December 2013

Table of ContentsSection 1 Executive Summary....................................................................................................61.0 Monitor Scorecard.............................................................................................................7

1.1 Summary Scorecard......................................................................................................8Section 2 Quality & Patient Safety...........................................................................................13

2.1 Executive Summary Headlines....................................................................................13

2.2 Registration with Care Quality Commission (CQC)..........................................................132.3 Incident Reporting August & September 2013................................................................14

2.3.1 Daily Situation Report...............................................................................................152.3.3 Serious Incidents (SIRIs)............................................................................................172.3.4 Inpatient Falls Data...................................................................................................182.3.5 Pressure Ulcers.........................................................................................................20

2.4 Patient Feedback.............................................................................................................232.4.1 Complaints................................................................................................................232.4.2 Compliments.............................................................................................................302.4.3 Patient Feedback Exit Questionnaires.......................................................................312.4.4 Patient Feedback Friends and Family Test................................................................31

2.5 Mortality Data................................................................................................................. 342.5.1 Summary Hospital level Mortality Indicator..............................................................342.5.1 Risk adjusted Mortality Index....................................................................................35

2.6 Infection Prevention & Control Performance...................................................................362.6.1 Clostridium Difficile...................................................................................................362.6.2 MRSA / MSSA Bacteraemia........................................................................................382.6.4 Hand Hygiene Audit..................................................................................................39

2.7 Maternity......................................................................................................................... 392.8 Venous Thrombo-embolism (VTE)...................................................................................39

Section 3 Operational Performance..........................................................................................433.1 Executive Summary Headlines........................................................................................433.2 Operational Performance................................................................................................433.3 Clinical Indicators............................................................................................................43

3.3.1 Emergency Readmissions.........................................................................................433.3.2 Average Length of Stay.............................................................................................443.3.2 Delayed Transfer of Care..........................................................................................46

3.4 Clinical Pathways............................................................................................................473.4.1 Cancer Services...........................................................................................................473.4.2 Stroke........................................................................................................................... 503.5 Emergency Access..........................................................................................................52

3.5.1 Emergency Department (ED) Performance...............................................................533.6 Elective Access...................................................................................................................58

3.6.1 Referral to Treatment (RTT)......................................................................................583.6.2 Referral to Treatment (RTT) Admitted......................................................................583.6.3 Referral to Treatment (RTT) Non-Admitted...............................................................593.6.4 Referral to Treatment (RTT) Incomplete...................................................................61

3.6.5 Choose and Book......................................................................................................623.7 Patient Flow....................................................................................................................63

3.7.1 Morning Discharges..................................................................................................633.7.2 Discharges at Night...................................................................................................64

Section 4 Human Resources.....................................................................................................654.1 Executive Summary Headlines........................................................................................654.2 Workforce....................................................................................................................65

4.2.1 Sickness................................................................................................................674.2.2 Statutory/Mandatory Training................................................................................684.2.3 Appraisal...................................................................................................................684.2.4 Flu Vaccines..............................................................................................................684.2.5 NHS Staff Survey 2013..............................................................................................684.2.5 Leadership Programmes...........................................................................................68

Section 5 Finance Report.........................................................................................................695.1 Executive Summary Headlines........................................................................................69

5.1.1 Statement of Comprehensive Income Position to Date.............................................695.1.2 Statement of Comprehensive Income Position in Month...........................................705.1.3 Savings Plan..............................................................................................................705.1.4 Cash.......................................................................................................................... 705.1.5 External Financing Limit............................................................................................705.1.6 Capital Resource Limit..............................................................................................705.1.7 Capital Cost Absorption rate.....................................................................................705.1.8 Better Payment Practice Code..................................................................................715.1.9 Forecast outturn.......................................................................................................715.1.10 Risk to delivery of financial plan.............................................................................71

5.2 Financial Dashboards 2013/14: Month 8.........................................................................725.3 The Income and Expenditure Position of the Trust..........................................................73

5.3.1................................................................................................................................... 735.4 Expenditure..................................................................................................................... 73

5.4.1................................................................................................................................... 735.4.2................................................................................................................................... 745.4.3................................................................................................................................... 75

5. 5 Savings Plans (SIP).........................................................................................................755.5.1................................................................................................................................... 755. 6 Activity and Income....................................................................................................765.6.1................................................................................................................................... 765.6.2................................................................................................................................... 78

5.7 Penalties......................................................................................................................... 805.7.1................................................................................................................................... 80

5.8 CQUINS........................................................................................................................... 825.8.1................................................................................................................................... 82

5.9 Statement of Financial Position at 31st July 2013............................................................825.9.1................................................................................................................................... 825.9.2................................................................................................................................... 825.9.3................................................................................................................................... 825.9.4................................................................................................................................... 825.9.5................................................................................................................................... 82

5.10 Capital Programme and Performance against Capital Resource Limit..........................825.10.1................................................................................................................................. 825.10.2................................................................................................................................. 835.10.3................................................................................................................................. 83

5.11 Foundation Trust Indicative Financial Risk Rating.........................................................835.11.1................................................................................................................................. 835.11.2................................................................................................................................. 835.11.3................................................................................................................................. 83

5.12 National reference costs 2012-13.................................................................................835.12.1................................................................................................................................. 835.13 Recommendation.......................................................................................................84

Appendix A – Statement of Comprehensive Income – Accumulated Variances as at Month 8 – November 2013....................................................................................................................85Appendix B – Statement of Financial Position as at 30th November 2013.............................86Appendix C - 12 Month statement of rolling cash flow..........................................................87Appendix D - Capital Programme 30th November 2013.........................................................88

The Care Quality Commission published its Inspection Report following their visit to the Trust in November 2013 which details the organisation as compliant with all outcomes. The narrative of the report is very positive and contains some encouraging comments from patients on the care they have received in the Trust.

