating actions.

• Focus remains on closing the 17-18 shortfall and any opportunities that can also be carried forward into the 18-19 plans.

Recommendation

The Board is asked to note the content of this report, progress made, and continued focus on delivery of existing schemes and ensure mitigating items are followed through to delivery.

Appendices 2017/18 CIP Summary Report – Month 08

10

Tab 10 CIP Update 2017/18


10

Tab 10 C

IP U

pdate 2017/18

155 of 201P

UB

LIC B


Trust Overview – 2017/18 Total Savings Programme

All values in £000 2

The monthly position has improved to 93.5% in month. The YTD position continues to increase from 87.9% to 89 % achievement. The forecast position has further improved to 94% as mitigations and improved performance recorded. The CIP gap is now forecast at just under £2m by year end.

10

Tab 10 C

IP U

pdate 2017/18

156 of 201P

UB

LIC B


3

Year to Date and Forecast Out-turn by Directorate

The Table shows the current YTD and FOT position by Directorate with the key messages of the variances by schemes. The FOT as at month 08 has improved by £2.212m compared to the month 04 due to the incorporation of mitigating schemes and now shows a forecast variance of £1.819m

10

Tab 10 C

IP U

pdate 2017/18

157 of 201P

UB

LIC B


Cash and Non Cash Releasing CiP

Mitigations to Date

The tables show the split of cash and non cash releasing CIPs. Non cash CIPs do not fully impact on the Income and Expenditure position of the Trust and therefore we will not see the full benefits within the run rate. The current forecast predicts £496k over performance on non cash releasing schemes and £2.316m underperformance on cash releasing schemes

As mentioned earlier, the FOT as at month 08 has improved by £2.212m(55% of original gap) compared to the month 04 FOT. This is due to new mitigating schemes totalling £496k and improvements to earlier forecasts totalling £1,716k. The forecast variance is now £1.819m (6% overall) A detailed schedule of mitigations is included within the main Finance Board Report

4

The % shown is against the original target of £30.5m

10

Tab 10 C

IP U

pdate 2017/18

158 of 201P

UB

LIC B


Page | 1

Report Title

Corporate Risk Assurance Framework – December 2017

Meeting

Board of Directors (Public)

Meeting Date

Friday, 5th January 2018

Agenda No.

11.

Report Type

To present Frimley Health NHS Foundation Trust’s high level risks to the Board of Directors

Prepared By

Debbie Barrow Governance Manager

Executive Lead

Sir Andrew Morris Chief Executive

Executive Summary

The Frimley Health Risk Assurance Framework (RAF) is the primary mechanism for high level risk management within the organisation. This report summarises the discussions regarding ‘high level’ risks facing Frimley Health NHS Foundation Trust at the December 2017 meeting of the Corporate Governance Group.

Background

Frimley Health NHS Foundation Trust is dedicated to establishing an organisational philosophy that ensures risk management is an integral part of corporate objectives, business plans and management systems. Compliance with legislative requirements is only a minimum standard. The specific function of risk management is to identify and manage risks that threaten the ability of the Trust to meet its objectives.

Issues / Actions

In this version of the RAF, There are 4 ‘extremely high’ graded and 12 ‘high’ graded identified and these are summarised in the attached paper. Five risks were regraded and one new risk identified

Recommendation

The Board of Directors is asked to note the high level risks included in the Trustwide Risk Assurance Framework

Appendices

Corporate Risk Assurance Framework – December 2017

11

Tab 11 Corporate Risk Assurance Framework


Page | 2

Risk Assurance Framework - Risk Scoring Guide

Risks included in the Risk Assurance Framework (RAF) are assessed as extremely high, high, medium and low based on a Impact/Consequence x Likelihood matrix. Impact/Consequence- The descriptors below are used to score the impact/ consequence of the risk occurring. If the risk covers more than one column, the highest scoring column is used to grade the risk.

Level Descriptor Risk Type

Injury/Harm Service Delivery Financial Reputation/Publicity

1 Negligible No injuries or injury requiring no treatment or intervention

Service Disruption that does not affect patient care

Less than £10,000 Rumours

2 Minor

Minor injury or illness requiring minor intervention.

Short disruption to services affecting patient care or intermittent breach of key target

Loss of between £10,000 and £100,000

Local media coverage

< 3 days off work if staff

3 Moderate

Moderate injury requiring professional intervention

Sustained period of disruption to services/sustained breach of key target

Loss of between £101,000 and £500,000

Local media coverage with reduction in public confidence RIDDOR reportable

incident

4 Major

Major injury leading to long term incapacity requiring significant increased length of stay.

Intermittent failures in a critical service Loss of

between £501,000 and £5M

National media coverage and increased level of political/public scrutiny Total loss of public confidence

Significant underperformance of a range of key targets

5 Extreme

Incident leading to death Permanent closure/loss of a service Loss of >£5M

Long term or repeated adverse national publicity

Serious incident involving a large number of patients

Removal of Chair/CEO or exec team

High Risk Tracking Matrix

Likelihood

Consequence

Insignificant Minor Moderate Major Catastrophic

Rare

Unlikely

Possible FGK

Likely ABCDHIMN0 EJLP Almost Certain

11

Tab 11 Corporate Risk Assurance Framework


Page | 3

High Risk Summary December 2017

Chart Ref Risk Name Source

Current Score

Target Score

Score Trend

Date Risk Added C L R

Previous Month

3 months ago

6 months ago

Corporate Objective 1: Pursuing the highest level of quality, patient experience and clinical outcomes

A Nurse Staffing Capacity FPH/WPH 4 4 16 8 Nov-12

B Bed Capacity FPH/WPH 4 4 16 4 Jul-15

C Recognition of Deteriorating Patient FPH/WPH 4 4 16 6 Apr-15

D Critical Care Capacity FPH/WPH 4 4 16 6 Jun-15

E A&E 4-hour target FH 4 5 20 8 Sep-12

F Medical Staffing Capacity FH 5 3 15 8 Nov-12

G Management of Patients with Mental Health issues & LD FH 5 3 15 4 Oct-16

H Cardiology WPH 4 4 16 4 Jul-17

I Delays in Discharge FH 4 4 16 8 Jun-16

J Infection Control FH 4 5 20 4 Aug-17

K Access to MRI OOH for Cauda Equina Patients WPH 5 3 15 4 Sep-17

L Specialist Commissioning FH 4 5 20 8 Nov-17

M Sepsis FH 4 4 16 6 Dec-17

Corporate Objective 2: Transforming our infrastructure

N Delivery of Informatics Strategy 2017/18 FH 4 4 16 4 Apr-13

Corporate Objective 3: Developing our Staff and our Culture

O Participation in Mandatory Training & Appraisals HWP/FPH 4 4 16 4 Jan-12

Corporate Objective 4: Breaking through traditional healthcare boundaries

Corporate Objective 5: Keeping Control of Resources & Delivery Key Standards

P Failure to achieve Medium Term Financial Sustainability FH 4 5 20 4 Sep-11

Corporate Objective 6: Developing sustainable clinical services

11

Tab 11 C

orporate Risk A

ssurance Fram

ework

161 of 201P

UB

LIC B


Page | 4

Risk Name Current

Risk Rating

Actions Assurance

Failure to achieve financial sustainability (FPH/HWPH)

1. Project Initiation Documents to be produced for all remaining savings schemes. 2. Quality Impact assessments to be completed for all remaining schemes. 3. Head of PMO appointed to ensure that all schemes are tracked and remedial actions developed where necessary. 4. Medium-term transformation projects to be developed. 5. CIP under achieving, over spend on medical staff but mitigation agreed to deliver £30m 6. Projected income is now above plan at £2-4m 7. CIP Board refocusing Performance Meeting around CIP delivery

• Reported to Board through Financial Assurance Committee. • Financial Assurance Committee

A&E 4-Hour Target Risk to Monitor governance rating due to failure to deliver A&E 4 hour target as per trajectory reaching 95% in March 18, potential 12-hour breaches, and pressures on bed capacity and patient flow with potential to impact ability to deliver routine and critical services, delay in patient treatment, quality of care, and patient safety..

1. Ambulatory Care Unit to open 7 days a week from Oct 17 2. Physicians now in ED at WPH 3. Establisihing GP streaming at Wexham. Alternative ESI model at FPH, awaiting sign off 4. Potential better staffing with Middle Grades (recruitment in Qatar) 5. Joint A&E Delivery Board established with STP delivery plan. North/South delivery plan in draft to support STP plan 6. Urgent Care Operational Group established on both sites with operational task and finish groups in place 7. Winter Plan signed off by Board 8. 91% admitted or discharged within 4 hours achieved in November 17, target 95% 9. Triggers document in draft with action cards 10. Managing flow in Paeds/Minors a challenge on both sites New Key Action To implement SAFER discharge bundle to improve discharge planning and length of stay where possible Commissioners to implement actions to reduce DeToC Risk reduced from 'Extremely high' to High'

• Weekly performance meetings. • Daily monitoring of breaches of A&E 4 hour target. • Daily alerts to CEO. • Performance on standard reported directly to the Board. • Reviewed by Hospital Executive Board and Quality Assurance

Committee on behalf of the Board.

