the boardroom, trust headquarters, hereford agenda part b … · 2014-03-24 · trust board meeting...

Trust Board Meeting The Boardroom, Trust Headquarters, Hereford

Thursday 28 November, 1.00 pm – 3.00 pm

AGENDA – PART B – (IN PUBLIC)

1.00 Patient/Staff Experience Story

1. Apologies for Absence

2. Declarations of Interest

3. To approve the minutes of the meeting in public of 26 September 2013

Enc. i

4. Matters Arising from the meeting in public of 26 September 2013

Enc. ii

5. Chief Executive Update DS Enc. iii -

6. Board Assurance Framework NL Enc. iv

1.45 Performance and Progress against Strategic Objectives

7 a. Quality & Patient Safety Overview Report MC Enc. v

b. Operational Performance Report ND Enc. vi

c. Finance Report HO Enc. vii

d. Workforce Report KH Enc. viii

2.30 For Decision/Discussion

8. NHS England National Core Standards for Emergency Preparedness, Resilience and Response.

9. NHS Trust Development Authority Self-Certification.

ND NL

Enc. ix Enc. x

10. Quality Committee Terms of Reference NL Enc. xi

2.45 For Information 11. Reporting Structure of Board and Committees NL Enc. xii

12. Any Other Business*

2.55 13. Questions from Members of the Public arising from the agenda (see Guidance)

3.00 14. Date of next meeting in Public: Thursday 30 January 2014 at 12.00 noon.

*The Chairman should be advised of any matters to be raised under “Any Other Business” before the meeting.

FOR INFORMATION ONLY

The following matters were considered in Part A of the Board meeting held in private:

Exclusion of the Press and Public - Having resolved that representatives of the press and other members of the public be excluded from Part A of the meeting due to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest. Section 1(2), Public Bodies (Admission

to Meetings) Act 1960. Declarations of Interest to items on the Agenda. The minutes of the meeting in private of 31 October 2013. Matters Arising from the meeting in private of 31 October 2013. Confidential matters arising from routine performance reports and or service

delivery. Confidential report on SIRI’s. Confidential report on Nursing Establishment Confidential matters arising from routine meetings of subcommittees. Confidential report on staff suspensions. Any Other Business. Date of next meeting in private: Thursday 19 December 2013.

FOR INFORMATION ONLY

The following matters were considered in Part A of the Board meeting held in private:

• Exclusion of the Press and Public - Having resolved that representatives of the press and other members of the public be excluded from Part A of the meeting due to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest. Section 1(2), Public Bodies (Admission to Meetings) Act 1960.

• Declarations of Interest to items on the Agenda. • The minutes of the meeting in private of 31 October 2013. • Matters Arising from the meeting in private of 31 October 2013. • Confidential matters arising from routine performance reports and or service

delivery. • Confidential report on SIRI’s. • Confidential report on Nursing Establishment • Confidential matters arising from routine meetings of subcommittees. • Confidential report on staff suspensions. • Any Other Business. • Date of next meeting in private: Thursday 19 December 2013.

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MINUTES OF THE TRUST BOARD MEETING IN PUBLIC

HELD ON 26th September 2013

PART B

Present: Mr Mark Curtis Mr Derek Smith Mrs Sara Coleman Ms Michelle Clarke Ms Christina Maclean Mr Frank Myers Mr Howard Oddy Mrs Simone Pennie Mr Mark Waller Dr Peter Wilson In attendance: Mr Ken Hutchinson Ms Nicola Licence Mrs Julia Marsh Apologies: Mr Neil Doverty

(CTB) (CEO) (NED) (DNQ) (NED) (NED) (DFI) (NED) (NED) (MD) (DHR) (CS) (EA) (COO)

(Chairman of the Trust Board) (Interim Chief Executive) (Non-executive Director) (Director of Nursing and Quality) (Non-executive Director) (Non-executive Director) (Director of Finance and Information, Deputy Chief Executive) (Non-executive Director) (Non-executive Director, Deputy Chairman) (Medical Director) (Interim Director of Human Resources) (Company Secretary) (Executive Assistant) for the minutes Chief Operating Officer

PATIENT/STAFF EXPERIENCE STORY

A NED introduced the staff experience story following attendance at a staff meeting during a Patient Safety Walk around on Monnow Ward. The meeting was positive, open and honest, which allowed staff to confidently raise any concerns.

The MD reported he had attended a male surgical ward where he spoke to three patients at different stages of their medical journey. The patients were happy with the care they were receiving and the overall experience was very positive. However, they felt completion of the Friends and Family questionnaire was a difficult concept as nobody would recommend a stay in hospital. Additionally, further written information for patients and their families/carers would be beneficial.

B001/09.13 i.

QUESTIONS FROM THE PUBLIC I am delighted that the Chair of the Quality Committee has confirmed that the Quality Committee papers would be published, albeit in a redacted form, in line with a desire to be transparent. How and when will these papers be made available?

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ii. iii. iv. v. vi.

In line with the desire to be transparent, will the report regarding, ‘Staffing Ratios’ be made available to the public? If so, how and when? I note the continuing pressures within the A&E department in Hereford. Can the Board explain who decided and why it was decided, that the Trust would not receive any of the additional resources from the special national A&E department allocation announced in Parliament? As part of the PLACE report it was highlighted that the ‘one shower’ in the Cardiac Care Unit at the County Hospital had been deactivated. This means that any patient from this ward who wishes to take a shower has to use the facilities in a neighbouring ward (it is noted that this fact is not included within the summary). Does the Board consider that this situation is acceptable? I understand Derek Smith, CEO and several senior staff worked for a day on the ‘shop floor’ a few weeks ago. I heard general approval from several people at the time and one commented, ‘so they should’. How did they get on? I have felt in the past that MBWA worked well and hope it does still. Is there a policy on whether female Muslim members of staff can/cannot wear the niqab or veil whilst at work?

B002/09.13

DECLARATIONS OF INTEREST There were no declarations of interest.

B003/09.13

MINUTES OF THE MEETING IN PRIVATE ON 25th JULY 2013

The minutes of the previous meeting were accepted as a true and accurate record subject to the following changes: • B003/0.13 Spelling correction to the title, ‘DECLARATIONS’.

RESOLUTION: Subject to the changes the minutes of the August 2013 Board were APPROVED as a true and accurate record of the meeting.

B004/09.13 MATTERS ARISING FROM MEETING IN PRIVATE HELD ON 29TH AUGUST 2013

Minute ref: Trust Board Meeting – Part B (in public)

B007/07.13 The Trust Development Authority (TDA) had requested continued completion of the Performance Management Regime (PMR) and sign off for the TDA submissions, until a TDA performance dashboard was published. The Trust will await the formal TDA dashboard to ascertain if it can be used as a Trust internal performance report going forward.

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B010/07/13 A breakdown of those specialities using external capacity with the activity and cash value added, had been circulated to Trust Board members and would be incorporated into the report as of next month. ACTION: A breakdown of those specialities using external capacity with the activity and cash value added, to be incorporated into future reporting. COO – Oct 2013 RESOLUTION: The Board DISCUSSED the action log.

PERFORMANCE AND PROGRESS AGAINST STRATEGIC OBJECTIVES

B005/09.13 QUALITY AND PATIENT SAFETY OVERVIEW REPORT

The DNQ presented the report and the following key points were noted: • There had been an unannounced visit to Theatres this week. A spot-check on the WHO

checklist confirmed 100% compliance. • The PLACE assessment was undertaken for the first time, involving larger numbers of

patients within all inpatient facilities. The combined score for acute and community areas did not compare like for like, with the only comparator Trust being South Warwickshire NHS Foundation Trust. The assessment predominantly involved members of the public with some clinical members and volunteers therefore the Trust’s PFI partner, Sodexo had not been invited. The DFI highlighted that at a recent meeting, Sodexo had reported they had not been furnished with any detail.

• The DNQ referred to the Public question (iv): The original building housed one domestic shower unit which was not deemed to be appropriate. The Estates Department are liaising with the Trust’s PFI partner, Mercia Healthcare Ltd to expedite a replacement shower.

ACTION: To liaise with the Estates Department regarding the feedback provided to Sodexo. DNQ - Oct 2013

• Discussion was held on the duplication of reporting between the Quality Committee and

the Trust Board. The DNQ highlighted that the public would not have the opportunity to see the whole picture if the information was not available on the Trust’s website. It was recognised that the Trust Board should be receiving assurance from the Quality Committee and reporting should be specific to the Board. Those members who did not attend the Quality Committee confirmed they received an appropriate level of information.

• The Herefordshire Council website had reported that there was an expectation that the local birth rate would decrease. If correct this would impact upon the required resource to meet the midwife to birth ratio performance indicator.

• The DNQ referred to the Public question (ii). National guidance regarding nursing staff ratios was expected at the end of November 2013. A review of staff ratios, excluding Paediatrics and District Nursing had taken place to inform a future business case. However, there was concern in issuing current nurse ratios without full explanation of the different anomalies. A presentation would be provided to the January Board meeting in public which described the function of the individual wards, the national guidance and the Trust’s plan to address any identified shortfalls.

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B006/09.13 PERFORMANCE REPORT The CEO presented the report in the absence of the COO, highlighting the following key points: • The Trust was delivering 18-weeks RTT for electives however not achieving the required

performance standard for emergency admissions. The issue related to ensuring patients were discharged from hospital to allow admissions. The Hereford County Hospital has a small bed base by acute hospital standards and would need to have a length of stay one day shorter than its peers. This element concerned the whole health economy however the Trust must ensure its own systems and practices are working effectively.

• The Transformation Project was currently looking at system procedures associated with delayed discharges. The use of escalation areas imported risk and was not satisfactory for patients or the Trust. A change in medical staffing arrangements had been agreed, with senior decision makers providing a 24-hour seven-day week cover to ensure timely and appropriate discharge of patients, together with a change to the way the discharge suite was used.

• Emergency admissions were lower than last year however A&E attendances were relatively higher. The Trust was currently receiving 120/125 patients a day, when the area was designed for a maximum of 80 patients. Attendances were also expected to increase further. Appropriate patients were being encouraged to use walk-in centres, their own GPs or GP out of hours’ services.

• The CEO referred to the public question (iii): Proposals for additional resources were put forward by the Trust, with support from the Herefordshire Clinical Commissioning Group (CCG) and the Area Team (AT) as part of NHS England. The decision regarding allocation was made at a national level and it was decided other health economies had larger scale difficulties than WVT. The Trust had approached the TDA who were considering its case however the Trust had been advised not to be optimistic. The CEO confirmed that the Trust’s position was being highlighted both through the NHS bureaucracy and the political route.

• The CEO confirmed that there was extensive performance data available including quality, financial and workforce measures. NEDs requested a concise set of criteria to be reported on a monthly basis. The Board noted the information was available within different areas of the report however agreed the benefit of a dashboard to highlight the progress in key areas. These included lengths of stay below five days, 95% plus on 4 hour waits in A&E, fewer escalation areas being used and less spend on agency staff. A reduction in mortality would also provide key evidence however this would take a longer period of time to identify.

• A NED highlighted the requirement to remember the patients behind the performance figures. A request was made to include the definition of the performance indicator within the narrative for those targets that had been breached.

ACTION: One page dashboard of key criteria to be provided on a monthly basis to monitor the progress of key initiatives.

COO – Oct/Nov 2013

ACTION: Performance indicator definition to be included within the narrative on those targets that had breached. COO – Oct 2013

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• There was a requirement for good new stories and press releases to ensure members of the public were aware and understood the concept of initiatives such as the Virtual Ward. The CEO confirmed that some public relations approaches were being considered. There was extensive data to highlight that ‘winter’ pressures were being experienced all year round.

• NEDs requested clarity on what the trigger point would be to cease elective care and how quickly the current situation could be resolved. The CEO reported that the Trust operated at a lower level of length of inpatient stay; efforts were being placed on a reduction. The CEO acknowledged that the Trust had a very small period of time to turn the situation around and the consequences of stopping elective care would also be hugely detrimental. The CEO confirmed that NEDs would be made aware when emergency action was required to address the current situation.

• There was concern that the overall productivity in Theatres had not increased. NEDs questioned why the Trust was consistently falling below the 4.5 average patients per session. The CEO confirmed there were multiple issues concerning the required increase in productivity. The Urgent Care Service Unit was working through speciality by speciality to ensure the productivity issue was resolved.

B007/09.13 FINANCE REPORT The DFI presented the paper highlighting the following points:

• The Additional Capacity Payments (waiting list payments) were £527k compared to a budget of £390k. Details of payments made to Consultants and the use of the private sector would be incorporated into the Finance report going forward.

• The Trust must ensure that Teme Ward and the Day Case Unit were kept free to ensure the level of activity and generation of income.

• The Trust had not made any formal decisions to utilise the fire dispute compensation monies but they continue to be planned into the forecast outturn.

• If the Trust continued to deliver the level of activity currently forecast, it would lead to an over performance against the Herefordshire CCG’s contract of £3.1m. Discussions with the CCG continue however the CCG had indicated that they were unable to afford the level of over performance. The Trust must deliver the level of activity to ensure 18-weeks RTT and any Payment by Results tariff should be paid by the CCG.

• There had been discussions with the TDA regarding potential external I&E support. The TDA had indicated that external support would be linked to delivering a higher level of savings, which would be difficult in the current circumstances.

• Discussions continued with the CCG and AT in relation to the investments that the Trust had made to address winter pressures. These investments had been taken at risk to the Trust’s financial position. It was assumed that the Trust would be required to utilise the fire dispute monies to offset a further increase in deficit. The cost of an increased nursing establishment on Leadon and Wye Wards had not yet been built into the forecast.

• A NED highlighted that the forecast outturn had been adjusted in isolation of the Section 75. The DFI confirmed that the annual budget had been set assuming Section 75 for a full year. The adjusted figures referred to the Section 75 contract not being renewed on the 13th September 2013. The contract included a 50:50 arrangement for dealing with overspends or underspends. Whilst figures had not yet been finalised, it was already anticipated there would be an understanding. The DFI confirmed that any change to the length of stay had not been factored in in-year. Financial forecasting had to make assumptions regarding agency usage over the remainder of the year in terms of new initiatives. The CTB highlighted that the Trust’s commitment to integrated care but it was not about organisational boundaries and work would continue on care pathways, highlighting that an additional benefit of integrated care was admission avoidance.

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• A NED questioned why, following contractual agreement the Trust’s activity had led to over performance. The DFI confirmed that both parties were explicitly clear regarding the position. At the start of the year the Trust had sought a particular level of contract in consideration of trends of activity. The CCG, partly due to financial considerations, wanted to set the contract at lower activity levels. The Trust explicitly agreed the lower level of contract but made clear at the outset that it expected the activity to be higher, which was accepted by the CCG. The Trust recently met with the CCG and they indicated they had put aside £1.7m for potential over performance. The NED expressed disappointment that the Trust knowingly agreed to this situation. The DFI reported that he felt the contract situation had been made clear to the Board throughout the year.

• A NED highlighted the Trust’s actual activity performance was under its budget levels and hence over performance seemed odd. The DFI reported that the mix of activity had meant that there was no negative impact compared to budget revenue. The NED asked at what point the Board would understand the level of activity for the rest of the year. The DFI highlighted that the Trust was not performing work merely to generate income. The Service Unit had indicated the level of activity that was required to meet RTT and the Trust was only on the cusp of fulfilling this in all specialities. A recovery plan for orthopaedics was dependent on some additional capacity payments and some additional activity going to the Nuffield private sector. The plan had been affected by a number of cancelled operations. The availability of external contractors would be significantly diminished, noting the Nuffield would be closed for a period of time over the Winter. Each week the Trust was getting closer to the point of knowing exactly what it could and could not deliver. The CEO highlighted that the Trust’s position was being monitored on a weekly basis and would be reflected in the Trust’s overall financial performance reporting.

• A NED reported that there was no detailed evidence within the report regarding the range of measures being taken to manage the risk of the year-end deficit deteriorating. The DFI confirmed that a range of actions had been taken, including the introduction of strengthened controls on a range of pay issues; the introduction of short-term vacancy control measures; new rules on bank and agency use; a range of meetings regarding non-pay expenditure; new rules regarding unavoidable against avoidable expenditure and a review of reserves. There was a wide range of actions to continue to deliver quality however keep costs down. A NED requested evidence in next month’s report to ascertain if these measures were addressing the issues and costs were decreasing.

ACTION; To include evidence in next month’s reporting to identify if the range of measures taken to manage the risk of the year-end deficit deteriorating, were working. DFI – Oct 2013

• A NED referred to the statement that the receipt of £9.7m external financial support could

no longer be assumed by the Trust. In terms of a ‘going concern’ there needed to be assurance that the Trust could pay staff and creditors. The DFI confirmed that the Trust would receive support either in terms of cash or in terms of income and cash. The NED felt that the wording within the report unnecessarily caused alarm. The DFI confirmed this would be made more explicit in future reporting.

• A NED questioned in terms of contract over performance how realistic it was that a management plan would change the reality of the situation. The DFI highlighted that it was an oddity that providers were asked to put an activity plan in place when the bulk of activity was outside the provider’s influence, other that one area of outpatient follow ups. The system was designed that Commissioners would underestimate the demand and providers would anticipate as much activity, whilst trying to be realistic and therefore figures would never balance.

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B008/09.13 WORKFORCE REPORT

The DHR presented the report highlighting the key points as follows: • Work had taken place on ensuring that it was more attractive to become a member of the

bank (than an agency). The Trust was attempting to recruit as many substantive staff as possible within budget. If agency staff were required, the Trust was ensuring it implemented block bookings and used those agencies that had a reduced premium. There had been 26 new bank recruits in the month of September 2013 to date.

• A NED questioned how the value of appraisal was ensured. Appraisals lead on to a Personal Development Plan (PDP) for staff. A NED enquired as to the monitoring of PDPs. The DHR confirmed the training database was now being administered by the Trust which would help identify any training interventions required. It was acknowledged that it would be beneficial to have an annual training plan which was costed.

• The DHR referred to the public question (vi). The Trust does have a dress code that refers to the use of headgear in regard of religions however it does not refer to any facial coverage. Some guidance could be found on the NHS Employers website. There appeared to be no set rules with the Secretary of State contacting the General Medical Council for advice on this matter. It appeared to be a matter for local discussion with individuals and religious groups as appropriate.

FOR DECISION/DISCUSSION

B009/09.13 PERFORMANCE MAANGEMENT REGIME (PMR) BOARD REPORT The DFI presented the report and confirmed the PMR would continue to be presented to the Board whilst the TDA continue to work on a new performance dashboard. The following key points were highlighted:

• The Board statements had now been superseded by the TDA monthly self-certification. • Once the TDA publish a performance dashboard in line with their Accountability

Framework, the Trust could look to adopt the dashboard and include it within performance reporting.

• Concern was expressed that there appeared to be no Board actions against performance indicators such as Never Events or SHMI. The DFI confirmed that actions were addressed elsewhere within Board reports however the Trust could indicate that corrective actions were in place with oversight by NEDs. The DFI interpreted that the ‘Board Action’ was an Executive action. The Chairman was not required to sign off the PMR on behalf of the Board.

• A NED highlighted it would be beneficial to highlight at an earlier point that there were contractual difficulties with the CCG regarding over performance.

RESOLVED: The Board APPROVED the PMR report.

B010/09.13 BOARD ASSURANCE FRAMEWORK The CS presented to the report to be taken as read.

RESOLVED: The Board NOTED the Board Assurance Framework.

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B011/09.13 RISK APPETITE The CS presented the report to be taken as read.

RESOLVED: The Board APPROVED the Trust’s Risk Appetite.

B012/09.13 COMPLAINTS ANNUAL REPORT

The DNQ presented the report, highlighting the following key points: • There had been a significant numbers of issues related to bed pressures that had been

experienced over the past year which were reflected in the subject of complaints. • The Trust was not being complacent and was examining the complaints process in line

with recommendations from the Francis and Keogh reports. • Human factors training had been implemented to improve patient care. • NEDs indicated that it would be beneficial to have ‘all aspects of care’ further

interrogated into categories. The DNQ confirmed that the quarterly complaints report included this breakdown.

RESOLVED: The Board APPROVED the Annual Complaints Report for WVNHST for 2012.13.

B013/09.13 NHS TRUST DEVELOPMENT AUTHORITY SELF CERTIFICATION The CS presented the report to be taken as read.

• Board Statement Item 2. A NED requested assurance that plans were in place to address the non-compliance with CQC standards within Day Case Surgery, as noted in the Board Assurance Framework. The CEO assured the Board that new plans were in place for a positive impact and mitigation of risk, to deliver in the next few weeks. The Board continued to agree to the compliance statement however would await the evidence of a reduction in the Board Assurance Framework scoring of this risk.

• Board Statement Item 3. The MD confirmed medical practitioners cannot practice unless registered with the General Medical Council. The revalidation process had commenced. Those in line for registration had received a positive recommendation bar two member of medical staff who had been referred; one who was on long-term sick leave and one under an on-going investigation.

• The Chair of Audit Committee reported that the Audit Committee were aware of a number of audit recommendations that were delayed in their implementation. There had been a significant improvement on delays in the summer however there were a few which would need to be brought to the attention of the Board if not improved.

• A NED highlighted the ambiguity of indicating that the Board was compliant with ‘all’ likely future risks.

RESOLVED: The Board APPROVED the NHSTDA self-certification.

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REPORTS FROM SUB-COMMITTEES B014/09.13 QUALITY COMMITTEE Meeting 19th October 2013

The Chair of the Quality Committee confirmed that in addition to the Quality and Safety Report, the Committee had received:

• A presentation regarding Infection Control. • An update on transition arrangements for the Section 75 contract with Herefordshire

Council. • A draft Governance Structure for committees reporting to the Quality Committee. • A revised draft of the Quality Governance Assurance Framework. A self-assessment

assurance of clinical governance issues which would feed into the Board Governance Assurance Framework.

• An extraordinary meeting of the Quality Committee took place on the 26th September 2013 to specifically discuss mortality data, attended by the MD and Associate Medical Director.

• The CS referred to the public question (i). The agenda and minutes for the Quality Committee in July and August 2013 had been published. Further reports will be made available when reasonably practicable. The redaction process had been onerous to comply with data protection, had therefore taken some time to publish, and the results were felt to be poor due to their resulting incompleteness. The CTB highlighted his frustration that the Trust could not place more in the public domain in line with transparency however the reports dealt with such small numbers, it effectively meant that patients could be identified.

RESOLVED: The board NOTED the verbal update

B015/09.13 REMUNERATION COMMITTEE

The Chair of the Remuneration Committee confirmed work continued to monitor and maintain continuity of Executive positions currently covered by interim appointments.

RESOLVED: The Board NOTED the verbal update

FOR INFORMATION B016/09.13 CHIEF EXECUTIVE UPDATE The CEO presented the report to be taken as read, confirming:

• The plan to join a consortium with Warwickshire and Worcestershire Acute Hospitals had now ceased and the Trust was reviewing longer term strategic partnerships for Community Pathology.

• The CEO referred to the public question (v). Executive Directors working on the ‘shop floor’ provides an excellent insight into the daily pressures faced by staff in the hospital and the visits had proved successful.

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B017/09.13 OFF LINE BOARD APPROVALS CQC APPLICATIONS REMUNERATION COMMITTEE TERMS OF REFERENCE

RESOLVED: The Board NOTED the off-line approvals

ANY OTHER BUSINESS There was no other business noted. B018/09.13 DATE OF NEXT MEETING 28TH November 2013

Members of the public proceeded to raise the following questions/comments:

• Would it be possible to read public papers electronically? The CTB confirmed that papers could be downloaded from the public facing website.

• Could mobile telephones be used to text details/reminders of patients’ appointments in order to save paper? The Trust was trialling the use of text reminders and work continued on using such technology.

• In order to change the culture regarding inappropriate attendances at the Accident and Emergency Department, could the Trust launch a mini public information campaign? The Trust continued to examine ways of relaying this message to the public.

• The Futures Project was not addressed with the CEO’s paper? The CEO confirmed there was no further progress to report at this meeting.

• Why was there no opportunity for members of the public to ask questions at the end of the meeting? The CTB confirmed that members of the public are given the opportunity to ask questions at the beginning of the meeting.

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Enclosure ii Wye Valley Trust Board Meeting – Part B

Action Log for meeting held on 31 October 2013

B007/07.13 Quadrant Dashboard To ascertain if the NHS Trust Development Authority (NHSTDA) dashboard could be made available to Trust Boards

28 November 2013

DFI

The DFI continues to ascertain if the NHSTDA dashboard could be made available to the Trust.

B011/07.13 Performance Report Examine with Head of Service and Consultants the potential to offer out of hours appointments together with an examination of the geographical pattern.

28 November 2013

COO

Work underway to survey patients regarding evening clinics and review pattern.

B016/07.13 NHS Trust Development Authority Self Certification NHSTDA submissions to be examined in greater depth on occasions to ensure shared learning.

28 November 2013

CS

Allocated to the December Board Workshop.

B006/09.13 One page dashboard of key criteria to be provided on a monthly basis to monitor the progress of key initiatives; suggested criteria included length of stay below five days, 95% plus on 4 hour waits in A&E, fewer escalation areas being used and less spend on agency staff.

28 November 2013

COO

Work in progress through the development of the SITREP daily report.

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WYE VALLEY NHS TRUST PUBLIC BOARD 28th November 2013

DEREK SMITH, INTERIM CHIEF EXECUTIVE [email protected]

CHIEF EXECUTIVE’S UPDATE REPORT

1.0 INTRODUCTION 1.1 The purpose of this report is to provide an update to the Board on key issues and events of the past month. The focus remains upon achievement of critical access targets for patents and ensuring that the necessary actions following the Rapid Responsive Review are being implemented. However, we are at that point in the cycle where business planning 2014/15 onwards intensifies. There is also a growing need to make progress with the Futures Project. 2.0 RECOMMENDATION 2.1 The Board is asked to note the content of this report.

3.0 MAIN BODY OF REPORT 3.1 Patient Access The 4 hour 95% target to determine the pattern of treatment for emergency patients is often wrongly considered to be a „political‟ or management requirement. As the Emergency Care Intensive Support Team have agreed, it is in fact good medicine and good for patients to have their pattern of future treatment determined and acted upon quickly. At Hereford there is another reason – the Accident and Emergency Department‟s physical limitations mean that patients need to be moved to ensure that cubicles are available for others to be assessed and treated. In October 2013 the 95% target was achieved. To date in November, 95.5% has been achieved, but there are days when performance has fallen to below 80%. These variations usually occur after days of admissions exceeding discharges and normally coincide with the beginning of the working week when emergency demand is higher. If this is a „spike‟ in demand with patients arriving in numbers over a short period of time, the hospital has difficulty in coping. The introduction of „physician of the day‟ for 7 days each week, „virtual wards‟ and ambulatory emergency care where patients are treated but admission avoided have all helped, but the balance of admission to discharges over the weekend determines, to a large extent, how well emergency flows are managed in succeeding days. It will be a testing winter! In a different way the 18 week „Referral to Treatment‟ Target for elective patients also presents a challenge. Ideally the patient should be assessed as an outpatient

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mailto:[email protected]

Enclosure iii

as early as possible after referral. This allows the urgency to be assessed and a treatment plan established. Patients are either „admitted‟ where they may have a procedure or some other therapeutic intervention. For most admitted patients, operating theatre scheduling, productivity and availability are critical. Recent difficulties with ventilation systems in operating theatres have caused cases to be postponed, which can risk breaches of the 18 week target and introduces the complexity of rescheduling operations. All emergency and urgent surgery nevertheless was undertaken. These two targets collide when capacity, usually beds, is required for both. Bed management, therefore, depends upon effective, safe discharge of patients who needed urgent care and minimal stays in hospital for those needing planned procedures. For this reason the shift to day case work using newer technologies, endoscopic procedures, laser and radio-frequency ablation, for example, is of increasing importance in achieving safe, effective and efficient services. 3.2 Business Planning CCGs are to learn their allocation for 2014/15 on 16th December 2013. However, Trusts and CCGs must submit an outline of their plans for 2014/15 and 2015/16 by 13th January 2014. The income position will become more difficult. Trusts are required to plan on a -1.9% tariff deflator and 2.1% inflation, making up the 4% efficiency requirement. Apart from the usual requirement for the Service Units to produce cost improvements there is a view that the financial pressures will require more radical changes. This is amplified by the post-Francis report pressure to increase staffing levels to the structure and cost of health services locally, otherwise the financial position of providers of service and commissioners will only worsen. 3.3 Futures Programme The Trust has continued with its analysis and modelling of options. The CCG has now indicated that it will have proposals to put to its Board in mid-January 2014 concerning the Commissioner Requested Services (CRS) it will determine must be provided locally. This is a two edged sword since providers may not give notice of ceasing to provide services commissioners regard as essential, but equally can apply to Monitor as the economic regulator for tariff support if such services for local reasons cannot be provided affordably. This will help cement the strategic options for Wye Valley, but will not describe all the services commissioners intend the Trust to provide. Nevertheless, it will be used to finalise options to be contained in the Outline Business Case (OBC) which will be drafted for review by the Board at the end of January 2014. In February 2014 the CCG intends to have its five year plan drafted. This in turn will have been informed by Wye Valley‟s OBC.

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3.5 ‘Going the Extra Mile’ Awards Two excellent awards for „Going the Extra Mile‟ were presented in September 2013:- Making an Outstanding Team Contribution: Leominster Community Hospital Team The team was nominated for the delivery of exceptional care for a palliative care patient. The patient‟s family contacted the Trust following the loss of their mother and commented on the excellent care both their mother and their family experienced prior to their mother‟s death. Specifically, they felt the team had delivered compassionate and skilful care which made a very difficult event more bearable for them all. They felt “privileged to be part of a fantastic family”. Making an Outstanding Individual Contribution: Pat Williams, Midwife, Delivery Suite Pat was nominated following a discussion with a mother on the SCBU Ward. The mother commended Pat for being amazing; for providing brilliant care; for being positive, happy, and cheerful; for being very supportive, staying by her side and for making her birth a lot easier. Three excellent awards for „Going the Extra Mile‟ were presented in October 2013:- Making an Outstanding Team Contribution: Health Records Team “The Health Records Department is a well-motivated and hard-working team. The conditions within the department have been very poor in the last few months with overcrowding of notes, lack of staff, and the team has worked extremely hard in these difficult conditions. They have always ensured that their work has not suffered and have not only managed to maintain a high standard of work but have done it with a smile. The team are an excellent example of team working, pulling together to ensure that the service to the staff/ departments of the Trust has not been disrupted, whilst keeping themselves motivated and priding themselves on doing an excellent job.” Making an Outstanding Individual Contribution: Stacy Edwards, Play Therapist,

Children‟s Ward

Stacy is excellent in her role and in the last few weeks has gone above and beyond the „outline‟ of her role in the care of some of our sickest young children. She has been arranging „play dates‟ to enable the children to reduce their fears and anxieties around hospital stays and procedures. For one very special young lady Stacy arranged a wish via the Rays of Sunshine Charity and she visited the young patient both at home and at Birmingham Children‟s Hospital when she was more poorly. The effect that Stacy had on this little girl was to raise a smile even on really bad days, and to give her Mum some „me time‟ as she knew that Stacy was there helping alleviate the little girl‟s fears. Stacy is always smiling and full of fun and has the most brilliant attitude to her „charges‟, never forgetting and she never forgets that the child‟s happiness is paramount at a time when they and the family are quite distressed.