The refurbished outpatient department was opened in November. The project design had considerable input from patients and has created a modern environment with facilities designed around the services run from the area.

November performance against the ED four hour standard was narrowly missed at 94.4% however significant changes to the pathway for emergency patients presenting to the hospital were made during the month, coupled with building work to further improve the patient flow which was completed in December. This has created a rapid assessment zone/ambulatory emergency care area, a Medical Day Case area and protected Surgical Assessment and Clinical Decision Units. Since the changes were put in place we have seen significant improvement in the Trust’s performance against the Emergency four hour target, being consistently in the top 10% of the country for the winter so far. The approach of all of the Emergency Department and Patient Flow teams has significantly improved the waiting times for non admitted patients.

The Trust has faced a challenging two months in respect of infection control and prevention, particularly Clostridium difficile. There were three cases reported in October and three in November. Additional resources including senior support to the infection control team and pharmacy form part of a Trust-wide plan to improve this position.

Work to improve performance against the eight cancer targets continues, including greater senior management attention in place from November, cancer performance is reported in arrears therefore it is anticipated the impact of these changes will be seen from the next reported figures. The referral to treatment (RTT) targets has continued to be achieved.

The Trust continues to remain on target to deliver the financial plan with actions in place to mitigate the risk of not fully delivering the efficiency programme and the over performance against contract.

Section 1 Executive Summary

1.0 Monitor Scorecard

Colour code Less than 1.0 Green - No or

low risk

1 1Amber – Green

– Limited concerns

2 2Amber – Red –

Material concerns

4.0+

Red – potential or actual breach of

authorisation

1.1 Summary Scorecard

Data reported in arrears - *

Section 2 Quality & Patient Safety2.1 Executive Summary Headlines

The Trust has continued to see a reduction in the Summary Hospital-level Mortality Indicator

The falls performance continued to be below the Trust target for the sixth consecutive month demonstrating that the changes put in place are having the desired impact.

The number of hospital acquired pressure ulcers increased after six months of continuous reduction with 22 in October and 17 in November. The cases have been reviewed by the Tissue Viability Nurse and necessary actions added to the action plan.

Three hospital attributed cases of Clostridium difficile were reported in October and three in November, making the overall number of cases ten against a trajectory of eight. A targeted recovery plan has been put in place. There were no cases of MRSA bacteraemia. One hospital attributed case of MSSA was reported in November.

2.2 Registration with Care Quality Commission (CQC)The essential standards of quality and safety set by the CQC government body are central to our work as a Trust and we are required to meet all of the set standards. Each of the standards has an associated outcome that we expect all people who use our services to experience as a result of the care they receive in Weston Area Health NHS Trust.

The Care Quality Commission revisited the Trust in November and found the Trust fully compliant against all essential standards.

2.3 Incident Reporting August & September 2013Incident reporting systems and policies are integral to patient safety and enable the Trust to analyse the type, frequency and severity of incidents that occur. The Trust’s open and honest reporting demonstrates a commitment to our patients and their safety.

The information arising from these reports is used to make active changes to improve our provision of quality care and to safeguard the wellbeing of our staff and patients.

Figure 1 depicts the number of patient incidents reported each month, compared to previous years.

Figure 1:

There were 310 patient incidents reported in October and 311 incidents reported in November. This is an increase in the number of incidents reported compared to the previous four months. This increase coincides with the release of the Daily Situation Report (explained in 2.3.1).

Analysis of the patient incident data shows that the top three reported incidents are falls, medication and pressure ulcers.

A total of 146 pressure ulcers were reported in October and November (total number of community and hospital acquired pressure ulcers), accounting for 18% of patient incidents. The Trust informs safeguarding adult’s leads across the healthcare community of the community acquired pressure ulcers it finds so that any services (for example nursing or care homes) can be risk assessed and supported by commissioning and local authority colleagues.

104 slips, trips, falls & collisions occurred within October and November.

84 medication incidents were reported. These errors included administration (meaning medication administered orally or intravenously) from a clinical area (such as ward areas),

medication error during the prescription process and preparation of medicines/dispensing. Pharmacy errors accounted for 10 of these incidents. Medications were omitted to be given on 15 occasions; this is a key area of focus for nursing medication improvements with monitoring of missed doses and appropriate follow up action being reviewed weekly. Fifteen incidents related to high risk medications (insulins and anticoagulants). Rapid improvement programmes have been put in place to address administration and monitoring for these drugs under the leadership of Matron Durston.