Potential risk to patient care due to nursing staff capacity (FPH &HWPH)

1. Revise Open days to increase attendance and experience of potential candidates. Increased attendance at external recruitment open days e.g. RCN careers fairs. 2. Currently exploring new partnerships with recruitment agencies to increase the supply of staff from Europe and International. 3. Since January 17 30 international nurses recruited (and a further 10 are due to start in November). There remain 87 international candidates undertaking pre-employment checks awaiting to start. We are exploring options for further trips to the Philippines and India. 4. Nursing recruitment remains a risk, decreased by 30% 5. Highly successful recruitment of newly qualified nurses & midwives on both sites 6. FPH no maternity vacancies, WPH 16 (lowest in the last year) Next Key Action Skype interviews with Australia/New Zealand & Canada Recruitment trip to Phillippines in May 2018

• Recruitment progress reviewed at Weekly Ward Moves meeting, chaired by Deputy COO

• Board will receive assurance via the Quality Assurance Committee

• Workforce Group established which monitors management of risk, reporting into Hospital Executive Board

11

Tab 11 C

orporate Risk A

ssurance Fram

ework

162 of 201P

UB

LIC B


Page | 5

Participation in Mandatory Training & Appraisals

1. Development of single metric for inclusion on Trust and divisional balanced scorecards. 2. Subject Training Leads meeting monthly 3. Hot spots and priorities identified and presented at Quality Committee, targetting shortfalls that may impact on patient safety 4. To evaluate e-learning to assess impact on training requirements 5. Monthly report with compliance and RAG status sent to all SME’s MAST group now established to include SME’s and review training on a regular basis 6. All specialities tasked with achieving 85% by 1/10/17 in high risk submect matter by CEO. 7. November 17 Currently at 76.84 % FH, further push to achieve 85% by March 18 Next Key Action All level 1 stat man training to be on micro site by 1/12/17 Focused improvement actions for November & December for Resus training in Paeds & Adults Email from CEO to all senior managers including CoS, ADs & HofN to achieve ambition of 85% by end Q4

• Board will be updated via the Trust Corporate Governance Group

• Workforce Group established which monitors management of risk, reporting into Hospital Executive Board

Bed Capacity Risk to patient experience due to potential for lack of sufficient bed capacity to meet demand during Winter months 15/16

1. Hospital hub for the Integrated Referral Information Service (IRIS). 2. Reviewed use of Ward 1 Heatherwood for medical long stay patients 3. Submitted bed capacity to NHSI to achieve 87% capacity for winter 4. Schemes being looked at to bridge gap including reducing LOS in ortho, ambulatory care position at 'front door' in an effort to keep conversion rate down 5. Total bed occupancy currently at 92% Next Key Action To ensure Commissioners deliver Detoc & CHC assessments

• 6-monthly updates presented to BOD

Critical Care Capacity Risk of poor outcome through failure to provide sufficient flow out of ICU and to generate increased level 2 capacity outside of Critical Care, potentially impacing on flow out of A&E

1. Difficulties in recruiting to Critical Care Consultant posts at Wexham 2. New MADU at WPH live June17 3. Critical Care Strategy Meeting 21/6/17, concluded need more capacity for level 3 4. Business case to Commissioners regarding additional level 3 critical care capacity 5. New cross-site Critical Care Lead appointed for Critical Care services to lead on development on new Critical Care strategy & vision for future Next Key Action To evaluate effectiveness of new MAU on the Wexham site

• Work of Trustwide M&M Committees monitored through Quality Committee and reported to Board verbally by Medical Director

Medical Staffing Capacity Risk of inadequate, appropriately trained staff, particularly in Middle and Junior Grades in A&E and Middle Grade Surgeons and difficulty in recruiting, with potential to impact on, and cause delays to, patient diagnosis and treatment, and lead to clinic cancellations, gaps in the on-call rota, lack of immediate urgent specialty support and compromise patient care.

1. Trust-wide workforce planning exercise commencing in September 2017 2. Locum agency bookings are now centralised at FPH apart from ED and anaesthetics; their centralisation is planned for September 2017 3. There are plans to form a shared doctor bank with Ashford and St Peters, Chertsey and the Royal Surrey County Hospital, Guildford and to extend this to cover the North of the FHFT patch – a benefits paper is going to be presented at Top Team 4. There are currently rolling adverts on NHS jobs for both ED and general surgery doctors of specialty doctor level and junior doctor grade 5. IR35 having a greater impact than first envisaged due to locums withdrawing from shifts at short notice 6. Skype Interviews (Qatar) in May for junior /middle grade positions. 6 recruited for each site, 2 for each site for ED. 7. Medicine 15% more doctors in post compared with last year

• Board will receive assurance via the Quality Assurance Committee.

• A Workforce Group established to monitor management of risk, reporting into the Hospital Executive Board.

11

Tab 11 C

orporate Risk A

ssurance Fram

ework

163 of 201P

UB

LIC B


Page | 6

8. By Q4 FPH will be in a better place but WPH remains a concern.

Recognition of the Deteriorating Patient Risk of poor outcome through failure to recognise a patient with a deteriorating condition. To ensure that all clinical staff have the right skills, knowledge and tools to recognise & deliver timely treatment to the deteriorating patient.

1. In depth review of recent cluster of SIs relating to deteriorating patient on Wexham site being undertaken 2. Marked improvement in Cardiac Arrest Audit, FHFT now at 30.60% against national average of 20% patients that survice a cardiac arrest in hospital and go home 3. Introduction of Adult Deteriorating patient study day with assessmnet 4alled ESCALATE (october 2017) 5. Deteriorating Patient Improvement Plan in place 6. New plan for improving compliance with mandatory training for resucitation being developed 7. Resus team now part of Patient Safety team 8. Continued improvement in compliance in Resus training stats, Adult Level 1 71.86% against target of 85% Next Key Action Focus over next 6 weeks targetting compliance with Paediatric Resus training To appoint to 2 Band 7 posts, one for each site Electronic observations to be a priority as part of IT Strategy

• Work of Trustwide M&M Committees monitored through Quality Committee and reported to Board verbally by Medical Director

Cardiology Interventional Service Potential risk to patient safety and patient experience due to staffing difficulties in maintaining continuity in pPCI 24/7

1. Spike in SIs from Cardiology 2. Lookback exercise of pPCI cases since 24/7 service started, Deputy Medical Director (FPH) reviewing on behalf of Medical Director 3. Temporary staffing changes leading to reduced numbers on pPCI rota 4. External case reviewer appointed 5. Extraordinary SI Panel Meeting to be held 18th October with Commissioners & NHS England 6. 75 patient case lookback undertaken, awaiting final report, report to go to Private BOD Next Key Action FPH senior Cardiologist appointed as Cardiology lead cross-site. To review effectiveness of Clinical Governance & Morbidity & Mortality in speciality

• Mortality Surveillance Group

Management of Patients with Mental Health issues & Learning Disabilities Potential risk to safe management of both adults & children with mental health needs or learning disabilities, to review with mental health colleagues the increase in number and complexity of these patients

1. Specialist Simulation Training to be provided for key stakeholders including security team around accountability and duty of care when managing patients sectioned under the MHA including use of restraint 2. 'Managing Challenging Behaviour' incidents roles & responsibilities in-house awareness video being developed. On-line roll out anticipated end Q3 3. On Wexham site, plan to arrange meeting with LA leads to address lack engagement in finding placements for young people with behavioural issues admitted following DSH and deemed not to have MH issues by CAMHS 4. Mental Health post financing through STP - awaiting confirmation 5. Learning Disabilities Specialist Nurse appointment for Wexham site to be confirmed 6. Current significant issues with CAMHS service on FPH site with long term young patients with behavioural issues but no acute clinical problems and no suitable placements in the community

• Annual Report to Board of Directors

11

Tab 11 C

orporate Risk A

ssurance Fram

ework

164 of 201P

UB

LIC B


Page | 7

7. Positive proposal from Berkshire CCG around CAMHS 8. Liaison Service at Wexham to be fully recruited to by February 18 Next Key Action Berkshire Healthcare to recruit Liaison posts for Wexham site

Infection Control Lack of engagement & compliance of staff with the Trust Hand Hygiene Policy leading to potential increased in risk of HCAIs & possible outbreaks

1. Greater clinical engagement has been requested at HICC, HEB and RCA including higher visibility of senior nursing staff within wards/depts to act as role models for junior staff 2. The Clinical Matrons' monthly audits are often carried out by junior ward/department staff 3. Evidence from Winning Ways audits are that those that attend sometimes do not feedback to their clinical areas 4. IPC Clinical Leads to re-inforce the message about hand-hygiene to clinicans at eductional half days 5. Performance in HCAIs deteriorated although incidence of CDiff increased nationally. 28 cases of CDiff to end of October, target for year 31 6. Hand hygiene compliance WPH 93%, FPH 95% Next Key Action Further revision of antibiotics but requires costing Risk rating increased as Trust will exceed target for 17/18

• Infection Prevention & Control meetings • Quarterly Report to Board of Directors • Trust Quality Assurance Committee

Delays in Discharge Potential risk to patients becoming unwell with hospital acquired infections, i.e. UTI, pneumonia due to delays in discharge

1. To appoint lead to manage private delays 2. 2 ED Delivery Boards focused on improving position 3. CCGs have target reductions 4. Discharge Groups established on both sites. Safer Discharge Bundle being implemented as first priority 5. IRIS planned to function from December 2017 6. FPH delays escalated to CCGs & Social services for assistance 7. 5.2% of bed occupancy lost due to delays in transfer of care, (equates to 89 patients) as at September 17 against target of 3.5% Next Key Action To relaunch ADT & implementation of ECFD & EDD by 1/12/17

• Joint Urgent Care Delivery Board (Whole System) to HEB • Trust Monthly Performance Report to Board of Directors • Quarterly report to Trust Quality Assurance Committee

Sepsis Risk of poor outcome through failure to recognise a patient with potential sepsis

1. Training increased for all staff 2. New Sepsis bundle launched across all sites 3. Performance discussed at all cliical meetings 4. All clinical leaders aware of need to improve recognition, escalation and timely treatment of sepsis 5. Q2 CQUIN requirements partially met 6. Inpatient screening & antibiotics within 1 hour of trigger time remains a challenge 7. Year to date percentage of acute inpatients screened for sepsis 35%

• 1. Sepsis Group in place on both sites • 2. Monitoring compliance with Sepsis Screening Tool

through quarterly audits

11

Tab 11 C

orporate Risk A

ssurance Fram

ework

165 of 201P

UB

LIC B


Page | 8

Access to MRI OOH for Cauda Equina Patients Currently patients are going to Oxford as per pathway for scanning & treatment. However, there are some challenges for patients leading to potential poor patient experience

1. The change to commissioning of specialist spinal work has forced discussions regarding activity flow for spine. Discussions underway & a sector wide meeting planned for 28/4/17 2. Current staffing levels have stablised and there is a plan in place to restructure and further strengthen service 3. AVM has supported FPH support, however resistance from FPH Radiology to report on these patients overnight 4. Current process is for patients to go to St Georges although there is no contract for MRI and then returned to WPH and then on to Oxford for treatment. Services at WPH vulnerable to not haeing access to MRI from 8 p.m. to 8 a.m. Pathway to be drawn up by Chief of Service. Chief of Service and Radiology determining how out of hours MRI to be provided 5. Chief of Service pursuing St Georges solution as an interim Next Key Action Chief of Service to confirm agreement with referral pathway to St Georges and implement

• Process in place for patients to go to St Georges for Out of Hours MRI. Last MRI in Radiology at WPH is 8.00 p.m.