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Enclosure iii

Making an Outstanding Individual Contribution: Sandra Parry, District Nursing Sister, City South Neighbourhood Team

Sandra has been very involved in supporting palliative patients at home. I have known her call on patients on her way home to make sure they have everything they need in the precious last days of life. Sandra has also phoned patients at home before commencing her day at work to ensure that her palliative patients‟ progress was reviewed in a timely fashion and to ensure that their last days were as well supported and as comfortable as possible. This extra mile service is the „norm‟ for Sandra and should be recognised. Despite managing a caseload of many patients, Sandra always seems to find time to guide and support staff in the City South Team. Sandra is a transformational leader; she works and leads through example, prompting others to „feed‟ off her enthusiasm and commitment. Despite being a Sister, Sandra is always happy and willing to turn her hand to any task for her patients and to facilitate detailed quality care. Sandra often works over her allotted time to ensure that her patients have all they need to prevent a crisis at home. She is always asking her staff how the patients are and if the staff are managing to deal with the workload allocated to them. Sandra values her staff, is keen to develop them and is proud of the team. She is passionate about her work, an innovative problem solver, contributes solutions to problems that staff and patients may encounter and is a truly multi-faceted leader with compassionate care at her heart.”

17 of 112

Enclosure iv

WYE VALLEY NHS TRUST BOARD MEETING ‘IN PUBLIC’ 28TH NOVEMBER 2013 COMPANY SECRETARY’S REPORT [email protected] BOARD ASSURANCE FRAMEWORK 1.0 INTRODUCTION

1.1 The Board Assurance Framework (BAF) is developed to provide Board Members with

detail on the risks that could prevent Wye Valley NHS Trust achieving its strategic objectives and the actions that are being taken to either manage those risks to an acceptable level or to mitigate them completely.

1.2 As a result of the Rapid Responsive Review it has now been agreed that the BAF will

in future be presented to the Quality Committee for discussion prior to the Board but after review by the Trust Executive Management (previously the Leadership Team).

2.0 RECOMMENDATION 2.1 For Board Members to review the risks currently held on the BAF. 2.2 For Board Members to approve the highest extreme risk identified at paragraph 3.5. 3.0 MAIN BODY OF REPORT

3.1 Review of Risk Registers and BAF since the October Trust Board Meeting:

Where When What

Service Unit Governance Meetings:

• Elective Care • Care Closer to Home and

Urgent Care • Integrated Family Health

Services

14.11.2013 14.11.2013 15.11.2013

Risk Registers

Service Unit Performance Meeting 19.11.2013 Risks which the Service Units were concerned about.

Trust Executive Management 12.11.2013 Board Assurance Framework

Quality Committee 21.11.2013 Board Assurance Framework

18 of 112


Enclosure iv

3.2 Two new extreme risks (escalated Operational Risks) have been added to the BAF: • The risk of harm or injury to a child due to the significant increase in the amount

of safeguarding referrals. • The risk to standards of care and safety of patients when demands on A & E

capacity are high.

3.3 The following operational risks have been reduced from ‘extreme’ to ‘high’ so are no longer on the BAF:

• Day Surgery Unit being used as an escalation area for inpatients which creates the potential for breaches in mixed sex accommodation.

• Inability to sustain antenatal intrapartum and postnatal service delivery within expected maternity standard. In order to ensure safe skill mix within the delivery suite there is a requirement to redeploy community staff, managers and specialist midwives.

• Insufficient numbers and quality of middle grade doctors to provide a consistently safe and reliable service.

3.4 The following risk has been closed: • Lack of maternity/ patient alarm call system leading to failure to provide

emergency care…

3.5 The highest extreme risk (score of 20 and above) which the Trust is currently facing is: • Risk to patients safety due to deficiencies in compliance with the clear air and air

extraction services within theatres. 3.6 There are a total of six strategic risks detailed within the BAF, three of which are

classed as ‘extreme’. In addition to the strategic risks there are a further nine ‘extreme’ operational risks which have escalated up through the risk management system.

3.7 The table below shows the current number or risk and their associated rating as at 15th

November 2013. As at 15th November 2013

Service Unit or Corporate Service

Low Risks

1-3

Moderate Risks

4-6

High Risks 8-12

Extreme Risks 15-25

Total

New Risks

01.04.13 to

15.10.13

Closed Risks

01.04.13 to

15.10.13 Urgent Care Closer to Home 0 4 7 2 13 5 28

Elective Care 0 2 10 4 16 8 10

Integrated Family Health Services 1 5 7 1 14 12 5

Corporate (inc. HR, Estates & Finance) 0 9 31 5 45 17 4

Totals: 1 20 53 12 88 42 47

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Enclosure iv

3.8 The cube shows the spread of the 87 risks by consequence and likelihood score:

4.0 POLICY AND BUSINESS PLAN CONSIDERATIONS 4.1 Providing the Board with appropriate assurances that the strategic objectives will be

delivered is essential to Wye Valley NHS Trust. 4.2 The table below shows which strategic objectives are most affected by the risks

currently held on the BAF. Primary Objectives No. of Risks %

• To enjoy a reputation for and be able to demonstrate exceptional quality, safety and customer service.

7 47

• To achieve sufficient financial prosperity to enable services to be sustained and developed.

1 6

Service Delivery Objectives: • To deliver community focused and integrated

health care services. 3 20

• To deliver a clinically sustainable portfolio of secondary care services.

4 27

• To extend the range and, where appropriate, the volume of health care services we offer.

0 0

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Enclosure iv

NPSA Risk Scoring Matrix Consequence x Likelihood Likelihood Likelihood score 1 2 3 4 5 Rare Unlikely Possible Likely Almost

certain 5 Catastrophic 5 10 15 20 25 4 Major 4 8 12 16 20 3 Moderate 3 6 9 12 15 2 Minor 2 4 6 8 10 1 Negligible 1 2 3 4 5 Grading of risk 1 - 3 Low Risk 4 - 6 Moderate Risk 8 - 12 High Risk 15 - 25 Extreme Risk

21 of 112

Wye Valley NHS Trust Strategic Board Assurance Framework as at 15th November 2013 Appendix 1

Wye Valley Trust Objectives

ENCLOSURE IVOpened Title Rating

(initial) Controls in place Risk level (current) Gaps in control Assurance Gaps in assurance Action summary Action Update Rating

(Target)Daye Last Reviewed Manager

To achieve sufficent financial prosperity to enable services to be sustained and developed

08/04/2013 Failure to deliver outturn position in 2013/14. This is due to the trust needing to make a target surplus of £600k and Cost Improvement Plans of £8.8m whilst significant cost pressures are being experienced and the position has been made even more challenging due to the implications of the Rapid Response review.

Anticipated financial support of £9.7m from the Trust Development Agency is now extremely unlikely. 25

Strategic Change Management Programme developed.Critical projects identified with Executive leads and set timescales to deliver.Experienced interim CEO on place.Project Management Office arrangements.Contract Monitoring meetings.Executive weekly programme meeting.Contract signed 30/04/132013/14 Cost Improvement Plans agreedElective Care Service Unit Recovery PlanRevised Forcast produced.Non pay review with all budget holders and service units issued with control totals which must be delivered.

16

None identified Formal governance arrangements in place through Executive Programme meeting against each component of CIP within the Business Plan.Finance report to Board

None identified 1. Progress of 2013/14 cost improvement plans continually under review.2. Ongoing discussions with Area Team and TDA regarding financial support.3. Monitor delivery of Elective Care Service Unit recovery plan.

1. Further additional CIP schemes constantly being sought.2. Service Units have been requested to do everything they can to deliver to budget.3. Director of Finance met with TDA to discuss likely outturn - Trust asked to do everything they can to keep outturn to £9.1m deficit.4. Financial controls strengthened. 8

12/11/2013 Director of Finance & Information

To deliver community focused and integrated health and social care service

21/01/2013 Current organisational form of Wye Valley NHS Trust at risk due to long term financial sustainability and ability to achieve FT status as a stand alone Trust.

20

Wye Valley NHS Trust Futures Programme established with Project Board and Oversight Board Governance.NHS Trust Development Agency SupportTransfer Agreement for integration of Community and Acute Services in place.Strategic Outline Case of Futures Options presented to Board March 2013.Draft OBC was presented to the Board in June 2013.

16

None identified Clinical Strategy being developed by CCG (Winter 13)Futures Project Oversight Board GovernanceStakeholder Reference GroupStakeholder and Partner engagement in Futures Programme

None identified 1. Clinical Strategy Review of Services.2. The complete OBC will be presented to the Board in January 2014 once negotiations with TDA and Commissioners and the development of the clinical strategy are complete3. Full Business Case on future organisational form to be developed at timescale dictated by procurement route.4. Financial support to be negotiated with NHSE and NHSTDA

1. Review led by Herefordshire CCG - due mid January 2014.2. LTFM has been updated to the end of October 2013 - needs to be updated on a monthly basis.3. Trust to identifiy ways of of reducing financial gap.

8

12/11/2013 Chief Executive


30/07/2013 Adverse impact on position of the Trust due to inability to invest in buildings, equipment and IT from 2014/15 onwards due to insufficient capital.

20

Existing Estates Strategy.Draft Information Management and Technology. Strategy discussed at Board Workshop.Long Term Financial Management Plan.Business Plan

16

None identified I & IT Management Group reportsCapital Planning and Equipment Committee reports.Capital position reported to BoardFinance and Performance Report to Executive and BoardBoard approval of Prioritised Capital Programme in March 2013.

None identified 1. Apply for funding from National Technology Fund - outcome awaited. 3. Production of revised Estates Strategy - due November 2013. 4. Issue to be highlighted in the Futures Outline Business Case.5. Situation to be brought to the attention of the Trust Development Agency.6. Additional capital required - business case to TDA to be produced.

1. Outline Business Case updated and next review is December 2013.2 Capital plans for 2014/15 being produced.

8


To enjoy a reputation for and be able to demonstrate exceptional quality, safety and customer service

23/11/2012 Possible prosecution if the Trust does not comply with the requirements of the fire safety enforcement notice.

25

Professional expert advisors appointed to support the Trust.Working in partnership with the Fire Authority who were informed immediately.Legal advice sought.Escalated to PFI.CEO's track progress weekly.Weekly meeting with Mercia. Theater shutdown to carryout fire works.Briefings in Trust Talk for all staff.Legal advice.

8

Trust is dependant on PFI partner to ensure compliance.

PFI Liaison GroupFire Safety GroupUpdates to Board (May 2013)

Work commenced by external experts is ongoing.Unlikely from current programme that works will be complete by deadlineTrust has had difficulties freeing up access to some areas (e.g. bed spaces) because of high activity levels.

1. Action plan and programme will be developed with Mercia - weekly meetings taking place. 2. Working with Communications Team to ensure staff and public accurately informed - regular briefings in Trust Talk for staff.3. A request for an extension of the enforcement notice has been accepted by HWFRS and the timeframe is now completion by 01/12/13.

Last met with HWFRS on 14th March 2013 and Fire brigade satisfied with actions taken.

Now agreed to jointly impact and there is a set of actions which are monitored by CEO's. Joint inspection took place on 25th September 2013 and review of evidence completed. No significant new issues found and Mercia responding to outstanding questions on evidence and completing additional repairs as required.

Small number of outstanding issues required to be resolved by Mercia. The Trust has written to detail these and has received verbal confirmation they will be resolved by the end of November 2013. 2

14/11/2013 Head of Estates


08/04/2013 The published high mortality indices are an alert of possible poor quality of care and therefore of potentially avoidable deaths.

16

Review of all in hospital deaths by clinicians.Escalation process for deaths which raised concerns by Mortality Review Group. Joint Primary and Secondary Care reviews with regard to deaths within 30 days of discharge, within one.Implementation of Care Bundles.Initial audit completed on usage of care bundles. 8

None Identified Mortality Indices reported to Leadership Team, Quality Committee and Board.Report to CCG led GP Education Day.

HSMR since November 12 has been above 100. Annualised HSMR is 106.6 & likely to be rebased upward.

1. Review of audits and lessons learned. 2. Return visit by TDA deputy Medical Director to review progress made on mortality rates. 3. Three monthly Dr.Foster reports will be targeted to Service Units.4. Report care bundle auit to be carried out - November 2013. 5. Creation of multidisciplinary working group to review Fractured Neck of Femur pathway and mortality - 19th November 2013.

5. Quarterly reports commenced - Service Unit specific.

4

12/11/2013 Medical Director

22 of 112

Wye Valley NHS Trust Strategic Board Assurance Framework as at 15th November 2013 Appendix 1

Wye Valley Trust Objectives

ENCLOSURE IVOpened Title Rating

(initial) Controls in place Risk level (current) Gaps in control Assurance Gaps in assurance Action summary Action Update Rating

(Target)Daye Last Reviewed Manager


04/01/2012 Lack of capital to fund replacements and invest in improvements and change due to financial position and cash shortages.

20

Scheme prioritisation by Capital Planning and Equipment Committee (CPEC)Revised Capital programme in place for 2013/14Emergency Capital Funding received from TDA for 2013/14 year

6

None identified I & IT Management Group Board reportsCapital Planning and Equipment Committee reports.Capital position reported to BoardFinance and Performance Report to Executive and BoardBoard approval of Prioritised Capital Programme in March 2013.

None identified 1. Prioritization of scarce capital resource undertaken.2. Identifying additional opportunities for capital funding.3. Business case being developed.

Revised capital programme approved at Board incorporating additional funds.

3


23 of 112

Wye Valley NHS Trust Operational Board Assurance Framework as at 15th November 2013 Appendix 2

Wye Valley Trust

ObjectivesOpened Title

Rating

(initial)Controls in place

Risk level

(current)Gaps in control Assurance Gaps in assurance Action summary Action Update

Rating

(Target)

Daye Last

ReviewedManager

1. Microbiological, air flow and ventalation checks for all theatres to be carried out over a series of time - Monthly basis until February 2014. 2. Review to be carried out by the Medical Director indicates within mitigations overriding clinical reason for use of theatres. 3. Case selection to be carried out by Clnical Director for Orthopaedics on a daily basis.

To enjoy a reputation for and be able to evidence exceptional quality, safety and customer service

08/03/2011 The risk of harm or injury to a child due to the significant increase in the amount of safeguarding referrals and children who require child protection plans, leading to potential delays in responses to information requests, Child in Need plans, Common Assessment Framework, the Lead Professional role, Multi-Agency Risk Assessment Conference (MARAC) procedures and Domestic Abuse notifications.

20

Safeguarding Supervision.Safeguarding Training.School Nurses working in teams to share responsibility. Team Leader has responsibility role for allocation of work - done on a weekly basis. Health Visitor or School Nurse sharing attendance at case conferences.Child Safeguarding database developed and active.Clear Interim Service Specification in place until September 2013. School Nurse Duty System developed.New School Nurse Team Leader in Post. 1WTE Bank Administrator appointed to carry out CPAS.

16

None Identified Case ReviewsSupervision and Training Audit Designated time for monitoring of work allocation by Team Leader

None Identified 1. All Chid In Need and CAF to be reviewed by Lead Nurse and School Nurse Team Leader - 4th December 2013.2. New interim service specification to be developed - 4th December 2013.

Commissioners wrote an action plan that was presented to the Safeguarding Board 11th November 2013.

MARAC reports information ceased.

3

15/11/2013 Service Unit Manager Integrated Family

Health

Director of Nursing & Quality


30/07/2013 The Trust is non compliant with the recommended ratios of 65:35 registered nurses to unregistered nurses (referenced in Keogh). The discrepancy in some areas is based on a previous ratio of 1.2 WTE per bed (Audit Commission recommendation).

This causes a higher usage of bank and agency staff which is acknowledged can lead to poor or compromised quality of care such as an increase in Serious Incidents, pressure ulcers and complaints.

20

Bank and Agency Escalation Procedure.Local Protocols for Staffing. Local Protocols for High Dependency patients.Trust Staff Induction.Bank and agency skill sets achieved by review of CV prior to commencement. Agency and bank staff not recalled if not competent after one shift. Block booking of bank staff.Paper sent to Executive Team.Briefing paper on staffing levels to Leadership Team.Audit of patient acuity. Findings from dependency and audit tabled at Quality Committee.Staffing paper presented to Board.Uplift of staffing agreed on Lugg and Wye Wards. Weekly meetings between Heads of Nursing and Director of Nursing & Quality.Induction Protocol .Weekly staffing meeting with Heads of Nursing, Director of Nursing & Quality, Director of Finance and Director of Human Resources.

16

None Identified Incident Forms. Health @ Work Reports.Clinical Audits. Friends and Family scoreComplaintsSIRI'sJuly paper to Executive Team, August paper to Leadership Team and BoardSeptember paper to Board

Incidents forms are not always completed.Staff may not go directly to Health @ Work but present at own GP.

1. Recruitment of Bank and permanent staff.2. Staffing paper to go to November Board Meeting - 28th November 2013.

Further review based upon 1 registered nurse to 8 beds in an additional 65 registered nurses and 17 health care assistants. Paper at October 2013 Board.

4

14/11/2013 Director of Nursing & Quality


18/10/2013 Failures to admit patients with Fractured Neck of Femur (#NOF) directly to the Trauma and Orthopaedic specialty wards, leading to breaches to the Fractured Neck of Femur pathway and British Orthopaedic Association Blue Book recommendations of admitting patients within 4 hours to acute specialist orthopaedic wards, which could result in increased length of stay, poor or reduced patient outcomes and significant injury or death.

25

Site Team to identify designated beds on the Trauma and Orthopaedic Wards (Redbrook) Daily. Nursing staff to identify patient’s who meet the criteria

who could be nursed safely on non Trauma and Orthopaedic Specialty Wards. Staff Competency Training. Consultant of the week for Trauma and Orthopaedic identifies high risk patients. Redbrook staff fully competent with the patient’s

specialist needs. Fractured Neck of Femur Database.British Orthopaedic Association Blue Book.Review of patients flow report 4 times a day.Review of medical outliers daily.

15

Inability to manage patient flows out of hours.Mandatory training currently unavailable.The inputting of the database is currently running behind.Non-compliance with the British Orthopaedic Association Blue Book recommendations.

Incident Forms Monitoring

Incident forms not always completed

1. Data to be collated on cases of Fractured Neck of Femurs - Monthly.2. Creation of working group to review Fractured Neck of Femur pathway - 19th November 2013.3. Draft decant plan for Fractured Neck of Femur to be written, agreed and implemented - November 2013. 4. Ringfencing of Redbrook Ward for Trauma & Orthopaedic cases - End November 2013.5. Clinical Director for Trauma & Orthopaedics to meeting with Urgent Care to agree return of income tariff generated from #NOF patients back to Elective Care - End November 2013.

5

14/11/2013 Service Unit Manager Elective Care

Chief Operating Officer


Risk to patients safety due to deficiencies in compliance with the clean air and air extraction services within theatres.

25

22/10/2013 Further testing indicates with mitigations all operating theathres may be used for overriding clinical reasons.

Medical Director

5

14/11/2013Consultation with Consultant Microbiologist taken place.Surgeonsato manage lists appropriately.Theatre staff aware of issues to ensure appropriate management of patients.Additional monitoring of microbiology and medical gases to provide ongoing assurance.Ventilation specialists to undertake a detailed assessment of the theatres ventilation performance and safety system.Review carried out of surgical cases.Further testing of Theatres

None Identified Incident Forms.External Asssessments.Monitoring.

Incident forms not always completed.

20

24 of 112


Wye Valley Trust


Rating


Risk level


Rating

(Target)

Daye Last

ReviewedManager

To deliver a clinically sustainable portfolio of secondary care services

28/04/2011 The National Quality Assurance Team may suspend the endoscopy service due to the lack of dedicated beds within the Day Case Unit and expected work not completed.

20

Local operational procedures in place to manage situation daily - and respond appropriately through flexible use of other areas.Dedicated male & female areas.Utilisation of current surgical pre assessment area to create more space to segregate patients and improve flow - separation of gender monitored.Escalation to Bed Management.Daycase and Endoscopy Unit Development Project Team - meets every two weeks.Change Notice provided to PFI partners - Nov 2012.Business case agreed.

16

Change Notice not processed and work not commenced 07/05/13Existing controls do not reduce the risk but manage it on a daily basis

Patient FeedbackReports on patient breaches

None identified 1. Provision of a minimum of 6 recovery beds dedicated solely to endoscopy is required and new build to include clear one way patient flow and gender segregation throughout journey.2. Work commenced and due to be completed by December 2013.3. Identify & implement measures to prevent unit being used as a thoroughfare.

Work ongoing and due to be completed in December 2013, at which point this risk will be mitigated and the risk closed.

4




05/06/2013 Non achievement of 18 weeks RTT target due to reduction in productivity in theatres in order to ensure safe staffing levels and patient safety due to 18 wte vacancies.

20

Block booking of Bank and Agency staff.Overtime incentives.Increased regular hours offered to part-time staff.Staff Training (Mandatory and Professional Development).Continue rolling advert on NHS Jobs.Recruiting for Recovery staff only [this will allow for redistribution of other staff].Advertising in National Medical media.Offering secondments for internal staff to Theatres for staff with theatre experience.Six agency staff appointed for Summer period.

16

Staff are unable to attend training due to lack of capacity for cover - Impact on Appraisals

Incident Forms Clinical Audits Key Performance Indicators Performance Reports

None Identified 1. Options appraisal drafted for consideration. 2. Paper to Trust Leadership regarding next steps.3. HR involvement and support to consider all options for recruitment and retention . 4. Retention plan to reduce turnover.5. Recruitment of Band 6 Clinical Trainers to coordinate Training & Development.6. Develop own ODPs and internal succession planning.7. Training Action Plan agreed.8. Job Description for new Theatre Training post drafted.9. Review of all Flexible working requests and current leavers to highlight changes in Theatres and tempt staff back.10. Continue to advertise in any media possible.11. Arrange recruitment Open Day. 12. Advertise in Association of Peri-Operative Practitioners (AFPP).13. Attendance at recruitment across country. 14. Explore recruitment through the use of Recruitment Agencies. 15. Appoint "Head Hunting" agencies to recruit staff .

7 staff have now started (4 operational an d 2 in training) - further recruitment ongoing to take establishment to agreed 4 WTE over for secondment's and maternity cover - still high agency spend as operational gap still 16.91 WTE.

21 new staff recruited taking establishment to budgeted levels - all due to join Trust between September and November. However, pressure on pay cost will remain until all new staff are trained and operational.

1



Additional waiting list initiative sessions established. Increased the headcount of Middle grades to ensure flexibility and cover and increase activity.Weekly theatre list review to maximise theatre capacity.New processes implemented to optimise theatre usage.Weekly review with medical secretaries of planned admissions over 2 months to fill any gaps.New administrative team resource to support T&O in place.Weekly 18 week meetings to review the validation, theatre capacity , diagnostic and outpatient support required.Flexible staffing to use out patient time for theatres.Extra capacity in pre-op assessment provided. Extra capacity acquired from Nuffield Hospitals, Hereford, Cheltenham and Spires, Droitwich.Health risk of all long waits reviewed and prioritised according to need.2013/2014 capacity/demand identified within business planning document.Plan developed to deliver activity over Winter re-directing Day surgery via Teme Ward.Locum Consultant T&O commenced January 2013 for 12 months. - Medical staffing being reviewed by CD.

1. Monitor effect of demand management demonstrated by Taurus and agree a process to ensure referrals are sent in a timely manner (not in batches).2. Raise awareness amongst surgeons regarding activity shortfalls and impact on achieving target.3. Utilise vacant theatre sessions due to leave to ensure maximum through put including Saturday sessions as able. 4. All available capacity at Nuffield utilised for cancelled operations - commenced. 5. Theatre scheduler commenced to review distribution of theatre lists to ensure capacity 6. Elective Care Recovery Plan in place.7. Elective Care scheduling forward look commenced to plan for inpatient and day case capacity includes daily forward looks to manage elective demands. 8. Scope extra day surgery capacity by Mid September 2013.9. Vanguard Day Surgery Unit ordered October 2013 to provide 7 additional trolleys over the Winter period.

Capacity managed daily including management of short term sick leave. Review of capacity through August to maximise use - 18 weeks achievement. remains fragile requires validation. Capacity planning for times of theatre shutdown.cancellation escalation policy controls in place to ensure maintenance of activity recovery plan.



16

Impact of urgent care admissionsMinimal capacity available in private sector partly due to patients' co-morbidities and/or reluctance to travel from HerefordshireCapacity and demand gap with current job plans

Theatre activty reports Finance and Performance reports to BoardMonthly Operations reportQuality & Perfomance Report

None identified

4

Fully booked for extra weekend work during September 2013.2 & 3. Support expressed from TO team to deliver extra activity with emphasis on 6/7 day working.6. Regular review of Elective care recovery plan in light of continuing events.8. Continued emergency pressures and use of recovery area a inpatient area resulted in cancellations - focus remains on meeting recovery plan.


14/07/2011 Non-achievement of 18 week pathways in Elective Care Service Unit due to reduction in waiting list initiative sessions and continuing capacity issues.

20

25 of 112


Wye Valley Trust


Rating


Risk level


Rating

(Target)

Daye Last

ReviewedManager

Urgent Care Programme Board established.Rapid decisions for out of panel funding on continuing health care needs and CCG spot purchase of nursing home/residential placement when requested.Medical Consultants engagement with the actual bed capacity position early in day.Multi-disciplinary capacity action meetings and daily meetings in time of increased demand.CCG communication and General practitioner involvement to avoid emergency admissions.Daily MDT meetings reviewing patients with Adult Social care needs to forward plan discharges. Additional Discharge registrar in place on Saturdays and Sundays.Consultant Physician of the day supported by consultant ward rounds at the weekend.Director/senior manager escalation to ensure WMAS control and other sites aware of capacity issues.Discharge District Nurse working with acute A&E and ward teams to support decision making and facilitate earlier discharge.Patient Flow Manager, directly responsible for Site and NNP team.Weekly (Friday pm) clinically led (Consultant or Registrar) weekend planning meeting to hand over patients requiring specific review and those which are potential for discharge. A&E system went live January 2013 benefits includes visible tracker of patient flows, links to clinical guidelines, alerts to delays.

Establishment of Urgent Care Programme Board with a focus on:1. Renew and revise ‘front end’ of the WVT

admissions arrangements to reduce emergency admissions- including Physician cover, job planning and recruitment.2. Complete rebuilding of the urgent care pathway including. a) Responsibilities across the inpatient pathwa.yb) Non-medical rapid response capability.c) Reducing LOS in Community Hospitals (including therapy capacity and nursing capabilities) - number of patients with a LOS more than 30 days to be less than 30.d) Bromyard Hospital services review.3. Facilitating elective flow.b) Discharge planning and aligning urgent and elective flows. 4. Reducing the costs of medical cover to Community Hospitals including standardisation of medical input/service specification.5. Piloting of ‘virtual wards’ commenced 16th

October 2013.6. Single Point of Access (SPA), to provide alternatives to admission plus bed management across Herefordshire health community from a single operational base - plans progressing for implementation early January 2014.

Regular press releases to raise public awareness.On site senior management presence at key times during weekend.2 hourly planning cycle to avoid 4 hour breaches.Increased performance management of length of stay above 30 days.Increased medical staffing out of hours.Out of hours on-call team bleeped for handovers. Risk Assessment undertaken of all areas being used as inpatient facility, prioritising suitability.Criteria for appropriate placement of patients. Redeployment of substantive WVT staff into temporary inpatient areas and backfill provided by bank or agency staff to permanent ward areas.Nurse staffing ratio's increased to meet capacity and acuity needs.Amalgamation of Care Closer to Home and Urgent Care Service Units into one new service unit.

7. Implement communication system for alerts using SMS, Email and voice mail to enable fast communication with specific staff groups in situations requiring escalation - not yet fully implemented but progress being made with database being populated - due January 2014.8. Use of extra capacity beds.9. CCN raised for costings associated with redesign of sub-wait area to ensure appropriate privacy, dignity and observation of patients.


15/03/2012 There is an impact on the standards of care and safety when demands on A&E capacity are high.

20

Extra nursing staff assist in patient flow within the department.Extra nursing staff on duty to manage the observation bay as inpatient facility.Triage of expected specialty patients.Physical walk arounds of the department.Cease to use cubicles in A&E majors as an inpatient facility. 15

Agency staff unfamiliar with department. Observation bay facilities are unsuitable for inpatient stays of longer than 23 hours.Sub wait areas do not allow for clear, constant observation of patients

Incident ReportsRoot Cause Analysis following Serious IncidentsPatient satisfaction surveysMonitoring against national standards

Some data for national standards is difficult/impossible to access due to lack of functional IT system

1. Linked to actions in risk 304.2. Urgent Care Programme includes development of CAU by December 2013.3. Urgent Care Programme, development of discharge planning processes.

9

12/11/2013 Service Unit Manager Urgent Care



18/04/2013 Inability to manage patient flow as a result of peaks in emergency admissions being greater than discharge numbers and capacity. This has also led to space within the A&E department becoming compromised.

20

Contingency plans remain in place if any need for rapid response to escalation including; control room opened within an hour, senior level ward rounds, staffing plans for extra capacity.6. Plans progressing for implementation.7. Not yet fully implemented but progress being made with database being populated.

6

12/11/2013 Service Unit Director Urgent Care


16

None identified Key Performance IndicatorsMonitoring against national standardsDaily reporting to TDA - slightly behind trajectory in terms of recovery

Potential for turnaround fines from WMAS

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Enclosure v

Trust Board 28th November 2013 AUTHOR: MICHELLE CLARKE, DIRECTOR OF NURSING & QUALITY QUALITY & SAFETY OVERVIEW REPORT 1.0 INTRODUCTION This report provides an overview of key quality and safety measures across the Trust for October 2013. This monthly dashboard will identify any key achievements and challenges that are facing the Trust. Where there is a negative direction of travel or any significant changes these issues will be highlighted within the narrative of the report with the inclusion of actions taken to address any deficiencies identified. For November 2013 the Quality Committee reviewed and approved;

• Patient Experience Quarterly Report • Learning Lessons from Complaints Report

2.0 RECOMMENDATION The Trust Board is asked to:

• Review and note the dashboard report. • Suggest any additional recommendations.

Key Highlights

• The number of complaints has increased from sixteen in September 2013 to twenty three in October 2013.

• One complaint was referred to the Ombudsman in October 2013. An investigation into this case is currently being undertaken by the Ombudsman.

• Four clinical claims were received in October 2013. Two of these claims relate to the same case.

• Fifteen mixed sex breaches have been reported within the Day Case Unit. • One Never Event was reported in October 2013. • A decrease in incidents being reported within seven days has been noted and

escalated to Service Units. • Seventeen SIRIs have been reported in October 2013. Of these eleven were

category three pressure ulcers. • There has been a significant increase in medication errors. This has been

escalated to the Service Units, particularly within Urgent Care. • The Friends and Family response rate is below the 20% target.