2.3.1 Daily Situation Report The governance situation report (SitRep), introduced by the Governance Team has been in place since the 1st October 2013. The report is updated and circulated to the Trust Executive and senior managers every Monday, Wednesday and Friday. The SitRep has been used as a management and assurance tool to highlight trends/issues in Trust departments so that the appropriate action can be taken. For example, an increase in incidents of violent and aggression against staff during November triggered both immediate support to affected staff and a review of current practice by the Health and Safety and Security Leads. At different times during November, high use (>3) of bank/agency staff occurred on Harptree, MAU, Uphill, Kewstoke, ACC, Rowan, Hutton, Cheddar, Steepholm and Waterside wards.

Triggers in the report include;

Incidents indicating potential mismanagement of care Increase in concerns reported to PALs Agency/bank usage (nurse – but intending to include medical) Leadership change Failure to respond to CAS alerts in accordance with national timeframes Presence of violent or aggressive inpatients

2.3.2 Staff Incidents

The Trust Health and Safety Committee reviews incident trends and receives reports on incidents reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995. Figure 2 depicts the number of staff incidents reported each month, compared to previous years.

Figure 2:

There were 48 staff incidents reported in October and 47 incidents reported in November. This increase reflects a continuing increase in incidents involving abuse of staff by patients. It should be noted that 11 of the incidents reported involved patients with dementia, or patients with cognitive impairment.

Sample of immediate actions taken as a result of staff incidents

Working group convened to look at Trust processes for management of patient aggression/violence towards staff members      

Urgent review of Trust inappropriate behaviour policy 

2.3.3 Serious Incidents (SIRIs)A Serious Incident is defined in the http://www.england.nhs.uk/ourwork/patientsafety/ (2013) as an incident that occurred in relation to NHS-funded services and care resulting in: 

Unexpected or avoidable death of one or more patients, staff, visitors, or members of the public.

Serious harm to one or more patients, staff, visitors, or members of the public or when the outcome requires life saving intervention, major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm (this includes incidents graded under the NPSA definition of severe harm)

A scenario that prevents or threatens to prevent a provider organisations ability to continue to deliver healthcare services, for example, acute or potential loss of personal/organisational information, damage to property, reputation or the environment, IT failure or incidents in population programmes like screening and immunisation where harm potentially may extend to a large population.

Allegations of abuse Adverse media coverage or public concern about the organisation or the wider NHS. One of the core set of Never Events

Figure 3 depicts the number of serious incidents reported to the Trust in October & November 2013. (October had 5 and November 7). The Trust reported 1 never event during the month of November, relating to a retained foreign object; a 72 hour report was undertaken and the SIRI investigation has been commenced.

Figure 3:

All serious incident reports are reviewed in detail at Divisional Meetings where staff will share their understanding of the causes of each incident and the lessons to be learned. Table 1 illustrates the categories of the serious incidents reported in October and November.

Table 1

Category Grade 1

Grade 2

Operational (e.g. unit closure) 0 0Adverse media attention 0 0Information Governance (e.g. loss of data)

0 0

Clinical Care of patient (e.g. pressure ulcer, delayed diagnosis, avoidable severe harm)

11 1

Safeguarding (e.g. allegation of abuse)

0 0

Avoidable severe harm to staff 0 0

The resultant investigation is reviewed by the local Clinical Commissioning Group and, for the most serious cases, also reviewed by the NHS Trust Development Authority. Between the 1 st

October and 30th November 12 serious incidents are currently under investigation, 1 of which is a never event.

2.3.4 Inpatient Falls Data

Patients fall in hospital for a variety of reasons. These reasons can encompass the following factors:

Chronic health conditions, such as heart disease, dementia and low blood pressure (hypotension), which can cause dizziness;

Impairments, such as poor vision or muscle weakness; Disabilities that can affect balance.

There were 34 patient falls in October and 28 in November. The rate of falls per 1,000 bed days for these months was 4.1 and 3.2 respectively (Figure 4), extending achievement of the falls reduction target for the sixth consecutive month. Two patients had repeat falls in October and one in November, which is a significant reduction compared to the previous period. Falls risk assessments were carried out on 100% of the patients who fell in the two months. There was one patient who suffered a Fractured Neck of Femur in October; root cause analyses of this incidents has been carried out with a review currently being undertaken to ensure all learning is identified so that the necessary improvements are made.

Figure 4:

Trust Actions:

The actions that have been taken to date to reduce the number of falls are continuing and include:

All Wards have reviewed appropriate visible bed spaces for patients at risk of falls.

Enhanced supervision of patients with cognitive impairment and risk of falling. Review of the new NICE guidance issued on falls prevention to ensure all

processes and procedures are in place. Leadership of falls prevention is moving to the physiotherapists to recognise a

multi-disciplinary input required.

2.3.5 Pressure UlcersA pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shearing. A number of contributing or compounding factors are also associated with pressure ulcers: the significance of all these factors is yet to be elucidated (European Pressure Ulcer Advisory Panel, 2009). Pressure ulcers are graded in severity from grade 1 which is early signs of skin damage, i.e. localised redness of the area, to grade 4, where damage extends beyond the skin to underlying tissue e.g. muscle.

