TB2020.06 Integrated Performance Report (IPR)

Trust Board

January 2020

Sam Foster: Chief Nursing Officer

Meghana Pandit: Chief Medical Officer

Sara Randall: Chief Operating Officer

Jane Nicholson: Interim Chief People Officer

Urgent Care; 4 hour performance in November 19 was 80.60%, a decrease from month 7.

Figure 2: Attendances in JR and HGH ED’s Figure 3: Breach reason, speciality and admission status

In November 2019, month 8, the Trust achieved performance of 80.60%.

The HGH experienced an improvement in performance from 80.39% to 81.8%. The JR performance decreased from 82.47% to 80.15%. (figure 1)

The majority of the breaches to the 4hr standard occur after 18:00hrs and continue overnight until 09:00hrs the following morning.

Breaches occur overnight due to the following; delay to be seen, results of investigations , wait for senior review and waiting for a bed.

MRC with the AMR directorate are planning to pilot January senior decision makers in the ED after 00:00hrs.

2

Urgent Care; Horton General Hospital(HGH) Urgent Care; John Radcliffe Hospital (JR)

Figure 4 Ambulance arrivals in HGH Figure 5 Ambulance arrivals in JR

Figure 6 Ambulance handovers over 60 mins JR site

Both the JR and HGH sites have had an increase in ambulance attendances which correlate's with the increase in acuity across both sites, particularly the JR site.

There were no ambulance handover delays over 1hr on the HGH site

The majority of the 1hr ambulance handover delays occur when there is an increase in ambulance arrivals at peak times of activity in the ED.

SCAS have had to leave two crew members (HALO) in the JR ED to release crews back on the road.

When ambulance delays go over 30mins there is an escalation process in place between the SCAS Bronze and the OUHFT senior ops person.

The JR ED team are also working closely with SCAS to further reduce the 1hr and 30min ambulance handover delays.

3

Emergency admissions continue to increase in November 2019, occupancy levels remain high at JR and HGH sites

Figure 7 Emergency admissions JR and HGH Figure 8 Bed occupancy HGH and JR

Figure 9 OUH Trust emergency admissions

Overall emergency admissions have increased which has had an impact on flow from both ED and EAU’s.

John Radcliffe Hospital

Emergency admissions increased in September – November which correlated with a reduction in the 4hr performance.

Bed occupancy continues to increase in the JR site from September 2019

Horton General Hospital

Emergency admissions continue to increase since September 2019.

Occupancy levels have slightly reduced in November. 4

Urgent Care; Discharges, LOS and extended LOS for patients over 21 days. Continued progress at the JR site, HGH seeing minimal improvement

Figure 11: Extended length of stay (21+ days July19 – Dec 19 by Hospital Site

Discharges and LOS

Figure 10 illustrates the discharges and LOS for patients in beds on the JR and HGH sites. It excludes maternity and children's.

The LOS increased at the HGH in October which had impact on flow from the HGH ED and EAU.

The average LOS increased in the HGH and JR from September to October when we also saw a decrease in compliance with the 4hr standard.

Reduction of LOS over 21 days

NHSI has set the OUH Trust a reduction of patients over 21 days to 110 patients by 30th March 2020.

There is a minimal reduction in LOS of patients over 21 days prior to the MADE event in December .

Following the MADE event in December 2019 we saw a reduction in the Churchill and John Radcliffe sites. The LOS has since increased over Christmas and New Year.

There was a minimal reduction in the HGH and the MADE event did not impact the Northamptonshire delays in the HGH.

Each Division within the OUH receives patient level information for every patient in an OUH patient bed for 21 days or more.

All patients delayed or medically fit for discharge are discussed every day to see what additional interventions/conversations are required to support the patients discharge.

Each Division has a process in place to peer review patients who are not medically fit.

Figure 10 discharges and LOS for wards on JR and HGH sites excluding maternity and children’s

5

Project 1 - Improve same day emergency care processes

Improve patient pathways for children and adults and improve allocation of patients to the most appropriate clinical areas and most appropriate clinical pathways.

KPI – 50% Increase in patients treated on ambulatory pathways

Project 5 - Daily reporting, data quality and external reporting

Data accuracy and transparency to enable clinical and operational staff to make improved decisions to improve patient care

KPI - Improve ED performance by 0.5% through accurately reporting breach performance (target 500 pts)01041969

Daily meeting are in the process of being set up to validate breaches in real time to develop process to make this sustainable.

Project 6 - Timely management of patients who present with mental health issues

Project 3 - Reduce out of hours breaches

Improve patient flow, ensure patient care is quicker and they are seen at the right time

KPI - Reduce non admitted over night breaches in JR by 50%

MRC division to pilot senior decision makers after 00:00hrs overnight

Project 4 - Improve compliance with OPEL escalation actions

Ensure patients get appropriate care in time by making system work more effectively when acute hospital is under pressure

KPI - Reduction in breaches from 0900 to 1700 by 50% by March 2020

Discussion with Divisional Teams on the use of OPEL escalations and actions and how they can be embedded further arranged.

The Urgent Care Improvement Programme has a number of projects aimed at improving current performance

Project 2 - Reduction in the number of patients with an extended LOS over 21 days

KPI - Reducing the number of patients with an extended length of stay (LOS) over 21 days by 31% from 160 to 110 by March 2020

The Information Team now use the weekly validated DPTL as the source for their reporting.

6

OUH remain in Upper Quartile of Type 1 ED Performance In November 2019

7

Nationally we are entering the most pressured Urgent & Emergency care period our system response includes:

Revised System escalation tool with explicit actions with system partners to equalise pressure across Oxfordshire – next steps include primary care escalation triggers;

Jointly commissioned additional short stay beds across Oxfordshire & opened addition inpatient capacity at JR & HGH sites;

Jointly commissioned Third sector support;

Executive Team oversight of ambulance delays and corridor nursing in to take mitigations actions & support staff;

Maximising ambulatory pathways in conjunction with System partners;

System wide review of patients with long lengths of stay;

Refresh & relaunch of Safer placement & Full capacity protocol;

8

Elective Care: Total Waiting List Size and Number of 52+ week waiters reduced in Month 8

Waiting List Size Trajectory 2019/20: As agreed in our annual planning submission we have committed to an increase in our waiting list size of 2,928 during 2019/20. This reflects the contractual position with Oxfordshire. The trajectory is heavily weighted during April – August 2019, to reflect the closure of theatres whilst we complete the refresh of the JR2 theatres, following the enforcement notice from the CQC in 2018. Month 8 Performance: The submitted total waiting list size for November 2019 (52,132) represents a decrease in waiting list size of 1,068 patients when compared to October 2019, the Trust has achieved ahead of its submitted trajectory in November 2019. 52 week wait positon month 8: November submission saw 13 patients waiting over 52 weeks for first definitive treatment, exceeding the trajectory volume of zero. Of the 13 submitted breaches, 3 have now been treated in December, 2 have TCI dates/plan to treat scheduled in late December, 5 patients have plans to treat in January, 2 patients have plans to treat in February, and 1 is with service for confirmation of next step. Clinical harm reviews: In line with the Trusts agreed protocol, harm reviews have been requested for the 13 patients, the deadline for completion is the 31st December 2019 Actions: Chief Operating Officer and central team are meeting weekly with all Divisions to discuss most challenged services and to support management and monitoring of the long waiting patients.

0

50

100

150

200

250

300

46000470004800049000500005100052000530005400055000

Total list size Actual Total list size Plan 52 week Plan 52 week Actual

Specialty

Number of

patients Plan for treatment

Plastic Surgery 4 1x stopped Dec treated, 1x TCI 22/01/2020, 2x TCI 12/02/20

Paediatric Spinal Surgery 2 1xTCI 16/01/20, 1x TCI 15/01/20

ENT 2 1 x stop December, 1x TCI 22/01/20 Trauma and Orthopaedics 1 1xTCI 28/01/20 Paediatric Plastic Surgery 1 1x TCI 31/12/19

Urology 1 1x POA 31/12/19

Maxillo Facial Surgery 1 1x Stopped treated Dec

Paediatric Respiratory Medicine (connected with Paed ENT pathway)

1 awaiting decision based on completed sleep study

Grand Total 13 9

Elective Care; Diagnostic Waits (DM01) increased in month 8

• Trajectory 2019/20 : The agreed Trust Trajectory was set to achieve the 1% standard at the end of September 2019, with MRI providing the most significant challenge. November Trust level position was 2.66% and therefore trajectory has not been met.

• Month 8 Performance: At the end of November 2019 2.66% of patients waiting for diagnostic test were waiting more than 6 weeks, therefore Trust level trajectory of 1.0% was not met for the month. The main areas of under performance were seen in; Gastroscopy 9.11 % against a trajectory of 1.5%, Flexi Sigmoidoscopy 10.38% against a trajectory of 0.4%, and Cystoscopy at 9.15% against a trajectory of 2.0%. MRI had the largest number of breaches at 200 (6.22%), and also did not meet trajectory of 3.1%.

• Actions: Endoscopy position has deteriorated due to implementation of FIT for Bowel Cancer Screening (BCS) resulting in an increase in the number of BCS colonoscopies required over above anticipated levels prior to implementation. In addition to this there has been limited uptake of additional lists due to tax/pension issue, which together have created a capacity and demand imbalance. Endoscopy mitigating actions include; Implementation of BSG guidance regarding surveillance procedures (based on pilot sites anticipate a reduction of 70% surveillance patients), continuation of Gutcare insourcing for nursing, and recruiting into admin team to improve admin booking process

• Continued plans to improve the MRI position are detailed in the “Radiology Resources” paper, mobile scanners at JR and NOC are operational and plans to have a relocatable in place at Horton in January. Focus on reducing radiology DNAs is a key workstream in the Diagnostic Improvement Programme

% Patients waiting >6weeks for diagnostic procedure against plan

Number of patients waiting over 6 weeks at submitted position for monthly diagnostic return:

0.00%

1.00%

2.00%

3.00%

Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20Actual Performance % Plan Performance % National standard

Specialty Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul -19 Aug-19 Sep-19 Oct-19 Nov-19 Trend rol l ing 12 month periodMagnetic Resonance Imaging 157 123 269 149 226 206 206 182 173 181 163 191 200Computed Tomography 9 5 4 5 2 6 6 5 8 8 9 3 4Non-obstetric ul trasound 0 0 0 0 0 3 4 3 0 0 0 0 0Barium Enema 0 0 0 0 0 0 0 0 0 0 0 0 0DEXA Scan 0 0 0 0 0 0 0 0 0 0 0 0 0Audiology - Audiology Assessments 3 8 21 9 5 12 28 30 12 25 60 25 11Cardiology - echocardiography 2 0 4 10 3 1 0 8 4 23 5 20 7Cardiology - electrophys iology 0 0 0 0 0 0 0 0 1 2 0 7 24Neurophys iology - periphera l neurophys iology 0 0 5 0 0 1 25 22 5 36 4 0 3Respiratory phys iology - s leep s tudies 1 0 15 35 37 28 13 4 1 9 5 8 1Urodynamics - pressures & flows 17 2 0 1 0 1 0 0 0 2 6 8 9Colonoscopy 4 3 3 2 3 1 11 8 6 6 10 12 30Flexi s igmoidoscopy 1 0 0 0 2 3 5 3 6 3 10 19 30Cystoscopy 7 15 17 13 6 28 34 21 12 12 13 24 29Gastroscopy 3 8 5 8 7 10 10 3 7 17 9 18 39

10

Elective Care; Elective on the day cancellations and 28 day readmission

Month 8 Performance: There were 44 reportable (hospital non clinical) elective cancellations on the day throughout the month of November, this represents a decrease in cancellations due to these reasons when compared to previous month. The specialties contributing to the 44 are listed on the table to the left, the top 4 cancellation reasons were: • 12 due to no bed available , this related mainly to Paediatric beds (plus additional 2 due to No

HDU/ITU bed) • 9 patients due to emergency case taking priority • 8 patients due to list overran/ran out of theatre time • 6 patients due to anaesthetist unwell/no anaesthetist The remaining were made up of; equipment failure, equipment unavailable, Surgeon sickness and Theatre staff sickness 5 patients were not able to be offered a date of readmission within 28 days of cancellation and therefore breached the 28 day standard. The reasons given for not being able to readmit within the 28 day standard were either due to all available capacity within the 28 day timeframe being booked with clinically urgent cases, consultant not operating within the 28day timeframe, or patient requiring ITU bed and none being available within 28 days. Action: A theatre improvement programme is up and running and includes a workstream on pre-operative assessment – aims to reduce the volume of patients cancelled on the day for clinical reasons, furthermore the data available to analyse reasons and target improvements is limited – the theatre improvement programme aims to improve this.