Specialist Commissioning Specialist Commissioning don’t recognise some of our established services. If this happens, the CCGs willnot be able to finance service

Series of meetings to Next Key Action be held with CCG to align List of services not recognised and value drawn up To review criteria and satisfy ourselves that Trust is compliant

•

11

Tab 11 C

orporate Risk A

ssurance Fram

ework

166 of 201P

UB

LIC B


Page | 1

Report Title

Q3 Board Objectives - 2018

Meeting

Public Board Meeting

Meeting Date


Agenda No.

12.

Report Type

The update the Board on progress against Board Objectives.

Prepared By


Executive Lead


Executive Summary

The attached paper sets out progress report for each objective. The key points are as follows:

Points to note

• Trust on track for the finance element of the STF support (£18m). The

STF for 4hr performance for 4 hrs for Q1 & Q2 (£3m) is secured but Q3 & Q4 are at risk

• Good progress on major capital projects

Maternity Unit upgrade at Wexham – complete New Emergency Dept at Wexham – under construction New Heatherwood Hospital – planning consent secured.

Income & Expenditure projects needs final sign off from the Board

• New Diagnostic & Inpatient Block – Detailed design in progress

• The Frimley Accountable Care System will go through an accreditation process in early 2018 and it is hoped that it will “go live” from April 2018

• The Trust continues to deliver 18 weeks, 62 day cancer and the 6 week

12

Tab 12 Quarter 3 Board Objectives


Page | 2

diagnostic maximum wait standards. Performance for 4hrs has fallen short of 95% but has been above 90% for every quarter.

The Board is asked to discuss the progress to date against the Board Objectives.

Recommendation

The Board is asked to note the Report.

Appendices

2017/18 Board Objectives

12

Tab 12 Quarter 3 Board Objectives


Q1 Q2 Q3 Q4 PROGRESSBSC Benefit Exec

Lead

1.

a.

NEWS Implemented. Latest audit results indicating improvement in compliance - Deteriorating patients and resus presentation to November BoardSEPSIS & AKI - Monitoring education continues. New agreed cross site Sepsis Bundle.AKI performance improving cross site (CRAB)Sepsis ED Performance Bundle re-audited with demonstrable improvement (Q3)Maternity Collaborative in place attended by HOM. Mental Health - active workstream. Successful STP bid in relation to improving service on WPH site. SSoN working with the CCG Chief Nurse requesting LD Nurse Liaison for WPH site.Mental Health Action Plan reviewed at QAC. Berkshire commissioning gap for CAMHS is being addressedM&M - Process and guidance has been implemented and the Trust has written guidelines and a consultant lead. Presentation of preventable deaths to the October Board

DB/TH

b.

IT consent solution being piloted to improve pre-op consent. EDMS Integration being implemented. Safe Handover and safety huddles implemented cross Trust. 85% compliance in undertaking these indicated in last Trust wide audit. Hospital at night handover relaunch in Q4. Site Leadership by Deputy Medical Directors.

Patients DB/TH

2.

a. All phases complete and the building will be in clinical use from December. The project is below budget and the final account is being concluded. JK/LG

b. Superstructure construction is progressing well according to programme and within budget. A topping out ceremony is planned for 5th Jan 18.

Patients/Operational Efficiency/Staff

JK/LG

c.

Following the approval of the interim FBC, Kier have now been appointed to undertake the next stage of design and the future programme is being agreed with them. Work continues to mitigate the risks identified with the project, notably the capital cost, I&E position and private patient income. Launch session held 21st Dec 17.


AVM/JK

d.

Following approval of the OBC by the Trust Board in November, the P22 construction partner (Kier) have been appointed and the future programme is being agreed with them. Detailed design can now commence. Kier have indicated an option of adding an additional floor to accommodate additional beds or a shell floor constricted instead. These possibilities will be considered by the Steering Group.


JK/HC

e.

Various projects are being undertaken to address backlog maintenance priorities including replacement of generators (in construction), refurbishment of corridors (on site), relaying drains (on site), fire stopping (on site0, fire alarm upgrade (tenders returned) and renewal of hot and cold water services (out to tender).


JK/LG

3.

a. Draft strategy due to be reviewed by PRC in January 2018, then to Board in February 2018. Staff JK

Frimley Health NHS Foundation TrustBoard Objectives 2017/18

OBJECTIVE

TRANSFORMING OUR INFRASTRUCTURE

DEVELOPING OUR STAFF AND CULTURE

Women's Services project complete on time (October 2017) to budget (11m inc £1m backlog)

EDAR project completed on programme (Watertight building Feb 2018 completion Dec 2018) and to budget £49m) subject to DH approval by end of March 2017.

Achieve FBC for Heatherwood (interim FBC May 2017) and obtain planning approval May 2017.

Produce OBC for Diagnostic Inpatient Unit at Frimley June 2017

Complete programmed backlog scheduled for 2017/18

Progress and deliver key capital investments:

Refresh of the Trust's People and OD Strategy Q2

Conclude the final year of the "Sign up to Safety" initiative - compliance with new consent policy compliance with handover policy reduce perinatal tears

Implement year 1 of the Quality Strategy. Compliance with: deteriorating patient standards sepsis and acute kidney injury bundles maternity collaborative new pathway for mental health patients national standards for mortality and morbidity reviews

12

Tab 12 Q

uarter 3 Board O

bjectives

169 of 201P

UB

LIC B


b.Strategy refreshed in line with NHS Leadership Framework `Developing People - Improving Care'. Draft strategy due to go to Top Team in January 2018, then to Board in February 2018.

Staff/Finance JK

C.

Strategy launched and implementation of year 1 plan now in progress. Plans developed for CQUINs. 67% of permanent patient-facing staff have now had the flu vaccination (target 70% by the end of February 2018). Bank are the only patient-facing staff who have worked during the flu season who will need to be added to the total.

Staff JK

d.

Workforce planning skills training organised for delivery to service managers 'clinical ADs during Autumn. Medical workforce planning sessions 75% completed and reviews with senior directorate leaders across the Trust have been undertaken. High level workforce plan due to be reviewed by Performance and Remuneration Committee in January 2018.

Staff JK

e.

We are on course to meet our financial target in 2017/18 to reduce agency spend by £6.2m across all staff groups.

In June 2017, we centralised medical agency bookings at Frimley Park and introduced new control processes for approvals. This work has resulted in us achieving a 50% decrease in medical locum spend (from £564k pm to £280pm) at Frimley Park. We are currently in the process of centralising medical bookings at Wexham Park where we believe similar savings can be achieved.

Staff Execs

4.

a.

"STP will run with a shadow control total• From October in shadow form. • MOU with NHSE signed• All projects have received pump priming finance• Capital bids to roll out GP hubs totalling £30m - national funding agreed• Hospital activity is on plan which is the result of more care being provided in the community and alternatives to admission being implemented in ED. The first meeting of the Health Alliance board has taken place with chairs of the Health and Wellbeing boards who fully endorse the STP. "

Patients/Finance Execs

5.

a.

• 6 week diagnostics/18 weeks/62 days achieved Q2 4 hour performance for Q3 at circa 91% (mid-month) for Trust; system performance expected to be above 92% and therefore will be mapped in for the Frimley target to be eligible to achieve the STF funding. • 4hrs will continue to very challenging for Q3/Q4

Patients/Finance/Operational Efficiency

LG, HC

5.2

"CIP Programme delivery YTD 89% at month 8. Expect to achieve £29m. Trust on track to earn Q3 STF payment. Additional mitigations in place " Finance NF

BREAKTHROUGH TRADITIONAL CARE BOUNDARIES

KEEPING CONTROL OF RESOURCES AND DELIVERING KEY STANDARDS

Refresh of the Leadership Development Strategy and Framework Q2

Launch of Well-Being Strategy and implementation of action plans to achieve CQUINSs on flu, MSK and health and well-being Q1

Support workforce planning in each directorate and produce Trust wide workforce plan Q3.

Deliver a Trust wide workforce plan and reduce agency staff expenditure to £23m maximum

Continue to work with the STP to progress the accountable care system; devise appropriate governance arrangements for a shadow year 2017/18.Agree and commence to implement the key initiatives

Deliver a surplus control total of £22m. Achieve a continuous improvement programme and synergy savings target of £30m by Q4. Achieve a £22m surplus by Q4.

Achieve segment 1 rating from NSI by delivering all targets including: 6 week max wait for diagnostics A&E 4 hours 18 weeks Cancer 62 days

12

Tab 12 Q

uarter 3 Board O

bjectives

170 of 201P

UB

LIC B


6.

a. MADU at Wexham Park Hospital established in June. Complete.Patients/Operational Efficiency

LG

b.