There were 22 Hospital Acquired pressure ulcers in October and 17 in November (Figure 5). After 6 months of reducing Hospital Acquired pressure ulcers numbers increased in October but reduced again in November. Investigation of the pressure ulcers found the increase relating to devices. As a result the pressure ulcer action plan (below) was revisited and additional actions added to combat this increase.

The split of community and hospital acquired pressure ulcers in October and November is illustrated in Figure 6.  

Figure 5:

Figure 6:

Trust Action:

The Trust has developed the following action plan to continue performance improvement:

Deliverable ProgressRaised awareness and ownership of pressure ulcer prevention by clinical leaders through weekly dashboard development and discussion at Ward Wednesday feedback.

Pressure ulcer incidents discussed at weekly review meeting.

Review of Tissue Viability champion programme.

Undertaken. TV link nurses to continue. They are expected to carry out an audit each month and feedback results and improvements at link nurse meetings.

Redesign of pressure ulcer prevention care guides.

In place and in use.

Further promotional campaign of what individual staff can do - monthly

First newsletter to be sent to nursing staff mid January.

newsletter.Use Social media and networking to raise profile of Tissue Viability and educate.

Twitter and face book movement has commenced using the Stop the Pressure Game.

Conduct staff survey using Moore and Price attitude survey to understand reasons for non-delivery of reductions to date.

Excellent response from surveys. Responses received from all staff groups indicating a ‘readiness for change’.

Participate in Somerset Pressure Ulcer Prevention collaborative and develop action plan further based on learning from this group.

Planning in place for peer review at WAHT.

Implement round table review for all grade 2 and above pressure ulcers

Round table reviews undertaken weekly since end of August 2013.

Reduce numbers of all device related pressure damage by way of raising awareness to this issue and education.

Smith and Nephew arranged training dates regarding device related pressure damage.

Plaster technician has arranged training sessions with Drs and staff in ED responsible for applying plaster and limb devices.

Review of patient information for patients who have had Plaster of Paris or limb device applied.

The existing patient leaflet is being reviewed. Outpatient clinics are being reminded to check patient understanding during appointments.

Training day /update regarding pressure relieving equipment.

Event run and further sessions being planned.

Tissue Viability Lead and one TV link Nurse to attend Tissue Viability event in Birmingham.

Tissue Viability nurse to share the learning gained from this at next TV Link nurse day and Ward Wednesday meeting with Sisters.

Improve pressure ulcer prevention care, using a controlled trial in a specific ward area by using electronic AVIN Patient Minder System.

Pilot/trial area identified. Meetings arranged to agree dates to commence trial and develop a project plan.

2.4 Patient Feedback2.4.1 Complaints Complaints management is critical to ensuring the Trust not only responds to the complainant in a timely manner, but to ensure the learning from complaints is translated into action. Complaints data enables the Trust to determine if there are any trends in subject matter, location or personnel.

Table 2 portrays that the total number of complaints received in October was 24 and November was 12. The number of complaints received equate to 1.3% of all inpatients in over this period. This is against inpatient activity of 2,777 Emergency Department attendance of 7,768 Outpatient Department attendance of 18,327 and Day case activity of 2,413. The Trust was also pleased to receive and record 271 compliment letters during October and November.

All complainants are offered the opportunity to meet with relevant staff should they wish. Five complaint resolution meetings were held in October and November resulting in satisfactory resolution. Should complainants remain unsatisfied with the final response from the Trust, and all options for internal resolution have been exhausted, complainants are advised of the option to refer their complaint to the Complaints Ombudsman. Two complaints were referred to the Complaints Ombudsman in October and November.

Table 2:

Jan Feb Mar Apr May

Jun Jul Aug

Sept Oct Nov

Dec

2012 22 28 26 16 36 25 25 18 26 21 19 16

2013 17 22 21 19 11 14 17 21 12 24 12

The Trust aims to provide a full response to all complainants within 30 working days. The response time to complaints as demonstrated in Figure 7 demonstrates the commitment of the Trust to resolve complaints in a timely manner. The response rate of 42% in October and 58% in November achieved by the Trust did not meet the 80% standard required. The patient experience manager has been meeting with the Heads of Nursing for the two clinical divisions to support the complaints process to ensure that high quality complaint responses are produced within the Trusts target.

Figure 7:

Figure 8 depicts that 10 complainants cited the Emergency Department over the last two months. The Emergency department sees the highest volume of patients and activity, wherein an attendance of 7,768 patients were seen in October and November, hence the complaints received equate to only 0.10% of patients seen in the department.

Figure 10:

Harptre

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Emerg

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Depart

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Pharm

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Medica

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t Unit

Seasho

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wan

Assess

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Centre

General

Medi

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Facilit

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Steeph

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Access

Team

Urology

Gastro

Ashcom

be

Day Case

Unit

Color

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Orthop

aedic

Watersid

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Endosc

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Gynaeco

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0

10

20

30

40

50

60

70

The Number of Complaints Recieved by Department/Wardper Month

Nov-13Oct-13Sep-13Aug-13Jul-13Jun-13May-13Apr-13Mar-13Feb-13Jan-13

Figure 11:

15

13

25

7

5

10

4 3 1

The Themes from the 36 Complaints - October and November 2013

Medical TreatmentNursing careCommunicationDischargeDelay appointment/treatmentAttitudeDiagnosisMedication Dignity

* The pie chart depicts the number of themes expressed in each of the 12 complaints.