28 Day reportable cancellations/readmission breaches by Month Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Total Hospital Non clinical cancellations in period 69 46 58 67 49 21 45 47 35 24 42 67 44 28 day Readmission breaches in period 2 1 5 1 4 8 4 3 1 3 2 7 5

Other - reasons for elective on the day cancellation by Month Clinical reason 60 27 39 29 34 51 37 33 42 26 29 56 44 Patient declined treatment on the day 7 6 8 4 6 5 6 6 8 6 6 6 5

Not cancelled on the day of admission - admin error 66 55 75 30 62 28 52 47 57 49 42 45 43

Grand Total 133 88 122 63 102 84 95 86 107 81 77 107 92

Specialty Cancellations 28 day Readmission Breaches

Interventional Radiology 2 0 Respiratory Medicine 1 0 Paediatric Neurosurgery 1 0 Paediatric Surgery 4 1 Paediatric Trauma and Orthopaedics 2 0 Paediatric Urology 1 0 Neurosurgery 2 1 ENT 1 0 Paediatric ENT 2 1 Paediatric Maxillo Facial Surgery 1 0 Plastic Surgery 1 0 Plastic Surgery Cleft 1 0 Plastic Surgery Craniofacial 1 0 Orthopaedics 9 0 Trauma and Orthopaedics 1 0 Endoscopy (Gastroenterology) 0 1 Gynaecological Oncology 1 0 Gynaecology 6 0 Endocrine Surgery 1 0 General Surgery 1 0 Hepatobiliary and Pancreatic Surgery 2 0 Upper Gastrointestinal Surgery 1 0 Urology 2 1 Grand Total 44 5

11

Cancer Waiting Time Standards Month 7 Performance: October 2019

In Month 7 we achieved 4 out of the 8 CWT Standards • The 2ww performance during October improved to 95.2%, against

a standard of 93% • The 31 day standard for first definitive treatment performance declined

in October and is below the standard at 87.6%

62 Day from a Screening Service There are 12 breaches in the screening service for October. 10 of these relate to the breast screening service and 2 to the bowel screening service. The breast service remains challenged by timely recall/ transfer to the 62 day pathway, out patient capacity and capacity for treatment.

62 Day from GP referral • Our 62 day CWT Standard was slightly improved on last month to 66.8%

against the CWT standard. • Whilst there are improvements in timeliness of diagnostics the demand

remains high and capacity for CT, MRI and PET continues to be challenged

• Ongoing developments of Infoflex are starting to make an impact on day to day pathway processes and data recording – this will continue over the coming months

Specific Actions • Infoflex Development to support E-MDT commenced with all tumour

sites expected to be rolled out by Feb 2020 • Cancer Pathways team working with Improvement team regarding

training package/ SOP’s in relation to patient pathways • Diagnostic action plan in place with trajectory for March 2020 • Chief Operating Officer & Cancer team meet weekly with all Divisions

to support management and monitoring of the long waiting patients.

S t a n d a r d O U H

O c t - 1 8 N o v - 1 8 D e c - 1 8 J a n - 1 9 F e b - 1 9 Mar-19 Apr-19 M a y - 1 9 J u n - 1 9 J u l - 1 9 Aug-19 Sept 19 Oct 19 A t l eas t 9 3 % o f pa t ien ts r e f e r r e d f r o m a G P wi th s u s p e c t e d c a n c e r wi l l b e s e e n w i th in 2 w e e k s o f re fe r ra l . 9 8 . 1 % 9 7 . 0 3 % 9 6 . 8 1 % 9 7 . 4 5 % 9 6 . 9 % 96.4% 96.3% 9 6 . 1 % 9 2 . 8 % 9 4 . 8 % 95.5% 94.1% 95.2% A t l eas t 9 3 % o f pa t ien ts r e f e r r e d f r o m a G P wi th b r e a s t s y m p t o m s b u t n o t s u s p e c t e d c a n c e r wi l l b e s e e n w i th in 2 w e e k s o f r e f e r r a l . 9 8 . 7 % 9 5 . 8 6 % 9 4 . 2 9 % 8 7 . 7 9 % 9 4 . 7 % 93.8% 97.3% 9 6 % 9 3 . 5 % 9 5 . 8 % 97.3% 95.3% 96.4% A t l eas t 9 6 % o f pa t ien ts wi l l r e c e i v e f irst def in i t ive t r e a t m e n t w i th in 3 1 d a y s o f a d e c i s i o n to t reat .

9 3 . 4 % 9 6 . 0 5 % 8 9 . 3 5 % 9 0 . 8 3 % 9 2 . 3 % 91.7% 95.7% 9 6 . 5 % 9 3 . 7 % 9 6 % 93.6% 91% 87.6%

A t l eas t 9 4 % o f pa t ien ts wi l l r e c e i v e s u b s e q u e n t t r e a t m e n t w i th s u r g e r y w i th in 3 1 d a y s o f d e c i s i o n to t reat . 9 2 . 1 % 9 6 . 8 8 % 9 5 . 1 2 % 9 5 . 2 4 % 1 0 0 % 96.2% 96.3% 9 5 . 1 % 9 8 . 2 % 9 5 . 5 % 85% 95.9% 89.4% A t l eas t 9 8 % o f pa t ien ts wi l l r e c e i v e s u b s e q u e n t t r e a t m e n t w i th ant i - c a n c e r d r u g r e g i m e n w i th in 3 1 d a y s o f d e c i s i o n to t reat .

1 0 0 % 1 0 0 % 1 0 0 % 1 0 0 % 1 0 0 % 99.2% 100% 1 0 0 % 1 0 0 % 1 0 0 % 100% 100% 100%

A t l eas t 9 4 % o f pa t ien ts wi l l r e c e i v e s u b s e q u e n t r a d i o t h e r a p y w i th in 3 1 d a y s o f a d e c i s i o n to t reat .

9 1 . 7 % 9 5 . 6 5 % 9 4 . 3 3 % 9 6 . 3 0 % 9 7 . 5 % 1 0 0 % 99.5% 9 9 . 5 % 9 9 . 5 % 9 9 . 2 % 99.5% 100% 98.6%

A t l eas t 8 5 % o f pa t ien ts wi l l r e c e i v e their f irst t r ea tmen t w i th in 6 2 d a y s o f r e f e r r a l f r o m a G P . 7 1 . 2 % 7 6 . 3 5 % 7 0 . 8 2 % 6 5 . 4 4 % 6 3 . 9 % 75.4% 74% 6 9 . 6 % 6 9 . 7 % 6 9 . 2 % 70.9% 64.4% 66.8%

A t l eas t 9 0 % o f pa t ien ts wi l l r e c e i v e their f irst t r ea tmen t w i th in 6 2 d a y s f o l l ow ing r e f e r r a l f r o m a s c r e e n i n g s e r v i c e . 5 8 . 3 % 8 8 . 8 9 % 9 4 . 7 4 % 5 7 . 1 4 % 5 6 . 5 % 68.8% 74.1% 7 5 . 5 % 5 9 . 5 % 4 4 % 66.7% 73.9% 54.9% 12

September 2019 is now the most recent NHSI Model Hospital data available.

Electronic rostering key performance indicators, (KPIs) for nursing and midwifery are included in the dashboard and are an important indicator of efficient and safe staffing. They are recommended by NHSI for review at Board in triangulation with the other dashboard staffing metrics. A further column has been added to the workforce metrics that includes factors such as long term absence. The director of midwifery is reviewing the midwifery HR workforce data and therefore not included in this month’s report at their request. November has seen a further improvement against trajectory of band 5 RN turnover Midwifery vacancy against HR data is at 5.5% . Band 6 RM is the biggest workforce In midwifery and the projected leaver data is being closely monitored by the director of midwifery. Options for increasing the number of midwives such as offering a shortened course in midwifery for RNs are being explored. How international recruitment can further support midwifery is under review.

Nursing and Midwifery Staffing Workforce report November 2019

13

Friends and Family Test: Response Rates (YTD Nov ‘19) 1. All response rates remain in line with 3 month trends. 2. Maternity and Childrens response rates remain consistent low. Action: 1. FFT for Maternity and Childrens services will transfer to SMS Text response

method during Quarter 2 in the 2020, previously reported to Trust Board.. 2. A trial for FFT SMS texting commences in children’s services during February

2020.

21.0%

10.0%

30.0%

Dec-18 Mar-19 Jun-19 Sep-19

ED Response Rate

OUH OUH 12mo mean Nat. Avg

21.3%

0.0%

50.0%

Dec-18 Mar-19 Jun-19 Sep-19

IP DC Response Rate

OUH OUH 12mo mean Nat. Avg

9.4%

0.0%

50.0%

Dec-18 Mar-19 Jun-19 Sep-19

Maternity Response Rate (L&B only)

OUH OUH 12mo mean Nat. Avg

3.3%

0.0%

20.0%

Dec-18 Mar-19 Jun-19 Sep-19

Children's Response Rate

OUH OUH 12mo mean 14

Friends and Family Test: Recommend Rate

1. The 5 Charts compare the Trust’s recommend rates- All within acceptable range concluding Nov 2019.

2. There are no exceptions to report this month.

93.8% 93.0%

98.0% Outpatients %

OUH

95.2% 90.0%

100.0%

110.0% Maternity %

OUH

95.4%

94.0%

96.0%

98.0% IP DC %

OUH

84.4% 80.0%85.0%90.0%95.0% ED %

OUH

100.0%

94.0%

96.0%

98.0%

100.0% Children's %

OUH

15

Trust Performance November 2019

MRC NOTSCaN SUWON CSS Corporate

Complaints received in November 2019 97 26 35 26 5 5

Acknowledgement

100%

Closure Q2

91% 95% 94% 93% 86% 71%

PALS and Complaints: Performance

0

20

40

60

80

100

120

140

Q3 18/19 Q4 18/19 Q1 19/20 Q2 19/20

Closed complaints MRC

Corporate

SWO

NOTSSC

CSS

0102030405060 Complaints over the previous seven months

MRC

Corporate

SWO

NOTSSC

CSS

The overall trend for the number of complaints received has increased (776) in comparison to 709 for the same time period in 2018/19

100% of complaints were acknowledged within the 3 day KPI and overall 91% of complaints were closed within the 25 working day (plus 15 day extension) timescale (Q2). The figures above show the number of complaints closed by each Division within the KPI.

16

Divisional comments on complaints performance:

CSS: The work carried out by the Division to investigate and respond to complaints within the internal KPI (25 working days plus one agreed extension of 15 working days) has continued, with an expectation of improvement in Q3. The attitude of staff (medical and admin/clerical) continues to be the main reason for complaints for the Division, and work to address this issue will begin in conjunction with the Complaints team.

MRC: The closure rate for the Division in Q2 was high, with 93% of complaints closed within the required KPI. Work between the Division and the Complaints Team to improve this further has continued, with a bespoke training session on how to respond to a complaint delivered to a large number of senior clinical staff. Complaints regarding clinical treatment remains a concern throughout the Division, with further work to look at the underlying issues around this planned for January 2020.

NOTSSCaN: The Division’s closure rate for Q2 has dropped from the previous report – from 94% to 86%. This is because of a number of overdue complaints that have since been investigated and responded to, that took longer than the measured KPI. Work to improve the response and closure of complaints will remain a priority for the Division.

SuWOn: The Division continues to work with the Complaints team to improve the closure rate of complaints. The Division remains concerned by the complaints regarding clinical treatment, and will work with the clinical teams to understand the reasons behind this further, and to identify ways to improve the situation.