Piloting new arrangements till January with RSCH ASU in place. New arrangements have been agreed with RSCH and Guildford & Waverley CCG, hyper-acute at FPH and stepdown at RSCH for their catchment of patients.ESD to be repatriated to FPH from ASPH Q4.

Patients/Operational Efficiency

HC

c. Roll-out complete.Smart indexing (to improve speed of access.) partially completed Patients NF

Establish a MADU with general medicine at Wexham by Q1.

Full roll-out of EDMS to cover all clinical services by Q4

Finalise new Surrey stroke service by Q3 and incorporate the outcome of the public consultation led by Guildford and Waverley CCG.

DEVELOPING SUSTAINABLE CLINICAL SERVICES

12

Tab 12 Q

uarter 3 Board O

bjectives

171 of 201P

UB

LIC B


Page | 1

Report Title Emergency Preparedness Resilience and Response (EPRR) Annual Report



Agenda No. 13.

Report Type To inform the Trust Board of the current EPRR position in respect of the 2017

Assurance process and future development

Prepared By

Alistair Smith - Resilience Lead Prevent Lead (Frimley Park)

Executive Lead

Lisa Glynn: Director of Operations Wexham and Heatherwood and Accountable Emergency Officer Helen Coe: Director of Operations Frimley Park Hospital and Accountable Emergency Officer

Executive Summary

This report details information in terms of EPRR progress and the outcome of the 2017 annual assurance process. Overall the Trust declares a Green (Substantial Compliance) position for EPRR which is a significant improvement on the previous year’s submission.

Background

This report provides an update of the work undertaken within the Emergency Preparedness Resilience and Response (EPRR) and Prevent portfolio since the previous board report in December 2016. The Trust is a category one responder under the Civil Contingencies Act 2004, which places a defined set of statutory duties on key agencies at the core of emergency planning and response, such as Police, Fire, Ambulance, Public Health and Local Authority. The Trust needs to plan for and be able to respond to a wide range of emergencies and business continuity incidents that could affect health or patient safety. The Trust as a provider of NHS funded care must show that they can effectively respond to emergencies whilst maintaining services to patients. This capability is measured against the core standards identified by NHS England through the EPRR Assurance programme. This details the minimum standards expected of NHS providers. The core standards for EPRR stipulate that the Trust has a ‘director level’ Accountable Emergency Officer (AEO) for EPRR (including business continuity). For Frimley Health, this function is led by the two Directors of Operations who

13

Tab 13 EPRR - Annual Emergency Plan


Page | 2

each have responsibility for their respective sites. EPRR matters have formal governance arrangements through a Trust wide Resilience Committee. This strategic Committee meets every quarter and is jointly chaired by the AEO’s. The 2017 assurance process requires the Trust to complete a comprehensive self-assessment against the Emergency Preparedness Resilience and Response (EPRR) Core Standards, together with a ‘deep dive’ of the Trust EPRR Governance arrangements. As in 2016 /17 the self-assessment has been completed on a Trust wide basis with a single return being submitted; it is a requirement that confirmation of the Assurance outcome is reported to Trust boards.

Issues / Actions

Acute Trusts are required to self-assess against 60 of the 66 core standards, Frimley Health were fully compliant with 56 of these core standards with the remaining 4 standards which require additional work forming the detail of the improvement plan for 2017 /18

Recommendation

The Board is asked to note the report; to approve the assurance position for 2017 and to support the future planned activity as identified.

Appendices Appendix 1 – EPRR areas of Compliance

13



Page | 3

Appendix 1

Areas of Compliance Self-assessment and compliance for 2017 /18 have been measured against 3 main areas:

• Core Standards • HAZMAT / CBRN • Deep Dive – Governance (This area does not feature as part of the final assessment of compliance)

The self-assessment of Core Standards for acute trusts is measured against 8 areas Area Standard Green Amber Assessment & Areas for Improvement Governance 1-4 4 0 Full Compliance Duty to assess risk 5-7 3 0 Full Compliance Duty to maintain plans 8-21

24-29 17 3 Substantial Compliance

Roll out of Trust wide Business Continuity arrangements

Mass Countermeasure Plan Command and Control (C2)

30-36 6 0 Full Compliance

Duty to communicate with the public


Information Sharing 39 1 0 Full Compliance Co-operation 40-42

45 & 48 4 1 Substantial Compliance

Attendance of AEO at Local Health Resilience Partnership meetings

Training & Exercising 49-52 2 0 Full Compliance The self-assessment of HAZMAT / CBRN Core standards for acute trusts is measured against 3 areas: Preparedness 53-57 5 0 Full Compliance Decontamination Equipment


Training 63-66 4 0 Full Compliance Deep Dive: Area Standards Green Amber Red Areas for Improvement Governance DD1-DD6 3 2 1 (A) Inclusion of the results of EPRR

Assurance as part of the Trust annual report

(A) Attendance of AEO at 75% of LHRP Meetings

(R) Appointment of Non-executive Director / Governing body representative to hold the EPRR portfolio

13



Page | 1

Report Title

Quarterly Report from Frimley Health Infection Prevention & Control Teams (the Frimley Park Hospital Infection Control Committee, and Heatherwood & Wexham Park Hospitals Infection Control Committee)

Meeting

Public Board

Meeting Date


Agenda No.

14.

Report Type

Governance and compliance report. Meeting in Public

Prepared By

Dr T Ho (Director of Infection Prevention and Control FHFT), Amanda Walker (Infection Prevention & Control Nurse Consultant FHFT), Vicky Gentry (Infection Prevention & Control Nurse Specialist FPH), & Jenny Wyeth (Lead Infection Prevention & Control Nurse HWPH)

Executive Lead

Dr T Ho

Executive Summary

This report provides the Board with an update on Trust healthcare-associated infection performance for 2017/18 to date, and the feedback on agenda items presented at the FPH and HWP infection control committees in the current quarter.

Background

A regular report to Board with assurance of healthcare-associated infection performance is a requirement of the Health & Social Care Act 2008: Code of practice for the NHS on the prevention & control of healthcare associated infections and related guidance.

Issues / Actions

Actions to note from the report are: • Need to ensure local ownership to continue and sustain improvement in hand

cleaning compliance by staff of all grades and to ensure clinical staff are dressed appropriately for carrying out clinical care

• Due to changes made to the mandatory training programmes at FHFT, attendance at Learning & OD-organised Staff & Patient Safety (SaPS) updates at the beginning of the year was very low, and is only slowly catching up resulting in high numbers of staff out of date.

• A need to highlight the requirement to involve IPCTs in the planning stage of new builds and refurbishments to ensure an understanding of compliance with national standards to improve the number of en suite single rooms for isolation of infectious patients (which will align the Trust with bench marked peers) and ensure an understanding of compliance with National guidelines for spaces between beds. Infection Control advice is not always followed in refurbishments and new builds and derogations are made.

• Clinical Medical Lead attendance has been low at HICC on both sites. Attendance is reported as part of the “Ward to Board” reports.

• There have been two Trust-apportioned MRSA bacteraemia cases to date, one in June 2017 at FPH (which was agreed to have been “avoidable”), and one at WPH in August (which was agreed to have been “unavoidable”).

14

Tab 14 Infection Control Report


Page | 2

Recommendation

Members are asked to discuss and note this Report.

Appendices NA MRSA bacteraemia There have been two MRSA bacteraemia cases apportioned to the Trust to date. A further case identified in November 2017 at FPH ward G5 is currently under appeal following the request for Third Party apportionment (as the infection was idenitifed 32 hours into the admission, was not as a result of healthcare provided by the Trust, and has no learning point actions for the Trust to take forward). Guildford & Waverley CCG have requested that a community-onset MRSA case is re-approtioned from the CCG to the Trust (due to Outpatient contact the patient had with the FPH Diabetic Foot Team). This assignment is awaiting final apportionment in January, after arbitration is complete.

Learning from these cases is fed back to staff in meetings, in the Infection Control Newsletter and included in mandatory annual training. Clostridium difficile infection (CDI) There have been 32 Trust-apportioned cases to date against the objective of 31 cases: 12 at WPH, 20 at FPH (summary of cases below). All cases undergo formal root cause analysis at meetings attended by CCG infection control representatives so that robust challenge and discussion can take place and any lapse in case can be identified and agreed. There have been eight ‘lapses in care’ identified to date: in seven of the cases antimicrobial prescribing did not follow Trust guidance, additionally in two cases there was a delay in stool sample collection (which delayed treatment of the patient), and for one case the root cause was identified as being an infected peripheral cannula for which additional antibiotics were required. A Period of Increased Incidence is being investigated on FPH ward G3 Stroke, where there have been three cases in consecutive months (Sept, Oct and Nov). Two cases have been identified as being caused by the same ribotype of Clostridium difficile, and as this is a relatively common ribotypes, the samples are undergoing MVLA sequencing at the reference laboratory, to identifiy whether this is cross-infection or not. Two of the CDI cases at FPH in October were found to be ‘false positive’ Cdifficile toxin (CDT) positive results (after samples were sent to the reference lab did not culture Clostridium difficile). One of these patients had not received treatment, as it was felt not to be a clinically significant result, but the other patient had been treated. The patients’ clinicians have contacted patient, and families of the patients, as Duty of Candour, to explain the incident. The Surrey & Berkshire Pathology Services are reviewing the CDT test currently being used.