Figure 11 depicts the themes identified from the 36 complaints received in October and November 2013.

Communication – 21 = 58%

The main theme of complaints for the past two months was communication. Patients have raised concerns with communication from both nursing and medical staff and in some cases they felt they had been forgotten or ignored. Families have also raised concerns about feeling left out of the discharge planning process. These complaints are being fully investigated in order to identify what can be improved.

Medical Treatment – 6 = 25%

Medical treatment was one of the main themes for October and November for complaints. Patient satisfaction of the treatment from the doctor from the exit questionnaires showed an improvement in October but dipped again in November.

Nursing Care – 6 = 25%

The number of complaints linked to nursing care significantly increased in October but this increase was not repeated in November. This trend is also reflected in the patient feedback. Improvements continue to be made to nursing care and dignity in care through initiatives such as Ward Wednesdays which are continuing to help the Trust focus on improving nursing care.

Table 3 shows three examples of the 36 complaints resolved by the Trust in October and November.

Table 3:

COMPLAINTSComplaint Trust Response

A patient who was transferred to the rehabilitation ward was not welcomed to the Unit. The patient experienced a long delay on discharge due to medication not being ready.

A new senior sister has recently been appointed to the rehabilitation unit. As a result of the complaint the sister met with the team and clarified the importance of good communication with the patient and family. The sister has also put in place a process where all wards in the main hospital ring before transferring a patient to the rehabilitation unit to ensure a nurse is available to welcome the patient and the family.

A pathway facilitator role has been introduced across the Trust, with one identified for the rehabilitation unit. This individual will work with the family, nursing and clinical teams to facilitate a high quality discharge for the patient.

A mother was not happy that the initial referral for her child to see a specialist at Drove Road was lost. The child was subsequently added to a long waiting list with no further communication.  The child should have been seen as a priority

Steps have been taken to minimise the risk of this situation arising in the future. From September 2013, all referrals are now centrally managed and details are entered onto an electronic database as soon as the referral is received. This will allow admin staff to quickly and easily check that a referral has been received and processed. This will also enable staff to advise parents of the likely length of wait for an appointment. The Trust is currently reviewing options for bringing the waiting list down to below the national standard of 18-weeks by March 2014. This will include identifying additional resources, the option of extending locum cover, and reviewing whether some care could be provided by specialist nurses rather than consultants in the first instance. A review of the admission criteria for community paediatrics is being undertaken and as part of this process we will be reissuing advice to GPs on the level of detail which is required, and writing to GPs where this is not provided to ensure that we always have adequate information to identify those patients who should be seen as a priority.

A patient contacted us to say that they were unhappy about the way they were treated by the Radiology staff; they also felt that they were being rushed. There was a delay in receiving the results and the terminology used in the report was not as sympathetic as it could have been to the personal circumstances of the patient.

The complaint has given the x-ray department a valuable insight into a patient’s experience and has served to remind staff to listen carefully and respond to patients concerns. The Radiologist has considered the report wording and is in the process of reviewing the need to adapt. A shortage of reporting staff contributed to the significant delay in reporting the patients results, the x-ray department recognise that this is a serious issue and have addressed it by reviewing the staffing levels and reiterating the importance of reporting within the set time frame.

2.4.1.1 Review of Complaints ManagementThe patient experience manager has undertaken a detailed review of the way the Trust currently manages complaints focusing on the following reports:

Patients Association – Good Practice Standard for NHS Complaints Handling NHS Hospitals Complaints System – Putting Patients Back in the Picture by the Right

Honourable Ann Clwyd MP and Professor Tricia Hart October 2013. Parliamentary and Health Service Ombudsman Helping more people by investigating

complaints about the NHS September 2013 Parliamentary and Health Service Ombudsman The NHS Hospital complaints System a

Case for Urgent Review April 2013

The main findings from the reports are:

1. People need to be able to raise concerns on the ward. Immediate listening, responding and action to prevent formal complaints, a good opportunity to learn from mistakes.

2. A simple easy to understand complaints process for complainants. Good sign posting and understanding of formal complaints by staff is also required.

3. Fear that a complaint might lead to poorer care. 4. Concerns to be investigated to be agreed at the outset.5. Complainants must be kept informed.6. Complaints must be risk rated.7. Apologise when things go wrong, however apologies must be sincere and show

compassion and sensitivity. The emotional trauma suffered is often ignored.8. Concerns are not responded to appropriately; simply things are not resolved without

the need for a formal complaint. 9. The investigation does not match the seriousness of the issues involved.10.The investigation process is not always thorough or appropriately evidenced.11.Complaints are not always dealt with promptly.12.All concerns are not covered if the complaint crosses boundaries.13.Complaints do not always result in change – making a difference14.There is not always independence in an investigation when there are serious care

failings. 15.Transparency of outcome from the investigation when making decision to uphold or not

uphold is not always demonstrated. Based on the balance of probability.16.Responses need to be clear adequate and accurate 17.Complaint documentation is accurate and complete18.Boards need to learn from the experiences of patients and then take action to improve

services. The information provide to boards should be more that bare statistics. Listening to patient stories and checking necessary actions are taken to resolve issues.