Corporate: Car parking is an ongoing concern for the Trust through the complaints received for Corporate services. The closure rate of complaints for Corporate services remains a concern, with only 62.50% of complaints closed within the internal KPI of 25 working days plus an agreed extension of 15 working days. Work by the senior managers of Corporate services along with the Complaints team is planned to improve the closure rate over the coming months.

Complaints dashboard page 40 & 41 17

Children Safeguarding Report

Chart 1: Activity Chart 2:ED Safeguarding Liaison Chart 3: Training

Activity Chart 1 indicates children safeguarding team consultation activity. Activity during November dropped by 21 (n=206). There was a significant increase in attendance and admissions for mental health concern (n=60) this being monitored and shared the self harm network and partner agencies and to raise awareness and identify any themes. There have been a number of complex cases requiring significant escalating to ensure robust plans are in place to support children and families. Maternity continue to have increased safeguarding cases requiring multi agency support.

ED Safeguarding Liaison Chart 2 shows referrals from ED over the have increased by 9 (n= 837), there was an increase in safeguarding and the expected seasonal attendances of babies. Information is shared with primary care and where relevant to children social care for open cases.

Training Compliance Chart 3 - safeguarding children training compliance is below the national and local KPI of 90%. Level 1 dropped 3% to 82%, Level 2 increased 3% to 86% and Level 3 also increased 3% to 84%. Staff are encouraged to complete either online training or face to face training. Bespoke training has been provided to maternity and children's to improve compliance.

Child Protection-Information Sharing (CP-IS) integrated within EPR to share information of unscheduled attendances (ED) with the local authority for children subject to a child protection plan or those that are looked after. The re is testing being undertaken to hopefully implement in December . The interim process to access CP-IS via the NHS spine portal is in place although and available to all clinical staff to access. This has to be done separately and is also being done by the safeguarding team for cases identified by ED.

Female Genital Mutilation (FGM) The Trust has a robust process to manage women who have undergone FGM to ensure safeguarding is in place. The National Team have met with the Trust and were reassured about the processes in place . There is a plan in place to start submitting data to the National FGM dataset from Jan 2020. A report on the FGM work from 2017-2019 has been produced, and will be presented to the Safer Oxfordshire Partnership Group and to the OSCB

0%

20%

40%

60%

80%

100%

Q4 Q1 Q2 Oct-19 Nov-19

Children Safeguarding Training

Level1

Level2

18

19

Adult Safeguarding Report

Chart 2: Consultations Chart 1: Activity

Section 42 (Sc. 42) Enquiries: • Chart 4 shows the 25 Sc. 42 enquiries, with outcome over the previous 2 years. • Serious incidents, claims, complaints, inquests and safeguarding concerns are reviewed and triangulated at the weekly ICCSIS Group (Incidents,

Complaints, Claims, Safety, Inquests and Safeguarding). This group has been formed to assure the Trust oversight of incidents and safeguarding concerns.

Chart 4: Section 42 Enquiries Chart 3: Training

Activity: Shown in Charts 1 and 2 show the team’s responsive activity over the previous 20 months. • The Electronic Patient Record Team (EPR) and the Safeguarding Teams are streamlining EPR for safeguarding and future proofing the system for the

implementation of Liberty Protection Safeguards (LPS) in 2020. Both work streams will be complete by 30th September 2020. • The Oxfordshire Safeguarding Boards (OSAB and OSCB) annual self assessment peer review is scheduled for 27th February 2020. • The national implementation of the Mental Capacity Amendment Act (MCAA) will be on 1st October 2020. The draft guidance is expected to be

published in January 2020. The draft implementation plan will be presented to Clinical Governance Committee on 19th February 2020.

Training Compliance: This is shown in Chart 3. • Level 3: The Mental Capacity Act training will be rolled out on 15th January 2020. This delay is to ensure the correct mapping of staff to the training. • The ACT Awareness eLearning (https://www.gov.uk/government/news/act-awareness-elearning) is also being rolled out on 15th January 2019. • Level 4: The Trust will use the level 4 training currently in development by the Regional Safeguarding Team. This will be aimed at the Safeguarding

teams A bespoke training will be developed for the Divisional Nurses, Deputy Divisional Nurses and Medical Directors. This is a change in the previous approach reported to Trust Board.

Learning Disability (LD): • The Trust is completing the national NHSI Learning Disability Standards. This is in three parts: patient survey, staff survey and data collection. It is due

to be submitted on 17th January 2020. • The maternity pathway for women with learning disability is being rewritten by the Lead Liaison Nurse and a Consultant Midwife and is due for

completion 28th February 2020. • The team has started to review all people with Learning Disability with three presentations to ED in three months and people with three

admissions in three months. This work is in its early stages and aims to identify who needs more or additional planning and support.

https://www.gov.uk/government/news/act-awareness-elearning

Key Quality Metrics Table Descriptor Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19Safety Thermometer (% patients receiving care free of any newly acquired harm) 97.80% 97.95% 97.32% 98.07% 98.07% 98.33% 98.11% 97.71% 97.33% 97.93% 98.68% 97.99%Safety Thermometer (% patients receiving care free of any harm - irrespective of acquisition)

94.38% 94.09% 92.87% 91.58% 92.04% 92.98% 92.32% 92.39% 90.81% 93.69% 94.97% 94.53%

VTE Risk Assessment(% admitted patients receiving risk assessment) 97.78% 97.77% 97.72% 97.88% 97.37% N/A 98.50% 98.38% 98.50% 98.26% 98.40% N/A

Number of cases of Clostridium Diffici le > 72 hours (cumulative year to date) 40 44 48 51 4 12 17 22 32 42 47 56

Number of cases of MRSA bacteraemia > 48 hours (cumulative year to date) 2 2 2 2 0 0 1 1 2 2 2 3

% patients receiving stage 2 medicines reconcil iation within 24h of admission 66.57% 69.27% 66.77% 64.33% 66.15% 65.46% 69.57% 75.05% 71.47% 67.13% 70.34% N/A

% patients receiving allergy reconcil iation within 24h of admission 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

% of incidents associated with moderate harm or greater 0.75% 0.83% 0.92% 1.30% 1.28% 1.78% 1.47% 2.00% 1.43% 1.99% 1.70% N/A

Cleaning Score - % of inpatient areas with initial score > 92% 25.53% 29.69% 42.50% 57.17% 66.67% 47.56% 40.91% 32.39% 40.68% 33.85% 39.51% 44.58%

% Radiology direct access 7 day turnaround times - Plain Film, CT, MRI & Ultrasound 85.81% 85.17% 87.65% 83.85% 74.46% 74.86% 79.62% 76.81% 76.62% 77.72% 83.43% N/ACAS alerts breaching deadlines at end of month and/or closed during month beyond deadline

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

Number of hospital acquired thromboses identified and judged avoidable 0 0 1 0 1 1 3 0 0 0 4 1

Crude Mortality 199 248 210 183 204 195 197 161 181 175 196

Dementia - % patients aged > 75 admitted as an emergency who are screened 78.87% 78.53% 75.03% 78.98% 75.17% 75.63% 77.90% 80.15% 73.98% 77.31% 79.82% N/A

ED - % patients seen, assessed and discharged / admitted within 4h of arrival 87.39% 86.03% 81.39% 85.86% 84.73% 86.63% 85.78% 86.83% 84.09% 84.24% 81.89% 80.60%

Friends & Family test % likely to recommend - ED 88.71% 90.07% 86.01% 87.57% 87.25% 87.15% 86.36% 86.54% 86.52% 87.51% 86.49% 84.44%

Friends & Family test % not l ikely to recommend - ED 6.88% 6.82% 8.62% 6.77% 8.48% 7.96% 9.41% 8.77% 8.17% 6.91% 7.81% 9.08%

Friends & Family test % likely to recommend - Mat 97.99% 96.41% 97.07% 96.03% 96.00% 97.35% 96.12% 95.00% 96.73% 97.50% 97.83% 95.20%

Friends & Family test % not l ikely to recommend - Mat 0.50% 1.35% 0.00% 1.44% 1.82% 0.88% 1.29% 4.50% 0.82% 0.89% 0.00% 0.87%

Friends & Family test % likely to recommend - IP 95.06% 96.44% 95.89% 95.85% 96.19% 96.58% 96.06% 96.33% 95.07% 96.03% 95.08% 95.42%

Friends & Family test % not l ikely to recommend - IP 2.80% 1.64% 1.83% 2.19% 1.93% 2.03% 2.12% 1.87% 2.17% 2.09% 2.48% 2.50%

Friends & Family test % likely to recommend - OP 95.02% 94.91% 94.37% 94.38% 94.48% 94.36% 94.30% 94.70% 94.40% 93.92% 94.19% 93.76%

Friends & Family test % not l ikely to recommend - OP 2.78% 2.55% 3.13% 3.21% 3.26% 3.30% 3.10% 2.73% 3.22% 3.21% 3.12% 3.44%

% patients EAU length of stay < 12h 55.83% 50.51% 50.08% 52.02% 45.45% 46.41% 48.46% 53.91% 54.49% 53.41% 49.61% 50.05%

% Complaints upheld or partially upheld [Quarterly in arrears] 64.87% N/A N/A 69.32% N/A N/A 55.04% N/A N/A 75.39% N/A N/A

20

Key Quality Metrics exception reports Red exceptions

PS06 Number of cases of MRSA bacteraemia > 48 hours (cumulative year to date) Target 0.

MRSA positive blood culture taken from elderly patient with complex medical problems admitted due to uncontrolled pain and frailty. The source of the infection was not clear. All aspects of the MRSA protocol were adhered to and no lapses in care identified.

PE15 % patients EAU length of stay < 12h - EAU is an assessment area and the majority of patients should either be admitted or discharged promptly following assessment. Target 70%

Both John Radcliffe and Horton General EAUs function as Emergency Assessment areas, receiving acutely ill patients from ED and Community settings. The key determinant of ‘flow’ and therefore Length of Stay (‘LoS’) is bed occupancy in ward settings, predominantly Medicine. Bed occupancy in Medicine has averaged 100% for the month, with at times extreme congestion of clinical areas. This has significantly impeded flow and resulted in unacceptably long length of stay. This is the focus of renewed ‘Whole System’ work around reducing the numbers of stranded patients staying in hospital for over 7 days without a clinical need to remain.

21

PS06 Number of cases of MRSA bacteraemia > 48 hours (cumulative year to date) Target 0.

MRSA positive blood culture taken from elderly patient with complex medical problems admitted due to uncontrolled pain and frailty. The source of the infection was not clear. All aspects of the MRSA protocol were adhered to and no lapses in care identified.

PE15 % patients EAU length of stay < 12h - EAU is an assessment area and the majority of patients should either be admitted or discharged promptly following assessment. Target 70%

Both John Radcliffe and Horton General EAUs function as Emergency Assessment areas, receiving acutely ill patients from ED and Community settings. The key determinant of ‘flow’ and therefore Length of Stay (‘LoS’) is bed occupancy in ward settings, predominantly Medicine. Bed occupancy in Medicine has averaged 100% for the month, with at times extreme congestion of clinical areas. This has significantly impeded flow and resulted in unacceptably long length of stay. This is the focus of renewed ‘Whole System’ work around reducing the numbers of stranded patients staying in hospital for over 7 days without a clinical need to remain.

Key Quality Metrics exception reports Red exceptions

PS17 Moderate or greater hospital acquired thromboses identified and judged avoidable. Target 0

Benchmarking demonstrates that OUHFT are reporting HATs at a similar rate to equivalent Trusts. One moderate-harm potentially preventable HAT (pulmonary embolism) was reported in November 2019. The patient was a high risk patient e.g previous history of VTE. No extended TP prescribed following surgery. The quarterly audit of inpatient in October 2019 shows 98.4% of inpatients received ‘appropriate thromboprophylaxis’.

PS14 % Radiology direct access 7 day turnaround times - Plain Film, CT, MRI & Ultrasound - 95% of routine radiology reports received by the requesting clinician within 7 calendar days of the examination. Target 98%

Radiology met their target (

Key Quality Metrics exception reports Red exceptions

CE03 Dementia - % patients aged > 75 admitted as an emergency who are screened - Elderly patients admitted on a non-elective basis should be screened for dementia using a screening question and / or a simple cognitive test. Target 90%

MRC Dementia screening compliance has improved in October 83.8% from 75.6% reported in September. NOTSSCaN Has seen a large decrease in performance for October 63.3% from September’s 85.5% compliance.