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3.0 SUMMARY OF QUALITY COMMITTEE BY QUALITY COMMITTEE CHAIR The Quality Committee received an excellent report on patient experience which illustrated innovative approaches to revising “customer service”. The revised Structure of Service Unit’s was communicated. A review of cancelled operations on day of surgery showed the impact of bed shortages due to pressures on admission from A & E. Updates were received on implementation of care bundles and Clinical Assessment Unit – both of which showed signs of early success. The Quality Committee recommended that the Terms of Reference reflected that the committee would become an executive committee with revised membership due to the number of subcommittees now reporting to the Quality Committee. 4.0 DASHBOARD KPI Sept 2013 Oct

2013 DoT Any exceptions to report?

Patient Experience % of complaints responded to within 10 days 100% 100% No

% of complaints responded to within 25 days 64% 72% No

Number of complaints received 16 23 Yes (4.1.1) Number of complaints referred to ombudsman 0 1 Yes

Number of complaints reopened 2 4 Yes Number of complaints where deadline has been extended 4 4 No

Number of clinical claims 0 4 Yes Number of non-clinical claims 0 0 No Number of mixed sex breaches 0 15 Yes (4.1.2) Patient Safety Number of incidents reported *The number of incidents is updated retrospectively.

454 505 No

Number of Never Events reported 0 1 Yes (4.2.1)

% of incidents received within 7 days (Tolerance level: 80%)

89% 71% Yes(4.2.2)

Number of SIRIs reported 19 17 Yes (4.2.3) Number of overdue SIRIs 0 0 No Number of patient falls 63 61 No Number of patient falls with severe harm or death 3 0 No

Number of category 3 pressure ulcers 11 11 No

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Number of category 4 pressure ulcers 0 0 No

Number of RIDDOR reportable incidents 1 0 No

Number of RIDDOR incidents reported outside of timeframe 0 0 No

Number of medication errors 24 40 Yes (4.2.4) Number of CAS alerts closed outside of timeframe 0 0 No

Health and safety audit compliance rate (Target: 75%)

N/A 74% N/A Yes (4.2.5)

Midwife to birth ratio 1:34 1:32 No

Number of Health Visitors 34.62 33.74 No

Clinical Effectiveness Number of audits not progressing 6 4 Yes (4.3.1)

Number of NICE TAGS not progressing 0 0 No

CQC conditions and/or warning notices 0 0 No

% compliance with WHO checklist (Target: 100%)

99.35% 99.45% Yes (4.3.2)

CQC Risk Band N/A 4 N/A Yes (4.3.3) Infection Control Clostridium difficile 0 1 Yes MRSA bacteraemia 0 0 No E Coli bacteraemia 1 1 Yes Hospital acquired bacteraemia 2 2 Yes MSSA bacteraemia 0 0 No CQUIN Friends & Family Response Rate (Inpatient) (Target: 20%)

26.2 26.9 No

Friends & Family Response Rate (A&E) (Target: 20%)

11.65 10.05 Yes (4.4.1)

Friends & Family Combined Response Rate (Target: 20%)

16.31 16.25 Yes (4.4.1)

Friends & Family Score 39.2 56.74 Yes Safety Thermometer Submission (Target: 100%) 100% 100% No

CQUIN (Provided a month in arrears)

KPI August 2013

Sept 2013 DoT Any exceptions

to report? Dementia Find (Target: 90%) 90.7% 92.5% No

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5.0 EXCEPTIONS 5.1 Patient Experience 5.1.1 Number of complaints received Issue: There has been an increase in the number of complaints received. In October 2013, twenty three complaints were received compared to sixteen received in September 2013. Action taken: Please see the Patient Experience Quarterly report for further information on the trends and themes identified in complaints and subsequent action taken. Outcome: Complaints will continue to be monitored on a monthly basis and escalated through Service Units to Service Unit Performance meetings and Quality Committee. In depth analysis into the trends and themes of complaints is also carried out on a quarterly basis and findings presented in the Quarterly Patient Experience Report.

Dementia Investigate (Target: 90%) 100% 100% No

Dementia Refer (Target: 90%) 100% 100% No

VTE Risk Assessment Completion (Target: 95%)

95.04% 95.20% No

PROMS (Provided a month in arrears)

KPI August 2013

Sept 2013 DoT Any exceptions

to report?

% of PROMS forms completed (Target: 80%) 94% 83%

No

Mortality

KPI July 2013 August 2013 DoT Any exceptions

to report? HSMR (National average: 100) 104.79 55.47 No

Upper confidence level 138.16 102.02 No Lower confidence level 77.77 26.56 No Crude death rate – acute 1.5% 1.5% No Crude death rate - community 2.1% 1.9% No

KPI Oct 2011 – Sept 2012

Jan 2012 – Dec 2012

DoT Any exceptions to report?

SHMI (published quarterly) (National average: 100) 111.92 111.67

No (The SHMI remains the same as the previous report).

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Quality Committee Recommendation: The Quality Committee encouraged the continuing monitoring of themes from complaints through the quarterly Patient Experience Report. 5.1.2 Number of mixed sex breaches Issue: There were 15 mixed sex breaches reported in October 2013. These were all within the Day Case Unit and related to the issues identified as part of the Rapid Response Review in October 2013. Action Taken: As reported previously;

• Immediate removal of trolleys 1-3 on male side to prevent patients looking into female side.

• Maximum of 12 inpatients on beds in Day Case Unit. In addition, no inpatients within the first three beds on male side.

• Complete risk assessment to include mixed sex issues, patient experience, infection control and patient flow.

• Identify and circulate patient pathways to and from Theatre to prevent passing through another sex area.

• To review use of day surgery recovery area (recliners) and how to maintain privacy & dignity.

• To review longer term flows and use of environment to meet day surgery activity. • A Standard Operating Procedure has been introduced in relation to the use of

Day Surgery and when it can be used for inpatients. Outcome: The Trust is now reporting all mixed sex breaches to Hereford Clinical Commissioning Group (CCG) on a weekly basis. Quality Committee Recommendation: The Director of Nursing and Quality informed the committee that the use of the Day Case Unit for inpatients has now reduced significantly. In addition, the committee were also informed that in addition to mixed sex accommodation breaches, bathroom breaches are also being reported. This is a requirement from the Care Quality Commission (CQC) but is not a requirement from the Department of Health (DoH). The Quality Committee noted the ambiguity in guidance in relation to mixed sex breaches and endorsed the reapplication of this guidance. The Quality Committee also endorsed and supported the openness and candour demonstrated by staff in reporting these breaches which were previously seen as non-reportable. 5.2 Patient Safety 5.2.1 Number of Never Events Reported Issue: One Never Event was reported in October 2013. Outcome: A root cause analysis investigation has been commenced and the outcome of this investigation will be reported to the Quality Committee on completion.

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Quality Committee Recommendation: The Quality Committee requested that the Clinical Director for Pharmacy attend the Quality Committee in December 2013 to present the findings of the root cause analysis in relation to this Never Event. It was also agreed that the Non Executive Director assigned to this Never Event be invited to attend the meeting. 5.2.2 % of incidents reported within 7 days Issue: The percentage of incidents reported within 7 days has decreased to below the 80% tolerance level. In October 2013, 71% of incidents were reported within timeframe. This equates to 147 incidents out of the 505 reported not being completed and sent to the Quality and Safety Department within 7 days. Action Taken: When reviewing the Service Unit breakdown it was evident that both Urgent Care and Elective Care were below the 80% tolerance level;

• Urgent Care – 63% • Elective Care – 69%

Service Units have been informed of their compliance rate and will be expected to provide an update on actions taken at the Service Unit Performance Meeting on 19th November 2013. Outcome: A verbal update on actions taken to improve the timeliness of reporting of incidents will be provided at the Quality Committee meeting on 21st November 2013. Quality Committee Recommendation: The Director of Nursing and Quality informed the committee that this issue had been raised at Service Unit Performance meeting on 19th November 2013. It was reinforced at the Service Unit Performance meeting that incidents must be reported and sent to the Quality and Safety Department within a timely manner. The Head of Quality and Safety also confirmed that Datix Web training will be fully implemented across the organisation by the end of December 2013. It is expected that this will see a significant improvement in reporting incidents in a timely manner.

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5.2.3 Number of SIRIs reported Issue: 17 SIRIs were reported in October 2013.

The chart above shows a decrease in the number of incidents reported when compared with September 2013. The number of SIRIs are however higher than for the same period for the past 2 years. A review of the types of SIRIs shows that the category 3 pressure ulcers remain the majority of SIRIs reported. 7 category 3 pressure ulcers were reported within Neighbourhood Teams and 4 category 3 pressure ulcers reported within the County Hospital. Types of SIRIs Reported in October 2013 Category 3 pressure damage 11 Fall resulting an injury 2 Health and safety 1 Never event - methotrexate 1 Screening issue 1 Sub optimal care of the deteriorating patient 1 Action Taken: All SIRIs are subject to an RCA investigation. RCA’s are ongoing for each of these SIRIs. Please see appendix 1 for further detail. The Director of Nursing and Quality is currently undertaking an audit of all nursing documentation. This will include tissue viability assessment tools. The SIRI incident relating to sub optimal care of the deteriorating patient is currently under investigation. In addition, an audit in relation to the use of National Early Warning Score (NEWS) across the organisation has commenced on 18th November. This is being led by the Clinical Effectiveness and Audit Department in conjunction with the Chair of the Resuscitation Committee and Resuscitation Officer. Outcome: SIRIs continue to be monitored on a monthly basis at Service Unit Performance meetings as well as Quality Committee. The Quarterly Patient Safety Report will provide additional in depth analysis into the themes and trends identified from SIRIs.

05

101520253035

Apr

il

May

June

July

Aug

ust

Sep

tem

ber

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

SIRIs Reported - Trustwide - 2011/12, 2012/13 and 2013/14 Comparison

2012/13 2013/14 2011/12

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Recommendations from Quality Committee: The Director of Nursing and Quality clarified the definition of the SIRI classified as ‘Sub optimal care of the deteriorating patient’ and confirmed that these incidents are now being escalated and reported as SIRIs. 5.2.4 Number of medication errors Issue: The number of medication errors has increased when compared to the previous report. The chart below shows that the number of medication errors for Urgent Care increased significantly when compared with previous months.

Action Taken: This information has been reported and highlighted at Service Unit meetings. Specifically, the Urgent Care Service Unit has been requested to provide details of actions taken at the Service Unit Performance meeting on 19th November 2013. From the Datix incident forms submitted there is no obvious trend or theme emerging. Outcome: A verbal update will be provided at the Quality Committee on 21st November 2013. Recommendations from Quality Committee: The Director of Nursing and Quality informed the Quality Committee that a comparison of medication errors had been carried out against a similar organisation. This comparison showed that Wye Valley NHS Trust is reporting much less medication errors than the other organisation.

0

5

10

15

20

25

30

35

40

45

50

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13

Number of Medication Errors by Service Unit - April 2013 to October 2013

UC & CCH EC IFH Other

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5.2.5 Health and safety audit compliance Issue: At present, the health and safety audit compliance rate is 74%. This is below the 75% target internally set by the Trust. Action taken: This is a new KPI introduced to the quality dashboard following an update on compliance with Health and Safety audits to Quality Committee in October 2013. This new measure is now reported to Service Unit Governance meetings on a monthly basis and exceptions are escalated and reported through Service Unit Performance meetings to the Quality Committee. Outcome: The compliance with health and safety audits will now be continually monitored on a monthly basis and any exceptions will be escalated through to the Quality Committee. Recommendations from Quality Committee: The Director of Service Delivery reported a much improved compliance across the Trust in relation to the completion of Health and Safety audits;

• Urgent Care – 96% • Elective Care – 92% • Integrated Family Health – 100%

5.3 Clinical Effectiveness 5.3.1 Number of audits not progressing Issue: 4 audits were reported as not progressing in October 2013. These were;

• 857 Audit of compliance of management of acute pancreatitis (Elective Care). • 791a Clostridium Difficile - audit following implementation of outbreak changes

(Urgent Care). • 431 National Lung Cancer Audit Data analysis (LUCADA) (Urgent Care). • 761 Audit of Neonatal jaundice, compliance with NICE Clinical Guideline 98

(Integrated Family Health). Action taken: It is important to note that these audits are not overdue but updates on the progress of these audits have not been provided to the Clinical Effectiveness and Audit team.

• 857 Audit of compliance of management of acute pancreatitis (Elective Care). o A report and action plan has been requested from the lead and still not

received. Medical Director will be asked to provide a verbal update at the Quality Committee.

• 791a Clostridium Difficile - audit following implementation of outbreak changes (Urgent Care).

o This was an audit that was chosen to be completed by the Service Unit. The lead has subsequently left the organisation and it would appear that this audit has been abandoned. This will be confirmed with the Service Unit.

• 431 National Lung Cancer Audit Data analysis (LUCADA) (Urgent Care). o The national requirements in relation to the collation data are being

complied with in relation to this audit. The outstanding issue relates to the

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lack of a summary and feedback internally. Medical Director has been asked to escalate this matter with the audit lead.

• 761 Audit of Neonatal jaundice, compliance with NICE Clinical Guideline 98 (Integrated Family Health).

o This was an audit that was chosen to be completed by the Service Unit. The lead has subsequently left the organisation and it would appear that this audit has been abandoned. This will be confirmed with the Service Unit.

Outcome: Following the Service Unit Performance meeting on 19th November 2013 a verbal update will be provided to Quality Committee. Clinical audits will also continue to be monitored through the Service Unit Performance meetings and newly established Clinical Effectiveness and Audit Committee. Recommendations from Quality Committee: The Medical Director provided a verbal update on the progress with clinical audits.

• 857 Audit of compliance of management of acute pancreatitis (Elective Care). o The Medical Director confirmed that this audit was now progressing.

• 791a Clostridium Difficile - audit following implementation of outbreak changes (Urgent Care).

o The Medical Director informed the committee that this audit is now progressing.

• 431 National Lung Cancer Audit Data analysis (LUCADA) (Urgent Care). o The Medical Director confirmed that this audit was now progressing.

• 761 Audit of Neonatal jaundice, compliance with NICE Clinical Guideline 98 (Integrated Family Health).

o It was confirmed that as this audit is a priority three and therefore not an essential audit for the Trusts it would be abandoned.

5.3.2 % of compliance with WHO checklist Issue: Compliance with the WHO checklist remains below 100% in October 2013. Non-compliance remains an issue in both the Integrated Family Health and Elective Care Service Units;

• 99.75% in Elective Care Service Unit. • 93.10% in Integrated Family Health Service Unit.

Action taken: Action taken as a result of non-compliance with the WHO checklist is listed below;

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Integrated Family Health Service Unit

Date

Exception Reason Action taken by Clinical

Effectiveness & Audit Dept

Actions Taken by Service Unit

01/10/2013 ‘Sign Out’ not

completed

Unknown Reported to Maxine Chong

as Helen Price on

Annual leave

Details of case being fedback to staff

08/10/2013 ‘Sign In’ and ‘Sign Out’

not completed

No indication on whether or not Ranitidine had

been given

All reported to Helen Price to take forward

Details of case being fedback to staff

08/10/2013 ‘Sign In’ not completed

Not known Details of case being fedback to staff

18/10/2013 ‘Sign In’ not completed

Post partum haemorrhage

following C.Section.

Checklist had been fully

performed for C.Section

Case investigated. Staff reminded of the importance of going through the safety checks for all operations, though accepted that this patient had recently been in theatre and this was an emergency situation

Elective Care Service Unit

Date Theatre Exception Reason Action taken by Clinical

Effectiveness & Audit

Department

Actions Taken by Service

Unit

01/10/2013 Theatre 2

‘Sign Out’ not

completed

Surgical Site infection prevention omitted on checklist

Reported to Andy Parker and Theatre Band 7s

Root cause analysis undertaken.

09/10/2013 Theatre 7

‘Time Out’ not

completed

Reason given as surgeon not participating

Reported to Simon Weaver routinely, but had already

been raised as incident within

Theatres

Root cause analysis undertaken.

29/10/2013 Theatre 6

‘Sign In’ not completed

Detail not known Reported to Andy Parker routinely, but had already

been raised as incident within

Theatres

Incident form being completed

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Outcome: Compliance with the WHO checklist continues to be closely monitored and individual cases of non-compliance are reviewed and followed up. Non-compliance with the WHO checklist will continue to be reported on a monthly basis through Service Unit Performance meetings and Quality Committee. Recommendations from Quality Committee: A significant improvement in the completion of WHO checklists was reported to the committee. The Quality Committee were advised that processes are now more robust and mini RCAs are completed for all areas of non-compliance. The Quality Committee commended the improvements that have been made and endorse the continuing efforts to improve compliance with the WHO checklist. 5.3.3 CQC Risk Band Issue: The CQC have now introduced risk banding for all NHS Trusts. The banding is from 1 to 6. 1 being the worst and 6 being the best. Wye Valley NHS Trust currently has a risk banding of 4. Within the report the CQC identify areas of risk and escalated risk which are then used to calculate a risk score the banding for the Trust. The following areas were highlighted in the October 2013 report; Elevated risks

• A&E waiting times more than 4 hours. • Safeguarding concerns.

Risk

• Never event incidence. • TDA – escalation score. • NHS staff survey – KF21, % reporting good communication between senior

management and staff. Action taken: It is unclear within the CQC guidance what data has been used to establish this risk rating. To this end, the Trust is currently liaising with the CQC to establish what data has been used to calculate the elevated risk in relation to ‘safeguarding concerns’. Outcome: The CQC risk banding will continue to be monitored on a monthly basis and key issues escalated to Quality Committee when required. Recommendations from Quality Committee: The Director of Nursing and Quality provided an update on safeguarding concerns. The CQC currently report on the number of safeguarding concerns per bed days and therefore the as the Trust is an integrated care organisation it is penalised when compared to organisations that do not provide community services.

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5.4 CQUINs 5.4.1 Friends and family response rate Issue: The target Friends and Family Test response rate has now been amended to 20% to reflect the CQUIN target.

Appendix 1 details the individual response rate for each area. However, it is important to note that the areas below did not achieve the expected 20%;

• Accident and Emergency • Frome AAU/SSU • Wye Ward

Action Taken: Please refer to the Patient Experience Quarterly Report for further details on the action taken. Outcome: Friends and family continues to be monitored on a monthly basis and results for ward areas are shared directly with Ward Sisters. Recommendations for Quality Committee: The committee were informed that from the Service Unit Performance meeting held on 19th November 2013 Service Units will now be held to account more their response rates and scores in relation to Friends and Family Test. In addition, the response rates and scores are raised at the Sisters Meeting and where appropriate poor results are challenged and good results celebrated. The initial response rates for A&E in November 2013 show an improvement. Volunteers are being used in A&E to promote the completion of Friends and Family Tests and on Teme Ward the use of Hospedia Televisions to complete the survey are being promoted. The Quality Committee endorsed continued efforts to improve the response rates in relation to the Friends and Family Test. 5.6 Additional Information 5.6.1 Mini Audit of SKINN Bundle Implementation Update: Neighbourhood Teams will now be undertaking a small simple audit in relation to implementation of the SKINN bundle. Action Taken: This audit will involve undertaking an audit of one set of patients’ notes each day for a six week period within each Neighbourhood Team. The following aspects will be included as part of this audit;

• Has the patient had a Waterlow Assessment on admission • Was this within 6 hours of admission to caseload • Has the ‘at risk’ patient (waterlow>15) been started on a care plan • Has the SKINN care bundle been utilised appropriately within the record with a

clear description of positional change • Is there evidence of monitoring and recording by care agency if involved • Has a full skin inspection been completed in line with community protocol

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Enclosure v

• Have all other assessments been completed in line with Pressure Ulcer prevention protocol

Outcome: The results of this audit will be shared with the Quality Committee in January 2014. Further recommendations from the Quality Committee: The Quality Committee agreed that an update on this audit be presented to the committee in January 2014. 5.6.2 Francis Inquiry Action Plan Update: In May 2013 the Trust created an action plan in response to the Francis Inquiry recommendations. The current status shows that of the 60 recommendations the Trust is;

• Compliant with 28. • Partially compliant with 24 • Non-compliant with 6.

Action Taken: There are currently five actions which are currently showing as overdue. Updates for these actions are currently being chased and a verbal update will be provided at the Quality Committee on 21st November 2013. Outcome: A further update on the implementation of the recommendations following the Francis Inquiry will be reported to the Quality Committee in February 2014. Further recommendations from the Quality Committee: At the time of the meeting only four actions were showing as overdue. The Medical Director provided an update in relation to the completion of death certificates by a senior fully qualified clinician. It was advised that this would be difficult to achieve and it is understood that this practice is not carried out at other Trusts. The Medical Director is to liaise with colleagues in other Trusts to establish whether this is being implemented elsewhere. 5.6.3 Air in Space Trial Update: Due to the company who produce the Innov8 units going into receivership, the infection prevention department have been exploring other options for air decontamination. Through this process a research protocol has been agreed to undertake a 5 month trial of the ‘Air in Space – Plasmair unit’. The Plasmair unit is a mobile, plug in air decontamination unit, effective on moulds, bacteria, viruses and spores. The unit sucks in, treats and diffuses air back into the room. The air is treated by passing the air through a 4 layer HEPA – MD reactor which has the combined effect of plasmerisation and electrically active plasmafiltration. The trial will be undertaken on Frome and Wye Ward and will be compared with the results of the non-treated areas of Lugg and Arrow. If a patient becomes infected or shows recognisable symptoms of Norovirus in a 4 bed ward they will be moved to a single isolation room within a maximum time of 1 hour (availability of isolation room permitting), a unit will be placed into the

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bay and 1 will also be placed into the single room. We have a 3rd unit which can be placed into a subsequent bay if affected. The unit will stay in the room until the infection incubation date range has passed (3 days) and no further cases materialise. Our target report will be based on numbers of Norovirus and C.diff cases over the test period. Depending in the starting date we will make an assessment of historical frequency at that time of year for norovirus and will set a review time when we should expect to see some variation against the untreated ward. At that time we can agree on a finish date to suit both the hospital and to ensure a data rich study which will have scientific validity. The units have been reviewed and accepted by the Trusts Health & Safety Officer, we are finalising arrangements currently with Sodexo, in order for the SSA team, to be used for the movement of the units. Full training will be provided and the company with retain all liability for the units during the trial. http://www.airinspace.com/en Recommendations from Quality Committee: The committee noted the trial and highlighted the need to define in advance what success of this pilot would look like. It was agreed that a further updated in relation to this trial be provided in February 2014.

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http://www.airinspace.com/en

Enclosure v

Appendix 1 – Friends & Family Test The Friends and Family CQUIN for 2013/14 has been amended to take into account response rates. The requirement is to achieve a combined response rate from inpatient and A&E department of 15% and for this to rise to 20% by the end of the financial year. The question has change to ‘How likely are you to recommend our ward/A&E department to your friends and family if they need similar care of treatment?’ Patients are required to answer;

• Extremely likely (+1) • Likely (0) • Neither likely nor unlikely (-1) • Unlikely (-1) • Extremely unlikely (-1) • Don’t know (-1)

Calculation:

- The way in which the patients are asked to complete the test has also changed. The patient can no longer be asked by staff in their care setting. The patients are now asked to complete an electronic discharge survey on their bedside televisions or via a comment card. All wards are continuing to receive their results on a monthly basis and action plans completed as a result of any deficiencies identified.

Friends & Family Scores by Ward By Month

X (No Scores Recorded) DoT Direction of travel

0 - 70 ↑ Positive direction of travel 70 - 80 ↓ Negative direction of travel >80 → No change

County Hospital Site Apr

-13 May-13

Jun-13

Jul-13

Aug-13

Sep-13

Oct-13

DOT Sept

to Oct 2013

A&E 11 35 26 26 34 15 33 ↑

Frome AAU-SSU 72 65 80 22 18 75 44 ↓

Lugg 28 52 74 55 50 33 56 ↑

Wye 72 75 76 48 25 27 60 ↑

Extremely likely responses Neither likely nor unlikely, unlikely and extremely unlikely

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Leadon 62 75 36 52 75 45 64 ↑

Redbrook 83 38 75 67 48 50 71 ↑ Arrow 83 70 69 74 79 39 73 ↑

Monnow 73 65 76 80 86 72 82 ↑

Teme 98 76 87 85 75 79 85 ↑

Women’s Health 78 76 88 73 89 75 91 ↑

Children’s 84 0 56 46 85 75 92 ↑ CCU 100 100 92 90 95 96 93 ↓

Maternity 66 53 37 39 51 n/a n/a

< 15% response rate 15-20% response

rate >20% response rate

Friends & Family Response Rate by Ward By Month

County Hospital Site Apr-13 May-

13 Jun-13

Jul-13

Aug-13

Sep-13 Oct-13

DOT Sept

to Oct 2013

A&E 13.1% 18.2% 15.8% 22.0% 18.4% 11.7% 10.5% ↓ Wye 38.7% 20.3% 49.2% 16.4% 5.8% 20.6% 13.5% ↓

Frome AAU-SSU 13.3% 11.6% 23.2% 12.6% 8.0% 13.0% 15.9% ↑

Children’s 21.4% 4.6% 9.4% 34.8% 16.5% 44.5% 24.2% ↓ Women’s

Health 28.1% 41.4% 59.7% 58.7% 40.3% 41.8% 32.4% ↓ Arrow 33.3% 31.9% 37.2% 26.1% 12.8% 35.9% 34.3% ↓

Redbrook 24.5% 22.4% 23.5% 12.6% 24.3% 35.3% 37.8% ↑

Lugg 30.0% 24.7% 43.9% 29.3% 12.9% 37.9% 37.9%

no chang

e Monnow 55.9% 55.2% 42.9% 37.1% 33.0% 32.9% 38.6% ↓

Leadon 25.6% 15.3% 15.7% 28.4% 14.8% 19.0% 38.8% ↑ Teme 60.0% 28.8% 61.6% 70.2% 66.7% 58.0% 49.5% ↓

CCU 36.4% 45.8% 57.1% 72.4% 44.9% 61.5% 72.7% ↑

Maternity 24.9% 16.4% 28.5% 24.7% 42.9% n/a n/a

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Ward

Response %

FFT Score

October

36 weeks 23.8% 54.1 Labour 73.7% 58.4 Post natal 50.3% 61.0 Home Birth 9.1% 100.0 Comm Midwife 9.4% 100.0 Total 37.8% 61.4

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Appendix 2 – CQUIN Dashboard

CQUIN Title Apr-13

May-13

Jun-13 Jul-13 Aug

-13 Sep-13 Oct-13

Friends and Family Test - Phased expansion

Complete

Friends and Family Test - Increased response rate

23% 22%

32% 26% 18

% 16% 16%

NHS Safety Thermometer - Data Collection

100%

100%

100% 100% 100

% 100% 100%

Dementia - Find, 93% 91%

93% 92% 91

% 93%

Reported a month in arrears

Dementia Assess 100%

100%

100% 100% 100

% 100%


Dementia Refer 100%

100%

100% 100% 100

% 100%


VTE Risk Assessment

95.1%

95.02%

95.50% 95.20% 95.0

4% 95.20%


VTE Root Cause Analysis 100%

Reported a month in arrears.

Neighbourhood/Community Teams - Personalised Care Plans

Draft care plans

submitted to CQRF

Baseline audit completed and

reported to CQRF.

Neighbourhood/Community Teams - Place of death preference

Baseline audit

submitted to CQRF

Baseline audit completed and

reported to CQRF.

Neighbourhood/Community Teams - Community delivery of IV antibiotics

Draft policy

submitted to CQRF

Implementation phase

completed and reported to

CQRF. Neighbourhood/Community Teams - Primary care survey

Primary care

survey completed.

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Enclosure vi WYE VALLEY NHS TRUST TRUST BOARD MEETING IN PUBLIC 28 November 2013 NEIL DOVERTY – CHIEF OPERATING OFFICER [email protected] OPERATIONAL PERFORMANCE 1.0 INTRODUCTION 1.1 This report highlights areas of good service performance and improvement during the month and indicates development priorities currently being taken forward. A short summarised glossary of key performance indicators / threshold criteria is included for the first time to inform Board members. 2.0 RECOMMENDATION 2.1 That the Board receives and notes the contents of the detailed operational performance report attached. 3.0 KEY ISSUES WITHIN REPORT 3.1 The agreed elective orthopaedic activity recovery is behind plan and the factors affecting this have continued over the last few weeks. The Trust is working very closely with our PFI Hospital service provider partners to address the non-availability of two operating theatres and daily updates are in place. During the period of non-availability some surgical activity is being re-allocated to other theatres and some cases can be diverted as day case surgery, but the top priority remains to bring back on line all our theatre capacity. The Trust is committed to working with the CCG on the developing of an activity management reduction plan for outpatient activity, which remains buoyant. 3.2 During September 2013 the Trust sustained a prolonged surge in emergency flow demand and this in turn necessitated the late cancellation of planned surgery for some of our patients. As a consequence, this then placed additional burdens on the Trust to attempt to quickly re-schedule patients during October and regrettably, we were unable to achieve this for 11 of our patients. 3.3 The Trust achieved the Emergency Department (ED) 4hr access target during the month despite experiencing several days of very high emergency flow demand. This success is attributed to the introduction of the 7-day 8am-8pm Extended Physician of the Day rota, the commencement of the new Virtual Ward service and the new mini-Clinical Assessment Unit in the ED. A comprehensive programme of service improvement initiatives designed to improve flow and throughput across the whole bed base is now in place and being developed by the Urgent Care Service Delivery Unit team. 3.4 The Trust met the national performance targets for RTT admitted patients during the month, but for a small number of patients in a few specialties they waited longer than expected due to the capacity shortfalls linked to more urgent clinical emergencies. Elective Care Service Delivery Unit is conducting a series of specialty level “deep dive” reviews to analyse demand and resolve capacity requirements. 3.5 The Trust maintained performance recovery on the 6/52 national access target for diagnostics, with just 6 people waiting longer than expected. This is a significant achievement in terms of the 1000s of referrals taken by medical imaging services.

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Operational Performance Report to 31st October (M7) 2013/14

Exception Report to the Board

Additional Information: The following schedules are held on file in the Information Department and available to all Board Members on request:

• Full suite of KPIs• Activity levels by specialty• Referral to Treatment performance by specialty• Stroke Vital Signs report• Going further on Cancer Waits report• Non PAS Operational Performance Report• Urgent care daily predictor

47 of 112

2

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A&E Attendances increased slightly compared to September and were on plan in the month (+8, 0.2%). Year to date performance is now above plan by0.7% (214 actual).

Emergency Activity remains slightly below plan in month, and also down year to date by 9 discharges (-0.5%) and 507 (-4.4%) respectively.