0

1

2

3

4

5

Trust Community 3rd Party Awaiting finalassignment

Num

ber o

f MRS

A ba

cter

aem

ia c

ases

14



Page | 3

Learning from these cases is fed back to staff in meetings, in the Infection Control Newsletter and included in mandatory annual training. Meticillin sensitive Staphylococcus aureus bacteraemia There have been 29 Trust-apportioned MSSA bacteraemia cases to date, with no objective set for 2017/18. A summary of the cases shown below: Month Ward Root cause Healthcare-associated? April WPH W9 Hospital-acquire pneumonia Yes April FPH F10 Unknown No April FPH G5 Peripheral cannula Yes April WPH W17 Endocarditis Yes April WPH W4 Unknown No April FPH MAU Unknown No April FPH G5 Parotitis No May FPH F9 Upper GI bleed No June WPH ITU Infected thrombus Yes June FPH SAU Dermatitis No June FPH G2A Peripheral cannula Yes July WPH Stroke Unit Skin and Soft tissue No July FPH F10 Hospital-acquired pneumonia Yes July FPH G9 Community-acquired pneumonia No August WPH NNU Peripheral cannula Yes August FPH F8 Osteomyelitis No August WPH W8 Skin/ Soft tissue No August WPH W4 Unknown No August FPH F9 PICC Yes September WPH ICU Unknown No September WPH Eden PICC Yes October WPH W4 Skin/soft tissue Yes October WPH AMU Skin/Soft tissue Yes October FPH Critical Care Necrotising pancreatitis No November WPH Eden Neutropenic sepsis Yes November WPH W3 Unknown No November WPH W7 Community-acquired pneumonia No November WPH Eden PICC Yes November WPH W2 Skin/soft tissue No Glycopeptide-Resistant Enterococci (GRE) There have been 4 GRE-positive blood cultures, with no objective set for 2017/18. Three cases at WPH (Paragon, W6 and W4), and one case at FPH (F8). The number of new GRE-colonised or infected patients identified at FPH has been maintained at baseline since May 2016. The majority (54%) of patients who have acquired GRE in sterile sites have been under Diabetic foot/ Vascular care, or had Gastro-intestinal surgery. Escherichia coli bacteraemia Cases are now being apportioned to Trust and CCG, as with MRSA and MSSA bacteraemia cases. There have been 96 Trust-apportioned cases to date (49 at FPH, 47 at WPH). 14 of the 49 cases (29%) at FPH have been sourced to urinary catheters. The IPCT continue to work closely with colleagues in the local CCGs Leads, identifying and addressing actions which can assist the CCGs in the 2017/18 objective to reduce the number of Ecoli bacteraemia cases

14



Page | 4

by 10%, and the number of Gram-Negative Bacteraemia cases by 50% by 2021. The actions are focussing on: • Improvements in sending, looking up results of, and interpretation of urine samples is needed (both in

hospital and community). • Prompts given for clinicians to review the need for any invasive devices (including urinary catheters) on

a daily basis. • Development of a catheter care passport, which will improve care across local healthcare

establishments. This is intended to be ratified and printed in January. • Public education on hydration and hygiene for those both with, or without a urinary catheter. Since August 2017, the local CCGs are permitted to make additions and changes to risk factor data for Gram-Negative Bacteraemia cases that the acute Trust enter on the Data Capture System, for up to a year after the data was already signed-off by the CEO. The IPCNs have written to Public Health England to express concerns over the loss of governance of this information. Klebsiella spp bacteraemia Reporting of Klebsiella bacteraemia cases began in April 2017. There is no objective for 2017/18, and cases are not apportioned to Trust or CCG. There have been 97 cases to date (43 at FPH, 54 at WPH). Pseudomonas aeruginosa bacteraemia Reporting of Pseudomonas aeruginosa bacteraemia cases began in April 2017. There is no objective for 2017/18, and cases are not apportioned to Trust or CCG. There have been 44 cases to date (20 at FPH, 24 at WPH). Antimicrobial Prescribing Stewardship Although Antimicrobial audits are completed by Pharmacy department, they are reported to the HICC in view of their impact on antibiotic resistance and CDI The September 2017 cross-site Antimicrobial Prescribing Audit results showed: • Compliance with Trust antimicrobial prescribing guidelines = 90% • Compliance with documentation of indication for the antimicrobial = 88% • Compliance with documentation of a stop or review date for the antimicrobial = 80%. Recommendations from the audit were: All board staff Continued investment in the antimicrobial stewardship team is essential in maintaining and improving antimicrobial stewardship across the trust. All medical staff • Ensure accurate diagnosis of infection • Ensure appropriate samples are obtained to facilitate diagnosis and tailoring of targeted antimicrobial

therapy • Ensure a stop date or review date is documented on all prescriptions at treatment initiation and

update review date when applicable • Document indication clearly on drug charts and update when applicable. • Ensure all treatment choices are compliant with trust antimicrobial guidelines available on

MicroguideTM. If deviating from guidelines reasons for not following guidelines must be documented in clinical notes.

• Duration of treatment – ensure all prescriptions follow trust guidelines for duration of treatment. MicroguideTM durations are for total treatment (IV and PO total).

• Continue to support IV to PO switch practice. Nursing staff Please ensure blood cultures are taken for all patients with signs of sepsis. Ideally this should occur prior to administration of antibiotics, although do not delay first dose of antibiotic if unable to take blood culture. • Challenge all antimicrobial prescriptions that don’t comply with the above recommendations made to

the medical staff. • Highlight to ward pharmacist if uncertain or non-compliance.

14



Page | 5

Pharmacy staff Continue to monitor and highlight the above to clinical teams in your area, supporting compliance with stewardship standards, in particular stop/review date documentation and durations. Ensure referrals are made to antimicrobial ward rounds of prescriptions not complying with stewardship guidelines. Antimicrobial stewardship team • Continue regular antimicrobial stewardship / microbiology ward rounds / consultant ward rounds on

AMU • Provide feedback to clinical governance teams on learning points picked up from the quarterly audit. • Reintroduce a ‘spot check’ system for high risk/poor performing wards or specialties to identify

patients for review by the stewardship team. Microbiology and Pharmacy staff at WPH have signed up to participate in the Antimicrobial Review Kit (ARK) study funded by the National Institute for Health Research (NIHR). ARK is a tool that provides resources to support the whole health care team to ensure patients’ antibiotic prescriptions are reviewed and revised appropriately ensuring individual patients get optimal antibiotic treatment. Death certificates with MRSA or CDI recorded as Primary or Secondary Cause Month MRSA Part 1 MRSA Part 2 CDI Part 1 CDI Part 2 April 2017 1 (WPH) September 2017 1 (WPH) 1 (FPH) October 2017 1 (FPH) Short term, non-tunneled CVC infections There has been one infection of a CVC, at FPH in Critical Care. This Renal patient had a femoral line sited due to difficulties in venous access. TPN related Peripherally inserted Central Catheter infections There has been one TPN-related PICC infection to date on FPH F9, which was one of the MSSA bacteraemia cases for the Trust. Restrospective surveillance of all PICC lines inserted at FPH begain in October 2017. In October, there were three invasive infections identified (2 in Critical Care, one on Parkside), and one infection of the insertion site (Critical Care). In November one localised infection of a PICC insertion site was identified on F4. Orthopaedic Mandatory Surgical Site Infection Surveillance FPH: There were no SSIs reported for the quarter July-Sept 2017. In the quarter Oct-Dec17 to date, two deep SSIs of revision hip replacements were identified. Both were revisions for trauma, in elderly, frail patients with multiple co-morbidities, and were considered to be unavoidable. Heatherwood: No SSI have been reported for either Total Hip Replacement (THR) or Total Knee Replacement (TKR) for the period July – Septemeber. No SSI have been identified for the current period -October to December. WPH: No SSI have been reported for the period July – September. No SSI have been identified to date for the current period Oct – December. Mandatory Infection Control Training Due to changes made to the Staff and Patient Safety (SAPS) programme in early 2016 the overall percentage of Trust staff in date with infection prevention & control training had fallen steadily during the year. Despite hundreds of classroom-based teaching sessions and clinical ward-based sessions, the overal percentage of clinical staff in date with Level 2 Infection Prevention & Control training was only 68% in November. In 2018, there are over 300 classroom-based sessions booked (220 of which are on the FPH site), which have sufficient spaces to train 30% more than the patient-facing staff in the Trust. However there remains a backlog of staff who had not received training in the past two years, training sessions are sometimes cancelled by Learning & Organisational Development if low numbers are booked on (rather than advertising again to increase attendance), there have been significant delays in the entry of course attendance records,

14



Page | 6

and a number of attendance records have gone missing. The IPCT have been informed at the MAST Group, that the process of booking and recording of attendance is being audited by Learning & OD, and the process for completion of attendance records is changing next year. Hand Hygiene A summary of the hand hygiene audits completed in the Oct-Dec 2017 quarter by the Infection Prevention & Control Nurses: FPH: Overall compliance = 95%. HWP: Overall compliance = 93%. The league tables for hand hygiene audit scores, and compliance by staff group, can be found in Appendix I. Hospital Infection Control Committee (HICC) HICC meetings are held for FPH and WPH, chaired by the Director of Infection Prevention and Control. Clinical Medical Lead attendance has remained low at both sites due to operational pressures on clinical staff. Changes to the meeting frequency, time held, and agenda items have been made for 2018 with an aim to make the meetings easier for Clinical Medical Leads to attend. Facilities and Estates Issues The Infection Control Doctors and Lead Nurses attend the Environment Group meetings held at Heatherwood, and have reviewed and agreed the updated Trust standard for sanitary fittings. FPH: Raised counts in the Neonatal Unit have remained since August 2017, after a new sink was installed in a drug preparation room. Disinfection and flushing of the system did not take place until November. The IPCT advised that care was needed when repairing ceiling and floor in the Cystic Fibrosis Unit after water damage from the roof, due to the vulnerability of these patients. WPH: Work is due to commence on NNU to provide a solution to the poor water distribution network and resolve issues relating to the water quality in this area. Heatherwood: Water quality issues remain ongoing however remedial actions are being taken to prevent reoccurances in the future. Routine Programme of 6-monthly Deep Cleans A programme of routine 6-monthly deep cleans for wards was implemented in the UK in 2007 and 2008. At FPH patients are moved to “decant areas” (ie endoscopy or day surgical areas that are not used during weekends) so that ward beds, lockers and furniture get a thorough clean, alongside items that are not easily accessible such as vents and radiators. Due to bed pressures the decant areas are now frequently unavailable resulting in the deep clean programme for side-rooms being behind schedule, and the deep clean of wards has reduced to annually from 6-monthly. At HWP there was no programme of routine 6-monthly deep cleans implemented in 2008, although areas can have enhanced cleaning on a case by case basis. Siderooms At FPH continues to be concerns about the sustained national increase in number of patients colonised with multi-drug resistant organisms (MDRO) occupying beds in open bays on surgical wards since January 2016, and there has been an increase in the number of DATIX reports coming through about this matter. This is likely to be an continuing problem (the number of FPH inpatients (on any given day) colonised with MDRO has increased five-fold in the past 6 years), so actions are needed to reduce the risk of onward transmission of the organisms to these high risk patient groups (especially within implant surgery). • Compliance with the Trust Hand Hygiene policy. • Housekeeping staff must change cloths after cleaning each bed space. • Bedspaces must be cleaned thoroughly after each patient discharge. • Single-patient-use equipment should be used where possible for patients in bays with MDRO (such as

blood pressure cuffs and hoist slings). • Where patients with MDRO are unable to be isolated due to side-room capacity, staff should contact

the Infection Prevention & Control Team for advice, to ensure patients are placed in as low risk bays as possible (eg. no recent surgery or CVCs).