SuWOn Performance was recorded at 78.4% in October and remains consistent with the 76.9% reported in September.

CE06 ED - % patients seen, assessed and discharged / admitted within 4h of arrival - % Patients attending ED who are discharged or admitted within 4 hours of arrival. Target 95%

November has been particularly challenging and there has been a drop in meeting the standard. Lack of automated audits for the ED patient safety checklist against the criteria to show compliance remains challenging. Discussions are being held between ED team and the reporting team for this to be resolved. The area continues to be under pressure and in times of high demand time to assessment, analgesia, observations and ECG’s is not being achieved against national guidance. Corridor nursing during high demands has not only impacted on patient outcome but also has shown significant implication on staff morale and wellbeing.

23

CE03 Dementia - % patients aged > 75 admitted as an emergency who are screened - Elderly patients admitted on a non-elective basis should be screened for dementia using a screening question and / or a simple cognitive test. Target 90%

MRC

Dementia screening compliance has improved in October 83.8% from 75.6% reported in September.

NOTSSCaN

Has seen a large decrease in performance for October 63.3% from September’s 85.5% compliance.

SuWOn

Performance was recorded at 78.4% in October and remains consistent with the 76.9% reported in September.

CE06 ED - % patients seen, assessed and discharged / admitted within 4h of arrival - % Patients attending ED who are discharged or admitted within 4 hours of arrival. Target 95%

November has been particularly challenging and there has been a drop in meeting the standard.

Lack of automated audits for the ED patient safety checklist against the criteria to show compliance remains challenging. Discussions are being held between ED team and the reporting team for this to be resolved.

The area continues to be under pressure and in times of high demand time to assessment, analgesia, observations and ECG’s is not being achieved against national guidance.

Corridor nursing during high demands has not only impacted on patient outcome but also has shown significant implication on staff morale and wellbeing.

Key Quality Metrics exception reports Amber exceptions

PE01 Friends & Family test % likely to recommend - ED- % likely to recommend – ED. Target 93%

The FFT recommended rate for Emergency Departments (EDs) in November was 86.44% marginally decreasing from 86.49 % in October, which is in the expected range (between 83.3% and 90.0%). The average recommended rate over the past 12 months is 87.05%.

PS08 % patients receiving stage 2 medicines reconciliation within 24h of admission - Proportion of inpatient for whom a second stage pharmacy-led medicines reconciliation is completed within 24 hours of admission. The audit captures medicines reconciliation tasks generated on admission by Cerner. Approximately 2500 medicines reconciliation tasks are audited monthly. Target 80%

The data shows an overall Trust achievement of 70% of patients receiving medicines reconciliation within 24 hours of admission. There is a significant difference between weekday and weekend performance, and hence the pharmacy and sterile services directorate are working on a PID to adjust weekend staffing to improve performance. The Pharmacist post in Maternity & Gynaecology is currently vacant, recruitment has been successful and improvement is expected once new post-holder commences.

MRC Numbers %AMR 837/1125 74%Cardiac 135/189 71%Spec Med 21/34 62%

NOTSSCaNChildren 15/16 94%Neurosciences 147/209 70%Spec Surg 128/200 64%Trauma & Orthopaedics 253/326 78%

SuWOnGastro 18/36 50%Gynaecology 27/53 51%Maternity 0/1 0%Oncology+Haem 79/105 75%Surgery 143/267 54%Transplant, Renal & Urol 75/120 63%

TrustwideWeekday 1676/2003 84%Weekend 203/681 30%

Meds Rec at 24 hrs

24

PE01 Friends & Family test % likely to recommend - ED- % likely to recommend – ED. Target 93%

The FFT recommended rate for Emergency Departments (EDs) in November was 86.44% marginally decreasing from 86.49 % in October, which is in the expected range (between 83.3% and 90.0%). The average recommended rate over the past 12 months is 87.05%.

PS08 % patients receiving stage 2 medicines reconciliation within 24h of admission - Proportion of inpatient for whom a second stage pharmacy-led medicines reconciliation is completed within 24 hours of admission. The audit captures medicines reconciliation tasks generated on admission by Cerner. Approximately 2500 medicines reconciliation tasks are audited monthly. Target 80%

The data shows an overall Trust achievement of 70% of patients receiving medicines reconciliation within 24 hours of admission. There is a significant difference between weekday and weekend performance, and hence the pharmacy and sterile services directorate are working on a PID to adjust weekend staffing to improve performance. The Pharmacist post in Maternity & Gynaecology is currently vacant, recruitment has been successful and improvement is expected once new post-holder commences.

MRC

Numbers

%

AMR

837/112574%

Cardiac

135/18971%

Spec Med

21/3462%

NOTSSCaN

Children

15/1694%

Neurosciences

147/20970%

Spec Surg

128/20064%

Trauma & Orthopaedics

253/32678%

SuWOn

Gastro

18/3650%

Gynaecology

27/5351%

Maternity

0/10%

Oncology+Haem

79/10575%

Surgery

143/26754%

Transplant, Renal & Urol

75/12063%

Trustwide

Weekday

1676/200384%

Weekend

203/68130%

Meds Rec at 24 hrs

Infection prevention and control

• In Nov 2019, 40/49 (82%) sepsis admissions received antibiotics in 90%)*

• Latest Dr Foster data: – SHMI for sepsis 85.8 (75.5-97.0) – SHMI for all bacterial infections 46.6 (12.5-119.3)

25

Infection Prevention and Control • C. diff: SPC chart reflects changes in apportion of cases for 2019/20. At the

end of Nov the Trust is 1 case under annual trajectory. • Gram negative blood stream infections (GNBSI): NHSI Target to reduce

health care associated GNBSI by 50% by 2023/24. • MRSA: 1 case, RCA did not identify any lapses in care, unclear source of

infection. • MSSA: 2 cases in November, back in statistical control • Estates & Environmental Concerns: Legionella Incident Management team

continues to meet weekly in addition to the Extraordinary Water Safety Group Meetings.

• Winter Respiratory Illness: Influenza and respiratory syntical virus (RSV) started to rise during November. ‘Flu point of care testing now introduced. Weekly flu graph represents both in-patient and ambulatory testing.

26

27

Quality Priority update: Reducing the number of Never Events

Aim for 100% Compliance with the WHO Surgical Safety Checklist • Currently: 98.6% WHO documentation audit results (655/664) with CSS and MRC 100% compliant. 98.4% WHO observational audit results (366/372) CSS, NOTSSCaN and SuWOn 100% compliant. Areas that are not 100% compliant are followed up by the Divisional leadership & presented to Clinical Governance Committee Produce a minimum of 10 Local Safety Standards in Invasive Procedures (LocSSIPs) over the course of the year • 21 have been completed. Finalise the remaining National Safety Standards in Invasive Procedures (NatSSIPs) policies: • All key NatSSIP policies have been completed Run an action planning workshop with input from NHSI, Patient Safety Academy and Clinical Governance • Action planning workshop was completed on 30/04/19

Complete all actions from root cause analysis Never Event investigations in 2018/19 • 93% of Never Event actions for 2018/19 for which the target date has passed have been completed;

outstanding actions are in progress and followed up by the Patient Safety team.

Demonstrate learning across all Divisions at Governance meetings • Learning demonstrated via external assurance visits and closure of 3 Never Event investigations • In 2019/20 there have been 3 Never Event investigation presentations to the Chief Executive. These have

included the investigator detailing the major findings and the specific area and Division discussing progress with the actions.

WHO Audit Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19Documentation 96.75% 97.91% 98.20% 98.57% 98.66% 98.64%Observation 98.27% 99.37% 99.20% 99.00% 100% 98.39%

Clinical Risk: Never Events

One new Never Event, 1920-062, was confirmed in November 2019, previously reported by exception. It concerned a wrong site nerve block on a patient who was undergoing foot surgery, which comes under the Wrong Site Surgery criterion, as defined in NHS Improvement’s Never Events list, January 2018. Immediate actions include sending the Stop Before You Block policy, and an associated instructional video, to all anaesthetists and anaesthetic assistants in the Trust. It was discussed at the 4 December Anaesthetic Clinical Governance meeting. An external expert has been arranged to assist in the investigation, considering the Trust’s history of anaesthetic block incidents. By exception, a Never Event, 1920-069, was confirmed in December. It concerns a guidewire which was retained following insertion of a central venous catheter in a patient requiring temporary haemodialysis. Seven Never Events have been called so far in 2019/20, inclusive of this.

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Clinical Risk: Serious Incidents Requiring Investigation (SIRI)

5 SIRIs were confirmed by the Trust in October 2019. 10 SIRI investigation reports were submitted for closure (approval) to the Oxfordshire Clinical Commissioning Group in the same period. SIRIs declared and completed in the last 24 months

29

Clinical Risk: Harm reviews from extended waits

The Trust has an established process for assessing clinical and psycho-social harm for patients waiting for over 52 weeks for an operation; this is in addition to the program of harm reviews for patients undergoing care for cancer whose pathways exceed 104 days.

Confirmed Harm reviews 1920 to date and level of harm The number of confirmed and potential 52 week breaches

Of the 698 harm reviews requested since the process began, 687 harm reviews have been completed (98%). The majority of reviews identified no harm or minor harm. The Gynaecology Directorate represents circa 70% of all 52 week harm reviews, though they only account for 10% of breaches to date in 19/20. The majority of the forms not received fall in Specialist Surgery and are being actively followed up. 21 reviews for breaches that occurred May 2018 to October 2019 inclusive have been confirmed as covering Moderate or Major harm, following discussion at the Harm Review Group and, where relevant, the Trust SIRI Forum. Of these, 2 have been called as SIRIs, 18 have been investigated at a Divisional level, and one at a Local level. 45 week breach reports are reviewed at the Harm Review Group. This demonstrated that the greatest numbers of potential 52 week breaches are likely to occur in ENT and Ophthalmology. The table above represents current status for the following 3 months between 40 and 52 weeks. 30

Weekly Safety Messages

Since 5 February 2019 a weekly safety message has been issued from the central Clinical Governance team, emailed to all staff accounts, and available on the intranet.

31

Incidents reported in the last 24 months and Patient Safety Response (PSR)

2004 patient incidents were reported to Datix in November 2019; the mean number over the past 24 months is 1909.

In November 89 incidents were discussed at PSR, 11 of which were downgraded following discussion at PSR meetings. In no cases was a delegation from the meeting’s attendees arranged to visit an area, to source further information, and to ensure that staff were supported and patients informed under Duty of Candour. This is the first month where a visit has not been required, since the PSR process began.

32

Mortality indicators

There have been no mortality outliers reported for the OUH from the Care Quality Commission or the Dr Foster Unit at Imperial College. The SHMI for the data period August 2018 to July 2019 is 0.92. This remains rated ‘as expected.