Daycase & Elective Activity overall was 68 cases above plan in the month. Daycase activity was 71 cases above plan but remains down on plan year todate by 125 (-1.4%), a continuing recovery compared to position last month. Elective inpatients was 3 cases below plan in the month and is alsodown year to date (158 actual, -5.4%). Specialties showing increased activity compared to previous month were Urology, Ophthalmology, PlasticSurgery and Haematology. The T&O Recovery Plan October position was 62 cases down; reasons for which include the Theatre laminar flowventilation issue, one Consultant sickness absence, and one Registrar compassionate leave. The mix of these separate issues meant significantamendments to operating lists and some sessions being lost to ensure adequate cover for Trauma lists

Outpatient Activity was up on plan for follow up in the month (+7%) and remains above plan year to date (9%). New activity was down on plan in monthbut remains above plan YTD (-3.6% and +3.4% resp)

Activity Urgent Care CancerPerformance

0

2000

4000

6000

8000

10000

12000

14000

16000

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

Follow Up Outpatient Attendances

Actual Plan

0

50

100

150

200

250

300

350

400

450

500


Elective

Actual Plan

0

200

400

600

800

1000

1200

1400

1600


Daycase

Actual Plan

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000


Accident & Emergency

Actual Plan

0

200

400

600

800

1000

1200

1400

1600

1800


Emergency

Actual Plan

0

1000

2000

3000

4000

5000

6000

7000


New Outpatient Attendances

Actual Plan

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The NHS Constitution – Summarised Glossary

There are a number of government pledges on waiting times, including access targets for the main acute services Wye Valley NHS Trust provides. The detail ofthese pledges is contained in the NHS Constitution Handbook. There are access targets for the following services:-

Cancer Treatment AccessNon Cancer Treatment AccessA&E AccessDiagnostic Test AccessCancelled Operations

Cancer Treatment Access Targets• a maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers;• a maximum 31-day wait for subsequent treatment where the treatment is surgery;• a maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy;• a maximum 31-day wait for subsequent treatment where the treatment is an anti-cancer drug regimen;• a maximum two month (62-day) wait from urgent referral for suspected cancer to first treatment for all cancers;• a maximum 62-day wait from referral from an NHS cancer screening service to first definitive treatment for cancer;• a maximum 62-day wait for first definitive treatment following a consultant’s decision to upgrade the priority of the patient (all cancers);a maximum two-week wait to see a specialist for all patients referred for investigation of breast symptoms, even if cancer is not initially suspected;

Non Cancer Treatment Access• start your consultant led treatment within a maximum of 18 weeks from referral for non-urgent conditions

A&E Access• a maximum four-hour wait in A&E from arrival to admission, transfer or discharge

Diagnostic Test Access• patients waiting for a diagnostic test should have been waiting less than 6 weeks from referral

Cancelled Operations• all patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered anotherbinding date within 28 days,or the patient’s treatment to be funded at the time and hospital of the patient’s choice

All of the above targets have non delivery fines attached to them which commissioners can levy through the NHS Standard Contract. Clinicalexceptions and exclusion rules also apply.

http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/handbook-to-the-nhs-constitution.pdf49 of 112

http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/handbook-to-the-nhs-constitution.pdf

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Cancelled OperationsThere were seven last minute hospital non-clinical cancellationsof elective surgery in October: two due to bed shortages; one tolack of theatre time/list overrun; one due to emergency ortrauma taking precedence and three to equipmentfailure/unavailability. There were 11 failures of the 28-dayrebooking target, which would be largely attributable to the 37last-minute cancellations reported in September. This meansthe indicator 2 figure (last-minute cancellations ÷ 28-daybreaches) is unusually high.

A total of 37 theatre slots were lost through on-daycancellations: seven hospital non-clinical; 17 clinical; and 13patient DNAs. External capacity continues to be utilised tomitigate risk of breaching both the 28 day target and the RTT 18week target further.

18 weeksAlthough the Trust Total performance for Admitted Pathwaysachieved the 90% target for October ENT, Plastic Surgery andOphthalmology failed. Cancellations and capacity shortfallscontributed to this, and although ACAPs are being used tomaintain the 18 week RTT target, not all specialties are able toutilise them during times of bed pressures due to increased non-elective flow into the bed base.

DiagnosticsThere were one adult and four paediatric Audiology patientswaiting over six weeks in October, but the overall total remainsabove the 99% threshold. These breaches were all capacitybreaches.


Threshold Apr May Jun Jul Aug Sep Oct YTD

Indicator 1 - last minute cancellations 0.8% 0.87% 0.35% 0.86% 1.02% 0.97% 2.10% 0.34% 0.92%

Indicator 2 - breach 28 day rebooking 5% 38.5% 0.0% 0.0% 0.0% 17.6% 2.7% 157.1% 17.5%

Av patients per session 4.5 3.5 3.8 3.8 3.8 3.8 3.5 3.9 3.8

% Utilisation 90% 89.3% 91.5% 91.3% 91.7% 92.6% 87.9% 92.0% 91.0%

Admitted % <18 wks 90% 97.4% 96.4% 94.9% 94.6% 96.3% 94.5% 92.1%

Admitted 95th centile (Wks) 23 17.6 17.5 18.0 18.2 17.8 18.0 TBC

Non Admitted % <18 wks 95% 99.8% 99.6% 99.7% 99.8% 99.8% 99.6% 99.8%

Non Admitted 95th centile (Wks) 18.3 12.0 13.5 13.5 13.4 13.5 14.1 TBC

Incomplete % <18 wks 92% 97.8% 97.9% 99.1% 98.3% 96.1% 98.1% TBC

Incomplete 95th centile (Wks) 28 15.8 15.5 14.5 14.0 16.5 15.2 TBC

Adult Audiology (over 6 weeks) 0 1 4 3 16 0 2 1

Paediatric Audiology (over 6 weeks) 0 0 5 1 0 0 1 4

Other (over 6 weeks) 0 0 35 69 0 0 0 1

Cancelled Operations

Theatres

Referral to Treatment

Diagnostics

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As referenced in the Finance report, the Trust has spent a considerable amount of money on ACAPs and the Private Sector. Both spend categories willexceed the expenditure budgets for these two areas. The table shows the amount that has been spent in each category by specialty, and the RTTperformance is also shown. It is clear that without the additional expenditure our RTT performance year to date would not have been maintained.

To date the Trust has sent 175 patients to the private sector and is planning to continue to use this capacity during the remaining months of the year.


Service Unit

SpecialtyAnnual budget

£000

In month Oct

£000

YTD Apr - Oct £000

Forecast year end

spend £000

Annual budget

£000

In month Oct

£000

YTD Apr - Oct £000

Forecast year end

spend £000

Apr May Jun Jul Aug Sep Oct Apr May Jun Jul Aug Sep Oct

MS - Radiology 72 20 146 166 0 0 0 0

MS - Clinical Haem 6 0 31 57 0 0 0 0 n/a 100% 100% - 100% - 100% n/a 100% 100% 100% 100% 100% 100%

MS - Cardiology 30 1 30 50 0 0 0 0 100% 100% 94.4% 100% 100% 100% 100% 100% 100% 98.7% 100% 100% 100% 100%

MS - Respiratory 36 4 22 40 0 0 0 0 100% 100% - 100% 100% - 100% 100% 100% 100% 100% 100% 100% 100%

MS - Nephrology 3 0 6 12 0 0 0 0 100% 100%

MS - Gastroenterology 48 2 10 30 0 0 0 0 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

MS - Histopathology 44 3 6 25 0 0 0 0

MS - Neurology 30 1 7 20 0 0 0 0 - 100% - 100% - - - 97.9% 100% 100% 100% 100% 100% 100%

MS - Clinical Neurophysiology 0 3 2 1 0 0 0 0

MS - Diabetes 0 1 1 7 0 0 0 0

269 34 262 408 0 0 0 0

MS - Anaesthetics 3 21 72 162 0 0 0 0

Theatre Suite 46 30 93 169 0 0 0 0

MS - Urology 120 13 64 100 0 5 41 45 99.1% 97.9% 96.3% 97.8% 96.0% 97.7% 90.7% 100.0% 100.0% 95.0% 96.6% 100% 100% 100%

MS - Gen Surg 70 87 208 309 34 25 54 72 92.7% 91.7% 90.2% 97.9% 95.2% 86.7% 96.3% 100% 100% 100% 100% 100% 95.3% 100%

MS - Orthopaedics 30 30 72 184 186 28 322 490 92.7% 90.9% 90.6% 92.0% 94.3% 89.2% 92.9% 100% 97.9% 98.6% 100.0% 95.3% 97.1% 98.6%

MS - Ear/Nose/Throat 5 5 30 44 0 4 9 13 100% 98.1% 98.5% 91.9% 91.4% 92.1% 86.8% 100% 98.6% 99.2% 100% 100% 100% 100%

MS - Dermatology 14 9 43 60 0 0 0 0 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99.1% 98.9%

MS - Plastic 0 2 2 12 0 0 0 0 75.7% 100%

MS - Oral & Orthodontics 30 3 36 59 0 0 0 0 n/a 97.6% 93.8% 85.5% 89.0% 91.7% 91.8% n/a 98.9% 100% 100% 100% 95.7% 100%

MS - Opthalmology 0 2 2 4 0 0 0 22 98.3% 94.8% 98.8% 97.9% 98.6% 96.4% 89.2% 99.5% 99.3% 100% 99.5% 100.0% 99.4% 100%

318 200 621 1,102 220 63 426 642

93 5 21 42 0 0 13 0 100% 100% 97% 100% 100% 98.7% 96.3% 100% 99% 100% 100% 100% 100% 100%

93 5 21 42 0 0 13 0TOTAL 680 239 903 1,553 220 63 439 642

IFH

S

MS - Obs & Gynae

ACAPs

CC

TH &

UC

Ele

ctiv

e

PRIVATE SECTOR Admitted Non Admitted

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6

Heat Map• Daily reporting incorporates a Heat Map which aggregates 6 key

indicators to measure the stress in the urgent care system againstset thresholds.

• October had six days where the system was operating within itscapacity (green), all in the latter part of the month. A total of 12days were significantly stressed (red) and 13 were at above-capacity amber level, compared to six days at amber and 23 atred in September.

• The majority of red days (75%) were in weeks ending 13th and20th October, which were amongst the highest levels of A&Eattendances in the month.

Acute

Variation Analysis• The number of patients with a length of stay over 30 days continued

at low levels during the first two weeks of October but haveincreased since then. A reduction can be seen into earlyNovember.

• A strong focus remains on discharge as this continues to hamperpatient flow and the knock on effect on A&E performance andoccupancy levels. Although occupancy averaged 93% in the month,no additional unfunded beds were opened during the whole ofOctober.

• A&E attendances reduced again in the month from a high in Julybut the average per day remained high at 137 compared to 125daily capacity, with with 23 days in the month having >125attendances. The number of daily attendances ranged from 112 to178.


0

10

20

30

40

50

60

70

80

-60%

-40%

-20%

0%

20%

40%

60%

19

Sep

21

Sep

23

Sep

25

Sep

27

Sep

29

Sep

01

Oct

03

Oct

05

Oct

07

Oct

09

Oct

11

Oct

13

Oct

15

Oct

17

Oct

19

Oct

21

Oct

23

Oct

25

Oct

27

Oct

29

Oct

31

Oct

Nu

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pat

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No

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te (s

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+/-

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Comparison of A&E Attendance, Emergency Adult G&A Admissions & Bed Occupancy variance (left hand axis) against Planned Capacity & Long-Stay Patients (right hand axis)

No of 30 day+ Pts Community No of 30 day+ Pts Acute Bed Occ cf 95% Target A&E Att cf 125 Capacity Emer Adm cf 40 Target No 30 days+ Pts Target

Mon Tue Wed Thu Fri Sat Sun23-Sep 24-Sep 25-Sep 26-Sep 27-Sep 28-Sep 29-Sep

30-Sep 01-Oct 02-Oct 03-Oct 04-Oct 05-Oct 06-Oct

07-Oct 08-Oct 09-Oct 10-Oct 11-Oct 12-Oct 13-Oct



28-Oct 29-Oct 30-Oct 31-Oct 01-Nov 02-Nov 03-Nov

Heat Map - October 2013

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7

• A&E attendances increased during October, though not tothe level of July/August. Daily attendances peaked at178, with 23 of the 31 days having more than the 125.

• Overall WVT performance reached 95.04% for 4-hourbreaches against target of 95%, despite having some verychallenging days in terms of pressures in the A&Edepartment

• The 95th percentile from arrival to admission decreasedcompared to September (now 7 hours 54 mins), as did thesingle longest time from arrival to admission (14 hours 53mins). These figures are closer to the average ytd.Median time from arrival to discharge dropped slightly to 1hour 40 minutes as did median time to admission, now 3hours 47 minutes.

• 95th percentile for arrival to discharge improved in themonth and below threshold.

• Ambulance turnaround compliance decreased slightly inmonth – this was due to the pressures in A&E and theinability to off-load patients in a safe and timely manner.

• Extended physician of the day was implemented on AAUand this has appears to have made a difference to thepatient flow and earlier discharges from AAU.

• The CAU is still on track aiming for late November, thiswill see an improvement in our overall performance


Target Apr May Jun Jul Aug Sep Oct

<5% 4.9% 4.6% 4.5% 5.6% 4.9% 4.3% 4.8%

4 hour target 95% 88.7% 95.7% 95.4% 93.3% 94.5% 83.5% 95.0%

Median time arrival to admission 03:56 03:40 03:35 03:51 03:44 04:55 03:47

Median time arrival to discharge 01:42 01:35 01:36 01:43 01:43 01:48 01:40

95th %ile time arrival to admission

<4 hours 11:55 07:15 08:01 08:52 07:46 12:48 07:54

95th %ile time arrival to discharge

<4 hours 04:41 03:52 03:54 03:57 03:58 05:10 03:56

Single longest time arrival to admission

<6 hours 19:49 15:12 16:09 15:27 15:09 19:42 16:29

Single longest time arrival to discharge

<6 hours 19:08 15:35 16:45 11:24 13:32 16:10 14:53

< 15 minutes

01:13 00:47 00:55 00:56 00:47 01:05 00:52

< 60 minutes

01:11 01:04 01:07 01:18 01:12 01:24 01:10

<5% 4.7% 2.9% 3.9% 4.3% 4.0% 4.3% 3.4%

Total time spent in A&E

Indicator

Unplanned re-attendances within 7 days

Time to treatment (median time)

Left without being seen

Time to initial assessment (95th percentile)

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8

The Finance report identifies a number of investments that are being made by the Trust in order to improve performanceand flow within the Urgent Care Pathway. The 3 main schemes are captured below with their expected benefit and methodof measuring change and success. The change will be monitored in the standard suite of performance reports that theTrust produces either on a daily or monthly basis.


Scheme Expected Benefit Measurement

Virtual Ward Risk Stratification - Reduced Admissions Early Supported Discharge – Reduced LOS Reduced medical outliers

Change in emergency admissions (City Practices Only) Change in LOS (City Practices Only) Change in volume of outliers

Clinical Assessment Unit Reduction in A&E Attendances Improved A&E 4 Hour Performance Shorter LOS for target cohort of patients

Volume based change Change in 4 Hour Performance % delivery LOS analysis from standard stay & short stay to zero LOS

Acute Physicians & Physician of the Day

Reduced medical outliers Reduction in number of patients with a LOS greater than 30 days Improved daily balance between admissions and discharges

Change in volume of outliers Change in volume of patients whose stay is greater than 30 days Change in daily bed state / reduced number of days in bed deficit

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9

• September 2013 position now afinal validated position withreporting a month in arrears toalign with national reporting.

• Breast symptomaticperformance has again fallenbelow threshold in the monthwith all breaches being patientchoice/cancellation. Discussionshave taken place with lead GPsand this issue will again beraised trough GP Parliament.

• Cancer 62 days remains belowthreshold in month and year todate. As with previous monthsbreaches span multiple cancersites with no specific theme.

• Actions are ongoing. Furtherawareness will be made withGPs, particularly around patientchoice. A survey will take placeover a 3 / 4 week period to betterunderstand patients reasons fordeclining appointments andwhether weekend / eveningclinics would be more suitable.


Indicator Standard Apr May Jun Jul Aug Sep Apr to Sep

Cancer Two Week Waits 93% (National Target) 96.1% 97.3% 95.0% 95.3% 93.4% 93.3% 95.0%

Two Week Waits (Breast Symptomatic)

93% (National Target) 86.3% 87.5% 87.0% 94.0% 89.1% 83.9% 87.8%

Cancer 31 Days 96% (National Target) 100% 100% 100% 100% 100% 100% 100%

Cancer 31 Days Subsequent Treatments

94 - 98% (National Target)

96.7% 100% 100% 100% 100% 100% TBC

Cancer 62 Days 85% (National Target) 83.3% 80.2% 87.2% 77.4% 82.0% 80.5% 82.0%

Cancer 62 Days Screening 90% (National Target) 80.0% 100% 100% 100% 100% 75.0% 93.2%

Cancer 62 Days Upgrades (no National Target set)

85% (no National Target set)

100% 100%No

patients in month

100%No

patients in month

100% 100%

Cancer 62 Days Rare cancers (31 Days)

85%No

patients in month

100%No

patients in month

100% 100%No

patients in month

TBC

Validated Position

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Enclosure vii

WYE VALLEY NHS TRUST PUBLIC BOARD MEETING 28th November 2013 AUTHOR : Howard Oddy, Director of Finance and Information Financial Performance Report to 31st October 2013 1.0 INTRODUCTION 1.1 The Financial Performance Report for the period to the end of October 2013 is attached. 2.0 RECOMMENDATION 2.1 The Board is asked to note the financial position at the end of the seventh month of the year and the actions that have been taken, and need to be delivered, in order to achieve the required year end outturn. 3.0 MAIN BODY OF REPORT 3.1 The attached report includes details of the financial performance during the first seven months of the year. 4.0 POLICY AND BUSINESS PLAN CONSIDERATIONS 4.1 The financial position is reported in the context of the agreed financial and business plan. 5.0 RISK ASSESSMENT 5.1 The attached report includes details of risks inherent in the financial position.

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Wye Valley NHS Trust Enclosure vii

Financial Performance Report to 31st October 2013 (M7 2013/14)

Contents Page 1 Statement of Comprehensive Income

& Expenditure 1

2 Income & Expenditure Outturn 3

3 Performance and variation to Business Plan

6

4 Income performance 7

5 Performance against Cost Budgets 10

6 Directorate Performance 12

7 CIP 13

8 Cashflow 15

9 Debtors & Creditor Performance 16

10 Capital 17

11 Balance Sheet 18

12 Risks and Opportunities 19

Headlines

Annual Budget Y.T.D. Budget Y.T.D. ActualCumulative

VarianceIn Month

Movement

Income 175.5 103.3 95.9 (7.4) (1.5)

Pay 102.5 58.6 61.3 (2.7) (0.8)

Non Pay 72.5 42.7 40.8 1.9 1.2

Surplus/(Deficit) 0.6 2.0 (6.1) (8.1) (1.1)

Month 7 2013/14 Trading Position - £m

• The year to date deficit increased to £6.1m (as a result of an in month deficit of £0.4m).

• The £0.4m in month deficit was also £0.4m more than the forecast position (£0.2m less income and £0.2m more cost)

• The Trust was £8.1m behind plan at the month end, £5.6m of which

related to the assumption regarding the receipt of external support. It has now been confirmed that this support will not be forthcoming this year.

• Under a medium case forecast, the Trust is forecasting a year end

deficit of £9.1m. This net value assumes £1.6m of mitigation is secured against the underlying medium case forecast of £10.7m

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Section 1 – Statement of Comprehensive Income & Expenditure The financial position is being monitored closely against the forecast (see section 2). Large variances have arisen against the original Business Plan (shown left) including non-receipt of external support, termination of the s75 contract and the virtual ward development. One sixth of the compensation following the PFI dispute settlement has been built-into the position (thus reducing non pay costs).

STATEMENT OF COMPREHENSIVE INCOME - To Month 7 - 31st October 2013 - 2013/14

MOVEMENTANNUAL IN

CURRENTBUDGET BUDGET ACTUAL VARIANCE MONTH

£000 £000 £000 £000 £000

Contract & PbR Income 139,619 82,290 80,731 (1,559) (113)Non Contracted Activity (NCA's) 1,553 896 921 25 41Other Income for Patient Care 19,972 11,670 11,095 (575) (776)Donations For Non Current Assets 20 12 0 (12) (2)Anticipated Support 9,700 5,658 0 (5,658) (808)Other Non Patient Income 4,649 2,809 3,188 379 179

Total Operating Income 175,513 103,335 95,935 (7,400) (1,479)

Pay Expenditure 102,453 58,603 61,262 64% (2,660) (799) Non Pay Expenditure 63,834 37,734 35,964 37% 1,770 1,119

Total Operating Expenditure 166,287 96,337 97,227 (890) 321

EBITDA 9,227 6,998 (1,292) (8,290) (1,159)

Depreciation 3,765 2,141 2,053 2% 88 15 Gain or loss on asset disposal 0 0 0 0% 0 0 Interest Receivable 21 12 17 0% 4 (0) Interest Payable on Loans 108 63 58 0% 6 1 Interest Payable on PFI 4,752 2,727 2,698 3% 29 (6) Dividends on PDC 64 27 0 0% 27 5

Operating Surplus/ (Deficit) 558 2,052 (6,084) 6% (8,136) (1,143)

YEAR TO DATE

% o

f In

co

me

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Section 2 – Income & Expenditure Outturn Forecast The Trust has assessed its medium case forecast outturn position to be a deficit of £10.7m, unless there are positive outcomes from three key mitigation actions. It should be noted that the Trust has submitted a return to the TDA showing a forecast of £9.1m deficit (i.e. the control total without financial support), though this depends on progress against the mitigation items below which will be assessed during the month 8 accounting process. The current mitigation items, which will have to be realised in order to bring the outturn back in line with the financial control total, are:

• Negotiating with the CCG regarding the appropriate use of the emergency threshold monies, required by the Trust to fund urgent care pathway investments (£1.1m)

• A further reduction (above the 20% reduction in the current forecast) in the use of agency nursing staff, particularly in escalation areas (£0.25m)

• A reduction in the shortfall against the elective care recovery plan (£0.25m). In relation to the first of the actions listed above, it should be noted that, in order to manage and maintain the urgent care pathway patient flow, the Trust has invested c.£1.1m in the current financial year which will clearly impact on the ability to meet financial obligations, if there is no external funding to support it. However, in addition to this, the Trust has also made additional prioritised investments following the recent Rapid Responsive Review. The actual in-month position is monitored closely against the previous forecast trajectory. In the table below, it can be seen that income was £0.2m lower than previously forecast for the month, and pay costs were £0.2m higher. The reduced income was primarily caused by the loss of high value elective case mix and the pay position was a combination of increased nursing costs and a redundancy payment made in month.

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M1 M2 M3 M4 M5

Prior month

forecast (M6) M6

Prior month

forecast (M7) M7

Prior month

forecast (M8) M8

Prior month

forecast (M9) M9

Prior month

forecast (M10) M10

Prior month

forecast (M11) M11

Prior month

forecast (M12) M12

Prior month

forecast (Outturn)

Current Medium

Case Outturn Forecast

Mitigation Plan (see

report narrative)

Outturn Including

Mitigation Items to

be acheived

Income 13.3 14.0 13.5 14.4 13.7 13.1 13.4 13.8 13.7 13.5 13.3 12.8 12.7 13.0 13.0 13.0 12.9 13.4 13.2 161.5 161.1 1.4 162.5 165.9Financial Support 0.8 0.8 0.8 (2.4) 0.0 0.0 0.0 0.0 9.7

14.1 14.8 14.3 12.0 13.7 13.1 13.4 13.8 13.7 13.5 13.3 12.8 12.7 13.0 13.0 13.0 12.9 13.4 13.2 161.5 161.1 1.4 162.5 175.6

Pay 8.6 8.6 8.6 8.7 8.6 8.6 8.8 8.6 9.2 8.9 9.1 8.9 9.1 9.1 9.2 9.1 9.3 9.2 9.3 105.4 107.0 (0.2) 106.8 102.5Non Pay 6.3 6.2 5.9 6.2 6.1 5.8 5.4 4.8 4.9 4.8 4.8 4.8 4.8 4.8 4.8 4.8 4.8 4.7 4.7 65.1 64.8 64.8 72.5Total Cost 14.9 14.8 14.4 14.9 14.7 14.4 14.2 13.4 14.1 13.7 13.9 13.7 13.9 13.9 14.0 13.9 14.1 13.9 14.0 170.6 171.8 (0.2) 171.6 175.0

Surplus/(Deficit) (0.8) (0.0) (0.1) (2.8) (1.0) (1.3) (0.8) 0.4 (0.4) (0.2) (0.6) (0.9) (1.2) (0.9) (1.0) (0.9) (1.1) (0.5) (0.8) (9.1) (10.7) 1.6 (9.1) 0.6

6 Months Actual Ledger

Combined with Current Base Case Forecast 1.6 (9.1)

Business Plan

(10.7)

Actual

(6.1)

Forecast

The table above illustrates the forecast position and the positive impact assumed from mitigating actions that improve the present position by £1.6m. The medium case outturn forecast of £9.1m deficit comprises the following: • Successful mitigating actions leading to additional income of £1.35m and reduced cost of £0.25m. • The gross outturn position, prior to the mitigating action, assumes that the Trust delivers 300 orthopaedic procedures less than the annual

plan (it currently stands at 370 less than plan). This has resulted in a £800k reduction in the overall income forecast for the Trust when compared with forecast produced at month 6.

• Delivery of increased elective activity against identified and agreed ACAP cost rates and a specific level of private sector usage. • £1.1m additional costs incurred in relation to the urgent care patient pathway (increasing to £2.6m full year effect in 14/15). • A 20% reduction in the cost of staffing extra capacity during the last four months of the year (£186k). • CCG pay all contractual over performance (currently assessed at £2.2m) and all fine monies are reinvested, without any increase in costs. • CQUINs targets are all delivered and income secured. • Full use of all the financial benefit from the fire dispute. • Redundancy costs limited to a total of £170k for the year. In addition to the medium case outturn scenario, two other outturn scenarios have been considered. These variations are shown in the following table.

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Although it is highly improbable that all variables will occur simultaneously under either the best case or worst case scenarios, the table illustrates a range of outturn scenarios from a best case deficit of £7.8m to a worst case deficit of £15.2m. It should be stressed that these outturn forecasts are prior to the impact of any further investment resulting from the recent Rapid Responsive Review.

Sensitivity RangeBest Case

Medium Case

Worst Case

Medium Case Outturn (above) (10.7) (10.7) (10.7)

Key Variables

1.1 1.1 0.00.3 0.3 0.00.2 0.2 0.0

(0.6)(0.3)

0.5 (1.0)

(1.8)

0.4 (0.2)

0.4 (0.1)

(0.2)(0.1)

0.0 0.0 (0.2)

Deficit Range (7.8) (9.1) (15.2)

Income activity risk

Mitigation PlanAppropriate application of Threshold funding by CCGImproved T&O Elective throughputReduction in Temporary Staffing Expenditure

Emergency Flow - Risk of fines and opportunity of threshold funding.Restricted payment on contract over-performance

Higher Risk items on CIP for future delivery (GP Bed Fund & Medicines Management)Total Redundancy costs (beyond £165k)Various invoice disputes with Council

Outlying beds - Medium case assumes 20% drop in funding in the last four months of the year (Worst Case no reduction & Best Case 50% reduction)

Elective Flow - Risk relating to Recovery Plan delivery (both delivery of elective activity and risk of Winter pressures restricting bed availability). Also, opportunity of full delivery of Recovery Plan (with increased internal delivery).

Contractual - potential for Activity Management impact, partial CQUIN failure 10% and continuation of low birth numbers).

Technical - partially completed Spells and financial provision reviews

Cost Risk

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Section 3] - Performance & variation against Business Plan

Given the significant changes which have occurred since the agreement of the Business Plan and given the Board decision that the opening budget would remain fixed throughout the year, the adjoining table has been produced to illustrate performance and variation against the Business Plan. Items in blue show changes both to the income and cost sides which are largely neutral in year and for which the plan requires updating when next reviewed. Items in green show income received above that originally planned, or the cost base has been non-recurrently reduced in year. Items in red show reduced income and increased cost above levels originally anticipated and targeted. The combined impact of the items in Green and Red represent the underlying drivers for the variance against the financial business plan. The CIP box serves to explain the treatment of items which in part relate to the CIP included within the original Business Plan.

2013-14 Forecast Outturn against Business Plan 2013-14

£mIncome Plan 175.6

Over performance on CIP Delivery 0.8 *S.75 Part Year only (5.7)No external financial support (9.7)Virtual Wards (excl overhead in CIP) 0.8Excluded Drugs increase 0.9Increase on Education Contracts 0.9Orthopaedic Under recovery (assuming Recovery Plan delivers) (1.2)General Surgery under-recovery of income (0.4)Emergency, critical care, Community elements below plan (1.8)Service Level Income 0.6Other 0.3Outturn 161.1

Cost Plan 175.0

Saving of Cost of redundancy (2.6) ** * CIP (** gain taken to CIP in part)

CIP recurrent cost out 4.1 *Fire Dispute (net I&E gain) (2.5) ** Income Cost Fire Dispute Redundancy

S.75 Part Year only (5.7) Plan 0.8 8.0 0.0 0.0

Accounting gains (0.5) Forecast 1.6 3.9 0.5 0.9

Virtual Wards (excl overhead in CIP) 0.8 Variance 0.8 (4.1) 0.5 0.9

Excluded Drugs increase 0.9Increase on Education Contracts 0.8Hoople - (Non Pay to Pay Change in year) 0.0 netNet Cost overspends (above underspends) incl. Nurse Agency, Clerical & non ACAP Medical Staffing Payments

0.4

Urgent Care Pathway Investment 1.1Outturn 171.8

Total Total Planned Surplus 0.6Variation (0.6)Medium Case Outturn Forecast prior to Mitigation (10.7)Mitigation Plan 1.6Outturn (9.1)

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Section 4 – Income Performance

INCOME - BY PATIENT CLASS

ANNUAL

MOVEMENT IN CURRENT

MONTHFORECAST OUT TURN

FORECAST OUT TURN

BUDGET BUDGET ACTUAL VAR. % VAR. VAR.