19.Accountability for complaints must run from ward to board it is everyone’s business.

The findings have been matched against our current complaint process. In order to ensure that best practice is being followed, it has been identified that further improvements are needed. The complaints manager has discussed the improvements with both Heads of Nursing who lead complaint management within the two Divisions and action is being taken.

2.4.2 Compliments The Trust received 271 compliments in October and November. Compliments formally recorded are received via email or letter. Table 3 depicts three examples of compliments received by the Trust in October and November. Where appropriate each compliment receives a letter to thank the individual for taking time to comment. Fewer compliments were received in October than for any other month this year.

Table 4:

COMPLIMENTSA thank you letter from a

daughter for the outstanding care that was given

to her mother in the last days of her life on the

Medical Assessment Unit

We would like to thank all of the staff who took care of mum on the ward, we could not have asked for more. In particular we would like to thank one nurse who cared for her the day she passed away; the nurse

was caring and attentive to both mum and the family, an excellent nurse. Anyone who has this nurse take care of a member of their family

I know will have the best care.

Once again a big thank you from all the family.

As part of a complaint a

family member included a note of praise for the

Stroke Unit

We would like to put on record the excellent care and dedication of your staff on the Stroke Unit. The staff were always available to answer any questions we had and would often volunteer updates to us upon our

visiting. In view of mum’s need (dementia) we spent many hours in the ward and were able to witness firsthand how care and attention was

given to all the patients on the ward. The staff obviously work well as a team and the atmosphere was always positive and happy which we

believe is a major factor in aiding recovery.A patient’s

relative thanked the receptionist and ward clerks for the fantastic customer service

I just wanted to say a big thank you to all the lovely reception staff for always being so helpful and friendly. It makes a huge difference to

relatives of patients especially when I came to visit my Grandfather. The staff at other hospitals could learn a lot from you.

2.4.3 Patient Feedback Exit QuestionnairesA total of 1,327 completed questionnaires were received in the two months; October and November. All wards are participating in the exit questionnaire and the overall response rate is improving in most areas. Satisfaction in October and November is demonstrated in Table 5. The key area highlighted for improvement this month is discharge although medication and treatment from doctors also remain a priority.

The Trust is undertaking a number of actions to raise the profile of medication administration across all areas. Audits are currently being undertaken on wards in relation to medication administration and missed doses. The medication management group has developed and action plan and driver diagram with the aim of improving standards.

In mid November Cheddar had a change in speciality to care of the elderly. The ward manager is currently looking to recruit volunteers to help with gathering patient feedback and other tasks.

Table 5:

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov TrendTotal questionnaires received.

188 337 332 582 707 612 764 855 769 750 577

Doctors talked about their care.

91.1 91.1 88.3 82.8 92.2 84.5 90.2 83.5 87.9 87.2 90.3

We listened to patients.

94.1 88.7 94.6 88.8 89.5 90 91.9 94.7 92.7 89.6 87.1

Nursing care was good for the patient.

96.8 95.8 97.6 97.1 95.6 84.3 91.8 96.7 96.7 92.8 96.8

Treatment from the Doctors was good.

92.6 85.5 73.5 84.4 85.7 87.7 88.6 91.5 90.1 93.4 88.2

Treated with dignity and respect.

97.3 94.4 94.6 89.2 96 91.5 92.7 95.9 94.8 92.7 96.8

Discharge home had been planned well.

77.7 68.6 80.4 80.8 81 89.1 77.2 87.9 86.2 88.3 84.6

Medication had been explained.

81.9 76.9 76.5 77.8 87.7 90.4 87.7 85.3 84.8 84.8 87.1

What did they think of the war/dept .

93.1 88.4 91 88.3 90.1 96.6 92.5 92.2 93 94.1 93.5

Patient feedback from the exit questionnaires for all wards and departments

2.4.4 Patient Feedback Friends and Family TestAs a national requirement the Trust is engaging in the delivery of the Friends and Family Test (FFT). This test has been implemented successfully across all areas. The Friends and Family Test is a single question survey which asks patients whether they would recommend the NHS service they have received to friends and family who need similar treatment or care. This encompasses Inpatients and Emergency Department attendees.

The Friends and Family Test Survey is offered to all patients at the point of discharge or on attendance at the Emergency Department. The Trust has chosen to include additional

questions in this survey to generate a richer database to inform learning and change. Each Division and ward receives a breakdown of the outcome of their survey results to ensure they can take relevant action.