* SHMI is normally expressed as a standardised ratio with a baseline of 1; this has been multiplied by 100 to express as a relative risk with a baseline of 100 to enable comparison to the HSMR

The HSMR is 87 for October 2018 to September 2019. This remains rated as ‘lower than expected’

33

34

OUHFT At A Glance 2019-20

IndicatorsConsolidate

d planCurrent Data

Period Trust CSS SUWON NOTTSCAN MRC Trust Trend YTD

Operational RTT - incomplete % within 18 weeks 81.20% 2019-10-31 80.28% 90.37% 87.86% 74.75% 85.23% 81.98%% Diagnostic waits waiting 6 weeks or more 1.00% 2019-10-31 2.26% 1.71% 5.23% 3.50% 2.91% 2.09%Zero tolerance RTT waits IP 0.00 2019-10-31 21.00 0.00 3.00 18.00 0.00 77.00RTT Incomplete pathways- List size 53689 2019-10-31 42708 338 10433 21138 10787 42708% of patients who spent 4 hours or less in A&E from arrival, transfer or discharge 90.21% 2019-10-31 81.89% 0.00% 0.00% 0.00% 81.89% 84.89%Last minute elective cancellations for treatment/surgery as a percentage of all elective admissions 0.80% 2019-10-31 0.74% 0.00% 0.46% 1.48% 0.00% 0.47%% patients not rebooked within 28 days 0.00% 2019-10-31 10.45% 0.00% 5.26% 12.50% 0.00% 9.96%Contract Variations Open 0 2019-10-31Contract Notices Open 0 2019-10-31* Delayed transfers of care: number (snapshot) NA 2019-10-31 70.00 0.00 6.00 16.00 48.00 431.00* Delayed Transfers of Care as a Percentage of Occupied beds 3.50% 2019-10-31 7.83% 0.00% 0.00% 0.00% 0.00% 6.94%Theatre Utilisation - Elective 80.00% 2019-10-31 75.91% 51.46% 73.08% 77.68% 92.73% 75.69%Theatre Utilisation - Emergency 70.00% 2019-10-31 43.24% 45.24% 37.44% 54.69% 134.17% 47.86%Theatre Utilisation - Total 75.00% 2019-10-31 69.46% 51.32% 59.38% 75.44% 93.83% 69.13%Results Endorsement within 7 days 85.00% 2019-10-31 75.49% 37.88% 76.27% 58.23% 88.75% 74.68%% of discharge summaries sent to GP within 24hrs 90.00% 2019-10-31 85.55% 75.00% 89.14% 76.05% 90.26% 86.29%Percentage of patients receiving first definitive treatment for cancer within 62-days of an urgent GP referral for suspected cancer 90.91% 2019-09-30

64.36% 0.00% 60.09% 35.90% 81.51%69.58%

Percentage of patients receiving first definitive treatment for cancer within 62-days of referral from an NHS Cancer Screening Service 90.48% 2019-09-30

73.91% 0.00% 73.91% 0.00% 0.00%65.70%

Percentage of patients receiving first definitive treatment within one month of a cancer diagnosis 96.03% 2019-09-30 90.96% 0.00% 88.12% 91.84% 97.53% 94.44%Percentage of patients receiving subsequent treatment for cancer within 31-days where that

i S95.65% 2019-09-30 95.92% 0.00% 95.92% 0.00% 0.00% 94.20%

Percentage of patients receiving subsequent treatment for cancer within 31-days where that treatment is an Anti-Cancer Drug Regime 100.00% 2019-09-30

100.00% 0.00% 100.00% 0.00% 0.00%100.00%

Percentage of patients receiving subsequent treatment for cancer within 31-days where that treatment is a Radiotherapy Treatment Course 95.33% 2019-09-30

100.00% 0.00% 100.00% 0.00% 0.00%99.53%

Percentage of patients seen within two weeks of an urgent GP referral for suspected cancer 97.93% 2019-09-30 94.09% 0.00% 93.03% 93.33% 97.08% 94.94%Percentage of patients seen within two weeks of an urgent referral for breast symptoms where cancer is not initially suspected 96.64% 2019-09-30

95.28% 0.00% 95.28% 0.00% 0.00%95.95%

Same sex accommodation breaches 0.00 2019-10-31 74.00 60.00 0.00 14.00 0.00 382.00Number of patients who spend at least 90% of their time on a stroke unit 85.00% 2019-10-31 50.00% 0.00% 0.00% 0.00% 50.00% 87.54%MRSA bacteraemia 0.00 2019-10-31 0.00 0.00 0.00 0.00 0.00 2.00CDI NA 2019-10-31 5.00 0.00 0.00 1.00 3.00 39.00% of all adult inpatients who have had a VTE risk assessment 95.00% 2019-09-30 98.26% 98.05% 99.07% 95.96% 97.52% 98.21%

Appendix 1a

35

Quality - Outcomes** Summary Hospital-level Mortality Indicator** NA 2019-03-31 92.00%

Total # of deliveries NA 2019-10-31 649.00 0.00 649.00 0.00 0.00 4488.00Proportion of normal deliveries 62.00% 2019-10-31 56.39% 0.00% 56.39% 0.00% 0.00% 60.94%Proportion of C-Section deliveries 23.00% 2019-10-31 27.89% 0.00% 27.89% 0.00% 0.00% 24.62%Proportion of Assisted deliveries 15.00% 2019-10-31 15.25% 0.00% 15.25% 0.00% 0.00% 14.15%Maternal Deaths NA 2019-10-31 0.00 0.00 0.00 0.00 0.00 1.0030 day emergency readmission NA 2019-10-31 3.53% 0.00% 2.81% 1.28% 5.60% 3.89%Medication reconciliation completed within 24 hours of admission 80.00% 2019-09-30 67.13% 69.23% 68.26% 58.97% 71.26% 69.26%Medication errors causing serious harm NA 2019-09-30 1.00 0.00 1.00 0.00 0.00 5.00Total Number of CAS alerts that were closed having breached during the month NA 2019-10-31 0.00 0.00 0.00 0.00 0.00 0.00Dementia CQUIN patients admitted who have had a dementia screen 90.00% 2019-09-30 77.31% 0.00% 76.92% 85.45% 75.56% 76.60%Dementia diagnostic assessment and investigation NA 2019-09-30 100.00% 0.00% 100.00% 100.00% 100.00% 100.00%Dementia :Referral for specialist diagnosis NA 2019-09-30 100.00% 0.00% 100.00% 100.00% 100.00% 100.00%

Quality - Patient ExperiencePatient Satisfaction -Response rate (friends & family -Inpatients) NA 2019-10-31 19.25% 28.39% 21.55% 13.08% 19.79% 19.54%Patient Satisfaction- Response rate (friends & family -Maternity) NA 2019-10-31 7.28% 0.00% 7.28% 0.00% 0.00% 14.27%Patient Satisfaction- Response rate (friends & family -ED) NA 2019-10-31 19.93% 0.00% 0.00% 0.00% 19.93% 20.15%Friends & Family test % not likely to recommend - ED NA 2019-10-31 7.81% 0.00% 0.00% 0.00% 7.81% 8.20%Friends & Family test % not likely to recommend - IP NA 2019-10-31 2.48% 0.74% 3.68% 1.76% 1.39% 2.18%Friends & Family test % not likely to recommend - Mat NA 2019-10-31 0.00% 0.00% 0.00% 0.00% 0.00% 1.02%Friends & Family test % likely to recommend - ED NA 2019-10-31 86.49% 0.00% 0.00% 0.00% 86.49% 86.83%Friends & Family test % likely to recommend - IP NA 2019-10-31 95.08% 98.15% 93.81% 96.27% 95.36% 95.90%Friends & Family test % likely to recommend - Mat NA 2019-10-31 97.83% 0.00% 97.83% 0.00% 0.00% 96.84%

Quality - SafetyNumber SIRIs NA 2019-10-31 6.00 0.00 4.00 1.00 0.00 58.00% of Patients receiving Harm Free Care (Pressure sores, falls, C-UTI and VTE) (All Harms - old &

)( C )NA 2019-10-31 94.97% 100.00% 92.44% 97.40% 94.39% 92.74%

Never Events NA 2019-10-31 0.00 0.00 0.00 0.00 0.00 4.00Cleaning Scores- % of inpatient areas with initial score >92% NA 2019-10-31 39.51% 58.33% 41.67% 34.62% 31.58% 41.52%% of incidents associated with moderate harm or greater 0.00% 2019-09-30 1.99% 0.62% 2.26% 2.64% 1.96% 1.66%# newly acquired pressure ulcers (category 2,3 and 4) 0.00 2019-09-30 58.00 0.00 20.00 15.00 23.00 350.00

Workforce - PerformanceVacancy rate 5.00% 2019-10-31 8.59% 10.96% 7.06% 8.53% 10.87% 9.79%** Sickness absence 3.20% 2019-10-31 3.27% 2.97% 3.08% 3.42% 3.54% 3.25%Turnover rate 12.00% 2019-10-31 13.61% 11.74% 14.19% 13.18% 15.05% 13.82%Substantive staff in post against budget 12403 2019-10-31 11347.00 2099.00 2703.00 2724.00 2530.00 77611.78Temporary Workforce expenditure as a total of Workforce expenditure 5.00% 2019-10-31 9.31% 7.58% 9.37% 11.50% 12.47% 8.91%

* The figures include acute hospital transfers which are not reported at a National Level** This measure is collected for a 12 month period preceding the latest period shown

IndicatorsConsolidate

d planCurrent Data

Period Trust CSS SUWON NOTTSCAN MRC Trust Trend YTD

Appendix 1b

Nursing and Midwifery Staffing; NHSI Model Hospital Data (September 2019)

Care hours per patient day (CHPPD) is a nationally used principal measure of staff deployment within inpatient areas only.

High or low CHPPD is not a measure of whether a clinical area is staffed correctly or not.

It is used within OUH alongside quality and safety outcome measures as represented on the safe staffing dashboard.

Appendix 2a

36

Nursing and Midwifery Staffing; Safe Staffing Dashboard – Nursing & Midwifery (Inpatients) Census

557 4.94 4.8 3.20 3.2 8.14 7.54 8.0 100.00% 2 0 1 5 31.34% 17.93% 2.40% 3.35% 35.9% Yes -2.30% 4.00 11.10% 11 4 1 0 0 0540 6.39 6.0 1.92 1.4 8.31 8.98 7.4 100.00% 2 0 0 1 10.87% 10.45% 1.15% 3.11% 16.4% Yes 2.00% 8.86 6.60% 11 1 0 0 0 0503 5.50 4.0 3.41 2.9 8.91 7.25 6.9 100.00% 4 0 0 0 29.39% 14.61% 5.55% 3.99% 32.2% Yes 1.00% 2.71 14.00% 2 0 0 0 0 080 16.60 10.6 3.31 2.5 19.91 - 13.1 N/A 0 0 0 1 21.48% 11.16% 6.93% 7.28% 27.2% No 3.20% 2.29 16.50% 0 0 0 0 0 0360 6.46 6.1 1.92 2.0 8.38 7.02 8.1 100.00% 3 0 1 1 18.85% 11.19% 7.86% 10.76% 25.7% No 7.50% 3.71 10.50% 12 2 0 1 0 0169 5.75 8.8 1.88 4.3 7.63 10.41 13.1 61.11% 0 0 0 0 25.15% 34.09% 8.10% 3.80% 35.1% Yes 12.20% 5.86 8.60%540 4.37 4.3 2.66 2.8 7.03 7.28 7.1 100.00% 0 0 0 2 2.75% 5.95% 1.07% 1.05% 3.8% Yes -0.20% 3.43 13.70% 15 3 0 0 0 0267 7.67 6.6 2.56 0.6 10.23 10.33 7.2 100.00% 1 0 0 0 -14.88% 9.08% 2.45% 9.64% -3.8% Yes 15.10% 4.71 15.20% 8 0 0 0 0 0343 5.75 6.6 0.96 2.1 6.71 10.28 8.7 100.00% 1 0 0 1 -58.24% 2.33% 2.07% 4.99% -50.3% No 8.00% 4.71 9.40% 2 0 0 0 0 0