£ 000's £ 000's £ 000's £ 000's Var £ 000's £ 000's £ 000's

Contract Income

Daycase 11,935 7,191 6,701 (490) -6.81% 37 (401) 11,535

Elective 12,963 7,757 6,725 (1,032) -13.31% (100) (1,410) 11,554

Emergency 32,237 18,934 18,588 (346) -1.83% (55) (503) 31,733

Outpatients 23,752 14,060 14,702 642 4.56% 272 933 24,685

Accident & Emergency 5,262 3,147 3,008 (138) -4.40% (149) (201) 5,061

Critical Care 3,748 2,186 1,968 (219) -10.00% 45 (318) 3,430

Pathology 2,720 1,587 1,637 51 3.20% 6 74 2,794

Diagnostics 2,423 1,414 1,479 65 4.61% 20 95 2,518

PbR Excluded Drugs 6,462 3,769 4,110 341 9.04% 90 584 7,046

Other Variable & Blocked 6,117 3,568 3,075 (494) -13.83% (377) (718) 5,399

Community Contract 32,026 18,682 18,556 (126) -0.67% (38) (183) 31,843

Any Qualified Provider 1,409 822 822 0 0.00% 0 0 1,409

In Year Adjustments 0 0 0 0 0.00% 0 0 0

Contract Variations 118 69 281 212 308.10% 176 1,100 1,218

Non Contract Income

Inter Trust SLAs - Cross Charges 5,820 3,395 3,610 215 6.33% 11 368 6,188

Central Funds 3,757 2,212 2,767 556 25.12% 79 920 4,677

Business Unit Service Income 4,649 2,809 3,188 379 13.50% 179 599 5,248

Strategic Change Reserve 9,700 5,658 0 (5,658) -100.00% (808) (9,700) 0

Donations For Non Current Assets 20 12 0 (12) -100.00% (2) (20) 0

Adult Social Care S75/Learning Disabilities 10,395 6,064 4,718 (1,346) -22.19% (866) (5,677) 4,718

Total Operating Income 175,513 103,335 95,935 (7,400) -7.16% (1,479) (14,457) 161,056

INCOME

YEAR TO DATE

MONTH 7 TO 31ST OCTOBER 2013/14

The above table reports the income position at month 7 and shows that the Trust was £7.4m behind plan. This has deteriorated by £1.5m in the month. The accrual for external financial support continues to be removed from the income statement, as does the adjustment for the cessation of the s75 agreement. These two variances account for £1.3m of the adverse movement in month. The orthopaedic recovery plan has not been delivered in month leading to a further deterioration in elective income.

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Day case and elective activity were above plan for the month but remained below plan for the year to date. However, in month, income generated was below plan, primarily because of case mix (day case -6.8% and elective -13.3%) and the shortfall in orthopaedics. The orthopaedic recovery plan now assumes 3191 cases will be performed compared with 3491 included within the business plan and this includes some further usage of the private sector. This level of activity has been assumed in the medium case outturn scenario. As the forecast outturn at month 6 assumed a shortfall of 125 cases against the original plan, the additional shortfall of 175 cases has reduced the outturn income forecast by a further £800k from the figure quoted last month. Further mitigating actions are being explored in order to reduce this gap. Emergency activity increased in month but remained below plan for the year to date. As the average unit price for emergency activity was 4.0% higher than the budgeted unit price, income was only 1.8% below plan. New outpatient activity was below plan in October but follow up activity was above plan. Cumulatively, outpatients remained above the plan to date in both activity and income. Overall GP referrals continued to rise. The CCG has levied fines totalling £101k in respect of the first quarter of the year (£71k relating to ambulance turnaround times). Further to discussions with the CCG, it has been assumed, within the financial position, that such fines will be reinvested in the Trust without any additional cost being incurred. However, there has already been one exception following the decision to appoint a fixed term Urgent Care Transformation post with fines monies. PbR excluded drug income increased in month and was above plan year to date. This has a matching cost pressure. CQUIN income has been assumed to deliver 100% in the current financial year. Contract Over-Performance - the Trust is expecting full payment for activity undertaken, and full payment of contract over-performance, with the CCG. The CCG has indicated that it can currently afford c£2.1m over-performance, which compares with our current estimate of £2.2m as a result of the reduction in orthopaedic activity. If the Trust manages to recover its orthopaedic performance, the difference between our positions will increase. Income of £0.9m (relating to the virtual ward investment) and £0.1m (relating to the Lucentis development) has been included in the forecast outturn as contract variations. The forecast income outturn has been adjusted to reflect the termination of the s75 agreement as well as the exclusion of financial support.

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Operational & Patient Flow Changes In Year – Measuring Success As outlined within this report, the Trust has committed additional monies on staffing in order to improve urgent flow and limiting the adverse impact of medical outliers in areas designated for planned work. Whilst the reporting of expenditure on these additional posts is largely about pay costs, the expected benefit from a patient flow perspective is more complex in terms of measurement. Further detail on the method of measurement and the expected benefit is contained within the Operational Performance Report.

Commissioner Contract Update The finance and activity schedules with all English commissioners have been agreed and the majority of contracts signed. Efforts have continued to be made to sign off the remaining contracts with English commissioners during November, however this is a commissioner led process and a number remain outstanding. In relation to Welsh commissioners, the final version of the contract has now been received from Powys and signing is considered to be imminent.

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Section 5 – Performance against Cost Budgets

The most significant cost event in month has been a step increase in the cost of nursing (significantly beyond that expected from the establishment of virtual wards, the additional Health Visitors and the transfer of Occupational Health back onto the Trust payroll). Outside the above developments, there has been an increase of £190k in month to the nursing pay bill. Whilst the in-month cost of staffing outlying areas reduced, temporary staffing costs significantly increased across both acute and community wards. There was also an increase in substantive staff across acute wards and theatres. The latter would have been expected to reduce temporary staffing costs in month, although this has not yet occurred. Other factors in-month driving the variance against the original cost plan included the termination of s75 contract, the repatriation of

functions from Hoople, the impact of the virtual ward and additional health visitors. These have corresponding offsets in either income or non pay. In addition, the PFI costs have reduced against plan, as a result of the dispute settlement.

COST POSITION BY CATEGORY - To Month 7 - 31st October 2013 - 2013/14

MOVEMENTANNUAL IN

CURRENTBUDGET ACTUAL VARIANCE BUDGET BUDGET ACTUAL VARIANCE MONTH

WTE WTE WTE £000 £000 £000 £000 £000Pay

43 40 3 Directors & Sen. Managers =>Band 8 3,483 2,077 2,170 (93) (43)311 299 12 Medical & Dental 30,181 17,618 18,225 (607) (164)

1219 1304 (85) Nurses & Midwives 42,192 24,226 25,654 (1,428) (359)237 225 12 AHPs 8,830 5,162 5,045 117 3015 15 (1) Pharmacists 792 462 510 (48) (18)

156 150 6 Professional, Technical, Scientific 5,501 3,188 3,187 2 2359 53 6 Managers/Technical >Band 5 2,410 1,288 1,229 59 (22)

345 410 (65) Clerical <=Band 5 8,044 4,793 5,200 (407) (111)0 0 0 Other Pay 0 0 0 0 00 0 0 Redundancy Pay 2,012 109 42 67 00 0 0 Remaining Pay CIP (992) (321) 0 (321) (134)0 0 0 Shared Services 0 0 0 0 0

2,385 2,496 (111) 102,453 58,603 61,262 (2,660) (799)Non Pay

Drugs 11,693 6,878 7,172 (294) (145)Med & Surg Supplies 9,827 5,621 5,691 (71) 2Implants & Accessories 2,347 1,368 1,437 (69) (53)Other Clinical Supplies 2,124 1,201 1,164 37 7Clinical Services contracts 2,804 1,657 1,737 (80) 13PFI Contract 8,172 5,342 4,783 559 397Transport & Travel 2,203 1,285 1,333 (48) 7Establishment expenses 3,767 2,140 2,119 20 16I.T. 914 534 485 49 2Trust Overheads (inc. Insurance) 3,588 2,092 2,016 76 4Other Non Pay 4,998 2,947 2,898 49 (66)Depreciation Recharge 0 0 0 0 0Shared Services 2,033 1,206 1,097 110 56ASC Council Recharge 9,364 5,462 4,032 1,430 881

63,834 37,734 35,964 1,770 1,119

Depreciation 3,765 2,141 2,053 88 15(Gain) or loss on asset disposal 0 0 0 0 0Interest Received 21 12 17 4 (0)Interest Payable on Loans 108 63 58 6 1Interest Payable on PFI 4,752 2,727 2,698 29 (6)Dividends Payable 64 27 0 27 5Sub Total 8,668 4,946 4,792 154 16

2,385 2,496 (111) GRAND Total Expenditure 174,955 101,282 102,019 (736) 337

YEAR TO DATEHEADING

MANPOWER POSITION

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The table to the left shows the year to date cost of ACAPs and the use of the private sector. In total, additional capacity costs for senior medical staff are as follows: Year to Date ACAP payments to substantive consultants £0.9m Non ACAP payments to substantive consultants £0.8m Sub contracted to private sector £0.4m Forecast ACAP payments to substantive consultants £1.6m Non ACAP payments to substantive consultants £1.4m Sub contracted to Private Sector £0.6m

Service Unit SpecialtyAnnual budget

£000

In month Oct

£000

YTD Apr - Oct £000

Forecast year end

spend £000

Annual budget

£000

In month Oct

£000

YTD Apr - Oct £000

Forecast year end

spend £000

MS - Radiology 72 20 146 166 0 0 0 0

MS - Clinical Haem 6 0 31 57 0 0 0 0

MS - Cardiology 30 1 30 50 0 0 0 0

MS - Respiratory 36 4 22 40 0 0 0 0

MS - Nephrology 3 0 6 12 0 0 0 0

MS - Gastroenterology 48 2 10 30 0 0 0 0

MS - Histopathology 44 3 6 25 0 0 0 0

MS - Neurology 30 1 7 20 0 0 0 0

MS - Clinical Neurophysiology 0 3 2 1 0 0 0 0

MS - Diabetes 0 1 1 7 0 0 0 0269 34 262 408 0 0 0 0

MS - Anaesthetics 3 21 72 162 0 0 0 0

Theatre Suite 46 30 93 169 0 0 0 0

MS - Urology 120 13 64 100 0 5 41 45

MS - Gen Surg 70 87 208 309 34 25 54 72

MS - Orthopaedics 30 30 72 184 186 28 322 490

MS - Ear/Nose/Throat 5 5 30 44 0 4 9 13

MS - Dermatology 14 9 43 60 0 0 0 0

MS - Plastic 0 2 2 12 0 0 0 0

MS - Oral & Orthodontics 30 3 36 59 0 0 0 0

MS - Opthalmology 0 2 2 4 0 0 0 22318 200 621 1,102 220 63 426 642

IFH

S

MS - Obs & Gynae 93 5 21 42 0 0 13 093 5 21 42 0 0 13 0

TOTAL 680 239 903 1,553 220 63 439 642

ACAPs PRIVATE SECTOR

CCTH

& U

CEl

ecti

ve

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Section 6 – Directorate Performance The key variances at Service Unit level were as follows: Elective Care – the Service Unit position showed a £1.6m under recovery of income against a £1.2m over spent cost base Integrated Family Health Services – income was under recovered, and pay costs increased in month significantly beyond the variance expected as a result of the increase in health visitors.

Urgent Care / Care Closer to Home – income over-recovered against plan by £0.9m (partly as a consequence of the emergency threshold payment mechanism) and contributed to partly offset the year to date cost over spend of £1.2m. The presently unfunded investment in this patient pathway will substantially accelerate this adverse cost variance over future months. The positive financial impact from the PFI dispute settlement, will be expected to result in a matching underspend within the Commercial Unit by year end.

DIRECTORATE POSITIONS - To Month 7 - 31st October 2013 - 2013/14

ANNUAL MOVEMENTINCOME IN& COST CURRENT

BUDGET ACTUAL VAR. BUDGETS BUDGET ACTUAL VARIANCE MONTH PAY NON PAY INCOME

WTE WTE WTE £000 £000 £000 £000 £000 £000 £000 £000

Front Line Directorates 732 754 (22) Elective Care 11,143 7,211 4,397 (2,814) (755) (944) (271) (1,599)

396 406 (10) Integrated Family Health Services 7,638 4,446 3,732 (715) (119) (378) (32) (304)

1,073 1,112 (38) Care Closer to Home & Urgent Care 10,119 6,431 6,189 (242) 188 (867) (328) 953

0 0 0 Adult Social Care 0 0 180 180 149 0 1,430 (1,250)

0 0 0 Remaining CIP 1,032 336 0 (336) (139) (336) 0 0

2,202 2,272 (70) 29,932 18,424 14,498 (3,926) (676) (2,525) 799 (2,200)

Support Directorates98 98 (0) Resources 3,761 2,110 2,058 52 (10) 93 (102) 6115 14 1 Chief Executive 4,215 2,508 2,488 20 (1) (39) 59 011 25 (14) Commercial Unit 18,079 11,033 10,617 416 320 (235) 590 613 4 (1) Medical Director (153) (126) (299) 173 28 (35) 27 181

-1 0 (1) Corporate Overhead 8,511 3,745 3,097 648 36 196 416 3651 50 1 Director of Nursing 2,043 1,187 966 221 10 89 7 12538 34 4 HR Directorate 1,076 503 558 (54) (4) (65) 14 (3)

-32 0 (32) Shared Services 1,562 1,081 1,096 (15) (13) (138) 110 14

183 224 (42) Total Support Directorates 39,094 22,042 20,581 1,460 365 (135) 1,120 475

Income not devolved 9,720 5,670 (5,670) (832)9,720 5,670 0 (5,670) (832)

2,385 2,496 (111) Total Operating Surplus/ (Deficit) 558 2,052 (6,084) (8,136) (1,143)

Total Contribution to Overheads (exc. income not devolved, below)

(YEAR TO DATE)VARIANCE DETAIL

MANPOWER POSITION YEAR TO DATE

DIRECTORATES

68 of 112


Section 7 – CIP The following table shows CIP performance by scheme as at month 7, together with the movement in the month. It shows that the programme has delivered £3,689k of savings in the first seven months and that there are firm plans to deliver £6.9m by year end. Of this sum, £5.2m is recurrent.

@ Month

Programme Stream Exec Lead Delivery Leads Ori

gina

l Tar

get &

Bu

dget

Cum

ulat

ive

Del

iver

y

Var

ianc

e To

Dat

e

Perf

orm

ance

aga

inst

O

rigin

al P

lan

Out

turn

For

ecas

t

Var

ianc

e fr

om P

lan

Var

ianc

e m

ovem

ent

in

mon

th

Non

recu

rren

t val

ues

with

in O

uttu

rn

Fore

cast

Prog

ram

me

Leve

l Q

IA P

rogr

ess

A Planned Care Nei l Doverty TBA 1,500 358 (525) 26% 392 (1,108) 0B Urgent Care Nei l Doverty V Alner/J Reynolds 1,000 113 (412) 33% 329 (672) 57C Estate Rationalisation Howard Oddy C Homers ley 82 104 68 218% 179 97 0 97D Admin & Clerical Nei l Doverty V Lewis 287 61 (70) 94% 270 (17) (0)E Procurement Howard Oddy J Wren/S Pahal 1,000 628 52 118% 1,178 178 (4)F Hoople Ken Hutchinson J Wren 187 62 (47) 32% 60 (127) 0G Best Practice Tariff Howard Oddy S Powel l 250 146 (0) 100% 250 (0) 0H Additional Powys Income Howard Oddy S Powel l 100 58 (0) 100% 100 (0) 0I Community Health Service Contract Howard Oddy S Powel l 500 292 0 100% 500 0 0J Workforce Efficiencies Ken Hutchinson M Turp 766 388 (42) 91% 699 (67) 0 43K Pathology Modernisation Nei l Doverty M Bolton 150 43 (0) 147% 221 71 0L PFI Savings Howard Oddy C Homers ley 500 250 170 100% 500 0 0 500M Corrective Actions on Loss Makers Howard Oddy Service Unit

'521 160 3 59% 306 (215) (13)

N Corrective Actions on Non contracted Howard Oddy Service Unit M ' t

780 84 (218) 26% 201 (579) (3)O FYE of 12/13 savings 289 169 0 100% 289 0 0P Redundancy Provision Slippage Ken Hutchinson 888 518 0 100% 888 0 0 888Q Additional Schemes 0 256 256 540 540 (20) 163 TBA

8,800 3,689 (766) 6,901 (1,899) 17 1,691

Recurrent savings 5,210

Actual Performance7

Version control 8-10-13 - 08.40

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This graph illustrates the profile of the CIP plan by month. The two separate scales indicate cumulative and monthly values. It can be seen that the actual savings delivered in the month were £173k less than the plan. This reflects a continuation of slippage in both the elective care and urgent care CIPs. Cumulatively, the programme was £766k below plan. This slippage was identified early in the year and replacement schemes have been put in place wherever possible. It should be noted that the recovery of elective income is directly related to £1.5m of the

CIP plan, as this scheme relates to the maximisation of in- house delivery and a significant reduction in the values of private sector and ACAP costs. Delivery against this CIP line is low as the Trust is currently reliant upon paying ACAP and private sector premium rates in order to deliver activity. The only way this CIP line can be delivered in the future is through improved maximisation of throughput during substantive core hours.

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Plan - Cumulative 460 920 1,389 2,010 2,776 3,591 4,454 5,318 6,183 7,047 7,922 8,800

Actual - Cumulative 413 945 1,481 1,982 2,447 2,997 3,688

Plan - In Month 460 460 470 620 766 815 864 864 865 865 875 878

Actual - In Month 413 532 536 501 465 550 691

Forecast - Cumulative 413 945 1,481 1,982 2,447 2,997 3,689 4,259 4,926 5,612 6,259 6,901

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

250

350

450

550

650

750

850

In M

onth

£00

0's

Cum

ulat

ive

£000

's

2013/14 CIP Phasing Profile

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Section 8 – Cashflow

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Total PlanActual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Year Year£000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

ReceiptsNHS Contract Income 13,476 17,804 6,171 11,459 11,862 11,729 15,620 12,462 12,462 13,526 12,462 12,462 151,495 151,666NHS Contract Performance 0 0 0 1 0 0 0 0 0 0 0 0 1NHS Adult Social Care 0 0 0 0 4,284 0 0 0 0 0 0 0 4,284 10,395Non NHS Receipts 153 240 96 139 130 139 137 160 160 200 160 160 1,874 2,051MacMillan MRU Contract 0 0 0 0 0 0 0 0 0 0 0 0 0Loans - Temporary 0 0 0 0 0 0 0 0 0 0 0 0 0Loans - Permanent 0 0 0 0 0 0 0 0 555 1,110 0 230 1,895 0Loans - Commissioner Advance 0 0 0 3,000 (1,500) (1,500) 3,000 (1,500) (1,500) 3,000 (1,500) (1,500) 0Loans - New Capital Advance 0 0 0 0 0 0 0 0 0 0 0 0 0 307Loans - Salix 0 0 0 0 0 0 0 0 0 0 0 0 0Interest Received 3 3 3 2 2 3 2 2 2 2 2 2 26 22Charitable Funds 10 28 14 89 23 27 26 38 15 8 32 19 328 288Sale Of Assets 0 0 0 0 0 0 0 0 0 0 0 0 0VAT Recoverable 179 610 228 543 934 159 200 1,078 186 186 1,078 186 5,567 6,637Other - Financial Support 0 0 0 2,300 0 0 3,000 0 4,400 0 0 0 9,700 9,707Total Receipts 13,821 18,685 6,512 17,533 15,735 10,556 21,985 12,240 16,280 18,032 12,234 11,559 175,171 181,073PaymentsSalaries & Wages (4,992) (4,874) (4,897) (4,955) (4,883) (4,991) (4,984) (4,996) (4,996) (4,996) (4,996) (4,996) (59,556) (59,615)Tax & NI (1,950) (2,051) (1,975) (1,959) (1,995) (1,862) (1,962) (2,060) (2,060) (2,060) (2,060) (2,060) (24,056) (24,601)Pension Contributions. (1,259) (1,338) (1,336) (1,344) (1,344) (1,417) (1,359) (1,344) (1,344) (1,344) (1,344) (1,344) (16,115) (15,400)Accounts Payable (4,656) (4,133) (3,904) (3,488) (3,442) (3,696) (3,990) (4,054) (3,370) (5,382) (4,127) (3,887) (48,129) (40,834)Atkins Energy (215) (120) (120) (120) (108) (108) (108) (108) (108) (96) (96) (96) (1,403) (1,320)CNST (256) (256) (256) (256) (256) (256) (256) (256) (256) (257) 0 0 (2,562) (2,561)Business Rates (63) (63) (63) (63) (85) (85) (86) (85) (85) (85) 0 0 (764) (650)Adult Social Care (784) 0 0 0 (964) 0 (2,494) (1,059) 0 0 0 0 (5,301) (10,664)Hoople - Shared Services (175) (175) 0 (329) 0 (336) (203) (94) (94) (94) (94) 0 (1,594) (1,868)Originating Debt Repayment 0 0 0 0 (48) (225) 0 0 (103) 0 (283) 0 (659) (669)Loan Interest 0 0 0 0 0 (47) 0 0 0 0 (33) 0 (80) (70)PDC Dividends 0 0 0 0 0 62 0 0 0 0 (32) 0 30 (64)Charitable Funds (28) (14) (89) (23) (27) (26) (18) (15) (8) (32) 0 (18) (297) (228)Other / Injury Benefit (0) 0 (1) (0) (10) (1) (0) 0 0 0 0 0 (13) 0PFI Related Payments (2,365) 0 (2,798) (4,175) 0 0 (5,167) 0 0 (5,351) 0 0 (19,856) (24,283)Capital Items (41) (25) (20) (15) (211) (5) (152) (200) (740) (880) (480) (475) (3,244) (1,809)MRU Speller Metcalfe 0 0 0 0 0 0 0 0 0 0 0 0 0 (65)Total Payments (16,783) (13,050) (15,458) (16,728) (13,374) (12,994) (20,778) (14,271) (13,164) (20,577) (13,545) (12,876) (183,598) (184,701)

Net Cash Inflow/(Outflow) (2,962) 5,635 (8,946) 805 2,361 (2,437) 1,207 (2,031) 3,115 (2,545) (1,311) (1,318) (8,427) (3,628)Balance B/fwd 9,428 6,466 12,101 3,155 3,959 6,320 3,883 5,090 3,059 6,175 3,629 2,318 9,428 9,428Balance C/fwd 6,466 12,101 3,155 3,959 6,320 3,883 5,090 3,059 6,175 3,629 2,318 1,000 1,000 5,800

The cash position of the Trust is entirely dependent on the receipt of £9.7m of cash support, which has been, and will continue to be, forthcoming. The cash flow position has been updated to reflect month 7 receipts and payments and the cash flow assumptions for future months have also been reviewed. NHS contract income has been phased to reflect an agreement with NHS Herefordshire to advance income on a quarterly basis repayable over the following 2 months. Receipts and payments relating to Adult Social Care have been amended to reflect the cessation of the Section 75 contract in September. Payments relating to salaries and wages, tax and NI and pensions contributions have been reviewed to reflect the transfer of staff from Hoople to WVT. PFI payments have been amended to reflect the settlement in relation to the fire dispute. The £9.7m cash support is still forecast to be received in three tranches aligned to points where the cash flow comes under specific pressure due to the quarterly PFI payment.

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Section 9 – Debtor & Creditor Performance SECTION 1 - BETTER PAYMENT PRACTICE CODE

NHS Non-NHS NHS YTDNon-NHS

YTD NHS Non-NHS

Number of Invoices paid in Period 72 3,850 584 29,396 907 33,357% of Invoices paid within target 36.1% 57.5% 64.7% 78.9% 70.8% 76.5%

Value of Invoices paid in period (£000s) 396 12,048 2,773 48,214 10,827 62,090% of value paid within target 76.3% 89.0% 86.9% 86.8% 77.2% 88.0%

SECTION 2 - NUMBER OF CREDITOR PAYMENT RUNS

In Full Reduced DelayedApril 4 4 0 0May 5 3 1 1June 4 4 0 0July 4 1 2 1August 5 0 4 1September 4 1 2 1October 4 3 1 0November 5December 4January 5February 4March 4

SECTION 3 - OUTSTANDING DEBTS

Host Comm-issioner

Other NHS

Welsh bodies Non-NHS

Private Patients Total

£000s £000s £000s £000s £000s £000s £000s

Current 43 687 164 137 19 1,050 5,9131 Month 1,417 712 229 531 2 2,892 1,1462 Months 492 303 299 32 2 1,128 532Over 3 Months 91 289 425 387 8 1,200 1,139Unallocated Credits (7) (146) (89) (2) (0) (244) (242)Total Value Outstanding 2,036 1,845 1,028 1,087 31 6,026 8,488Last Month 84 6,411 979 996 18 8,488

Debt outstanding as at end of the Month

Previous Month

Age of Debt

2012/13

Planned Runs

Actual RunsMonth

The performance of the Trust in paying its creditors in line with the requirements of the better payment practice code has been hampered in year by the pressures on cash flow felt by the Trust. This has necessitated reducing some weekly payment runs in order to maintain a positive cash flow. However, the reduction in payment performance in October was mainly due to resourcing issues within the Creditors Section, which have been addressed following the relocation of the team to the County Hospital. During the month, three payment runs were paid in full. The other run was reduced. This was due to cash availability issues. Payment runs are reduced or delayed in circumstances where the cash flow forecast indicates a potential deficit arising from completing a full payment run. In circumstances where payments are limited, the most longstanding creditors held are paid first. The total value of outstanding debtors as measured by invoices raised has reduced by £2.46m from month 6. This decrease was primarily due to invoices being paid by NHS England to the value of £3.65m

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Section 10 – Capital

As agreed in Trust's

business plan

Revised Budget

Revised Budget

subject to Board

approval

YTD exp. including Creditors Variance

Forecast Outturn

£000s £000s £000s £000s £000s £000s

Estates SchemesEndoscopy Endoscopy/DSU Development 227.0 248.0 248.0 (0.9) (248.9) 248.0Impr birth en Improving Birthing Environments 307.0 307.0 307.0 (307.0) 307.0Works Project Management 80.0 60.0 60.0 (7.0) (67.0) 60.0Works Minor Building Schemes 250.0 250.0 250.0 164.8 (85.2) 250.0Distress Vanguard Unit Enabling Works 80.0Distress CAU Works (cost subject to review) 600.0 502.0 (502.0) 502.0Distress Accident and Emergency 200.0 200.0Works Referral Management System 20.0 25.0 1.4 (23.6) 25.0Works Health Records Urgent Works 20.0 25.0 4.2 (20.8) 25.0

Clinical EquipmentEqupt Radiology - PFI end of Contract 175.0 175.0 176.0 167.1 (8.9) 176.0Equpt Autoclaves 80.0 80.0 80.0 (80.0) 80.0Equpt Endoscopy Washers 100.0 79.0 79.0 (79.0) 79.0Equpt Anaesthetic Room Monitors x 2 10.1 10.0 (10.0) 10.0Equpt Replacement Equipment 75.4 210.3 140.4 71.5 (68.9) 140.4Distress CAU Equipment 93.0 123.0 99.8 (23.2) 123.0Distress Other Equipment 178.0 (178.0) 178.0

IT Programme Group (Incl PAS/RIS)Distress Maternity System 150.0 400.0 188.0 (0.7) (188.7) 188.0IT IT Infrastructure 150.0 150.0 150.0 70.2 (79.8) 150.0Distress Mobile Working 275.0 199.0 18.7 (180.3) 199.0IT Service Line Management 30.0 30.0Distress Other 62.0 62.0Distress Pseudonomisation 50.0 50.0 (50.0) 50.0Distress IT Project Management 75.0 75.0 (75.0) 75.0IT Medical Engineering System 25.0 (25.0) 25.0

Total 1,594.4 3,182.4 3,182.4 589.1 (2,301.3) 3,182.4

Year End Creditors CfwdMRI Replacement (5.2) (5.2)Beds 1st floor build (20.8) (20.8)MRU Cancer Unit (39.0) (39.0)

Total 524.1 (2,366.3)

As at 31 October 2013

Scheme Description

The plan for the allocation of capital resources totals £3.182m for 2013/14. A further revision to the capital programme has been proposed following changes to the Clinical Assessment Unit (CAU) project and the outcome of the tender exercise in relation to the Maternity information system. A revised CAU programme has been identified which is reduced in scope and involves the purchase of a temporary building for the CAU and a reduction in other works originally planned within the hospital. The project to implement a new Maternity system has identified a preferred solution requiring a lower capital investment. The chosen system offers the best value for money of the systems reviewed as well as being the best system in terms of specification. Actual expenditure for the period to date is recorded against each scheme. Although actual recorded expenditure appears to be very low at this stage, reassurance has been received from each project lead that all of these schemes will be completed in the second half of the year. Resources relating to replacement equipment have been allocated to specific items of equipment approved by the Capital Planning and Equipment Committee.

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Section 11 – Balance Sheet

Closing Balance 31 Mar 2013

Month 731 Oct 2013

Fcst Closing Balance

31 Mar 2014£000s £000s £000s

NON-CURRENT ASSETS:Property, Plant and Equipment 67,814 80,437 82,097Intangible Assets 126 524 0Investment Property 0 0 0Other Financial Assets 0 0 0Trade and Other Receivables 116 0 0TOTAL Non-Current Assets 68,056 80,961 82,097CURRENT ASSETS:Inventories 2,212 2,629 2,212Trade and Other Receivables 6,641 15,099 7,194Other Financial Assets 0 0 0Other Current Assets 0 0 0Cash and Cash Equivalents 9,428 5,090 1,000TOTAL Current Assets 18,281 22,818 10,406TOTAL ASSETS 86,337 103,779 92,503CURRENT LIABILITIESTrade and Other Payables (16,274) (22,549) (5,899)Other Liabilities 0 0 0Provisions (445) (880) (221)Borrowings (2,256) (2,257) (3,152)Other Financial Liabilities 0 0DH Working Capital Loan 0 (5,300) (9,700)DH Capital Loan (470) (235) (445)TOTAL Current Liabilities (19,445) (31,221) (19,417)NET CURRENT ASSETS/(LIABILITIES) (1,164) (8,403) (9,011)TOTAL ASSETS LESS CURRENT LIABILITIES 66,892 72,558 73,086NON-CURRENT LIABILITIES:Provisions (755) 0 (736)Borrowings (57,782) (56,241) (55,535)DH Working Capital Loan 0 0 0DH Capital Loan (2,935) (2,935) (4,053)TOTAL Non-Current Liabilities (61,472) (59,176) (60,324)ASSETS LESS LIABILITIES (Total Assets Employed) 5,420 13,382 12,762

TAXPAYERS EQUITYPublic Dividend Capital 17,724 17,724 19,619Retained Earnings Reserve (24,596) (16,635) (19,150)General Fund 0 0 0Revaluation Reserve 12,292 12,293 12,293Other Reserves 0 0 0TOTAL TAXPAYERS EQUITY 5,420 13,382 12,762

IFRS STATEMENT OF FINANCIAL POSITION

The balance sheet at month 7 reflects the following changes to the balance sheet in 2013/14. On 1 April, the Trust received assets to the value of £13.3m in respect of the transfer of assets that took place with the demise of the PCTs. The assets transferred relate to premises from which the Trust delivers community services. The services provided and the assets from which they are delivered have thus been aligned. Whilst the transfer of assets helped to strengthen the balance sheet, the impact of the Trust's deficit incurred in the year to date and projected to the year-end impacts adversely on the Trust's balance sheet. The Trust's PDC remains unchanged at month 7 but is projected to increase by the year-end as the Trust draws down the PDC funding awarded in respect of the improving birthing environments funding and the distress capital funding awarded in 2013/14. These resources will be drawn down as and when required in line with DH guidance. The balance sheet currently shows £5.3m of temporary borrowing drawn down from the DoH. This relates to the £9.7m cash funding agreed by the TDA. The year-end position shows £9.7m borrowing. Although it is probable that the funding will be provided as PDC, the final decision has not yet been made and therefore the resource is currently identified as a creditor.