14



Page | 7

• Drs must be made aware of patient’s MDRO status prior to prescribing antibiotics, as it may have an impact on the antibiotic choices for that patient.

Capital Projects The number of Capital Projects is placing a demand on the Infection Prevention and Control Team (IPCT) resource due to the large number of meetings to attend (some of which are off-site). Infection Control representatives attend the meetings, and if, derogations are made the plans are signed off at Director level as recorded below. Current involvement is with:

- FPH Renal Unit – derogation due to concerns raised about insufficient storage for the ward, lack of a treatment room, and lack of partitioning between bed spaces in line with National Guidelines for prevetion of blood bourne Viruses. Costing is underway to ascertain if these can be added.

- FPH F9 – derogation due to a reduction in exisintg bed spacing, insufficient toilet facilites and lack of storage room. Due to unforeseen issues taking longer than anticipated, these works have now been halted meaning the remaining (third) sideroom that has been taken out of action will not be reinstated.

- Heatherwood – meetings have not yet resumed - Wexham ED – derogation as due to bed layout, bed spacing in 4-bedded bays does not comply with

National standards. Multiple meetings held to discuss how to ensure these comply. - Wexham Maternity – derogation as plans did not comply with National standards for bed spacing.

This build is now complete and returned to full operational use - Wexham Radiograpy - Refurbishment plans are being drawn up and will include the provision of a

designated bed-waiting area - FPH & WPH Parkside Refurbishment - Work is underway to refurbish Parkside, including installation

of clinical hand wash basins in the rooms. - FPH New Diagnostic Building – plans have been sent to the Infection Control Team for comment.

Staffing There are three Band 6 IPCN vacancies (two at WPH, one at FPH). There has effectively been a reduction in nursing staff at FPH following acquisition and additional wards added at community hospital sites.

14



Page | 8

Appendix I Hand Hygiene Compliance Audit Results

Hand Hygiene League Tables

Frimley Park Hospital Heatherwood & Wexham Park Hospitals

Ward/ DeptHand Hygiene Audit Compliance Month of last audit Ward/ Dept

Hand Hygiene Audit Compliance

SADU 100% Sep-17WX Christiansen Unit

100%

Parkside LS & SS 100% Feb-17 WX NNU 100%NNU 100% Aug-17 WX11 100%Main Recovery 100% Sep-17 WX10 100%

Critical Care 100% Dec-17 HW 4 Ortho 100%G2B EC 100% Sep-17 WX ITU 100%MADU 100% Sep-17 WX MIDU 100%SAU 100% Oct-17 WX2 Surg 100%F8 Surg 100% Nov-17 WX7 MSS 100%G9 Cardiac 97% Nov-17 WX24 & PAU 95%F7 Sur & Urol 96% Oct-17 WX GIU 95%F5 Ortho 96% Aug-17 WX6 95%Maternity 96% Sep-17 WX2 Med 95%G1 Haem 96% Oct-17 WX1 90%F15 Gynae 96% Aug-17 WX20 90%G6 Med 96% Oct-17 WX21 90%F2 Med 96% Oct-17 WX Parkside 90%F1 Paed 96% Oct-17 WX CCU 90%G5 Resp 96% Oct-17 MADU 90%SSS 96% Nov-17 WX Eden 85%F9 Gastro 96% Dec-17 WX18 85%F14 EC 93% Jul-17 WX22 85%Calthorpe 93% Jun-17 WX5 85%F10 Rheum 92% Oct-17 WX9 & MADU 85%CCU 92% Sep-17 WX17 80%F3 Endocrine 92% Aug-17 WX GP Unit 80%Bourne 92% Jun-17 WX ASU 80%F4 Ortho 92% Oct-17 WX8 AMU 80%G3 Stroke 91% Nov-17 WX4 80%AMU/ MAU 91% Nov-17 WX3 80%F6 Ortho 91% Aug-17G2A EC 90% Nov-17Renal Unit

95% and over76%-94% Audit data to December 201775% and below

New ward for audit in Dec17

14



Page | 9

Hand Hygiene Compliance by Staff Group Frimley Park Hospital:

Heatherwood & Wexham Park Hospitals:

0

10

20

30

40

50

60

70

80

90

100

% H

and

Hygi

ene

com

plia

nce

Drs Reg Nurses Unreg nurses Ancillary AHPs

0

10

20

30

40

50

60

70

80

90

100

Oct-15 Dec-15 Jan-16 Apr-Jun16 Jul-Sept16 Oct-Dec16Jan-Mar17 Apr-Jun17 Jul-Sept17 Oct-Dec17to date

% H

and

Hygi

ene

Com

plia

nce

Drs Reg nurses UnReg nurses AHPs Ancillary

14



Page | 1

Report Title

Update Summary from the Charitable Funds Committee, (CFC)

Meeting

Public Board

Meeting Date


Agenda No.

15.1

Report Type

Information

Prepared By

Mike O’Donovan, Chair of the CFC and Kevin Jacob, Asst. Company Secretary

Executive Leads

Nigel Foster, Director of Finance and IM&T and Janet King, Director of Human Resources and Corporate Services.

Executive Summary

This report briefs the Board on the main items discussed at the 5th December 2017 meeting of the Charitable Funds Committee.

Background

1. Charitable Funds Significant Income and Expenditure 2017/2018 M1-7 The Committee noted a report on:

Recent income received from individual donations over £5,000 and details of individual purchases from charitable funds in excess of £10,000 highlights of which included income of £150,000 and expenditure of £513,000 for the purchase of X-Ray equipment funded by the Frimley Breast Care Appeal

2. Charitable Fund Balances and Treasury Management Report The Committee noted a report on:

The current combined fund which as of 31st October had a combined total of £3.9 million

How investments had been made in line with the Charitable Funds Investment Policy together with an update on the current case position and future commitments.

It was noted The Treasury Management position had not significantly changed since the previous report, but the recent small increase in the Bank of England base rate was expected to feed through into slightly increased interest income although this would not be significant.

3. Application from PGEC at Frimley to establish a new charitable fund The Committee noted the delegated decision by the Director of Finance and IM&T and Director of HR & Corporate Services to approve an application to create a new charitable fund associated with the PGEC at Frimley.

15.1

Tab 15.1 Charitable Funds Committee, 5th December


Page | 2

4. Fundraising Activity Report The Committee considered a comprehensive report setting out an update on the Trust’s major appeals the Stroke Appeal at Frimley and the Children’s Critical Care Appeal at Wexham and other charity fundraising activities. Re-Branding The Committee discussed a number of options around the potential re-branding of the Frimley Health Charity and site specific appeals. It was noted that ultimately a final decision on the branding of the charity would need to be made by the Charitable Trustee. 5. Community Health Lottery The Committee considered a paper setting out options around the potential establishment of a community health lottery. It was noted that ultimately a final decision on the branding of the charity would need to be made by the Charitable Trustee.

Recommendation

This Board is asked to note the issues highlighted in the reports and agree any further action as required.

15.1

Tab 15.1 Charitable Funds Committee, 5th December


Page | 1

Report Title

Update Summary from the Quality Assurance Committee, (QAC)

Meeting

Public Board

Meeting Date


Agenda No.

15.2

Report Type

Information

Prepared By

Mike O’Donovan, Chair of the QAC and Kevin Jacob, Asst. Company Secretary

Executive Leads

Duncan Burton, Director of Nursing and Tim Ho, Medical Director

Executive Summary

This report briefs the Board on the main items discussed at the 8th December 2017 meeting of the Quality Assurance Committee.