1081 12.87 11.2 2.19 1.6 15.06 - 12.8 N/A 10 8 0 0 7.73% 17.24% 4.19% 3.29% 12.3% No 7.30% 4.43 12.70%479 3.86 4.3 3.95 4.4 7.81 11.04 8.6 100.00% 2 0 1 9 27.78% 17.87% 3.24% 3.98% 34.2% Yes 5.70% 8.57 13.60% 30 6 0 0 0 0544 4.58 5.0 2.58 4.7 7.16 10.86 9.8 100.00% 2 0 4 3 17.16% 0.00% 3.97% 0.00% 20.6% Yes 24.80% 5.00 4.20% 34 5 2 0 1 2342 4.99 5.2 6.02 5.3 11.01 13.88 10.5 100.00% 0 0 0 2 25.52% 8.45% 5.91% 8.79% 32.1% Yes 5.40% 4.71 5.50% 16 6 0 3 1 2578 6.27 6.5 4.26 6.5 10.53 13.70 13.0 100.00% 2 0 0 0 5.18% 7.87% 1.00% 4.45% 12.8% Yes 7.60% 8.71 9.30% 20 1 0 0 0 0408 23.00 19.8 3.29 1.0 26.29 - 20.8 N/A 5 2 0 0 -6.04% 15.17% 2.39% 4.19% -1.6% Yes 24.40% 11.29 11.00% 0 0 0 0 0 0258 5.95 6.5 0.82 0.3 6.77 9.68 6.8 100.00% 11 5 0 0 21.97% 11.90% 0.52% 13.22% 36.4% Yes -3.40% 7.86 8.20% 13 0 0 0 0 0750 5.98 5.3 2.66 2.5 8.64 7.81 7.8 100.00% 3 0 1 1 25.80% 17.46% 4.47% 3.93% 30.2% No -0.40% 3.71 7.70% 34 3 0 0 1 0438 6.33 6.7 1.92 1.2 8.25 10.04 7.9 100.00% 1 0 0 0 -0.46% 16.45% 5.60% 5.49% 5.1% No 6.80% 6.43 14.00% 17 0 0 0 0 0675 5.05 4.2 2.99 2.5 8.04 7.95 6.8 100.00% 10 0 3 4 23.26% 14.46% 5.26% 0.00% 25.6% No -2.30% 3.57 9.60% 1 0 0 0 0 0552 4.93 5.0 2.92 2.7 7.85 7.6 7.7 100.00% 0 0 3 3 24.15% 0.00% 0.23% 1.08% 25.0% Yes 1.30% 7.86 8.60% 27 4 0 0 0 0637 4.30 3.5 2.52 2.7 6.82 7.58 6.2 100.00% 2 0 0 3 11.26% 0.00% 3.58% 0.00% 11.3% Yes -0.20% 2.29 10.30% 4 1 0 0 0 0648 4.13 3.7 2.42 2.7 6.55 7.13 6.4 100.00% 0 0 2 6 20.92% 14.12% 10.90% 6.14% 31.7% Yes 1.50% 2.29 5.00% 3 0 0 0 0 0379 26.67 24.1 0.00 2.2 26.67 - 26.3 N/A 6 1 2 1 22.52% 10.43% 2.56% 3.64% 25.3% Yes -2.70% 7.57 12.50% 0 0 0 0 0 0

1196 4.95 4.5 1.85 1.5 6.80 7.44 6.0 100.00% 1 0 3 5 7.40% 18.14% 7.02% 1.72% 8.7% No 1.00% 6.71 7.10% 4 2 0 0 0 0745 5.06 4.2 2.30 1.8 7.36 6.52 6.0 100.00% 4 1 0 5 23.26% 20.41% 2.54% 4.70% 26.9% Yes 0.20% 0.86 10.30% 15 4 1 0 0 0540 4.47 3.9 3.19 3.8 7.66 8.69 7.8 100.00% 0 0 1 4 15.52% 17.10% 4.09% 3.29% 21.0% No 3.20% 3.00 10.10% 7 1 0 0 0 0503 4.74 4.1 3.38 4.0 8.12 11.19 8.1 98.89% 0 0 2 2 24.23% 11.15% 3.51% 0.00% 27.1% No 8.40% 3.86 14.10% 2 2 0 0 1 0660 4.24 3.6 3.63 3.0 7.87 10.67 6.7 100.00% 2 0 1 7 18.17% 2.07% 2.98% 3.39% 20.9% No 2.80% 3.00 8.00% 2 3 0 0 0 0595 4.03 3.5 3.45 3.3 7.48 8.24 6.9 100.00% 1 0 4 5 30.30% 18.27% 10.94% 3.99% 33.1% No 4.70% 3.00 11.30% 2 2 0 0 1 1454 18.95 20.0 0.00 0.0 18.95 - 20.0 N/A 2 0 1 0 26.32% 18.75% 2.43% 5.10% 30.1% Yes 1.10% 8.86 7.60% 0 0 0 0 0 0

- 5.43 - 3.84 - 9.27 7.04 - 100.00% 0 0 2 7 20.25% 15.54% 1.91% 2.89% 22.6% No 2.10% 4.29 12.10%- 10.91 - 4.36 - 15.27 - - N/A 1 0 0 2 27.40% 17.86% 6.24% 2.46% 31.0% No -1.70% 4.29 11.60% 311 63 16 21 17 5- 7.28 - 2.93 - 10.21 6.98 48.89% 3 0 2 11 16.47% 18.16% 3.50% 1.67% 19.3% No 2.30% 4.00 11.20%- 8.99 - 2.71 - 11.70 - - N/A 7 0 0 10 16.59% 20.88% 3.66% 5.03% 22.8% No -3.70% 9.43 8.40% 673 190 62 37 58 12

480 6.20 5.0 3.89 3.3 10.09 10.09 8.3 100.00% 2 0 0 1 2.76% 24.40% 7.83% 3.34% 9.3% Yes 3.50% 4.14 11.60% 23 6 1 3 2 0900 3.84 3.4 4.03 2.9 7.87 7.32 6.3 100.00% 1 0 7 3 -11.44% 14.75% 2.53% 2.19% -7.1% No -2.20% 2.86 10.10% 3 2 0 0 0 0840 4.13 3.4 2.88 2.8 7.01 7.51 6.2 100.00% 0 0 3 5 -2.99% 14.32% 7.35% 6.91% 8.0% No -1.40% 0.71 10.60% 0 0 0 0 0 0537 4.05 4.0 6.71 4.4 10.76 9.03 8.4 100.00% 0 0 0 0 1.95% 10.28% 3.86% 2.08% 8.1% No -2.90% 3.29 10.20% 0 0 0 0 0 0540 4.47 3.9 3.19 3.6 7.66 10.27 7.5 100.00% 0 0 3 5 13.25% 13.15% 5.21% 3.49% 19.3% No 2.00% 3.00 10.30% 18 11 0 1 0 0540 5.75 4.5 3.19 2.9 8.94 8.28 7.4 100.00% 0 0 2 4 -20.72% 9.11% 14.88% 5.52% -10.9% No 5.80% 5.71 9.10% 2 0 0 0 0 0660 5.97 3.9 3.66 2.7 9.63 8.09 6.7 100.00% 1 0 2 1 29.55% 25.71% 1.40% 0.00% 32.1% No -1.40% 3.00 13.00% 8 0 0 0 0 0630 6.26 5.3 2.83 2.7 9.09 8.04 8.0 100.00% 0 0 0 3 20.48% 9.71% 4.98% 2.30% 26.9% No 4.60% 4.14 4.80% 26 0 0 0 0 0

456 4.72 6.0 2.35 2.7 7.07 6.8 8.7 100.00% 0 0 0 1 -1.92% 21.47% 7.10% 2.15% 2.5% Yes 3.00% 5.57 9.20% 84 2 0 0 0 0600 5.18 5.3 2.88 2.3 8.06 7.33 7.6 100.00% 2 0 1 2 -2.45% 13.03% 2.95% 4.20% 12.0% Yes -12.50% 1.57 5.60% 3 0 0 0 0 0604 5.23 5.5 4.42 2.8 9.65 7.15 8.4 100.00% 0 0 1 2 30.99% 26.41% 1.97% 0.00% 31.0% Yes 4.30% 7.29 11.70% 8 1 0 0 0 0600 5.20 5.2 2.90 2.6 8.10 8.21 7.7 100.00% 1 0 6 9 23.85% 26.63% 1.79% 0.00% 26.3% No 5.50% 6.86 7.70% 2 0 0 0 0 0480 6.18 6.2 3.02 2.6 9.20 7.16 8.8 100.00% 2 0 1 1 3.81% 4.23% 2.07% 0.00% 9.3% Yes 2.70% 6.71 10.10% 9 0 0 0 1 0438 5.37 5.4 3.10 2.9 8.47 7.08 8.3 100.00% 0 0 1 1 -4.10% 25.46% 1.20% 6.63% 2.8% Yes 2.80% 7.43 7.40% 13 2 0 0 0 1360 5.78 5.2 1.92 1.7 7.70 6.36 6.8 100.00% 0 0 0 1 13.69% 6.73% 10.33% 0.00% 13.7% No -0.30% 7.57 11.70% 14 2 0 2 2 1532 5.13 5.0 3.50 2.7 8.63 6.93 7.7 100.00% 1 0 1 3 12.95% 17.18% 0.45% 0.00% 15.9% Yes 2.30% 7.57 8.70% 15 2 0 0 1 0587 4.62 4.5 2.39 2.0 7.01 6.87 6.5 100.00% 3 0 1 2 25.76% 27.80% 1.99% 0.00% 25.8% No 0.80% 7.57 6.50% 6 2 1 0 0 0476 5.44 5.7 3.07 2.7 8.51 8.82 8.4 100.00% 3 0 6 3 24.23% 21.07% 2.47% 0.00% 27.2% Yes 4.30% 3.57 12.70%500 6.82 6.8 2.88 2.5 9.70 10.35 9.3 100.00% 0 0 1 2 12.65% 12.22% 6.60% 6.73% 20.8% No 0.10% 7.71 12.80% 29 2 0 0 0 0451 6.59 6.3 2.21 2.5 8.80 8.92 8.8 100.00% 0 0 0 0 15.82% 7.43% 0.68% 6.96% 21.7% Yes -0.10% 4.29 11.60% 74 1 0 0 0 0555 4.26 4.2 3.27 2.3 7.53 6.23 6.5 100.00% 2 0 1 5 19.43% 0.00% 1.32% 0.00% 21.6% Yes -2.60% 5.57 9.80% 5 2 0 0 0 1223 16.29 8.0 7.67 5.4 23.96 - 13.3 N/A 0 0 0 0 r Yes 4.60% -3.14 9.60%510 19.07 15.4 12.40 3.4 31.47 - 18.8 N/A 2 0 0 1 Yes 19.90% 2.43 14.90%990 4.22 2.49 2.12 1 6.34 - 3.7 N/A 2 0 0 0 Yes 14.70% 2.71 10.00%430 3.10 4.33 1.84 2 4.94 - 6.3 N/A 2 0 0 0 Yes 2.80% 2.71 13.20%

91 11.77 15.7 7.77 8.9 19.54 - 24.7 N/A 1 0 1 0 18.02% 0.00% 1.77% 5.65% 22.6% No 4.40% 7.43 15.00% 0 0 0 0 0 0594 29.12 24.1 4.61 2.8 33.73 - 26.9 N/A 2 0 0 0 20.44% 26.04% 4.63% 3.69% 24.5% Yes 2.10% 4.43 14.70% 0 0 0 0 0 0

084%

Neurosurgery Blue Ward

6 0 0.48%

Oncology Ward

Complex Medicine Unit B

Ward E (NOC) Ward F (NOC)

WW Neuro ICU

Neurosurgery Green/IU Ward

HH EAUHH Emergency Department

Emergency Assessment Unit (EAU)

OCE Rehabilitation Nursing (NOC)Short Stay Ward (SSW)

Cardiothoracic Ward (CTW)

Juniper Ward

Haematology Ward Jane Ashley Colorectal Centre

Stroke Unit

7

HH ICU JR ICU

Laburnham

JR Emergency Department

Complex Medicine Unit C

Tom's WardWard 6A - JR

Ward 7F Trauma

MW Level 6

MW The Spires

Upper GI WardUrology Inpatients

SEU E SideSEU F Side

Sobell House - Inpatients

Ward 5F - JR

MW Delivery Suite

Ward 5A - JR Ward 7E Osler Chest Ward

MW Level 5

Renal Transplant Ward

SUWON

Complex Medicine Unit D

Gynaecology Ward - JR

Nurse Sensitive Indicators HR

Sickness (%)

Medication Administratio

n Error or Concerns

Pressure Ulcers

Category 2,3&4

Vacancies (%)

Turnover (%)

Extravasation Incidents Falls

Medication errors (

administration, delay or omission)

Proportion of births where the intended place of birth was changed

due to staffing

Maternity (%)

Actual Regis tered nurses and midwives

November 2019

Budgeted Care Staff

Required Overa l l

Budgeted Overa l l

Census Compliance

(%)