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Section 12 – Risks and Opportunities

• It has been stated to the Trust that £9.7m external I and E support will not be made available and that the proposal of £8.1m support, conditional upon break-even, will not be available either. The consequence of this is that the Trust will outturn with a deficit and will not achieve its five year breakeven duty.

• In order to ensure that the Trust remains a going concern, temporary in-year cash borrowing totalling £9.7m has been agreed, thus ensuring that adequate working capital is maintained. Additionally, the Trust has to submit a bid to the Independent Trust Financing Facility for permanent cash funding (through PDC) to cover the deficit – this will now happen in February 2014.

• The medium case outturn forecast has been assessed at a deficit of £10.7m, reducing to £9.1m through mitigating actions which have to be secured over the next month. This position does also contain a number of significant additional risks, as listed in various sections of the report above. The range of outturns, prior to additional actions resulting from the Rapid Responsive Review, is from a best case of £7.8m deficit to a worst case £15.2m deficit.

• As outlined in section 2 of this report, the outturn has to be achieved by mitigating actions, delivery of the elective care recovery plan, receipt of income due under PbR rules, delivery of the CIP and strong financial control in relation to issued budgets.

• As previously reported, the Trust is facing a significant risk in terms of not delivering to the planned level of activity (and particularly through

efficient and affordable internal capacity). This has been demonstrated by elective activity falling significantly behind plan during the first seven months of the year and the recovery plan has consistently failed to deliver each month. It is, however, critical to the Trust’s position that the planned care recovery plan is successful.

• The need to deliver the CIP remains critical and schemes totalling £6.9m have been implemented so far. This figure is secure but it would clearly be advantageous to the Trust if CIP delivery could be improved.

• In relation to capital, the Trust submitted a request for additional emergency capital resources which was approved. The Trust has thus been

provided with an additional £1.588m funded through the allocation of additional PDC. It is critical that the available resource is fully utilised in the current year and robust monitoring arrangements are in place to ensure that this does occur.

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Enclosure viii

WYE VALLEY NHS TRUST PUBLIC BOARD MEETING 28th NOVEMBER 2013 KEN HUTCHINSON – INTERIM DIRECTOR OF HR WORKFORCE REPORT – OCTOBER 2013 1.0 INTRODUCTION This report provides an analysis of workforce information and issues covering:

• Whole time equivalent (WTE) analysis including bank and agency usage • HR Key Performance Indicators (KPIs) • Composition of the pay bill • Workforce challenges

2.0 RECOMMENDATION The Board are invited to note the contents of the report. 3.0 MAIN BODY OF REPORT 3.1 Appendix 1: Breakdown of Whole Time Equivalents (WTE) in WVT in

October 2013

• In October, the overall size of the workforce increased by just over 44 WTE. This included an increase of 22.07 WTE in bank workers, but a decrease of 0.54 WTE in agency workers. There was an increase of 22.52 WTE in the substantive workforce. This increase was due to the return of Occupational Health staff from Hoople Ltd, staffing of the new Virtual ward and the successful recruitment of midwives.

• The increase in bank workers was due to an increase in nursing and midwifery staff required (24.25 WTE up on last month) mainly in the Care Closer to Home & Urgent Care unit.

• Bank and agency workers comprised 7.60% of the WTE workforce in October 2013, an increase on the previous month (6.87%).

3.2 Appendix 2: HR KPI Dashboard for October 2013

• The in-month sickness absence rate for the Trust has increased to 4.56% (from 4.18% in September) with sickness absence in the 3 Service Units being flagged as red.

• As at the end of October, the number of staff on long term sick has increased from 56 to 62 (2.05% absence rate).

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Enclosure viii

• The main reason for sickness absence continues to be anxiety/stress/ depression/other psychiatric illnesses; this is not all work related but includes personal issues.

• Short term sickness has increased from 2.34 % to 2.51% this month mainly due to an increase in Colds/flu.

• Turnover in month has decreased to 0.7%. • The appraisal rate has increased slightly from 69% to 72% at the time of

writing this report.

3.3 Appendix 3: Composition of the Pay Bill October 2013

• From September to October the total pay bill increased by £345,000 mainly due to an increase in Bank (£47,000) and Additional M&D activity (£102,000) costs. This is a new high for the Pay bill.

• Tables showing Bank and Agency pay costs by Service Unit have been included.

3.4 Workforce Challenges Bank and Agency Costs. Nursing and Midwifery Further Analysis of the Nursing Bank and Agency statistics shows;

1. Nursing and Midwifery qualified staff accounted for 25.99 WTE Bank and 48.32 WTE Agency usage.

2. Additional Clinical Services (HCA’s) accounted for 54.9 WTE Bank and 13.47 Agency WTE usage.

3. Other staff groups accounted for 2.54 Bank usage which has been removed from the nursing stats.

The main three areas of deployment of Agency staff are: Maternity, Theatres and Admissions. (Successful recruitment in maternity and Theatres will reduce agency costs substantially early in 2014.) The main three areas of deployment of Bank staff are: Daycase Overspill, Bromyard and Lugg ward.

Medical & Dental In Medical and Dental there was an overall decrease again this month of 203 hours in Agency usage from the previous month. Medical Staff (Medicine) has the highest number of hours in month; this was to cover vacancies.

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Enclosure viii

Workforce Planning The Workforce Planning Lead for the Trust is currently working on a tool that reviews current Staff in Post, Vacancies, Bank and Agency usage and Acuity of the patients on the wards and in Community Hospitals. This should then be able to assist nursing managers with their future requirements and give better control of Agency usage. Recruitment International Recruitment Successes Recent service developments have highlighted that there is a limited pool of professional staff in the UK, making successful recruitment increasingly difficult; the recruitment of staff from overseas was commenced. In August this year we successfully recruited 4 Theatre Practitioners from Portugal and Bulgaria who are starting in November. It was a team effort to invest in this recruitment campaign to ensure that the candidates had a positive impression of the Trust. As this was a very successful event we are continuing with this channel of recruitment and we will be holding another event on 27 November to recruit more theatre posts. The following is a quote from Carla Beirao, Theatre Nurse, who started work with the Trust in November: Dear colleagues, I arrived to Hereford in early November 2013 along with my family, and has proved to be a wonderful experience. The Wye Valley Hospital welcomed me in a super warm and friendly way, all staff have been tireless in my reception. The city and the surrounding landscape are an amazing beauty and tranquility. I took this decision to change after 20 years of service in Portugal and I'm sure it was the best decision. Best regards Carla Beirão Nurse Recruitment Trust staff will be going to Lisbon, for trained Band 5 Nurses. Head of Nursing, Linda Howells and HR Recruitment, Manager Karen Miller are working with HCL recruitment agency to facilitate an event in Lisbon Portugal on 22-23 November, where 25-30 trained overseas nurses will be interviewed over a 2 day period. The successful candidates will be supported by the Educational Development Support programme before they start in their substantive roles across the Trust. This reflects the shortage of British trained nurses which is forcing NHS hospital trusts to look for staff from overseas. This is supported by

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Enclosure viii

the RCN who see that overseas recruitment is an increasingly permanent part of the employer’s recruitment and retention strategies in the health care sector. A specialty doctor in A&E has also been recruited through the international agency route. Interviews are also being held for Consultants in Acute Medicine (3 posts) during December. Trained Nurses recruitment campaigns We have since August this year introduced monthly recruitment days for trained nurses (Band 5s) to raise profile of Trust and ensure standards are met regarding competencies. All Band 5 Staff Nurses, including bank trained nurses, undertake a drugs and management test as part of the recruitment and selection process. Branding The Trust has improved the quality of adverts, and recruitment material which has raised the profile of the Trust especially when using this material for external recruitment campaigns and overseas events. Successful recruitment campaign in Maternity From the beginning of the year we have successfully recruited 21 Band 5 Midwives, 20 newly qualified, and 16 of these have commenced; there are still 5 in who are in the recruitment process due to start in January 2014. We are also interviewing for Band 6 Midwives this month, and we are positive that we will appoint to 3 posts. ITU and A&E Specialties We are also working with agencies to recruit permanent ITU and A&E trained nurses to fill the current gaps as these areas are struggling to keep up to establishment figures. Bank recruitment We are continuing to recruit to the internal bank for trained nurses and HCAs (to try and reduce agency costs) and admin and clerical as and when required. Since 1st October we have recruited 54 HCAs who are in the recruitment pipeline – some have started as well as 23 trained nurses. Health & Wellbeing Flu Campaign The flu campaign has gone well and to date we have vaccinated 1510 (53.1%) staff, meaning we have already beaten our total percentage from last year of 49%. The team are continuing to ‘floor walk’ and have drop in sessions for half an hour on a Tuesday, Wednesday and Friday.

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Enclosure viii

Education & Development The Education and Development Team continue to focus on supporting workforce transformation and new ways of working to enhance service delivery. Skills Enhancement In Rural Communities The Education and Development Team are hosting a 6 month clinical trainer post in the community after being part of a successful bid to enhance clinical skills in rural communities led by Health Education England. The post will be held within the neighbourhood teams and linked to education and development. Jennet Cowles has been seconded from the District Nursing Team into this post and commenced on 11th November 2013.

Pre-Registration Nursing Plans have been made for the new academic year to train 20 more pre-registration nursing mentors. Widening Participation 28 clinical and 12 admin apprentices have now commenced in the Trust and are being supported across both acute and community settings, supporting local and national initiatives. Education and Development plan to develop a new role within the team to support Bands 1-4 within the Trust to enhance support for career development, succession planning and widening participation. Theatres An Education and Development facilitator post has now been filled by Kim Simpson (an existing Nurse in theatres) to support theatre staff. The post will be based in theatres but hosted by Education and Development to enhance skill acquisition and maintain links to wider educational considerations for the department.

Two pre-registration operating department practitioner places are being supported by education and development through Heath Education West Midlands. These are university based courses and lead to an operating department practitioner qualification.

Education and Development are also supporting a nurse to undertake an anaesthetic nursing course.

Midwifery

The 2nd Midwifery Academy, run by Education and Development in partnership with Midwifery senior staff, has commenced and been a great success. This is currently being evaluated and the success written up for publication by one of our Education and Development Facilitators and the Project Lead for midwifery. The

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Enclosure viii

team are supporting the recruitment and retention of midwives by exploring return to practice and 18 month midwifery programmes. An Education and Development action plan for midwifery has been developed in partnership with midwifery and university staff, to ensure students and preceptors are well supported; mentors are being reviewed to ensure we have adequate support for learners. Education and Development is supporting ‘Human Factors’ training for midwifery staff development and the programmes are well underway. Mandatory Training The mandatory training service has now been repatriated to Wye Valley and the new mandatory training team is now in place. Induction and mandatory training programmes are being overhauled and capacity for courses increased. The Trust has adopted the Oracle Learning Management System for recording and monitoring training compliance. We are currently working with the provider to upload training data from the external provider, but the data needs cleansing before being uploaded. This is a long and tedious process which we are addressing subject by subject. However, we plan to report the first full compliance report by the end of January 2014, by Service unit and professional group. E-Learning Education and Development are leading on the implementation of e-learning to support mandatory training in the Trust. This will enable full adoption of e-learning as a blended learning process across the Trust. This approach will aid in the delivery of high quality care through cost effective education, training and continuous development to the workforce, offering less time away from the workplace. Further work now needs to be undertaken in response to the need to use information technology to facilitate and complement learning across Wye Valley NHS Trust. An e-learning strategy is being developed to set out a series of actions that need to create equitable access. Library Service The library service has been reviewed with Health Education England and a new structure is currently being introduced incorporating the wider considerations for information and resource development, to support regional, national and organisational plans.

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Enclosure viii

Bank and Agency Staff The Head of Education is now supporting the nurse bank as the professional Lead for Bank and Agency Staff. Work is underway to scope the skills of existing staff. Management Development Programme Education and Development are working with workforce planning and the Systems Improvement Facilitator to deliver a management development programme to support succession planning and talent management.

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Appendix 1: Breakdown of Whole Time Equivalent (WTE) for WVT in October 2013

Oct-13 Service Unit

Add Prof Scientific and Technic

Additional Clinical Services

Adm

inistrative and Clerical

Allied H

ealth Professionals

Estates and Ancillary

Healthcare Scientists

Medical and D

ental

Nursing and M

idwifery Registered

Students

Grand Total

Agency

Care Closer To Home & Urgent Care 5.80 34.80 40.60 Elective Care Services 0.00 3.41 17.54 20.95 Integrated Family Health Services 0.84 9.45 10.29 Corporate 0.00

Agency Total 0.00 0.00 0.00 0.00 0.00 0.00 10.05 61.79 0.00 71.84

Substantive Staff

Care Closer To Home & Urgent Care 23.82 252.99 120.30 172.13 9.87 41.03 85.98 311.59 1.00 1018.71 Elective Care Services 66.60 136.18 90.76 11.90 10.60 1.00 132.03 247.26 696.33 Integrated Family Health Services 87.01 51.58 7.71 2.95 39.25 180.08 15.47 384.05 Corporate 3.40 182.14 9.53 17.16 212.23

Substantive Staff Total 93.82 476.18 444.78 191.74 32.95 42.03 257.26 756.09 16.47 2311.32

Bank Staff

Care Closer To Home & Urgent Care 5.27 6.96 2.52 52.40 67.15 Elective Care Services 0.00 12.28 0.00 16.21 28.49 Integrated Family Health Services 2.28 0.00 14.41 16.69 Corporate 5.76 0.36 6.12

Bank Total 5.27 0.00 27.28 2.52 0.00 0.00 0.00 83.38 0.00 118.45

Grand Total 99.09 476.18 472.06 194.26 32.95 42.03 267.31 901.26 16.47 2501.61 Notes: 1. Corporate: includes Trust HQ, Planning, HR, Director of Nursing & Finance 2. WLI and additional M&D FTE - not included

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Appendix 2: HR KPI Dashboard for October 2013 Sickness Turnover Appraisals1

Service Units In-

month Absenc

e %

Quarterly Moving Average

%

Rolling 12

Month %

No. of Staff off

sick for

whole month

Total no. of days

lost by staff on

long term sick

Monthly Turnover % (excluding Jnr Docs)

Quarterly Moving

Average % (exc Jnr Docs)

Rolling 12 Month % (exc Jnr Docs)

No. of staff

Appraised

Total No. of Staff to be Appraised

Rolling 13

Month %

Care Closer To Home & Urgent Care 4.04% 3.79% 4.15% 21 2034 0.93% 1.63% 12.54% 733 1023 72% Elective Care Services 6.04% 5.16% 4.46% 26 3226 0.48% 1.20% 9.45% 418 670 62% Integrated Family Health Services 4.25% 4.24% 5.06% 10 1201 0.40% 1.09% 12.39% 357 384 93% Corporate 1 2.81% 2.26% 2.42% 5 546 0.40% 0.57% 14.66% 106 148 72%

TRUST 4.56% 4.15% 4.26% 62 7007 0.66% 1.33% 11.80% 1614 2225 72% Notes: 1: Corporate includes Trust HQ, Planning Director of Nursing, Finance & HR RAG Ratings

KPI Description Red (%) Amber (%) Green (%) Sickness (in month) > 4.00 Between 3.5 to 4.00 <=3.49

Sickness (quarterly moving average) > 4.30 Between 3.7 to 4.30 <=3.69 Sickness (rolling 12 months) > 4.30 Between 3.7 to 4.30 <=3.69

Staff Appraised (in rolling 12 month period) <= 70 Between 71 to 89 >= 90

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Top Three Reasons for Sickness Absence, October 2013

Reasons Total No. of Calendar Days

Lost Anxiety/stress/depression/other psychiatric illnesses 755 Gastrointestinal problems 652 Other musculoskeletal problems 621

Sickness Absence – Rolling Quarterly Average by Service Unit – November 2012 – October 2013

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Appendix 3: Composition of the Pay Bill Monthly Pay Costs (£000s) November2012 – October 2013 £'000s Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 July-13 Aug-13 Sep-13 Oct-13 Substantive 7584 7561 7785 7650 8068 7804 7854 7842 7887 7879 7859 8138 Bank 220 197 232 204 255 235 246 182 191 207 201 248 Agency 151 203 197 337 546 363 287 301 415 511 564 509 Add'l M&D Activity 86 62 84 53 38 82 62 131 125 126 137 239 M&D Cover 112 76 93 55 71 113 161 95 52 97 75 47 Total Pay Bill 8,152 8,099 8,392 8,298 8,977 8597 8,610 8,551 8,670 8,820 8,836 9,181

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Variable Pay Costs as a % of Total Pay Costs (£000s) November 2012 – October 2013 £'000s Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 July-13 Aug-13 Sep-13 Oct-13

Total Variable Pay 568 538 607 648 909 793 756 709 783 941 977 1043

% Variable to Total Pay 6.97% 6.64% 7.23% 7.81% 10.13% 9.22% 8.78% 8.29% 9.03% 10.67% 11.06% 11.36% Pay Cost of Bank and Agency Usage by Service Unit, October 2013 Bank Usage Agency Usage Bank & Agency UsageService Unit Pay Cost MPE Service Unit Pay cost MPE Service Unit Pay costCare Closer to Home & Urgent Care 144,302.80 67.18 Care Closer to Home & Urgent Care 280468.19 45.33 Care Closer to Home & Urgent Care 424,770.99Elective Care 56712.01 28.12 Elective Care 156438.7 16.22 Elective Care 213,150.71Integrated Family Health Services 36575.39 16.69 Integrated Family Health Services 79717.25 10.29 Integrated Family Health Services 116,292.64Corporate 10,035.02 6.09 Corporate -9,776.00 0 Corporate 259.02TOTAL BANK 247,625.22 118.08 TOTAL AGENCY 506,848.14 71.84 TOTAL BANK & AGENCY 754,473.36

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Enclosure ix WYE VALLEY NHS TRUST TRUST BOARD MEETING IN PUBLIC 28 November 2013 NEIL DOVERTY – CHIEF OPERATING OFFICER [email protected] NHS Core Standards for Emergency Preparedness, Resilience & Response 1.0 INTRODUCTION 1.1 This is a report for the Board for information. The NHS needs to plan for, and respond to, a wide range of incidents and emergencies that could affect health or patient care. These could be anything from extreme weather conditions to an outbreak of an infectious disease or a major transport accident. The Civil Contingencies Act (2004) requires NHS organisations, and providers of NHS-funded care, to show that they can deal with such incidents while maintaining services. This programme of work is referred to in the health community as emergency preparedness, resilience and response (EPRR). New arrangements for local health EPRR form some of the changes the Health & Social Care Act 2012 is making to the NHS in England.

1.2 The NHS Commissioning Board has revised national core standards governing EPRR which all NHS organisations are required to meet. Each NHS body is tasked to undertake a self-assessment and a brief rectification plan against the core standards and return the submission to NHS England by 29 November 2013. The purpose of the core standards is to enable agencies across the country to share and co-ordinate activities within a consistent framework and apply a national control process. The new core standards will also provide for peer review across NHS organisations. 1.3 The attached self-assessment return is the output of an internal review of Trust performance against the new core standards and will now be issued to NHS England. 2.0 RECOMMENDATION 2.1 That the Board receives and notes the contents of the Trust’s submission against NHS national core standards for emergency preparedness, resilience and response. 3.0 KEY POINTS 3.1 A review of the NHS Trust performance against the new national core standards has been completed by the Trust’s Emergency Planning Officer and is attached for information. The Trust scores well against many of the key performance criteria, but there is still considerable development work to take forward during 2013-14 and a rectification plan is also attached, for return to NHS England. 3.2 The Trust participated in a formal major incident stress-test and training exercise in 2012, known as Exercise Emergo. This stress-tested the Trust’s Major Incident Plan and our readiness and organisation of our Incident Control Room and Communications functions. As part of the exercise, the Trust’s surge capacity including patient flow

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Enclosure ix management options was critically examined. The stress-test was formally evaluated by accredited external assessors and the emergency response / business continuity performance was scored at 92%, indicating a high level of confidence. 3.3 The Trust has a standing committee charged with overseeing the ongoing development of emergency preparedness, resilience and response. This committee meets monthly and will now address the outstanding issues and actions set out in the rectification plan. During 2013, the Trust has revised the Major Incident Plan and the Managing Incidents (Low-Level / Business Continuity) Plan. 3.4 The immediate priorities for the Trust concerning strengthening our EPRR are re-running staff training events for senior staff likely to be involved in managing major incidents and extending the adoption of formal business continuity plans for local key services across the Service Delivery Units. The Emergency Planning Group will address both these priorities as from their next meeting. Enclosures

(i) Trust’s completed return for EPRR core standards (ii) Trust’s draft rectification plan for EPRR

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Wye Valley NHS Trust GREEN - arrangements in place now, compliant with core GREEN - AssuredAcute Select your organisation AMBER - draft or scheduled on action plan for completion by Dec AMBER - Partially assured, seeking clarification/ draft Paul Dubberley Trust Emergency Planning Officer type using Autofilter RED - arrangements not in place or scheduled for completion RED - Not assured; insufficient evidence providedNeil Doverty, Trust Chief Operating Officer and Accountable Emergency Officer dropdown arrow(s) N/A - Not applicable to organisation N/A - Not applicable to organisationTrust Board 28 November 2013 N/R - Not rated by reviewing team N/R - Not rated by reviewing team

Cat 2

NHS Core Standards for Emergency Preparedness, Resilience & Response (EPRR)

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Suggested Minimum Level of Evidence to be submitted to review group

Commentary/ References to Evidence Supplied

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Assessment

1

All NHS organisations and providers of NHS funded care must nominate an accountable emergency officer who will be responsible for EPRR and business continuity management.

X X X X X X X

● Accountable Emergency Officer (AEO) details (name, role)● AEO job description●Evidence that AEO completed relevant training (SLC, witness familiarisation etc - dates completed) ● Competency assessed against National Occupational Standards

Neil Doverty, Trust Chief Operating Officer and Accountable Emergency Officer has undertaken formal MAJAX training 2011/12; Operational Director experience of leading MAJAX crises; Note there is no requirement to have completed SLC

2

All NHS organisations and providers of NHS funded care must share their resources as necessary when they are required to respond to a significant incident or emergency. X X X X X X X

● Articulated in Incident Response Plans (IRP)● MoU/ mutual aid arrangements, evidence of participation in multiagency planning groups/ LHRP as appropriate

Trust is committed to principle and will support drawing up MOU by LHRP

3

All NHS organisations and providers of NHS funded care must have plans setting out how they contribute to co-ordinated planning for emergency preparedness and resilience (for example surge, winter & service continuity) across the area through LHRPs and relevant sub-groups. These plans must include details of: X X X - X X X

● Local Health Resilience Partnership (LHRP) and Local Resilience Forum (LRF) where applicable● Borough Resilience Forum (BRF)/ subgroup participation

Trust has a range of plans including Major incident Plan and its addendum (service continuity plan) which provide resilience to prevailing risk and support both LRF and LAT planning arrangements

3 . 1 director-level representation at the LHRP; and X X X - X X X ● LHRP Terms of Reference (ToR), membership list● most recent LHRP minutes

Member of West Mercia and Herefordshire & Worcestershire LHRP's and regular attendance/representation made

3 . 2 representation at the LRF. - X X - - - - ● LHRP ToR, membership list● most recent LHRP minutes

LAT attending West Mercia LRF Forum and BMG meeting cascading minutes and notes. Trust reps routinely attend LRF County Silver, Risk Working Group, Fuel, Communications and specific meetings and exercises when required ensuring minutes and notes are cascaded

4

All NHS organisations and providers of NHS funded care must contribute to an annual NHS England report on the health sector’s EPRR capability and capacity in responding to national, regional and LRF incidents. Reports must include control and assurance processes, information-sharing, training and exercise programmes and national capabilities surveys. They must be made through the organisations’ formal reporting structures. X X X X X X X

● Participation in annual NHS Safe System process● EPRR Board report/ formal reporting structure outlined● Training and exercise programmes● Post exercise reports, showing lessons identified, with an action plan to address gaps

Complied with . Copy of Emergo 2012 lessons learnt attached previously submitted to SHA

4 . 1

Organisations must have an annual work programme to reduce risks and learn the lessons identified relating to EPRR (including details of training and exercises). This work programme must link back to the National Risk Assessment (NRA) and Community Risk Register (CRR).

X X X X X X X● Work plan for EPRR● Risk Register reflects community risk register● EPRR Board report, issues/ lessons log

Trust operates an Emergency Planning Group which draws representation from across Trust and which acts as internal consultation Group. Progress is charted using Cabinet Office Expectations and Indicators of Good practise Set for Category 1 and 2 Responders and routinely reports upon Risk (Group maintains its own register) Emergency Planning, Communications and Business Continuity - copy attached

4 . 2 Organisations must maintain a risk register which links back to the National Risk Assessment (NRA) and Community Risk Register (CRR). X X X X X X X ● Risk register

● Details on the process/ schedule of review See above

5

All NHS organisations and providers of NHS funded care must have plans which set out how they plan for, respond to and recover from disruptions, significant incidents and emergencies. Incident response plans must:

X X X X x x x● PLEASE SUPPLY ONE COPY OF YOUR MAJOR INCIDENT/ INCIDENT RESPONSE PLAN AND APPENDICES

Copy of Major Incident Plan and its Addendum attached. Other planning arrangements include Consort - VIP or member of Royal Family admitted CBRNe Lock Down Excess Death and Emergency Mortuary Provision Pandemic Flu and specific Comms Plan Gastroenteritis(Norovirus like) Illness Diarrhoea and Vomiting and Specific Comms Plan Heatwave and Cold Weather Plans - action cards from national Plans adopted and Trust arrangement described in MIP + addendum

5 . 1 be based on risk-assessed worst-case scenarios; X X X X X X X

● Page/ section reference in arrangements demonstrating how the organisation plans for incidents● Demonstration of risk assessments ● ToR of MI/BC Planning Groups

Page 14 of MIP references LRF CRR. Exercises constructed on reported worst based sceanrio on CRR

5 . 2 make sure that all arrangements are trialled and validated through testing or exercises; X X X X X X X

● Testing and Exercising programme / log that complies with national exercising standards● Post exercise/ incident reports, showing lessons identified, with an action plan to address gaps

Exercises are routinely exercised - last year Trust completed 3 yearly live test in July 2012 using PHE Emergo Exercise.(copy of evaluation report attached) Planned table for this year, an evacuation exercise has been postponed due to pressures within the Trust but stress test of recently reviewed capcity Plan will be completed on 6th December.

5 . 3 make sure that the funding and resources are available to cover the EPRR arrangements; X X X X X X X● Details of agreed budget ● EPRR business cases/ papers for funding, ● EPLO job description showing WTE EPRR had dedciated cost code which is routinely reported

5 . 4

plan for the potential effects of a significant incident or emergency or for providing healthcare services to prisons, the military and iconic sites; and

X X - X - X X

● Demonstrate representation on relevant planning groups, ToR/ minutes (eg: Security Liaison Groups for COMAH sites etc) ● Associated risk reflected on local risk register● IRPs recognise specific local challenges

N/A - none of the sites listed are idnetifed on CRR or local risk register.

5 . 5

include plans to maintain the resilience of the organisation as a whole, so that the Estates Department and Facilities Department are not planning in isolation.

X X - X - X X

● Business Continuity planning arrangements demonstrate joint working between EP and estates/ facilities staff (ToR for related meetings, task and finish groups) ● Action card for E&F in IRP/ BCP

Consultation when plans are reviewed Plans occurs routinely and thereafter circulated to Estatesand Facilities. Identified that Estates and faciltiaties to be invited to become generic members of EPG rather than on specirfic circumstances.

Incident response plans must be in line with published guidance, threat-specific plans and the plans of other responding partners. They must:

X X X X X X X

ncategoriseCat 1

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5 . 6refer to all relevant national guidance, other supporting and threat-specific plans (eg pandemic flu, CBRN, mass casualties, burns, fuel shortages, industrial action, evacuation, lockdown, severe weather etc) and policies, and all other supporting documents that enhance the organisation’s incident response plan;

X X X X X X X ● Page/ section references in IRP, annexes to plans or standalone plans

Plans routinely follow national and local area guidance and referenced within context of plan

5 . 7 refer to all other associated plans identified by local, regional and national risk registers; X X X X X X X ● Page/ section references in IRP, annexes to plans or standalone plans Page 14

5 . 8 have been written in collaboration with all relevant partner organisations; X X X X X X X ● Page/ section references in IRP, annexes to plans or standalone plans routinely circulated to relevant partner agencies -page 76

5 . 9 refer to incident response plans used by partners, including LRF plans; X X X X X - - ● Page/ section references in IRP, annexes to plans or standalone plans Page 15 - 16

5 . 10 have been written in collaboration with PHE; X X X X X - X ● Page/ section references in IRP, annexes to plans or standalone plans

This was previously routinely achieved but practise needs reaffirming as new PHE Organisation is grounded

5 . 11have been written in collaboration with all burns, trauma and critical care networks; and

X X X X X X -● Page/ section references in IRP, annexes to plans or standalone plans● Information how to access capabilities

page 25

5 . 12define how the organisation will meet the Prevent strategy’s objectives for health (1. prevent people from being drawn into terrorism and ensure that they are given appropriate advice and support and 2. work with sectors and institutions where there are risks of radicalisation which we need to address, and the wider CONTEST strategy).

X X X - X X X Not rated in 2013 N/R N/R

Incident response plans must follow NHS governance arrangements. They must: X X X X X X X

5 . 13 be approved by the relevant board; X X X X X X X● Page/ section references in IRP, annexes to plans or standalone plans● Notes from relevant approving Board meeting

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5 . 14 be signed off by the appropriate Senior Responsible Officer; X X X X X X X ● Page/ section references in IRP, annexes to plans or standalone plans Page 8

5 . 15 set out how legal advice can be obtained in relation to the CCA; X X X X X - X ● Page/ section references in IRP, annexes to plans or standalone plans Page 24

5 . 16 identify who is responsible for making sure the plan is updated, distributed and regularly tested; X X X X X X X ● Page/ section references in IRP, annexes to plans or standalone plans Page 6 - Trust Emergency Planning Officer and or plan holder

5 . 17explain how internal and external consultation will be carried out to validate the plan;

X X X X X X X ● Page/ section references in IRP, annexes to plans or standalone plans

Page 17 -Consulation in achieved internally through membership of EPG and by circulation to estates etc. to to key partner agencies as denoted in plan - page of MIP

5 . 18 include version controls to be sure the user has the latest version; X X X X X X X ● Page/ section references in IRP, annexes to plans or standalone plans Routine compiance - see page 7 of MIP

5 . 19 set out how the plan will be published – for example, on a website; X X X X X X X ● Page/ section references in IRP, annexes to plans or standalone plans

Adopted practise is to place edited version on Trust Internet site page 76 MIP

5 . 20 include an audit trail to record changes and updates; X X X X X X X ● Page/ section references in IRP, annexes to plans or standalone plans Standard practise page 7 of MIP

5 . 21 explain how predicted and unexpected spending will be covered and how a unique cost centre and budget code can be made available to track costs; and X X X X X X X ● Page/ section references in IRP, annexes to plans

or standalone plansCost code is established and reporting of expenditutre is to Chief Operating officer

5 . 22demonstrate a systematic risk assessment process in identifying risks relating to any part of the plan or the identified emergency. X X X X X X X ● Page/ section references in IRP, annexes to plans

or standalone plans

Risk is routinely considered and reported through EPG process and as part of debrief into incidents and exercises page 49 of addendum

Staff must be aware of the Incident Response Plan, competent in their roles and suitably trained. X X X X X X X Key staff within plans are largely members of EPG or are made aware of progress through organisational briefings

5 . 23 Key staff must know where to find the plan on the intranet or shared drive. X X X X X X X

● Training plan for staff with a specific role● Training Needs Analysis for those staff● Training materials ● Training records

Referenced in plans - previously ad-hoc training has been delivered but identified that more systematic approach is required with analysis, need and records to be kept

5 . 24There must be an annual work programme setting out training and exercises relating to EPRR and how lessons will be learnt. X X X X X X X

● Testing and Exercising schedule● Details on process for reviewing plans in light of lessons learnt

Assessment Framework based on CO Expectations Framework adopted approx 2 1/2 years ago and acts as work programme and progress check

5 . 25

Key knowledge and skills for staff must be based on the National Occupation Standards for Civil Contingencies. Directors on NHS on-call rotas must meet NHS published competencies.