Table 6:

November Total Response

s

Total Eligible

Response Rate

Friends and Family Test

Score

Extremely Likely

Likely

Neither

Unlikely

Extremely

Unlikely

Don't Know

Inpatients 198 684 26.1 67 134 45 11 2 4 2Emergenc

y Departme

nt

323 2521 14.5 65 230 76 10 5 1 1

Maternity 38 294 12.9 58 26 7 4 0 0 1

Using the data above the net promoter score is calculated using the proportion of patients who would strongly recommend minus those who would not recommend, or who are indifferent. In October the score for our hospital was 65 and for November the score decreased slightly to 64 out of a possible 100.

Five areas achieved a net promoter score of less than 60: Harptree, Rowan, Berrow, Stroke Unit, and Waterside which impacted negatively on the Trust score, as demonstrated in Figure 12/13. Rowan and Hutton failed to submit any results for October which also contributed to the low score. However they both reported results in November. Waterside, Kewstoke, Hutton wards, MAU and A&E did not achieve the required 15% response rate.

The Head of Nursing for the Emergency Department is setting up a working group to review what improvements can be made in gathering patient feedback.

The friends and family test results are being fed back to Divisional Management and continue to be discussed at each Ward Wednesday meeting where good practice is being shared and ideas for improving response rates. Permanent ward sisters have recently been appointed on Uphill and Rowan wards providing consistent leadership and helping to improve the focus on gathering patient feedback.

Figure 12: Net Promoter October 2013

Figure 13: Net Promoter November 2013

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ACC ED

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0102030405060708090

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Table 7 compares the Trust family and friends test response rate and net promoter score with the average scores for NHS acute services across England. The responses are divided into two categories; inpatients and Emergency Department attendees. The data highlights that overall our response rate is comparable to the national average however continuous improvements in service delivery and patient experience are necessary to improve our net promoter performance.

Table 7:

2.5 Mortality Data2.5.1 Summary Hospital level Mortality IndicatorThe statistic used to measure Trust mortality is called the Summary Hospital Mortality Indicator or SHMI. Its calculation takes into account all inpatient hospital deaths as well as those which occur within 30 days of discharge from hospital. The latest SHMI figure for the Trust covers the period April 2012 to March 2013. The Trusts SHMI has improved once again from the previous value of 1.03 to the current value, 1.01. This index represents deaths which occur both within the Trust and those which occur in the 30 days following discharge from hospital.

Figure 13: SHMI for the 12 months beginning April 2012

Figure 14 illustrates the SHMI position of the Trust for the same period as above but for deaths solely within the Trust itself.

Figure 14:

Apr May Jun Jul Aug Sep Oct NovRe

spon

se R

ate Inpatient Trust 24.4% 23.9% 25.2% 29% 20.6% 30.7% 26.1% 28.9

%England 21.5% 24.0% 27.0% 27.9

%28.7% 29.4% 30.7%

A&E Trust 11.0% 13.9% 12.0% 13.3%

16.7% 14.7% 15.5% 12.8%

England 5.6% 7.5% 10.3% 10.4%

11.3% 13.2% 13.8%

Net

Pr

omot

er

Inpatient Trust 63 64 64 65 62 59 67 64England 70 70 71 70 71 71 71

A&E Trust 57 78 42 55 72 68 65 66England 49 55 54 54 56 52 55

The In Hospital SHMI is 68.8 and is approaching the top quartile performance which starts at 66. The previous value for the In Hospital SHMI for the period January 2012 to December 2013 was 69.

One of the most frequent causes of death in the Trust as a result of the local demogrpahics is Bronchopneumonia. Table 8 illustrates the Trusts performance is very close to what might be expected give the characteristics of the patients who the Trust treats.

Table 8:

Diagnosis Trust Peer PerformanceBronchopneumonia with Major CC 201 198

     

2.5.1 Risk adjusted Mortality IndexThe index solely relates to inpatient deaths. Figure 15 illustrates the Trusts performance for the period December 2012 to November 2013 and demonstrates performance which is just outside the top quartile but within the expected range.

Figure 15:

2.6 Infection Prevention & Control Performance

2.6.1 Clostridium DifficileThree hospital attributed cases of Clostridium difficile were reported in October and three in November. Ten cases have now been reported this financial year against a target of eleven. This will make it very difficult for the Trust to achieve its target this financial year. As a result of the level of Clostridium difficile being above trajectory the Infection Prevention and Control Team have re-reviewed all cases in detail, looked at national and international best practice and reviewed current procedures and processes and developed a detailed action plan to improve performance.

Action Progress

Designate Infection Control Nurse as C diff lead daily who will review all patients with specimens sent to lab. Review of all admissions

This has been implemented and is being evaluated as to the benefits

Introduce risk assessment tool for diarrhoea

Tool being modified from an original kindly shared by Coventry and Warwick Trust. Risk Assessment for patients with diarrhoea produced to be implemented January 2013

Enhanced monitoring of antibiotic prescribing and increased challenge

Microbiologists are undertaking antimicrobial ward rounds. Reports on antibiotic prescribing compliance are being discussed with Divisions monthly. Enhanced antimicrobial stewardship is planned from January 2014 with the appointment of a locum pharmacist to focus on this issue

Review of environment on Rowan Ward

A review has been completed with recommendations for the environment

Enhance leadership to infection prevention and control across the health community and work with commissioners and community partners to prevent community acquired infection

Appointment to a senior infection control programme lead has been made from January 2014. This post will be based at the hospital with outreach to community settings. The focus of this post will be C diff and Norovirus prevention

Figure 16:

2.6.2 MRSA / MSSA BacteraemiaThere was one hospital attributable case of MSSA bacteraemia reported in November. This was a patient admitted with a MSSA bacteraemia but this reoccurred 3 weeks later. No source was identified for the first bacteraemia; the second may be related to an elbow problem. This case is currently being investigated to establish if it could have been prevented. There were no cases of MRSA in October and November.