Actual Care s taffWard Name

Budgeted Registered nurses and midwives

Care Hours Per Patient Day

Melanies Ward

Head and Neck Blenheim WardHH Childrens Ward

Cumulative count over

the month of patients at 23:59 each

day

HH F WardKamrans Ward

Bellhouse / Drayson WardBIU

Neurology - Purple Ward

HDU/Recovery (NOC)

Neonatal Unit

Actual Overa l l

CSS

Maternity Sensitive Indicators

Delay in induction (PROM or

booked IOL)

Pressure Ulcers

Proportion of women

readmitted postnatally

Proportion of mothers who

initiated breastfeedin

g

NOTTSSCaN

MRC

Renal WardSEU D Side

CTCCU

John Warin Ward

Cardiology Ward

Robins WardSpecialist Surgery I/P Ward

Adams Trauma

Complex Medicine Unit A

Neurosurgery Red/HC WardPaediatric Critical Care

Revised Vacancy HR Vacs plus LT Sick & Mat Leave (%)

CSS

Rostering KPIs

Roster manager approved

for Payroll

Net Hours 2/-2%

8 week lead time

Annual Leave 12-

16%

NOTTSSCaN

MRC

SUWON

FFT - Total responses in each category for each ward

1 - Extremely

Likely

2 - Likely

3 - Neither likely

nor unlikely

4 - Unlikely

5 - Extremely

unlikely

54 13 2 1 0 0

6 - Don't Know

Appendix 2b

37

Nursing and Midwifery Staffing; Band 5 RNs in post, budget, leavers and starters and turnover trajectory in October 2019 Non-inpatient/theatre or critical

care areas RN vacancy rates Staff in Post and Budget by Month

Appendix 2c

38

Nursing and Midwifery Staffing; Band 5 Registered Nurse Turnover Trajectory – November 2019

Appendix 2d

39

Nursing and Midwifery Staffing; RN and Midwifery turnover by Band November 2019

FTE Leavers FTE Annual Turnover Rate Oct-19 Sep-19 Aug-19 Jul-19 Jun-19 May-19 Apr-19 Mar-19 Feb-19 Jan-19 Dec-18 Nov-18 Oct-18 Sep-18 Aug-18 Jul-18 Jun-18 May-18 Apr-18 Mar-18

All Nursing Turnover 3016 416 13.8% 13.8% 14.2% 14.4% 15.2% 14.5% 14.4% 14.6% 15.1% 14.3% 14.1% 14.0% 13.6% 14.0% 14.4% 15.1% 14.5% 15.1% 15.4% 15.3% 15.5%

Band 5 Nursing Turnover 1382 271 19.6% 19.7% 20.6% 21.0% 22.6% 21.6% 21.3% 21.4% 21.9% 19.7% 19.6% 19.9% 19.2% 19.6% 20.2% 21.8% 20.7% 21.1% 21.5% 21.6% 21.5%

Band 6 Nursing Turnover 1036 102 9.9% 9.9% 10.1% 10.2% 10.2% 9.7% 9.1% 9.5% 9.8% 10.3% 9.9% 9.6% 9.1% 9.2% 9.5% 9.3% 8.7% 9.3% 9.8% 8.7% 8.7%

Band 7+ Nursing Turnover 598 42 7.0% 6.9% 6.7% 6.7% 7.0% 6.5% 7.1% 7.2% 7.5% 7.5% 7.2% 6.7% 6.9% 7.0% 7.3% 7.5% 7.5% 8.1% 7.2% 7.7% 8.3%

Registered Nursing Turnover

FTE Leavers FTE Annual Turnover Rate Oct-19 Sep-19 Aug-19 Jul-19 Jun-19 May-19 Apr-19 Mar-19 Feb-19 Jan-19 Dec-18 Nov-18 Oct-18 Sep-18 Aug-18 Jul-18 Jun-18 May-18 Apr-18 Mar-18

All Midwifery Turnover 286 37 12.9% 11.1% 11.6% 12.3% 13.6% 15.2% 14.5% 14.7% 14.5% 13.1% 14.0% 15.0% 14.8% 15.3% 16.0% 16.5% 16.9% 14.6% 15.0% 15.9% 15.4%

Band 5 Midwifery Turnover 46 3 6.0% 6.1% 7.3% 12.0% 10.8% 6.8% 4.6% 4.4% 4.3% 4.3% 6.3% 6.3% 6.2% 5.9% 5.1% 3.5% 12.6% 11.0% 13.8% 16.7% 16.7%

Band 6 Midwifery Turnover 178 29 16.2% 14.1% 14.4% 13.8% 15.3% 17.8% 17.1% 18.2% 17.4% 16.2% 17.1% 18.4% 16.6% 17.4% 18.2% 19.0% 19.7% 17.8% 17.4% 18.2% 17.8%

Band 7+ Midwifery Turnover 61 5 8.6% 6.2% 6.2% 8.0% 10.5% 13.2% 13.4% 11.7% 13.0% 10.1% 10.0% 11.5% 15.6% 16.1% 16.4% 14.7% 10.5% 7.3% 8.3% 8.3% 7.0%

Registered Midwifery Turnover

Appendix 2e

40

Directorate View

Directorate Level View - Band 5 Nurses in Clinical Areas

Select your Area*All numerical values are in FTE*

BudJFMAMJJASONDJFM393.59999999999997393.59999999999997393.59999999999997401.46401.46401.46401.46391.8389.1389.1389.1389.1393.59999999999997393.59999999999997393.59999999999997SIP

JFMAMJJASONDJFM296.67280999999997300.84999999999997297.48292.58287.10999999999996287.39000000000004284.47000000000003281.49292.03999999999996286.7288.84000000000003293.52999999999997296.27298.75000000000006302.06Vac

JFMAMJJASONDJFM96.92718999999999692.7596.119999999999948108.88114.35000000000002114.06999999999994116.98999999999995110.3197.060000000000059102.40000000000003100.25999999999999future VacJFMAMJJASONDJFM100.2599999999999995.5700000000000597.32999999999998494.84999999999990991.539999999999964StarterJFMAMJJASONDJFM7.61332999999999953401.7630313.643.16333000000000022.3199999999999998LeaverJFMAMJJASONDJFM218.133330000000000812.61333000000000042.0666700000000002066.322.89332999999999975.52TurnoverJFMAMJJASONDJFM0.185751295336787580.177620400958137360.185742179279806380.167025738076854920.167100899389481750.166158383079322320.169675707304414450.17428716324445390.17044119651807740.171509731806953970.18206043116524678

Division Level

Trust View

Staff in Post and Budget by Month

Assumptions:We have assumed a 60% take up rate for Band 5 Nurses recruited through the international recruitment schemes

We have assumed an 80% take up rate for Band 5 Nurses recruited in the UK through Oxford Brookes and other universities

We have calculated the starters and leavers for a given month by taking a mean average of the previous 3 months.

We have calculated the distribution of nurses recruited through international/Oxford Brookes recruitment schemes to each area of the Trust, based on the current WTE proportional size of each area.

We have only included departments that are either inpatient or theatres areas.

BudNov17Dec17Jan18Feb18Mar18Apr18May18Jun18Jul18Aug18Sep18Oct18Nov18Dec18Jan19Feb19Mar19Apr19May19Jun19Jul19Aug19Sep19Oct19Nov19Dec19Jan20Feb20Mar201744.41747.341747.341747.341747.341618.98999999999981654.56000000000021662.311662.98999999999981656.861657.861662.22999999999981658.37000000000011647.37000000000011647.37000000000011647.37000000000011647.37000000000011610.341609.29000000000021610.341610.341589.62000000000061590.72000000000031590.72000000000031592.72000000000031590.72000000000031590.72000000000031590.72000000000031590.7200000000003SIP

Nov17Dec17Jan18Feb18Mar18Apr18May18Jun18Jul18Aug18Sep18Oct18Nov18Dec18Jan19Feb19Mar19Apr19May19Jun19Jul19Aug19Sep19Oct19Nov19Dec19Jan20Feb20Mar201394.18403000000011391.15000000000031337.21999999999981332.621312.36000000000011272.09000000000041267.23000000000021249.87000000000031220.65000000000011207.85999999999991230.18999999999981245.47999999999981242.68999999999981221.45999999999981228.02545999999981227.97999999999981208.26999999999981181.951158.471150.27999999999971133.90999999999991131.741172.48000000000021183.79000000000041194.13000000000011221.45999999999981244.33999999999991266.781291Starter

Nov17Dec17Jan18Feb18Mar18Apr18May18Jun18Jul18Aug18Sep18Oct18Nov18Dec18Jan19Feb19Mar19Apr19May19Jun19Jul19Aug19Sep19Oct19Nov19Dec19Jan20Feb20Mar2010.253335.519.26666000000000215.600000000000001811.426679.76666999999999959.720000000000000610.19999999999999916.8399943.2431.42667000000000115.9733300000000019.426669999999999720.746660000000002101174.346669999999999685.3599999999999994946.623.7766617.64LeaverNov17Dec17Jan18Feb18Mar18Apr18May18Jun18Jul18Aug18Sep18Oct18Nov18Dec18Jan19Feb19Mar19Apr19May19Jun19Jul19Aug19Sep19Oct19Nov19Dec19Jan20Feb20Mar2028.4933326.11787000000000315.515.05332999999999920.5225.41333999999999818.77333000000000116.01333999999999921.7632.29332000000000121.43866999999999819.1666616.23334000000000220.23999999999999813.7599914.4933339.22666000000000317.1733312.63999000000000115.1820.39333000000000211.99734000000000119.36000000000000313.14666000000000114.013329999999998