X X X X X X X

● Training Needs Analysis● Training schedule● Training materials● Training records

informal training is delivered as part of normal business particularly in lad to participation in exercise - recognised that formal package could be delivered as part of PDC training and remedial action to be delivered including formal training needs analysis

5 . 26

It must be clear how awareness of the plan will be maintained amongst all staff (for example, through ongoing education and information programmes or e-learning). X X X X X X X


informal training is delivered as part of normal business particularly in lad to participation in exercise - recognised that formal package could be delivered as part of PDC training and remedial action to be delivered

5 . 27 It must be clear how key staff can achieve and maintain suitable knowledge and skills. X X X X X X X


informal training is delivered as part of normal business particularly in lad to participation in exercise - recognised that formal package could be delivered as part of PDC training and remedial action to be delivered

Set out responsibilities for carrying out the plan and how the plan works, including command and control arrangements and stand-down protocols.

X X X X X X X

5 . 28 Describe the alerting arrangements for external and self-declared incidents (including trigger points, decision trees and escalation/de-escalation procedures) X X X X X X X ● Page/ section references in IRP, annexes to plans

or standalone plans Part 3 of plan

5 . 29 Set out the procedures for escalating emergencies to NHS England area teams, regions, national office and DH - - X X - X -● Page/ section references in IRP, annexes to plans or standalone plans● Responsibility assigned to an Action Card

Trust already has established level 3 and level 4 call out system managed through Trust Switchboardpart 3 of plan

5 . 30

Explain how the emergency on-call rota will be set up and managed over the short and longer term.

X X X X - X -

● Provide detail on how this is delivered ● Provide detail on contingency arrangements regarding call-out● Function assigned to IRP/ ICC Action Card

Trust already has established level 3 and level 4 call out system managed through Trust Switchboard page Page 40 and page 25

5 . 31

Include 24-hour arrangements for alerting managers and other key staff, and explain how contact lists will be kept up to date.

X X X X X X X

● On-call arrangements/ processes, On-call pack, On-call staff lists● Responsibility assigned to an Action Card● Admin / support role assigned to maintain systems● Reports from COMMEX/ regular cascades using contact lists

Trust already has established level 3 and level 4 call out system managed through Trust Switchboard - part 3 of both MIP and its addendum

5 . 32 Set out the responsibilities of key staff and departments. X X X X X X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards Part 2 of plan with supporting action card

5 . 33Set out the responsibilities of the appropriate Senior Responsible Officer or nominated Executive Director.

X X X X X X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards part 2 of plan with supporting action card

5 . 34Explain how mutual aid arrangements will be activated and maintained.

X X X X X X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards page9

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5 . 35Identify where the incident or emergency will be managed from (the ICC).

X X X X X X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards Pages 25 and 71

5 . 36Define the role of the loggist to record decisions made and meetings held during and after the incident, and how an incident report will be produced. X X X X X X X

● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards Pages 62 and 66

5 . 37 Best Practice: Use an electronic data-logging system to record the decisions made. X X - - - - - Not rated in 2013, unless organisation provides evidence

5 . 38 Best Practice: Use the National Resilience Extranet. X X X X - X - Not rated in 2013, unless organisation provides evidence

5 . 39 Refer to specific action cards relating to using the incident response plan. X X X X X X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards

Pages 45 - 64

5 . 40Explain the process for completing, authorising and submitting NHS England standard threat-specific situation reports and how other relevant information will be shared with other organisations. X X X X X X X

● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards NHS Arden Plan adopted and sits in Trust Intranet EP page

5 . 41Explain how extended working hours will apply and how they can be sustained. Explain how handovers are completed.

X X X - X X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards Page pages 40 and 41

5 . 42Explain how to communicate with partners, the public and internal staff based on a formal communications strategy. This must take into account the FOI Act 2000, the Data Protection Act 1998 and the CCA 2004 ‘duty to communicate with the public’. Social networking tools may be of use here.

X X X X X X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards pages 22

5 . 43 Have agreements in place with local 111 providers so they know how they can help with an incident X X X X X X -● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards

Managed by Herefordshire clinical Commissioner Group and accessed by A and E / CSM

5 . 44Consider using helplines in an emergency. Set up procedures in advance which explain the arrangements. Make sure foreign language lines are part of these arrangements. X X X X X X X

● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards page 23

5 . 45 Describe how stores and supplies will be maintained. X X - - X X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards

page 32 addendum

5 . 46Explain how specific casualties will be managed – for example, burns, paediatrics and those from certain faiths.

X X - - - X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards page 25

5 . 47Explain how VIPs will be managed, whether they are casualties or visiting others who are casualties.

X X - X --

X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards Operational Plan Consort -

5 . 48Explain the process of recovery and returning to normal processes.

X X X X X X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards Page 42

5 . 49Explain the de-briefing process (hot, local and multi-agency)at the end of an incident.

X X X X X X X● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards

Trust routinely debriefs incidents and exercises. LRF Guidance document adopted and kept on Trust intranet site

5 . 50Explain how to support patients, staff and relatives before, during and after an incident (including counselling and mental health services). X X X X X X X

● Page/ section references in IRP, annexes to plans or standalone plans● Action Cards Page 40

Set out how surges in demand will be managed. X X X X X X X WVT Capacity Escalation Plan

5 . 51

Explain who will be responsible for managing escalation and surges.

X X X X X X X

● Page/ section references in IRP/ Surge Management arrangements, annexes to plans or standalone plans● Action Cards

Trust maintains specific Capacity Escalation Plan which has been reviewed and rewritten in light of lessons learnt 2012/13 and to align with recently renewed RCMT escalation trigger levels . Surges are managed by level 3 Clinical Site Manager/Duty Manager with escalation to level 4 duty director.

5 . 52

Describe local escalation arrangements and trigger points in line with regional escalation plans and working alongside acute, ambulance and community providers.

X X X X X X X

● Page/ section references in IRP/ Surge Management arrangements, annexes to plans or standalone plans● Escalation framework including trigger points for ambulance, acute and community● Action Cards

Plan has adopted RCMT trigger levels routinely reported by Clinical Site Manager.

Link the Incident Response Plan to threat-specific incidents X X X X X X

5 . 53 CBRN incidents; X X - - - X X

● Page/ section references in IRP/ Surge Management arrangements, annexes to plans or standalone plans● Specific CBRN plans

Trust maintains specific planning arrangements for response to CBRNe incident - Trust held live exercise in August 2011 and the following year August 2012 saw A and E have to respond to real live incident which resulted in Trust having to destroy and then replace it's decontamination test. Arrangements inspected by WMAS in August 2013 and found to be satisfactory

5 . 54 mass casualty incidents; X X - - - X X

● Page/ section references in IRP/ Surge Management arrangements, annexes to plans or standalone plans● Specific Mass Casualties plans

Current Major Incident Plan and ancillary plans including capacity escaltion are considered equal to threat on CRR and County Risk register. Support to other areas will b corodianted by RCMT and NHS England

5 . 55 pandemic flu; X - X - - X X

● Page/ section references in IRP/ Surge Management arrangements, annexes to plans or standalone plans● Specific Pandemic Flu plans

Trust maintains a planning group who report to EPG and consider strategy, plans, staff vaccination infection control etc.

5 . 56 patients with burns requiring critical care; and X - - - - X X

● Page/ section references in IRP/ Surge Management arrangements, annexes to plans or standalone plans● Specific Burns plans page 25 MIP

5 . 57 severe weather. X X X - X X X

● Page/ section references in IRP/ Surge Management arrangements, annexes to plans or standalone plans● Specific Severe Weather plans

Major Incident Plan addendum considers risks and mitigation measures open to Duty Managers in the event of Severe Weather. Trust is member of Herefordshire LRF Severe Weather Group and receives alerts from Council , met office and EA direct

6

All NHS organisations must provide a suitable environment for managing a significant incident or emergency (an ICC). This must include a suitable space for making decisions and collecting and sharing information quickly and efficiently. X X X X X X X

● Page/ section references in IRP, annexes to plans or standalone ICC plans● Action Cards

Trust has operated dedicated control room which was purpose built as poart of new hosptial. And is able to contain the MCI Control Team.The MCI Hub (ICC Control Room)has been created this year as an trial towards more effective response arrangments around patient management and flow. Page

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6 . 1There must be a plan setting out how the ICC will operate.

X X X X X X X● Page/ section references in IRP, annexes to plans or standalone ICC plans● Action Cards Page

6 . 2There must be detailed operating procedures to help manage the ICC (for example, contact lists and reporting templates).


6 . 3There must be a plan setting out how the Incident Coordination Team will be called in and managed over any length of time


6 . 4

Facilities and equipment must meet the requirements of the NHS England Corporate Incident Response Plan.

X X X X X X X

● Page/ section references in IRP, annexes to plans or standalone ICC plans● Action Cards● Provide detail on equipment available within ICC ● Provide detail on the programme for exercising ICC arrangements

The Hub is devoid of some of preferred equipment listed in appendix 1 NHS CB C and C Framework such as TV with news channel access but the room is considered fit for purpose for most sudden impact emergencies with migration to other sites appropriate to consequences faced of offering necessary facilities' to facilitate command and control

7

All NHS organisations and providers of NHS funded care must develop, maintain and continually improve their business continuity management systems. This means having suitable plans which set out how each organisation will maintain continuity in its services during a disruption from identified local risks and how they will recover delivery of key services in line with ISO22301. Organisations must: X X X X X X X

● PLEASE SUPPLY ONE COPY OF YOUR BUSINESS CONTINUITY POLICY, BUSINESS CONTINUITY PLAN AND APPENDICES● Arrangements dealing with site/organisation specific risks (eg: flooding)● Action plan for transition to/ alignment with ISO22301

BCMS has been identified as area for development since previous work is now has been superseded by organisational changes introduction of standard ISO22301 and changes to new way of working and BCMS. However, critical areas of Hospital continue to have individual plans and Trust has organisational plan which examines worst case scenarios including those listed 7.13 post.

7 . 1

make sure that there are suitable financial resources for their BCMS and that those delivering the BCMS understand and are competent in their roles; X X X X X X X

● Page/ section references in Business Continuity Management System arrangements/ Business Continuity Policy/ Business Continuity Plan, annexes to plans or standalone plans Page 42 MIP

7 . 2 set out how finances and unexpected spending will be covered, and how unique cost centres and budget codes can be made available to track costs; X X X X X X X ● Page/ section references in BC arrangements Page 42 MIP

7 . 3develop business continuity strategies for continuing and recovering critical activities within agreed timescales, including the resources required such as people, premises, ICT, information, utilities, equipment, suppliers and stakeholders; and X X X X X X X ● Page/ section references in BC arrangements

remedial work required to deliver BCP and BCMS

7 . 4 develop, use and maintain business continuity plans to manage disruptions and significant incidents based on recovery time objectives and timescales identified in the business impact analysis X X X X X X X ● Page/ section references in BC arrangements

Addendum in place and incident team will set objectives and timescales as appropriate

Business continuity plans must include governance and management arrangements linked to relevant risks and in line with international standards. X X X X X X X Major Incident plan addendum

7 . 5 Each organisation’s BCMS must be based on its legal responsibilities, internal and external issues that could affect service delivery and the needs and expectations of interested parties. X X X X X X X ● Page/ section references in BC arrangements Page 7 - to be developed in BCP and BIA's

7 . 6 Organisations must establish a business continuity policy which is agreed by top management, built into business processes and shared with internal and external interested parties. X X X X X X X ● Page/ section references in BC arrangements identified as piece of remedial work

7 . 7 Organisations must make clear how their plan will be published, for example on a website. X X X X X X X ● Page/ section references in BC arrangements Adopted practise is to place edited version on Trust Internet site

7 . 8 The BCMS policy and business continuity plan must be approved by the relevant board and signed off by the appropriate Senior Responsible Officer. X X X X X X X ● Page/ section references in BC arrangements Page 6

7 . 9 There must be an audit trail to record changes and updates such as changes to policy and staffing. X X X X X X X ● Page/ section references in BC arrangements Page 5

7 . 10

The planning process must take into account nationally available toolkits that are seen as good practice.

X X X X X X X ● Page/ section references in BC arrangements

The expected new EPRR tool kit is yet to be delivered and progress is being tracked through engagement with LAT. Aim to develop link with Worcester Acute to benchmark and develop good practise

Business continuity plans must take into account the organisation’s critical activities, the analysis of the effects of disruption and the actual risks of disruption. X X X X X X X

7 . 11Organisations must identify and manage internal and external risks and opportunities relating to the continuity of their operations. X X X X X X X ● Page/ section references in BC arrangements

2009 work to be revisited and brought up to ISO22301 standard. BIA's to be revisited - A and E, ITU, Mortuary and Neighbourhood Teams current

7 . 12 Plans must be maintained based on risk-assessed worst-case scenarios. X X X X X X X ● Page/ section references in BC arrangements● Risk assessments/ methodology page 8 addendum

7 . 13

Risk assessments must take into account community risk registers and at very least include worst-case scenarios for:• severe weather (including snow, Heatwave, prolonged periods of cold weather and flooding);• staff absence (including industrial action);• the working environment, buildings and equipment;• fuel shortages;• surges in activity;• IT and communications;• supply chain failure; and• associated risks in the surrounding area (e.g. COMAH and iconic sites).

X X X X X X X ● Page/ section references in BC arrangements● Risk registers and arrangements for review

Addendum in place and addresses risks described

7 . 14 Organisations must develop, use and maintain a formal and documented process for business impact analysis and risk assessment. X X X X X X X ● Page/ section references in BC arrangements remedial work required to deliver BCP and BCMS

7 . 15They must identify all critical activities using a business impact analysis. This must set out the effect business disruption may have on the organisation and how this will be overcome, including the maximum period of tolerable disruption. X X X X X X X ● Prioritised list of critical activities/ services

● Business Impact Analysis methodology remedial work required to deliver BCP and BCMS

7 . 16 Organisations must highlight which of their critical activities have been put on the corporate risk register and how these risks are being addressed. X X X X X X X ● Appropriate risk register remedial work required to deliver BCP and BCMS

Business continuity plans must set out how the plans will be called into use, escalated and operated. X X X X X X X

7 . 17

Organisations must develop, use, maintain and test procedures for receiving and cascading warnings and other communications before, during and after a disruption or significant incident. If appropriate, business continuity plans must be published on external websites and through other information-sharing media. X X X X X X X

● Page/ section references in BC plans, annexes to plans or standalone plans● Action Cards

Trust has recently introduced alert available to Comms Team and Duty managers for warning key staff of disruption and significant issues. This is in additionally measure to switchboard alerting MCI Team and staff

7 . 18Plans must set out: the alerting arrangements for external and self-declared incidents, including trigger points and escalation procedures; X X X X X X X

● Page/ section references in BC plans, annexes to plans or standalone plans● Action Cards Page of addendum

7 . 19 the procedures for escalating emergencies to CCGs and the NHS England area, regional and national teams; X X X X X X X● Page/ section references in BC plans, annexes to plans or standalone plans● Responsibility assigned to Action Card

Rotas for CCG and LAT held by Duty managers and CSMs

7 . 20

24-hour arrangements for alerting managers and other key staff, including how up-to-date contact lists will be maintained;

X X X X X X X

● On-call arrangements/ processes, On-call pack, On-call staff lists● Responsibility assigned to an Action Card● Admin / support role assigned to maintain systems● Reports from COMMEX/ regular cascades using contact lists Part 3 of MIP

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7 . 21 the responsibilities of key staff and departments; X X X X X X X● Page/ section references in BC plans, annexes to plans or standalone plans● Action Cards

Page 12 addendum

7 . 22the responsibilities of the appropriate Senior Responsible Officer or Executive Director;

X X X X X X X● Page/ section references in BC plans, annexes to plans or standalone plans● Action Cards Pages 12 and 47 addendum

7 . 23how mutual aid arrangements will be called into use and maintained;

X X X X X X X● Page/ section references in BC plans, annexes to plans or standalone plans● Action Cards page 33 addendum

7 . 24where the incident or emergency will be managed from (the ICC);

X X X X X X X● Page/ section references in BC plans, annexes to plans or standalone plans● Action Cards Pages 14

7 . 25how the independent healthcare sector may help if required; and

X X X X X X X● Page/ section references in BC plans, annexes to plans or standalone plans● Action Cards Consideration for BCMS

7 . 26the insurance arrangement that are in place and how they may apply.

X X X X X X X● Page/ section references in BC plans, annexes to plans or standalone plans● Action Cards PFI Partners have insured NHS Trust business continuity

Business continuity plans must describe the effects of any disruption and how they can be managed.Plans must include: X X X X X X X

7 . 27 contact details for all key stakeholders; X X X X X X X ● Page/ section references in BC plans, annexes to plans or standalone plans

Part achieved at Departmental level but needs considering as part of BCMS

7 . 28

alternative locations for the business;

X X X X X X X ● Page/ section references in BC plans, annexes to plans or standalone plans

Unlike the MIP which identifies specific areas for specific tasks the BC relies on the Incident Control Team to develop an operational plan around the consequences they are faced with

7 . 29a scalable plan setting out how incidents will be managed and by whom;

X X X X X X X● Page/ section references in BC plans, annexes to plans or standalone plans● Action Cards The MIP and its addendum promote the use of scalable plans

7 . 30

recovery and restoration processes and how they will be set up following an incident;

X X X X X X X

● Page/ section references in BC plan, annexes to plans or standalone plans● Action Cards● Link to IRP (Standard 5.48) if using these arrangements Page 42 MIP

7 . 31

how decisions and meetings will be recorded during and after an incident, and how the incident report will be compiled;

X X X X X X X

● Page/ section references in BC plan, annexes to plans or standalone plans● Action Cards● Sample incident log● Post exercise/ incident reports, showing lessons identified, with an action plan to address gaps Pages41 and 68 MIP and page 54 addendum

7 . 32

how the organisation will respond to the media following a significant incident, in line with the formal communications strategy; X X X X X X X

● Page/ section references in BC plan, annexes to plans or standalone plans● Spokespersons identified and assigned to an Action Card page 23 MIP

7 . 33 how staff will be accommodated overnight if necessary; X X X X X X X ● Page/ section references in BC plan, annexes to plans or standalone plans Page 40 MIP

7 . 34 how stores and supplies will be managed and maintained; and X X - - X X X ● Page/ section references in BC plan, annexes to plans or standalone plans Page 32 Addendum

7 . 35details of a surge plan to maintain critical services.

X X X X X X X ● Page/ section references in BC plan, annexes to plans or standalone plans

Remedial work needed to achieve thisPlan in place - Incident Control Team will evaluate consequences attached to incident and prioritise according

Business continuity plans must specify how they will be used, maintained and reviewed. X X X X X X X

7 . 36

Organisations must use, exercise and test their plans to show that they meet the needs of the organisation and of other interested parties. If possible, these exercises and tests should involve relevant interested parties. Lessons learnt must be acted on as part of continuous improvement. X X X X X X X

● Testing and Exercising programme / log that complies with national exercising standards● Post exercise/ incident reports, showing lessons identified, with an action plan to address gaps Trust conducts annual exercise and BC earmarked for 2014

7 . 37 Plans must identify who is responsible for making sure the plan is updated, distributed and regularly tested. X X X X X X X ● Page/ section references in BC plan, annexes to plans or standalone plans Page 6

7 . 38Organisations must monitor, measure, analyse and assess the effectiveness of their BCMS against their own requirements, those of relevant interested parties and any legal responsibilities. X X X X X X X

● Page/ section references in BC plan, annexes to plans or standalone plans● Reports to Board or Management Teams remedial work required to deliver BCP and BCMS

7 . 39

Organisations must identify and take action to correct any irregularities identified through the BCMS and must take steps to prevent them from happening again. They must continually improve the suitability and effectiveness of their BCMS.

X X X X X X X

● Page/ section references in BC plan, annexes to plans or standalone plans● Business Continuity strategies developed in response to problems identified● Reports to Board or Management Teams● Post incident / exercise debrief reports● Details of expenditure/ investment remedial work required to deliver BCP and BCMS

Business continuity plans must specify how they will be communicated to and accessed by staff. Plans must include: X X X X X X X Copy of plan can be accessed by staff on Intranet

7 . 40

details of the training provided to staff and how the training record is maintained;

X X X X X X X

● Training Needs Analysis● Training schedule● Training materials● Training attendance records


7 . 41

reference to the National Occupation standards for Civil Contingencies and NHS England competencies when identifying key knowledge and skills for staff; (directors of NHS England on-call rotas to meet NHS England published competencies);

X X X X X X X



7 . 42

details of the tools that will be used to make sure staff remain aware through on-going education and information programmes (for example, e-learning and induction training); and

X X X X X X X



7 . 43 details of how suitable knowledge and skills will be achieved and maintained. X X X X X X X



8 NHS Acute Trusts must also include: X - - - - - -

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8 . 1 detailed lockdown procedures; X - - - - - - ● Page/ section references in IRP, annexes or standalone plans Lock Down Plan in place

8 . 2detailed evacuation procedures;

X - - - - - - ● Page/ section references in IRP, annexes or standalone plans

Each unit Department has evacuation plan in place but at present no overarching plan - matter will be forwarded to Trust EPG to consider requirement and risk.

8 . 3 details of how they will manage relatives for any length of time, how patients and relatives will be reunited and how patients will be transported home if necessary; X - - - - - - ● Page/ section references in IRP, annexes or

standalone plans Page s 37 and 40

8 . 4 details of how they will manage fatalities and the relatives of fatalities; and X - - - - - - ● Page/ section references in IRP, annexes or standalone plans Pages 35, 37 and40

8 . 5 Best Practice: reference to the Clinical Guidelines for Major Incidents. X X - - - - - ● Page/ section references in IRP, annexes or standalone plans

Act as Trauma Unit and linked to QE2 - lead A and E consultant Jules Walton

9 NHS Ambulance Trusts must also: - X - - - - -

9 . 1 refer to the National Ambulance Service Command and Control Guidance 2012 and any other relevant ambulance specific guidance relating to major incidents; - X - - - - - ● Page/ section references in IRP, annexes or

standalone plans

9 . 2 manage up to four incidents at a time in urban areas and two in rural areas; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 3 have flexible IT and staff arrangements so that they can operate more than one control centre and manage any events required; - X - - - - - ● Page/ section references in IRP, annexes or

standalone plans

9 . 4 have formal arrangements for recalling staff to duty if necessary; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 5 be able to provide a forward control team if necessary; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 6 have an on-call and an on duty Loggist drawn from a wide pool of staff; - X - - - - -● Page/ section references in IRP, annexes or standalone plans● Action Card

9 . 7 have arrangements to communicate with and control resources from other ambulance providers; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 8 have a 24-hour specialist adviser for incidents involving firearms or chemical, biological, radiological, nuclear, explosive or hazardous materials, and support gold and silver command in managing these events; - X - - - - -

● Page/ section references in IRP, annexes or standalone plans for Tactical Adviser or other specialist (eg HART team)

9 . 9 have 24-hour radiation protection supervisor arrangements in line with local and national mutual aid arrangements; - X - - - - -

● Page/ section references in IRP, annexes or standalone plans for Tactical Adviser or other specialist (eg HART team)● Action Card

9 . 10 make sure all commanders maintain a continuous personal development portfolio; - X - - - - - ● Demonstrate individual use of Personal Development Programme logs

9 . 11 have a Hazardous Area Response Team (HART) in line with the current national service specification, including a vehicles and equipment replacement programme; - X - - - - - ● Most recent HART review report

9 . 12 be able to respond to firearms incidents in line with National Joint Operating Procedures; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 13 have a Mobile Emergency Response Incident Team (MERIT) to cover the area in line with Department of Health guidance; - X - - - - - Not rated in 2013, unless organisation provides evidence

9 . 14 be able to manage a casualty clearing station with large numbers of patients for a long period of time in line with Department of Health guidance; - X - - - - - ● Page/ section references in IRP, annexes or

standalone plans

9 . 15 be able to identify the location and availability of assets across the organisation and the country; - X - - - - -● Page/ section references in IRP, annexes or standalone plans● Action Card

9 . 16 be able to respond with assets across the organisation and the country and provide situation reports to the National Ambulance Co-ordination Centre; - X - - - - -

● Page/ section references in IRP, annexes or standalone plans● Action Card

9 . 17 be able to dispatch and receive assets following an agreed trigger mechanism, supported by a robust audit process; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 18 have a trigger mechanism for requesting mutual aid and a nominated person to agree to these requests, supported by a clear profile of what is required, what can be provided and how the response will be managed in the field; - X - - - - -


9 . 19 have systems to manage the media at Emergency Operational Centres, fall-back locations and across the organisation; - X - - - - -● Page/ section references in IRP, annexes or standalone plans● Action Card

9 . 20 have arrangements in place for routine public events, for example, demonstrations and public gatherings; - X - - - - - ● Detail planning processes employed for routine events

9 . 21 attend safety advisory groups to reduce organisational risk during planning and at the actual event; - X - - - - - ● Detail planning processes ● Demonstrate attendance at SAG/ Tor/ Minutes

9 . 22 have arrangements in place to deal with public disorder incidents; - X - - - - -● Page/ section references in IRP, annexes or standalone plans● Action Card

9 . 23 have arrangements in place to provide radiation protection supervisors; repetition of 9.9 so no need to answer9 . 24 have arrangements in place to train voluntary and community first responders - X - - - - - ● Detail arrangements

9 . 25 have arrangements in place to provide training support to NHS partners in the use of personal protective equipment for chemical, biological, radiological, nuclear, hazardous material and casualty clearing. - X - - - - -

● Detail training arrangements● Training needs analysis● Training materials● Training records

9 . 26 have processes and an audit trail which allow all staff to train with partner agencies; - X - - - - -


9 . 27 have arrangements in place to train with the voluntary sector; - X - - - - -


9 . 28 have arrangements in place to train with acute trusts; - X - - - - -


9 . 29 have arrangements in place to share the outcome of training and exercises with other ambulance trusts and government stakeholders across the country; - X - - - - -

● Detail training and exercising arrangements●Training log/ records/ outcomes report● Exercising programme/ log that complies with national exercising standards● Post exercise/ incident reports, showing lessons identified, with an action plan to address gaps

9 . 30 have strong processes for profiling staff and managing facilities to accommodate EPRR and store assets in line with CCA requirements; - X - - - - - Not rated in 2013, unless organisation provides

evidenceN/R N/R

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9 . 31 have arrangements in place for counselling and supporting staff, and advising on long-term clinical care following a traumatic or high-profile incident; - X - - - - - ● Page/ section references in IRP, annexes or

standalone plans

9 . 32 have suitable IT arrangements in place to support a significant incident or any event that requires specialised IT; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 33 explain the systems for alerting, mobilising and co-ordinating all primary NHS resources necessary to deal with an incident on the scene (in coordination with NHS England area team gold command); - X - - - - -


9 . 34 list their key strategic, tactical and operational responsibilities as set out in the NHS Emergency Planning Guidance 2005 (or subsequent relevant guidance); - X - - - - -


9 . 35 explain how and when MERIT, HART and MIA (the Medical incident Adviser) will be used; - X - - - - -● Page/ section references in IRP, annexes or standalone plans● Action Card

9 . 36 identify how voluntary aid societies will be used; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 37 explain working arrangements with all emergency services; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 38 explain the arrangements for managing triage, treatment and transport for casualties; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 39 state who will represent the service at LHRP, LRF and similar groups; - X - - - - - ● ToR from LHRP, LRF● Meeting minutes

9 . 40 explain the roles of the Hospital Ambulance Liaison Officer (HALO) and Hospital Ambulance Liaison Control Officer (HALCO) in acute trusts; - X - - - - -


9 . 41 refer to other relevant plans such as REAP; - X - - - - - ● Page/ section references in IRP, annexes or standalone plans

9 . 42 explain how the Mobile Privileged Access Scheme (MTPAS) and Fixed Telecommunications Privileged Access Scheme (FTPAS) will be provided across the organisation; and X X - - X X X ● Detail arrangements for MTPAS enabled telecoms

in the service/ invocation arrangements

9 . 43 describe how Airwave systems will be managed within the organisation and how talk groups will be used to communicate with the emergency services. - X - - - - - ● Detail arrangements for use of Airwave

10 NHS England area teams must also: - - X - - - -

10 . 1 make sure that the incident response plans for all providers in an LRF are co-ordinated and compatible; - - X - - - -

● Evidence from LHRP - statement to CCG commissioners that plans of healthcare providers in LRF boundary are coordinated ● Distribution processes for IRP● Briefing to organisations● Peer assessment from other area teams● Meeting minutes

10 . 2 define when the NHS will take the leading role in a significant incident or emergency`; - - X - - - - ● Page/ section references in IRP, annexes or standalone plans

10 . 3 mobilise primary and secondary care resources to support acute and non-acute trusts; - - X - X - -● Page/ section references in IRP, annexes or standalone plans● Action Card

10 . 4 describe the arrangements for setting up a Science and Technical Advice Cell (STAC) in consultation with local Public Health England centres; - - X X - - -

● STAC Plan● Page/ section references in IRP, annexes or standalone plans● Page/ section references to PHE incident response plan

10 . 5 identify who will attend the Strategic Co-ordination Group (SCG); - - X X - - -● Page/ section references in IRP, annexes or standalone plansReferences to tactical coordination group

10 . 6 provide a co-chair and secretariat for LHRPs; - - X - - - - ● TOR for LHRP10 . 7 define the roles and responsibilities of LHRP; and - - X - - - - ● TOR for LHRP

10 . 8 develop plans which demonstrate the command and control of resources from all NHS organisations and providers of NHS funded care within an LRF area to respond to a significant incident or emergency; and - - X - - - - ● Page/ section references in IRP, annexes or

standalone plans

10 . 9 outline how GP services will be delivered 24 hours a day – either directly or through out-of-hours services. - - - - X - - ● Page/ section references in IRP, annexes or standalone plans

11 NHS England corporate and regional offices must also: - - - X - - -

11 . 1 assign an NHS England area team to each LHRP or LRF; - - - X - - - ● Refer to State of Readiness provided in transitional assurance

11 . 2 define how strategic EPRR advice and support will be given to these teams; - - - X - - - ● TOR heads of EPRR and minutes

11 . 3 make sure that area team incident response plans in a region are co-ordinated and compatible; - - - X - - -

● Evidence from LHRP - statement to CCG commissioners that plans of healthcare providers in LRF boundary are coordinated ● Distribution processes for IRP● Briefing to organisations● Peer assessment from other area teams● Meeting minutes

11 . 4 outline the procedure for responding to incidents which affect two or more LHRPs or LRFs; - - - X - - - ● Page/ section references in IRP, annexes or standalone plans

11 . 5 outline the procedure for responding to incidents which affect two or more regions; - - - X - - - ● Page/ section references in IRP, annexes or standalone plans

11 . 6 define how links will be made between the NHS England, the Department of Health and PHE - - X X - - - ● Page/ section references in IRP, annexes or standalone plans

11 . 7 define how the NHS’s ability to respond to emergencies will be measured and controlled; - - - X - - - ● Page/ section references in IRP, annexes or standalone plans

11 . 8 outline how the Department of Health will be supported in its emergency response role; - - - X - - - ● Page/ section references in IRP, annexes or standalone plans

11 . 9 outline how information relating to national emergencies will be co-ordinated and shared; and - - X X - - - ● Page/ section references in IRP, annexes or standalone plans

11 . 10 establish a link between the Regional Prevent Co-ordinator in the NHS England local area and those involved in Protect. - - - X - - - Not rated in 2013, unless organisation provides evidence

N/R N/R

12 CCGs will, in addition: - - - - X - -

12 . 1 carry out their duties as category two responders under the CCA and provide details of how they will do this; - - - - X - -

● Page/ section references in IRP, annexes or standalone plans● Demonstrate attendance at BRF meetings and other planning forums

12 . 2 Core Standard 12.2 has been TRANSFERRED to 10.9 above.