Background

1. Serious Incidents – Deep Dive and themes DB introduced a report which gave details of the number and make up of serious incidents (SIs) that had occurred since April, summarised the key themes from an analysis of the incidents on each site and gave details of action plans and worksteams in response to the SIs. It was noted that unfortunately there had been a significant increase in the number of SIs during the first six months of 2017/2018 and that the Board had asked the Committee to undertake a deep dive on the subject as part of its biannual review of serious incidents. The Committee was provided with an update in respect of: • Deteriorating patients and unexpected deaths • Patient falls • Pressure ulcers • Neonatal deaths • Never events (wrong site surgery) • Wrong nerve block • Wrong site surgery • Wrong route administration • Changes in practice and actions plans

15.2

Tab 15.2 Quality Assurance Committee, 8th December 2017


Page | 2

It was noted that there particular hotspots around sub optimal care of the deteriorating patient and unexpected deaths and the Committee explored the background to this and actions being taken to address the situation. Discussion also focussed on the follow up of actions agreed as part of action plans in response to serious incidents, particularly with regard to the discussions that took place six weeks after the conclusion of a serious incident. The importance of ‘closing the loop’ to ensure that learning from serious incidents was embedded was stressed and it was noted that it was intended that future summary reports to the Trust Board would have a sharper focus on follow up. The Committee also discussed the importance of maintaining a climate and culture that encouraged staff to be open and honest in declaring serious incidents without fear of repercussions as the serious incident process was designed so that learning could take place. This had to be balanced against the need to take appropriate action where there had been individual negligence. The Committee noted the report. 2. Four Hour Emergency Department Target Deep Dive – Winter Resilience and

Quality The Committee received a presentation from the Head of Nursing Emergency & Cardiovascular Medicine on the 4 hour ED target including matters relating to winter resilience and quality. This covered the challenges faced by the Emergency Departments, patient experience, safety, quality and some of the solutions put in place to overcome some of the challenges. The report was noted. 3. Progress on Quality Improvement Priorities for 2017/2018 and Quality

Improvement Strategy The Committee received an update report setting out progress in achieving the Trust’s Quality Improvement Priorities for 2017/2018. The report was noted. 4. Clinical Audit Programme 2017/2018 Update The Committee was briefed by the Head of Quality at Frimley on progress with the 2017/2018 Clinical Programme. Highlights included: • Further audits had been added to the programme taking the expected total for

the year to be approximately 400 which was in line with the number in 2016/2017, but there had been some reductions

• There had been a good response rate in terms of audits around SIs and good levels of clinical engagement and drive around the audits

• There were a number of clinical audits yet to start and there was a real push to progress this, but a balance needed to be struck in recognising the operational day to day pressures staff were facing.

• A challenge was that although there had been a good level of clinical engagement generally this needed to be maintained across all areas.

In discussion, the Committee sought reassurance that the size of the clinical audit programme was delivered and discussion took place regarding the impact of nationally mandated audits. The Committee was pleased that the programme had continued to improve.

15.2



Page | 3

The Committee noted the report. 5. Medicines Management Audit The Committee considered a copy of the review undertaken by the Trust’s internal auditors of staff compliance with the Trust’s medicine management policies and procedures which had returned an overall assurance assessment of limited assurance. The report had also been considered by the Audit Committee at its meeting on 16 November. The Committee discussed the findings of the report and further progress made in implementing the action plan. It noted that it was fully accepted by the Trust that the result was disappointing, but had been helpful in that that it had established what needed to done and where the gaps were. The Committee noted the progress being made which included the establishment of a specific task and finish group which was due to meet before the end of December 2017. The Committee noted the report. 6. Review of Terms of Reference The Committee conducted a review of its Terms and Reference and a number of amendments were suggested including adding the Trust Chief Executive to the Committee’s membership and number of technical updates. It was agreed to recommend that the Board approve the revisions to the Committee’s Terms of Reference. 7. Clinical Governance Committee Minutes and Highlights The Committee noted the reports from the Clinical Committee. 8. Patient Safety Committee and Patient Experience Forum The Committee noted the reports form the Patient Safety Committee and Patient Experience Forums.

This Board is asked to note the issues highlighted in the report.

15.2



Page | 1

Report Title

Quality Assurance Committee Sub-Committees Terms of Reference

Meeting

Public Board

Meeting Date


Agenda No.

16.

Report Type

For Review

Prepared By

Kevin Jacob, Assistant Company Secretary

Executive Lead

Duncan Burton, Director of Nursing and Quality

Executive Summary

This paper asks the Board to approved the attached Terms of Reference of Board Sub-Committees.

Background

Board Sub-Committees review their Terms of Reference on an annual basis prior to approval by the full Board. The Terms of Reference of Board Sub-Committee were last considered by the Board at its meeting in November 2017, but it was noted that the Quality Assurance Committee would not consider Terms of Reference until itsmeeting on 8 December 2017. Arising from this meeting a number of changes are proposed shown in the attached document.

Issues / Actions

In the interests of transparency it is appropriate to bring the Terms of Reference to a public meeting for review.

Recommendation

That the Board review and approve the attached Quality Assurance Committee Board sub-committee Terms of Reference.

16

Tab 16 Quality Assurance Committee Terms of Reference


Page | 2

Appendices

Proposed amendments to Quality Assurance Committee Terms of Reference

16



Quality Assurance Committee (QAC)

Terms of Reference

1. Constitution

The Quality Assurance Committee is established as a Committee of the Board of Directors of Frimley Health NHS Foundation Trust (the Trust).

The Quality Assurance Committee will review these Terms of Reference on an annual basis as part of a self-assessment of its own effectiveness. Any recommended changes brought about as a result of the yearly review, including changes to the Terms of Reference, will require Board of Directors approval.

2. Authority

The Quality Assurance Committee is directly accountable to the Board of Directors. All minutes of committee meetings will be reported directly to the Board of Directors and Audit Committee (Assurance).

The Quality Assurance Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Quality Assurance Committee.

The Quality Assurance Committee is further authorised by the Board to obtain external independent professional advice and to secure the attendance of specialists with relevant experience and expertise if it considers this necessary.

3. Aim

The aim of the Quality Assurance Committee is to provide assurance to the Board of Directors that there is an effective system of risk management and internal control across the clinical activities of the organisation that support the organisation’s objectives and the Trust’s ability to provide excellent quality care by excellent people.

4. Objectives

Specific responsibilities of the Quality Assurance Committee include:

• Providing assurance that the risks associated with the Trust’s provision of excellent care are identified, managed and mitigated appropriately. In doing so, the Quality Assurance Committee may consider any quality issue it deems appropriate to ensure that this can be achieved.

• Providing assurance to the Board by:

Ensuring that the strategic priorities for quality assurance are focused on those which best support delivery of the Trust’s quality priorities in relation to patient experience, safety of patients and service users and effective outcomes for patients and service users;

Reviewing the independent annual Clinical Audit Programme, ensuring it provides a suitable level of coverage for assurance purposes, and receiving reports as appropriate;

16



Reviewing compliance with regulatory standards and statutory requirements, for example those

of the Duty of Candour, the CQC, NHSR NHSLA and the NHS Performance Framework. Reviewing non-financial risks on the Risk Assurance Framework which have been assigned to the

Quality Assurance Committee and satisfying itself as to the adequacy of assurances on the operation of the key controls and the adequacy of action plans to address weaknesses in controls and assurances;

Reviewing the Annual Quality Report ahead of its submission to the Board for approval. • Overseeing ‘Deep Dive Reviews’ of identified risks to quality identified by the Board or the Committee,

particularly “Serious Incidents Requiring Investigation” and how well any recommended actions have been implemented.

• The Committee may also initiate such reviews based on its own tracking and analysis of quality trends

flagged up through the regular performance reporting to the Board. 5. Method of Working

A standard agenda as follows will be used by the Quality Assurance Committee:-

1. Apologies for Absence 2. Declarations of Interest 3. Minutes of the Previous Meeting 4. Action Log 5. Progress on Quality Improvement Priorities 6. Clinical Governance Committee Reports 7. Any Other Business 8. Date of Next Meeting

All Minutes of the Quality Assurance Committee will be presented in a standard format, as set out in Appendix A.

All meetings will receive an action log (detailing progress against actions agreed at the previous meeting) for the purposes of review and follow-up. The action log template is attached at Appendix B.

6. Membership

The Members of the Quality Assurance Committee shall comprise three Nthree No0n-Executive Directors, one of whom will be Committee Chair, the Director of Nursing, and the Medical Director and Chief Executive. In the absence of the Committee Chair and with the agreement of the other attending members’ one of the other Non-Executive Directors will chair the meeting.

The Chief Executive and Executive Directors along with any other appropriate attendee will be invited to attend by the Committee Chair when the Committee is discussing areas of risk or operation that fall under their direct responsibility.

The Company Secretary or deputy will attend all meetings to ensure coordination.

7. Quorum

The quorum shall be four members, of which at least two must be Non-Executive Directors.

8. Frequency of Meetings

The Quality Assurance Committee will meet at least on quarterly basis to ensure it is able to discharge all its responsibilities.

16



9. Secretariat

The agenda will be prepared by the Committee Chair with input from the Committee members and other regular attendees, who may propose items for inclusion in the agenda. Items for inclusion in the agenda will be submitted a minimum of two weeks prior to the meeting. The agenda with associated meeting papers will be distributed to members of the Committee one week prior to the meeting. Draft minutes of the meetings will be distributed to all members within one month of the meeting. The date for the next meeting will be arranged and distributed to all members within one month of the meeting. The date for the next meeting will be arranged and distributed to all members with the draft minutes.

10. Reporting Lines The minutes of each Committee meeting will be reported to the private Board of Directors. Furthermore, the minutes will be shared with the Audit Committee (Assurance) and vice versa. A summary of the minutes of each meeting will be included in the next public board agenda. Where a significant risk emerges either through a report or through discussion at a Committee meeting, this will be reported to the Board by the Committee Chair. The outcomes of any ‘Deep Dive Reviews’ will be reported to the Board and any follow up action kept under review by the Committee. The Quality Assurance Committee has no formal sub-committees but will receive a variety of reports from other committees, as needed, to allow it to carry out its stated duties. The minutes of the Clinical Governance Committee (CGC), Patient Experience Forums, (PEF) and Patient Safety Committee, (PSC will) will be reported to the Committee. The Committee Chair will advise the Board of issues requiring action that have been raised at the CGC, PEF and PSC.. In accordance with their terms of reference, the Quality Assurance Committee and the Audit Committee (Assurance) will work together, share information with each other, and may refer issues to each other for investigation.