Trust Pivot

Column Labels

ValuesBudSIPStarterLeaverGrand Total

Nov171744.41394.1840310.2533328.493333177.33069

Dec171747.341391.155.526.117873170.10787

Jan181747.341337.2219.2666615.53119.32666

Feb181747.341332.6215.615.053333110.61333

Mar181747.341312.36820.523088.22

Apr181618.991272.0911.4266725.413342927.92001

May181654.561267.239.7666718.773332950.33

Jun181662.311249.879.7216.013342937.91334

Jul181662.991220.6510.221.762915.6

Aug181656.861207.8616.8399932.293322913.85331

Sep181657.861230.1943.2421.438672952.72867

Oct181662.231245.4831.4266719.166662958.30333

Nov181658.371242.6915.9733316.233342933.26667

Dec181647.371221.469.4266720.242898.49667

Jan191647.371228.0254620.7466613.759992909.90211

Feb191647.371227.981014.493332899.84333

Mar191647.371208.271139.226662905.86666

Apr191610.341181.95717.173332816.46333

May191609.291158.474.3466712.639992784.74666

Jun191610.341150.28815.182783.8

Jul191610.341133.915.3620.393332770.00333

Aug191589.621131.74911.997342742.35734

Sep191590.721172.4846.619.362829.16

Oct191590.721183.7923.7766613.146662811.43332

Nov191592.721194.1317.6414.013332818.50333

Dec191590.721221.462812.18

Jan201590.721244.342835.06

Feb201590.721266.782857.5

Mar201590.7212912881.72

Directorate Pivot

Column Labels

Row LabelsBudSIPTurnoverStarterLeaver

Acute Medicine and Rehabilitation

Sum of Nov-17321.14273.329340.264973820109.56

Sum of Dec-17321.14265.890.273458583436.76667

Sum of Jan-18321.14258.750.28236872844.645

Sum of Feb-18321.14256.660.289023229222.53333

Sum of Mar-18321.14251.680.27171698705.61333

Sum of Apr-18311.22248.430.26734771422

Sum of May-18313.02250.070.264783407212.24

Sum of Jun-18313.02246.470.259121772634.66667

Sum of Jul-18313.17241.240.239492460532.61333

Sum of Aug-18313.17230.140.27800564392.2266614.06666

Sum of Sep-18313.17233.570.24686100117.613330

Sum of Oct-18318.41230.70.23498513155.613346.25333

Sum of Nov-18318.41228.060.22323009453.923.10667

Sum of Dec-18318.41227.460.209019753922.4

Sum of Jan-19318.41230.141330.19424401112.81.61333

Sum of Feb-19318.41231.510.19725433612.92

Sum of Mar-19318.41229.190.20706741626.92

Sum of Apr-19308.25225.070.221804784835

Sum of May-19307.2216.280.221804784804.02666

Sum of Jun-19308.25209.870.239157563615

Sum of Jul-19308.25207.70.24314787331.84.68667

Sum of Aug-19298.19208.810.195284814610.30667

Sum of Sep-19298.19218.240.194964711481.26667

Sum of Oct-19298.19224.60.191128283.613335.8

Sum of Nov-19298.19228.250.183734718141.53333

Sum of Dec-19298.19233.28

Sum of Jan-20298.19236.85

Sum of Feb-20298.19241.43

Sum of Mar-20298.19245.82

Cardiology Cardiac and Thoracic Surgery

Sum of Nov-17126.67105.5780.241315720112

Sum of Dec-17126.67103.310.207333303601

Sum of Jan-18126.67103.380.196001531411

Sum of Feb-18126.67100.380.201572226701

Sum of Mar-18126.6797.380.222961256203

Sum of Apr-18126.6797.260.186983429121

Sum of May-18127.3894.640.195811414612.61333

Sum of Jun-18127.3893.720.19484681381.921.61333

Sum of Jul-18127.3895.640.18850773690.613331

Sum of Aug-18127.3892.640.21799151470.613332.61333

Sum of Sep-18127.3893.880.177212895530.75867

Sum of Oct-18127.38101.020.180136941141

Sum of Nov-18127.38103.190.158929068610

Sum of Dec-18127.3898.340.192705830403.92

Sum of Jan-19127.38101.343340.192258445801

Sum of Feb-19127.38101.340.204111605422

Sum of Mar-19127.38101.110.215870174504

Sum of Apr-19126.8699.950.214313125710

Sum of May-19126.8697.950.214313125701

Sum of Jun-19126.8686.030.261686724903.61333

Sum of Jul-19126.8684.030.261803245902

Sum of Aug-19126.8680.790.264152040101

Sum of Sep-19126.8681.860.263990176611

Sum of Oct-19126.8684.170.23917510053

Sum of Nov-19126.8686.30.254865719222

Sum of Dec-19126.8688.37

Sum of Jan-20126.8690.77

Sum of Feb-20126.8692.61

Sum of Mar-20126.8694.72

Childrens

Sum of Nov-17196.82182.821210.21360706171.921

Sum of Dec-17196.82178.470.214392416511.92

Sum of Jan-18196.82179.310.21078685082.922

Sum of Feb-18196.82178.030.216255212602

Sum of Mar-18196.82177.030.210286876701

Sum of Apr-18195.56179.20.176946277632

Sum of May-18195.56177.280.162866022900.92

Sum of Jun-18195.56177.150.156159258812.46667

Sum of Jul-18195.56174.970.154369102612

Sum of Aug-18195.56173.050.139253802600

Sum of Sep-18195.56181.550.11832611747.422.88667

Sum of Oct-18195.56185.430.12806000355.613334.91333

Sum of Nov-18195.56181.950.149206984924.68667

Sum of Dec-18195.56180.710.166633900812.92

Sum of Jan-19195.56183.704660.16761111114.533332.61333

Sum of Feb-19195.56184.540.171244518312.61333

Sum of Mar-19195.56178.930.217907778608.56

Sum of Apr-19194.22171.210.223183271412.53333

Sum of May-19194.22171.130.223183271410

Sum of Jun-19194.22177.60.206905734721

Sum of Jul-19194.22174.610.209986903615.61333

Sum of Aug-19194.22173.740.242451503711.69067

Sum of Sep-19194.22183.690.249355298512.533334.53333

Sum of Oct-19194.22192.810.224195015282.53333

Sum of Nov-19194.22193.160.203335570530.45333

Sum of Dec-19194.22200.45

Sum of Jan-20194.22206.85

Sum of Feb-20194.22212.91

Sum of Mar-20194.22219.5

Critical Care Anaesthetics Pre-Operative Assessment Pain Relief Unit & Resuscitation

Sum of Nov-1795.2482.064530.19937775261.613330

Sum of Dec-1795.2481.480.231631727702.4312

Sum of Jan-1895.2477.540.229945328301.2

Sum of Feb-1895.2486.540.204586361840

Sum of Mar-1895.2487.540.204129758400

Sum of Apr-1879.3573.240.237918157403

Sum of May-1883.876.080.240679734922

Sum of Jun-1883.876.080.231221248100

Sum of Jul-1883.871.560.266273164702

Sum of Aug-1883.877.560.271066111541

Sum of Sep-1883.874.490.225022783802.46

Sum of Oct-1883.876.90.218683129732

Sum of Nov-1883.877.590.204916600100

Sum of Dec-1883.868.590.213458140502

Sum of Jan-1983.863.186670.266109269114

Sum of Feb-1983.864.310.261477129511

Sum of Mar-1983.860.310.358475809515

Sum of Apr-1982.9559.690.370793311212

Sum of May-1982.9557.690.370793311202

Sum of Jun-1982.9558.290.381785445321

Sum of Jul-1982.9555.370.404340899703

Sum of Aug-1982.9557.870.393671880711

Sum of Sep-1982.9557.660.383572833701

Sum of Oct-1982.9564.870.32678190091

Sum of Nov-1982.9567.870.332287228511

Sum of Dec-1982.9568.66

Sum of Jan-2082.9569.8

Sum of Feb-2082.9570.71

Sum of Mar-2082.9571.65

Gastroenterology Endoscopy and Churchill Theatres

Sum of Nov-17149.94112.893350.199899632603.53333

Sum of Dec-17149.94109.630.194142886802

Sum of Jan-18149.94106.230.206125582311

Sum of Feb-18149.94105.720.189097395900

Sum of Mar-18149.94104.070.204311540423

Sum of Apr-18149.94101.880.200547356311.26667

Sum of May-18149.94100.790.178781484700

Sum of Jun-18148.34102.240.16397934900.66667

Sum of Jul-18148.3495.880.16095367051.666671

Sum of Aug-18147.1290.40.177814896413

Sum of Sep-18147.1288.960.18458053782.442.8

Sum of Oct-18147.1286.770.187223994132

Sum of Nov-18147.1286.860.17680676611.80.8

Sum of Dec-18147.1285.650.171448380801

Sum of Jan-19147.1286.413330.16187510

Sum of Feb-19147.1288.720.159458037320

Sum of Mar-19147.1288.520.18727918406.13333

Sum of Apr-19147.1283.750.187473060800

Sum of May-19147.1282.790.187473060800.76

Sum of Jun-19147.1280.230.200073043500.76

Sum of Jul-19147.1276.810.211395901100

Sum of Aug-19133.3876.690.209543625110.58667

Sum of Sep-19133.3876.360.209777690512.4

Sum of Oct-19133.3873.370.20114899681

Sum of Nov-19133.3873.730.214048539321.88

Sum of Dec-19133.3874.04

Sum of Jan-20133.3874.57

Sum of Feb-20133.3875.24

Sum of Mar-20133.3875.74

Horton Theatres

Sum of Nov-1718.7214.99000

Sum of Dec-1718.7214.99000

Sum of Jan-1818.7214.05000

Sum of Feb-1818.7214.05000

Sum of Mar-1818.7213.150.070981434800.90667

Sum of Apr-1814.0113.150.070981434800

Sum of May-1815.5313.150.070981434800

Sum of Jun-1815.5313.150.071616847100

Sum of Jul-1815.5315.050.066601583400

Sum of Aug-1815.5315.050.066601583400

Sum of Sep-1815.5316.050.062242734800

Sum of Oct-1815.5316.050.062442794500

Sum of Nov-1815.5316.050.062442794500

Sum of Dec-1815.5314.050.069458851100

Sum of Jan-1915.5315.053340.067158671610

Sum of Feb-1915.5315.050.066896425500

Sum of Mar-1915.5315.05000

Sum of Apr-1923.3915.05000

Sum of May-1923.3914.15000

Sum of Jun-1923.3914.73000

Sum of Jul-1923.3914.73000

Sum of Aug-1923.3914.73000

Sum of Sep-1923.3914.9000

Sum of Oct-1923.3915.3800.55

Sum of Nov-1923.3913.920.06409070120.320

Sum of Dec-1923.3914.38

Sum of Jan-2023.3914.93

Sum of Feb-2023.3915.43

Sum of Mar-2023.3915.94

JR and WW Theatres

Sum of Nov-17144.95111.966660.129620022521.8

Sum of Dec-17144.95110.970.157244344802

Sum of Jan-18144.95104.490.15689277512

Sum of Feb-18144.95102.590.169566935111.90667

Sum of Mar-18144.95100.590.169810079101

Sum of Apr-18105.87101.590.167948173810

Sum of May-18136.46100.590.207025074115

Sum of Jun-18136.4695.590.2243730201

Sum of Jul-18136.4695.130.218214312802

Sum of Aug-18136.4698.130.229731621343

Sum of Sep-18137.46103.370.231074172612

Sum of Oct-18137.46105.220.224878328311

Sum of Nov-18137.89104.220.223385078603

Sum of Dec-18126.89101.370.227480395502

Sum of Jan-19126.8995.833320.225346455110.53333

Sum of Feb-19126.8995.330.209766398200

Sum of Mar-19126.8993.230.221217724722

Sum of Apr-19128.9589.030.246904944702

Sum of May-19128.9589.030.246904944711

Sum of Jun-19128.9588.670.212011571901

Sum of Jul-19128.9589.910.21112552060.640.76

Sum of Aug-19128.9588.910.163530073310

Sum of Sep-19128.9589.240.170002074822.73333

Sum of Oct-19128.9588.980.15555551072

Sum of Nov-19128.9585.540.13802354392.81

Sum of Dec-19128.9587.62

Sum of Jan-20128.9590.29

Sum of Feb-20128.9592.83

Sum of Mar-20128.9595.26

Neurosciences

Sum of Nov-17119.8293.520.129620022522

Sum of Dec-17119.8292.520.233592152700

Sum of Jan-18119.8291.520.227380094900

Sum of Feb-18119.8293.520.221768912232

Sum of Mar-18119.8290.130.239994567413

Sum of Apr-18119.9782.40.249981487814

Sum of May-18119.9780.010.242068899400

Sum of Jun-18119.9780.010.22473643511

Sum of Jul-18119.9779.320.197322046211

Sum of Aug-18119.9776.160.195883957401

Sum of Sep-18119.9774.280.213738632433

Sum of Oct-18119.9774.030.203280383430

Sum of Nov-18119.9777.770.18682493072.613331

Sum of Dec-18119.9777.50.188128326611

Sum of Jan-19119.9780.296660.18624141540.80

Sum of Feb-19119.9779.220.174686057101

Sum of Mar-19119.9782.140.171568310602.61333

Sum of Apr-19112.3981.380.142687430911

Sum of May-19112.3980.660.142687430901

Sum of Jun-19112.3983.510.154266344101

Sum of Jul-19112.3983.610.15482811281.920.53333

Sum of Aug-19111.3984.730.138559628310

Sum of Sep-19110.3986.110.110475105910.50667

Sum of Oct-19110.3980.450.12393998260.92

Sum of Nov-19110.3981.450.107693887500

Sum of Dec-19110.3982.2

Sum of Jan-20110.3982.73

Sum of Feb-20110.3983.45

Sum of Mar-20110.3984.11

Oncology

Sum of Nov-1788.3655.989610.269509908302.6

Sum of Dec-1788.3653.890.27979225270.51.6

Sum of Jan-1888.3656.90.27828147152.60.5

Sum of Feb-1888.3657.70.2524811430.80

Sum of Mar-1888.3656.70.241223979510

Sum of Apr-1873.152.240.317717543803

Sum of May-186555.240.30998303610.766670

Sum of Jun-186553.170.33849997690.82

Sum of Jul-1867.6156.30.28671358930.920

Sum of Aug-1865.1255.70.224992703201

Sum of Sep-1865.1258.470.20058419726.766671

Sum of Oct-1865.1259.870.19330252041.20

Sum of Nov-1865.1260.870.157105257910

Sum of Dec-1865.1257.520.188522465103

Sum of Jan-1965.1259.416280.17346053772.613330

Sum of Feb-1965.1260.820.170213895910

Sum of Mar-1965.1260.9