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12 . 3 make sure agreements with providers of NHS funded care include suitable EPRR provisions and categorise funds allocated to EPRR activities (for example, testing and exercising); - - - - X - - ● Terms of National Contract passed on to providers

● Details of negotiations/ funding lines

12 . 4 Core Standard 12.4 has been DELETED. - - - - X - -

12 . 5 define a route for their commissioned providers to escalate issues 24 hours a day, supported by trained and competent people, in case they cannot maintain delivery of core services; - - - - X - -

● Details of escalation procedure● Details of On-call arrangements● On-call manual● If the rota is provided on a cluster arrangement copies of service level agreements that the individual On-call can assume command and control and commit resources, including financial, of the partner organisations

12 . 6 outline how the CCG will carry out its supporting role during and after an incident; - - - - X - - ● Page/ section references in IRP, annexes or standalone plans

12 . 7 Demonstrate the annual plan for training and exercises as part of the duties of a category two responder; and - - - - X - -

● Detail training and exercising arrangements●Training log/ records/ outcomes report● Exercising programme/ log that complies with national exercising standards● Post exercise/ incident reports, showing lessons identified, with an action plan to address gaps

12 . 8 those CCG's with ambulance Trust commissioning responsibilities must ensure, in relation to both planned and non-planned events, that specific EPRR-related services in response are itemised. - - - - X - - ● Terms of National Contract passed on to providers

● Details of negotiations/ funding lines

13 Community pharmacists must also: - - - - - - -

13 . 1 explain how they will support essential care in the community during a significant incident or emergency; - - - - - - - Not to be reviewed in 2013

13 . 2 support hospitals, GPs and ambulance services during the treatment phase of an influenza pandemic or any other public health emergency; - - - - - - - Not to be reviewed in 2013

13 . 3 outline how they will give accurate and specific clinical advice; - - - - - - - Not to be reviewed in 201313 . 4 outline how they will share information with other relevant organisations; and - - - - - - - Not to be reviewed in 201313 . 5 describe how the police or other emergency services can get access to a key-holder list for any pharmacy. - - - - - - - Not to be reviewed in 2013

14 NHS Logistics must also: - - - - - - -

14 . 1 outline how healthcare products and supply chain services can be provided 24 hours a day in times of crisis; and - - - - - - - Not to be reviewed in 201314 . 2 explain how an efficient and effective procurement service can be maintained for NHS organisations. - - - - - - - Not to be reviewed in 2013

15 NHS Protect must also: - - - - - - -

15 . 1 refer to all relevant guidance that provides a safe and secure environment for NHS staff and resources - - - - - - - Not to be reviewed in 201315 . 2 define its aims for managing security issues across the NHS; - - - - - - - Not to be reviewed in 2013

15 . 3 outline how conflict resolution training can be used by all NHS organisations to prevent violence against staff and patients; - - - - - - - Not to be reviewed in 2013

15 . 4 outline how NHS organisations can manage risks relating to economic crime such as fraud, bribery and corruption; - - - - - - - Not to be reviewed in 201315 . 5 describe how their plans will be related to the national threat levels for counter terrorism security; - - - - - - - Not to be reviewed in 2013

15 . 6 explain how threat levels will be based on the broad nature of the threat but could include specific areas of business, geographic vulnerabilities, acceptable risk and specific events; - - - - - - - Not to be reviewed in 2013

15 . 7 describe how NHS sites can be locked down by managing site security and the security of staff, patients and visitors; - - - - - - - Not to be reviewed in 201315 . 8 outline how NHS organisations can access Project Artemis and Project Argus Health; - - - - - - - Not to be reviewed in 201315 . 9 outline how local security management specialists (LSMS) can advise on managing a security culture; - - - - - - - Not to be reviewed in 201315 . 10 outline how NHS organisations can manage specific security issues, for example, VIPs and bomb threats; - - - - - - - Not to be reviewed in 201315 . 11 explain how it will use effective communication strategies to work in partnership with EPRR stakeholders; and - - - - - - - Not to be reviewed in 201315 . 12 establish links with LSMS and Prevent leads in trusts. - - - - - - - Not to be reviewed in 2013

16 NHS Direct / 111 - X - - - - -

16 . 1must also outline how they will support NHS organisations affected by service disruption, including communications and response procedures for significant incidents and emergencies (for example, informing the public and GPs if local emergency departments are closed).

- X - - - - -

● Page/ section references in IRP, annexes or standalone plans● BCP should cover loss of staff, premises, telephony, mutual aid and cross boundary issues ● Commissioning specifications should include provisions for appropriate support

17 Community providers must also: - - - - - X -

17 . 1 take into account how vulnerable adults and children can be managed to avoid admissions, with special focus on providing healthcare to displaced populations in rest centres; - - - - - X - ● Page/ section references in IRP, annexes or

standalone plans

17 . 2 outline how they can assist acute trusts and ambulance services during and after an incident (with reference to specific roles that support discharge from hospital); - - - - - X - ● Page/ section references in IRP, annexes or

standalone plans

17 . 3 where relevant, set out detailed plans for lockdown, evacuation and managing relatives. - - - - - X - ● Page/ section references in IRP, annexes or standalone plans

18 Mental healthcare providers must also: - - - - - - X

18 . 1 co-ordinate and provide mental health support to staff, patients and relatives in collaboration with Social Services; - - - - - - X ● Page/ section references in IRP, annexes or standalone plans

18 . 2 outline how, when required, Ministry of Justice approval will be gained for an evacuation; - - - - - - X ● Page/ section references in IRP, annexes or standalone plans

18 . 3 identify locations which patients can be transferred to if there is an incident; - - - - - - X ● Page/ section references in IRP, annexes or standalone plans

18 . 4 support local acute trusts by managing physically unwell inpatients if there is an infectious disease outbreak; and - - - - - - X ● Page/ section references in IRP, annexes or standalone plans

18 . 5 make sure the needs of mental health patients involved in a significant incident or emergency are met and that they are discharged home with suitable support. - - - - - - X ● Page/ section references in IRP, annexes or

standalone plans

19 Urgent care centres must also: X - - - - X X

19 . 1outline how they can support NHS organisations affected by service disruption, especially by treating minor injuries to reduce the pressure on emergency departments. They will need to develop procedures for this in partnership with local acute trusts and ambulance and patient care transport providers.

X - - - - X X

● Page/ section references in IRP, annexes or standalone plans● Commissioning specifications should include provisions for appropriate support

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Enclosure ix

EPRR Assurance Framework 2013/14 - Rectification Plan The guidance that has been issued to submitting this year’s framework is;

1. The process is set by NHS England. Trusts need to complete their self-assessment and gain approval from both their Accountable Emergency Officer and their Trust Board and then return their completed form to NHS England by Friday 29th November 2013.

2. There is also a need for a rectification plan to show how those areas which are not compliant will be progressed. 3. When NHSE receive the individual returns they will be considered by the respective LHRP’s – probably virtually – and NHS Trust’s then have to produce a report which has to be with NHS

England Regional EPRR Team on January 8th 2104 The below template captures the lessons learnt from the exercise and subsequent hot debrief in which exercise participants contributed to ensuring we action the learning. Action Required By whom and when 5.23 5.25 5.26 5.27

Staff must be aware of the Incident Response Plan, competent in their roles and suitably trained. Key knowledge and skills for staff must be based on the National Occupation Standards for Civil Contingencies. Directors on NHS on-call rotas must meet NHS published competencies. It must be clear how awareness of the plan will be maintained amongst all staff (for example, through on going education and information programmes or e-learning). It must be clear how key staff can achieve and maintain suitable knowledge and skills.

Referenced in plans - previously ad-hoc training has been delivered but identified that more systematic approach is required with an training analysis, need and records to be maintained

Trust EPO is currently preparing SILVER Training package for level 3 managers. Training needs analysis to be agreed through EPG Group. Target to complete March 2014 SILVER Training and training analysis

6.4

All NHS organisations must provide a suitable environment for managing a significant incident or emergency (an ICC). This must include a suitable space for making decisions and collecting and sharing information quickly and efficiently. Facilities and equipment must meet the requirements of the NHS England Corporate Incident Response Plan.

The Hub is devoid of some of preferred equipment listed in appendix 1 NHS CB C and C Framework such as TV with news channel access but the room is considered fit for purpose for most sudden impact emergencies with migration to other sites appropriate to consequences faced of offering necessary facilities' to facilitate command and control

No action required at this since Trust is confident that Hub and associated arrangements are fit for purpose whilst not meeting preferred standard

7.00

All NHS organisations and providers of NHS funded care must develop, maintain and continually improve their business continuity management systems. This means having suitable plans which set out how each organisation will maintain continuity in its services during a disruption from identified local risks and how they will recover delivery of key services in line with ISO22301. Organisations must:

BCMS has been identified as area for development since previous work is now has been superseded by organisational changes introduction of standard ISO22301 and changes to new way of working and BCMS. However, critical areas of Hospital continue

BC Policy and Management System to be introduced by March 2014 through EPG and managed by EPO. BIAs and Departmental Plans owned and delivered by respective Service Unit managers and Directors – target March 2015.

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Enclosure ix

7.1 7.3 7.4

make sure that there are suitable financial resources for their BCMS and that those delivering the BCMS understand and are competent in their roles;

to have individual plans and Trust has organisational plan which examines worst case scenarios including those listed 7.13 post. develop business continuity strategies for continuing and recovering

critical activities within agreed timescales, including the resources required such as people, premises, ICT, information, utilities, equipment, suppliers and stakeholders; and

develop, use and maintain business continuity plans to manage disruptions and significant incidents based on recovery time objectives and timescales identified in the business impact analysis

7.5 Each organisation’s BCMS must be based on its legal responsibilities, internal and external issues that could affect service delivery and the needs and expectations of interested parties.

To be developed in BCP and BIA's

As above

7.6 Organisations must establish a business continuity policy which is agreed by top management, built into business processes and shared with internal and external interested parties.

BCP to be developed As above

7.10 The planning process must take into account nationally available toolkits that are seen as good practice.

The expected new EPRR tool kit is yet to be delivered and progress is being tracked through engagement with LAT. Aim to develop link with Worcester Acute to benchmark and develop good practise

As above

7.11 Organisations must identify and manage internal and external risks and opportunities relating to the continuity of their operations.

2009 work to be revisited and brought up to ISO22301 standard. BIA's to be revisited - A and E, ITU, Mortuary and Neighbourhood Teams current

As above

7.14 Organisations must develop, use and maintain a formal and documented process for business impact analysis and risk assessment.

Remedial work required to deliver BCP and BCMS

As above

7.15 They must identify all critical activities using a business impact analysis. This must set out the effect business disruption may have on the organisation and how this will be overcome, including the maximum period of tolerable disruption.


As above

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7.16 Organisations must highlight which of their critical activities have been put on the corporate risk register and how these risks are being addressed.


As above

7.25 How the independent healthcare sector may help if required; and

Consideration for forthcoming BC work As above

7.27 Business continuity plans must describe the effects of any disruption and how they can be managed. Plans must include:

contact details for all key stakeholders;

Part achieved at Departmental level but needs considering as part of BCMS. The MIP and its addendum promote the use of scalable plans Unlike the MIP which identifies specific areas for specific tasks the BC relies on the Incident Control Team to develop an operational plan around the consequences they are faced with

As above

7.28 alternative locations for the business;

As above As above

7.29 a scalable plan setting out how incidents will be managed and by whom;

As above As above

7.38

Business continuity plans must specify how they will be used, maintained and reviewed. Organisations must monitor, measure, analyse and assess the effectiveness of their BCMS against their own requirements, those of relevant interested parties and any legal responsibilities.

As above As above

7.39 Organisations must identify and take action to correct any irregularities identified through the BCMS and must take steps to prevent them from happening again. They must continually improve the suitability and effectiveness of their BCMS.

As above As above

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Enclosure ix

7.40 7.41 7.42 7.43

Business continuity plans must specify how they will be communicated to and accessed by staff. Plans must include: details of the training provided to staff and how the training record is maintained; reference to the National Occupation standards for Civil Contingencies and NHS England competencies when identifying key knowledge and skills for staff; (directors of NHS England on-call rotas to meet NHS England published competencies); details of the tools that will be used to make sure staff remain aware through on-going education and information programmes (for example, e-learning and induction training); and details of how suitable knowledge and skills will be achieved and maintained.

Informal training is delivered as part of normal business particularly in lad to participation in exercise - recognised that formal package could be delivered as part of PDC training and remedial action to be delivered including formal training needs analysis

To be delivered as part of overall BCMS – target date for completion of overall piece of work March 2015

8.2

NHS Acute Trusts must also include: detailed evacuation procedures;

Each Unit /Department has evacuation plan in place but at present no overarching plan.

Matter will be forwarded to Trust EPG Dec 2013 meeting to consider requirement and risk.

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Enclosure x WYE VALLEY NHS TRUST TRUST BOARD MEETING HELD IN PRIVATE 31ST OCTOBER 2013 COMPANY SECRETARY’S REPORT NHS TRUST DEVELOPMENT AUTHORITY – MONTHLY SELF CERTIFICATIONS 1.0 INTRODUCTION 1.1 There is a requirement for all NHS Trusts to provide the NHS Trust Development Authority

(NHSTDA) with a number of monthly self-certifications in relation to the Foundation Trust (FT) application process. This report details what Wye Valley NHS Trust is required to submit.

2.0 RECOMMENDATION 2.1 For Board Members to approve the self-certifications to be submitted to the NHSTDA by 31st

October 3.0 MAIN BODY OF REPORT 3.1 As part of the NHSTDA oversight and escalation process (detailed within the Accountability

Framework for NHS Boards) each Trust is required to self-report monthly against a number of requirements. These form part of the conversation with NHS Trusts in relation to on-going oversight as well as each organisation’s journey towards a sustainable organisational form. These cover:

• Monitoring progress against the Trust’s timeline to sustainable organisational form

• Compliance against Monitor Licencing Requirements

• Self-assessment against Board Statements.

3.2 The Act requires Monitor to introduce a licence for all providers of NHS services. The Act also requires everyone who provides an NHS health care service to hold a licence. Monitor has issued licences to NHS Foundation Trusts from April 2013 and other providers will require a licence from April 2014.

3.3 The standard licence conditions are grouped into seven sections. Section 1 – General

Conditions, sets out standard requirements and rules for all licence holders. Sections 2 to 5 of the licence are about new functions, Section 6 is about translating the core of the current oversight of NHS foundation trust governance into the new licence based system of regulation. Section 7 contains definitions and notes.

3.4 There are 12 Conditions which apply to Wye Valley NHS Trust. We are required to assess

whether we are compliant, not compliant or at risk of compliance. If we are not compliant or at risk of compliance we are required to comment and give a timescale as to when the Trust will be compliant.

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Enclosure x NHS TRUST DEVELOPMENT AUTHORITY

Oversight: Monthly self-certification requirements - Compliance with Monitor licence requirements

Submission Date: 30th November 2013 Reporting Year: 2013/14 Month: October 2013

1. Condition G4 Fit and proper persons as Governors and Directors Compliant

2. Condition G5 Having regard to Monitor Guidance Compliant

3. Condition G7 Registration with Care Quality Commission Compliant

4. Condition G8 Patient eligibility and selection criteria Compliant

5. Condition P1 Recording of information Compliant

6. Condition P2 Provision of information Compliant

7. Condition P3 Assurance report on submissions to Monitor Compliant

8. Condition P4 Compliance with National Tariff Compliant

9. Condition P5 Constructive engagement concerning local tariff Modifications

Compliant

10. Condition C1 The right of patients to make choices Risk of compliance

The Trust will review its policies and practices in relation to the rights of patients to make choice

Timescale: December 2013

11. Condition C2 Competition oversight Compliant

12. Condition IC1 Provision of integrated care Compliant

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Enclosure x Oversight: Monthly self-certification requirements - Board Statements Submission Date: 30th November 2013 Reporting Year: 2013/14 Month: October 2013 1. Clinical

Quality The Board is satisfied to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight model (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the Trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

Compliant

2. The Board is satisfied that plans in place are sufficient to ensure the on-going compliance with the Care Quality Commission’s registration requirements.

Compliant

3. The Board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the Trust have met the relevant registration and revalidation requirements.

Compliant

4. Finance The Board is satisfied that the trust shall at all times remain a going concern, as defined by the most up to date accounting standards in force from time to time.

Compliant

5. Governance The Board shall ensure that the Trust remains at all times compliant with the NTDA Accountability Framework and shows regard to the NHS Constitution at all times.

Compliant

6. All current key risks to compliance with the NTDA’s Accountability Framework have been identified (raised either internally or by external audit and assessment bodies) and addressed – or there are appropriate action plans in place to address the issues in a timely manner

Compliant

7. The Board has considered all likely future risks to compliance with the NTDA Accountability Framework and has reviewed appropriate evidence regarding the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued compliance.

Compliant

8. The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliver the annual operating plan, including that all Audit Committee recommendations accepted by the Board are implemented satisfactorily.

Compliant

9. An Annual Governance Statement is in place, and the Trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from H M Treasury.

Compliant

10. The Board is satisfied that plans in place are sufficient to ensure on-going compliance with all existing targets as set out in the NTDA oversight model; and a commitment to comply with all know targets going forward.

Compliant

11. The Trust has achieved the minimum of Level 2 performance against the requirements of the Information Governance Toolkit.

Compliant

12. The Board will ensure that the Trust will at all times operate effectively. This includes maintaining its register of interests, ensuring that there are no material conflicts of interest in the Board of Directors; and that all Board positions are filled, or plans are in place to fill any vacancies.

Compliant

13. The Board is satisfied that all Executive and Non-Executive Directors have the appropriate qualifications, experience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.

Compliant

14. The Board is satisfied that: that Management Team has the capacity, capability and experience necessary to deliver the annual plan; and that the management structure in place is adequate to deliver the annual operating plan.

Compliant

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Enclosure xi

WYE VALLEY NHS TRUST TRUST BOARD MEETING ‘IN PUBLIC’ 28TH NOVEMBER 2013 COMPANY SECRETARY’S REPORT [email protected] TERMS OF REFERENCE – QUALITY COMMITTEE 1.0 INTRODUCTION 1.1 The Terms of Reference for the Quality Committee were last reviewed in

December 2012. Final approval of those Terms of Reference, as part of Standing Orders, was given at the Trust Board Meeting in March 2013. It is a requirement of the Terms of Reference that they are reviewed annually or sooner if required.

1.2 The attached Terms of Reference have been reviewed as a result of recommendations made by the Rapid Responsive Review (RRR) which stated:

• ‘Review the Terms of Reference, membership and attendance of

the Quality Committee’.

• ‘Ensure all current risks are reviewed and discussed at the Service Unit Governance Meetings with all significant risks discussed at the Quality Committee. The Committee should include attendance by representatives of the three service units to ensure timely escalation.

1.3 In addition to the above the Quality Committee is recommending to the

Trust Board that the Committee should be an Executive Committee. This was agreed by Members of the Quality Committee due its operational focus.

1.4 The Terms of Reference have been reviewed and amended to reflect the

recommendations of the Rapid Responsive Review and the discussion held at Quality Committee on 21st November 2013.

2.0 RECOMMENDATION 2.1 For Members of the Trust Board to review approve the recommended

changes as a result of the Rapid Responsive Review and the Quality Committee.

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Enclosure xi

Quality Committee 1. Purpose The Quality Committee is an Executive Committee of the Board. The purpose of the Quality Committee is to provide the Board with an independent and objective review of all aspects of quality and safety relating to the provision of care and services in support of getting the best clinical outcomes and experience for patients. To assure the Board that the Trust is aligned to the statutory quality and safety demands of existing legislation relating to all areas of the Trust. To assure the Board through consultation with the Audit Committee, that the structures, systems and processes are in place and functioning to support an environment for the provision and delivery of excellent quality and care services. To assure the Board that where there are issues that may jeopardise the Trust’s ability for the provision and delivery of excellent quality care and services that these are being managed in a controlled and timely way. 2. Membership The Committee shall be appointed by the Board from amongst its Members and will comprise 3 Non-Executive Directors and the Chief Executive, Medical Director, Director of Nursing & Quality, Chief Operating Officer and the Director of Finance and Information. 3. Attendance Service Unit Directors are required to attend where there are relevant agenda items only and to send nominated deputies when they are unable to attend. Other members of staff including senior managers and clinicians will be invited to attend as appropriate by decision of the Committee or the Committee Chair. 4. Chair The Chair of the Committee shall be a Non-Executive Director appointed by the Trust Board. 5. Secretary The Secretary to the Committee shall be the Company Secretary whose duties in this respect will include: • Agreement of agenda with Chair and attendees and collation of papers

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• Taking the minutes & keeping a record of matters arising and issues to be carried forward

• Advising the Committee on pertinent areas. • Ensuring the agenda, papers, and corresponding minutes reflect confidential

items. 6. Quorum A quorum shall be five Members (two Non-Executive Directors and three Executive Directors). 7. Frequency of Meetings Meetings shall be held at least monthly with additional meetings if necessary. 8. Notice of Meetings Meetings of the Quality Committee, other than those regularly scheduled as above, shall be summoned by the Secretary to the Quality Committee at the request of the Chair of the Quality Committee. Unless otherwise agreed, notice of each meeting confirming the venue, time and date together with an agenda of items to be discussed and supporting papers, shall be forwarded to each member of Committee, any other person invited to attend, no later than 5 working days before the date of the meeting. 9. Minutes of Meetings The minutes of Committee meetings shall be formally recorded and made available to the Board. Redacted minutes shall also be made available to members of the public following redaction of all confidential and patient-identifiable, or commercially-confidential content. 10. Duties The 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 member of staff and all members of staff are directed to co-operate with any request made by the Committee. In order to fulfil its purpose the Committee will review:

• The content and effectiveness of the structures, systems and processes for quality assurance, clinical, information and quality governance.

• The Board Assurance Framework (focusing on quality and safety) after discussion by the Trust Executive Management and prior to submission for discussion and approval to the Trust Board.

• The Quality Strategy to ensure continuous improvement is delivered in quality and safety

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• Reports about compliance with external assessment and reporting, e.g. Care Quality Commission’s registration requirements set out in the essential standards of quality and safety, the NHS litigation authority (NHSLA) standards, the National Patient Safety Agency (NPSA) reporting requirements, assessments or reports from the Medicines and Healthcare Regulatory Authority (MHRA) or the Health and Safety Executive (HSE), the reporting framework for serious incidents and any others that may arise in relation to compliance.

• Locally-sensitive quality indicators and metrics to aid continual improvement in the quality of services and the patient’s experience of care and services provided by the Trust.

• The meaning, significance and learning from trends in complaints, incidents and Serious Incidents Requiring Investigation (SIRIs).

• The learning from internal reports, local or national reviews and enquiries and other data and information that may be relevant for understanding quality and safety within the Trust.

The Committee will also:

• Seek to ensure that the quality agenda leads to improvements in quality, productivity and prevention through innovation and seek to develop a robust process for ensuring patient safety is paramount.

• Consider the development and compliance requirements for the NHS outcomes framework, the Trusts Quality Accounts, other KPIs relating to quality measures and how these impact across the organization.

• Ensure active engagement of patients, staff and other key stakeholders on quality and safety matters.

11. Reporting Responsibilities The Committee will report to the Board no less than monthly highlighting discussions that have taken place at Committee meetings and actions which have been recommended in seeking to provide assurance to the Trust Board. The Committee will also report annually to the Board on its work in support of the Statement on Internal Control and by exception as and when necessary. The Groups /Committees stated below will report to the Quality Committee on either a monthly, quarterly or annual basis. Reports will be received by the Committee from the designated responsible Executive Director:

• Annual reports - Point of Care Testing Committee (Medical Director) - Research Committee (Medical Director)

- Blood Transfusion Committee (Medical Director) - Resuscitation Committee (Medical Director)

• Quarterly Reports - Medicines Management Committee (Medical Director)

- Clinical Effectiveness and Audit (Medical Director) - Infection Prevention and Control Committee (Director

of Nursing & Quality)

• Monthly Reports - Mortality Review Group (Medical Director)

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The Committee may work with the Audit Committee specifically when issues arise in relation to the Audit Committees role in maintaining effective systems of governance, risk management and internal control within the Trust. 12. Review

These Terms of Reference will be reviewed annually or sooner if required and recommendations made to the Trust Board for approval. Next Review Date: DD/MM/YYYY 13. Approval Date of Approval: DD/MM/YYYY Approving Body: Trust Board

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WYE VALLEY NHS TRUST TRUST BOARD MEETING ‘IN PUBLIC’ 28TH NOVEMBER 2013 COMPANY SECRETARY’S REPORT [email protected] BOARD AND COMMITTEE REPORTING STRUCTURE 1.0 INTRODUCTION 1.1 The Quality Committee raised concerns regarding the reporting structure

and the possibility that there may be ‘orphan’ Committees which were not accountable to or reporting into any hierarchy. A structure was presented to the Committee in September which Committee Members discussed and requested that the accountable Executive Directors for each of the Committees / Groups be identified within the structure.

1.2 The Governance Reporting Structure, attached at Appendix A, now provides clarity on where each Committee or Group is required to report in addition to who is the accountable Executive Director.

2.0 RECOMMENDATION 2.1 For Members of the Trust Board to note the Board and Committee

Reporting Structure. 3.0 MAIN BODY OF REPORT 3.1 The attached Board & Committee Reporting Structure now provides clarity

on what Committee and Groups are in place and where they report into and are accountable to. It also details the frequency of reporting required.

3.2 The Quality Committee will receive reports from the following through the

relevant accountable Executive Director:

• Mortality Review Group • Infection Prevention & Control Committee • Point of Care Testing Committee • Research Committee • Blood Transfusion Committee • Resuscitation Committee • Clinical Effectiveness and Audit Committee.

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Enclosure xii

3.3 An appropriate cycle of reporting has also been developed. This will be in the form of either a monthly, quarterly or annual report to the parent Committee or Group. This has now been reflected in the Quality Committee work plan and Terms of Reference.

4.0 POLICY AND BUSINESS PLAN CONSIDERATIONS 4.1 It is good governance to have an appropriate and effective hierarchy of

reporting in place which provides assurance to the Committees and Trust Board.

5.0 RISK ASSESSMENT 5.1 Now that the structure has been reviewed and updated the risk associated

with Committee and Groups not receiving appropriate reports or assurance is deemed to be 2 (unlikely) x 2 (minor) = 4 moderate risk.

6.0 CONSULTATIONS 6.1 Each Executive Director, Service Unit Director / Manager and Corporate

Heads of Service has had input into the review of the Governance Reporting Structure.

6.2 The structure was approved by the Leadership Team (now Trust

Executive Management) on 10th September and the amended structure has been agreed with the Chief Executive.

7.0 NEXT STEPS 7.1 Once the structure has been agreed the following will then happen:

• Review all Terms of Reference of the Committees and Groups stated to ensure appropriate and in a standard format.

• Develop a reporting template for use by the various Committees or Groups to ensure that appropriate assurance and evidence is provided.

• Develop Governance Reporting Structures for the Service Units which accurately reflect what meetings are taking place below the Governance Group Meetings.

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Enclosure xii

Trust Board

Audit Committee2

*

Quality

Committee3

Chief Executive

Remuneration

Committee2

*

Charitable Funds

Committee2

*

Medical

Director

Chief

Operating

Officer

Director of

Human

Resources

Director of

Finance &

Information

Director of

Nursing &

Quality

Point of Care

Testing

Committee1

Research

Committee1

Blood

Transfusion

Committee1

*

Medicines

Management

Committee2

*

Resuscitation

Committee1

Mortality

Review

Group3

*

Clinical Audit

&

Effectiveness

2

Education

Committee2

JLNC2 Infection

Prevention

and Control

Committee2

*

Health

Records

Committee1

Child

Safeguarding

2

*

Health &

Safety

Committee2

*

Capital

Planning

and

Estates

Committee

1

Information

& IT Group1

Partnership

Forum1

Policy

Group3

Trust

Executive

Management

Executive

Programme

Group3

Service Unit

Performance

Meeting3

Decontamination

Group2

Cleanliness

Strategy

Group2

Integrated

Family

Health

Services

Governance

Group3

Care Closer

to Home

Governance

Group3

Elective

Care

Governance

Group3

Medical

Devices

Committee

2

Fire Safety

Group1

Asbestos

Management

Group2

Water

Management

Group2

Waste

Management

Group2

Medical

Gases

Group2

Reports to Quality Committee through relevant Executive Director Reports to Trust Executive Management through relevant Executive Director

* Denotes statutory Requirements

1 Annual Report to Board/ Committee / Group

2 Quarterly Report to Board/ Committee / Group

3 Monthly Report to Board / Committee / Group

BOARD & COMMITTEE REPORTING

STRUCTURE

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