Reviewed by: Board of Directors

Date: 2nd September 2016

Approved by: Board of Directors

Date: 2nd September 2016

Review date: September 2017

16



Page 1 of 8

ACRONYM BUSTER

A A&E - Accident and Emergency AD - Associate Director ADT - Admission, Discharge and Transfer AfC - Agenda for Change AGM - Annual General Meeting / Annual Governance Meeting AHP - Advanced Health Professional AKI - Acute Kidney Injury AMM - Annual Members Meeting AMR - Antimicrobial Resistance AMU - Acute Medical Unit AOS - Acute Oncology Service ANP - Advanced Nurse Practitioner AR - Annual Report ASPH - Ashford and St. Peter’s Hospital

B BAU - Business As Usual BBE - Bare Below Elbow BME - Black and Minority Ethnic BCF - Better Care Fund BMA - British Medical Association BMI - Body Mass Index BoD - Board of Directors

C CAMHS - Child and Adolescent Mental Health Services CAS - Central Alert System CAU - Clinical Assessment Unit CCG - Clinical Commissioning Group CCU - Coronary Care Unit CDI - Clostridium Difficile Infection CDIC - Commercial Development and Investment Committee Cdif / C.Diff - Clostridium Difficile CEA - Clinical Excellence Awards CEO - Chief Executive Officer CFO - Chief Finance Officer

Acronyms Buster


Page 2 of 8

CHC - Continuing Health Care CHD - Coronary Heart Disease CIO - Chief Information Officer CIP - Continuous Improvement Plan CoG - Council of Governors CoS - Chief of Service CoSRR - Continuity of Service Risk Rating CPA - Care Programme Approach CQC - Care Quality Commission CQUIN - Commissioning for Quality and Innovation CRAB - Copeland’s Risk Adjusted Barometer C.Section - Caesarean Section CSU - Commissioning Support Unit CT - Computerised Tomography CTG - Cardiotocography CVC - Central Venous Catheter

D DBS - Disclosure Barring Service DGH - District General Hospital DH / DoH - Department of Health DIPC - Director of Infection Prevention and Control DNA - Did Not Attend DNACPR - Do Not Attempt Cardiopulmonary Resuscitation DNAR - Do Not Attempt Resuscitation DNR - Do Not Resuscitate DoLS - Deprivation of Liberty Safeguards DoN - Director of Nursing DoO - Director of Operations DPA - Data Protection Act DSU - Day Surgery Unit DVT - Deep Vein Thrombosis

E E&D - Equality and Diversity EAU - Emergency Assessment Unit EBITDA - Earnings Before Interest, Taxes, Depreciation and Amortization ECG - Electrocardiogram ECIST - Emergency Care Intensive Support Team ED - Emergency Department EDD - Estimated Date of Discharge EDMS - Electronic Document Management

Acronyms Buster


Page 3 of 8

System EEG- Electroencephalogram EHR - Electronic Health Record EHRC - Equality and Human Rights Commission EIA - Equality Impact Assessment ELSCS - Elective Caesarean Section EM - Emergency Medicine EMLSCS - Emergency Caesarean Section ENT - Ear, Nose and Throat EOLC - End of Life Care EOLCA - End of Life Care Audit EPR - Electronic Patient Record EPRR - Emergency Preparedness, Resilience and Response ESD - Early Supported Discharge ESR - Electronic Staff Record ETP - Electronic Transmission of Prescriptions EEA - European Economic Area

F FBC - Full Business Case FFT - Friends and Family Test FH - Frimley Health FOI - Freedom of Information FPH - Frimley Park Hospital FRR - Financial Risk Rating FT - Foundation Trust FTE - Full Time Equivalent FPH - Frimley Park Hospital FYE - Financial Year End

G GI - Gastrointestinal GMC - General Medical Council GMS - General Medical Services GP - General Practitioner GRE – Glycopeptide Resistant Enterococci

H HAI - Hospital Acquired Infection HASU - Hyper Acute Stroke Unit HCA - Health Care Assistant HCAI - Healthcare-Associated Infection

Acronyms Buster


Page 4 of 8

HDU - High Dependency Unit HEB - Hospital Executive Board HED - Healthcare Evaluation Data HEKSS - Health Education Kent, Surrey and Sussex HETV - Health Education Thames Valley HICC - Hospital Infection Control Committee HoN - Head of Nursing HSE - Health and Safety Executive HSMR - Hospital Standardised Mortality Ratio HTC - Hospital Transfusion Committee HWB - Health and Wellbeing Board HWD - Heatherwood HWP - Heatherwood and Wexham Park HWPH / H&WPH - Heatherwood and Wexham Park Hospitals

I I&E - Income and Equity IC - Information Commissioner ICM - Integrated Case Management ICP - Integrated Care Pathway ICU - Intensive Care Unit IG - Information Governance IGT / IGTK - Information Governance Toolkit IM&T - Information Management and Technology IPCN - Infection Prevention and Control Nurse IPCT - Infection Prevention and Control Team IPR - Individual Performance Review ITU - Intensive Therapy Unit / Critical Care Unit IV - Intravenous

J JAG - Joint Advisory Group

K KPI - Key Performance Indicator

L LA - Local Authority

Acronyms Buster


Page 5 of 8

LCFS - Local Counter Fraud Specialist LD - Learning Disability LHRP - Local Health Resilience Partnership LiA - Listening into Action LINAC - Linear Accelerator LOS / LoS - Length of Stay LUCADA - Lung Cancer Audit Data

M M&M - Morbidity and Mortality MAU - Medical Assessment Unit MDT - Multi-Disciplinary Team MHPS - Maintaining High Professional Standards MIDU - Medical Investigations Day Unit MiG - Medical Interoperability MIU - Minor Injuries Unit MRI - Magnetic Resonance Imaging MRSA - Methicillin-Resistant Staphylococcus Aureus

N NBOCAP - National Bowel Cancer Audit Programme NCASP - National Clinical Audit Support Programme NED - Non-Executive Director NHS FT - NHS Foundation Trust NHSE - NHS England NHSLA - NHS Litigation Authority NHSP - NHS Professional NICE - National Institute for Health and Care Excellence NICU - Neonatal Intensive Care Unit NMC - Nursing and Midwifery Council NNU - Neonatal Unit NOGCA - National Oesophago-Gastric Cancer Audit NRLS - National Reporting and Learning System / Service

O O&G - Obstetrics and Gynaecology OBC - Outline Business Case

Acronyms Buster


Page 6 of 8

ODP - Operating Department Practitioner OHD - Occupational Health Department OLM - Oracle Learning Management OOH - Out of Hours OP - Outpatient OPD - Outpatient Department OT - Occupational Therapist/Therapy

P PACS - Picture Archiving and Communications System PACU - Post-Anesthetic Care Unit PALS - Patient Advice and Liaison Service PAS - Patient Administration System PAU - Paediatric Assessment Unit PbR - Payment by Results PCI - Percutaneous Coronary Intervention PDC - Public Dividend Capital PDD - Predicted Date of Discharge PE - Pulmonary Embolism PEAT - Patient Environment Action Team PFI - Private Finance Initiative PHE - Public Health England PICC - Peripherally Inserted Central Catheters PID - Patient / Person Identifiable Data PILS - Patient Information Leaflets PID - Project Initiation Document PLACE - Patient-Led Assessments of the Care Environment PMS - Personal Medical Services PMO - Programme Management Office POD - Pre-Operative Department POSSUM - Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity PPE - Personal Protective Equipment PPI - Patient and Public Involvement PSED - Public Sector Equality Duty

Q QA - Quality Assurance QAC - Quality Assurance Committee QI - Quality Indicator QIP - Quality Improvement Plan QIPP - Quality, Innovation, Productivity and Prevention QIA - Quality Impact Assessment

Acronyms Buster


Page 7 of 8

QOF - Quality and Outcomes Framework

R RAF - Risk Assurance Framework RAG - Red Amber Green RBH - Royal Berkshire Hospital RCA - Root Cause Analysis RCN - Royal College of Nursing RCP - Royal College of Physicians RCS - Royal College of Surgeons RIDDOR - Reporting of Injuries, Diseases and Dangerous Occurrences Regulations RSCH - Royal Surrey County Hospital RTT - Referral to Treatment

S SADU - Surgical Day Unit SAU - Surgical Assessment Unit (FPH) / Surgical Assessment Unit (WPH) SCAS / SCAmb - South Central Ambulance Service SDIP - Service Development and Improvement Plan SHMI - Summary Hospital-level Mortality Indicator SHO - Senior House Officer SI - Serious Incident SIRI - Serious Incident Requiring Investigation SIRO - Serious Incident Risk Owner SID - Senior Independent Director SLA - Service Level Agreement SLR - Service-Line Reporting SLT / SaLT - Speech and Language Therapy SME - Subject Matter Expert SMR - Standardised Mortality Ratio SoS - Secretary of State SPS - Surrey Pathology Service SSI(S) - Surgical Site Infections (Surveillance) SSNAP - Sentinel Stroke National Audit Programme SSS - Short Stay Surgical Unity STP - Sustainability and Transformation Plan SUI - Serious Untoward Incident

T

Acronyms Buster


Page 8 of 8

TIA - Transient Ischaemic Attack TLC - Turn off, Lights out, Close doors TMG - Theatre Management Group TNA - Training Needs Analysis TPN - Total Parenteral Nutrition TTA - To Take Away TTO - To Take Out TUPE - Transfer of Undertakings (Protection of Employment) Regulations 1981

U UCB - Urgent Care Board UI - Untoward Incident UGI - Upper Gastrointestinal UTI - Urinary Tract Infection

V VfM - Value for Money VSM - Very Senior Manager VTE - Venous Thromboembolism

W WHO - World Health Organization WLI - Waiting List Initiative WPH - Wexham Park Hospital WTE - Whole Time Equivalent

Y YTD - Year to Date

Acronyms Buster


Download - BOARD OF DIRECTORS · PDF fileJoanne Philpot (Chief of Service Paediatrics) Attached/ To follow . ... excel & other versions\3. public board minutes 01dec17 final mom.docx Page 3 of

Top Related