2.6.3 OutbreaksIn October there were no outbreaks of diarrhoea and vomiting. However, on the 25 th

November there was an outbreak on Uphill ward and on the 27th November a second outbreak on Kewstoke. The details of the two outbreaks are shown in Table 9. A full review of the outbreaks was undertaken with actions implemented by the Infection Prevention and Control Team. In preparation for winter the Health Community is using a Norovirus toolkit produced by Public Health England to inform prevention activities

Table 9:

Ward Date ward

closed

Date ward

opened

No of patien

ts affecte

d

No of staff

affected

Norovirus

confirmed

No of days ward

closed

Uphill 25.11.2013

30.11.2013

9 3 Yes 5

Kewstoke 27.11.2013

1.12.2013 9 3 No 4

2.6.4 Hand Hygiene Audit Internal audits reported Trust wide compliance for the question 'Are hands decontaminated at the five moments determined by the World Health Organisation?' as 99%

2.7 MaternityIn October and November the Trust achieved the national target for 78% of mother initiating breast feeding in hospital with a score of 85% and 92%. However, smoking cessation experienced a dip in performance in October (72%) but this recovered to achieve the national target in November ensuring the Trust was on target to achieve performance against both national targets for quarter three 2013/14.

Trust Action:

The consistent achievement of the breast feeding target is as a result of the continuous work by the Ashcombe Birthing Centre in becoming an accredited Baby Friendly Maternity Facility. The Baby Friendly Initiative is a worldwide programme for the World Health Organisation and UNICEF. It was established in 1992 to encourage maternity hospitals to implement the Ten Steps to Successful Breastfeeding. The team are continuing to build on this achievement providing mothers with the best information and support to encourage breastfeeding.

2.8 Venous Thrombo-embolism (VTE)Figure 17 illustrates the percentage of patients at Weston Area Health NHS Trust undergoing a VTE risk assessment (RA) against the national picture using the National Patient Safety Thermometer. It can be seen that the Trusts performance is better than the national picture and has improved over the past four months.

Figure 17:

Figure 18 highlights variable performance of patients with a new VTE as captured using the National Patient Safety Thermometer. However, from May 2013 there has been an overall decline in the number of hospital acquired VTE’s.

Figure 18:

However, despite the improvement in performance as illustrated in the National Patient Safety Thermometer, performance against the completion of the VTE Risk Assessment Using the National Tool on admission after four months of continuous improvement reduced in November to 81.7%. Improvement against this target has led to the introduction of the VTE Committee run and led by Trust clinicians. Below is the action plan developed by the committee to improve performance.

Trust Action:

Action Progress Submission of all party parliamentary

VTE Score card Complete

Monthly presentation of (NHS Safety Thermometer) VTE assessment figures at

Junior Doctors Forum

Complete. Junior Doctors now involved in collecting and presenting data at the VTE

Committee. Audit of VTE assessment compliance

against national guidelines feeding CQUIN 

Regular agenda item at ongoing VTE and Divisional meetings

Monthly Prevalence audit of VTE assessment and prophylaxis  compliance

using NHS Safety Thermometer

Complete. Junior Doctors now involved in collecting and presenting data at the VTE

Committee. Inclusion of VTE measures from Safety

Thermometer in Ward Performance Assurance Framework

Complete

Review of medication incidents regarding VTE prophylaxis

Complete. Analysis of incidents has been conducted by Medicines Management Group.

Revised Medication chart including proforma for TEDS and TINZ and VTE

Assessment forms as integral

Initial pilot to commence on MAU throughout December.

Revised clerking proforma including VTE risk assessment  

In line with local Trusts and following feedback from current Junior Doctors the paperwork has been trialled to include the VTE assessment in

the prescription chart. Carry out root cause analysis for VTE  Complete. Sharing results at clinical forums.

All patients to receive anti thrombolytic stockings, where appropriate 

Complete

Further raise Awareness of VTE assessment amongst clinical staff via new

newsletter

Complete. Production of monthly newsletter with regular article featuring ward compliance

of VTE assessment. Gain Consultants' awareness and engagement by highlighting and

publishing individual compliance re VTE assessment

Development of consultant specific report currently being compiled.

Trust to have zero tolerance to poor compliance with VTE assessment and

prophylaxis

Culture of reporting cases via Datix system is progressing.

Section 3 Operational Performance 3.1 Executive Summary Headlines

Performance against the 95% four hour Emergency Department standard was 92.4% in October and 94.4% in November.

The Trust achieved six of the eight Cancer targets during both September and October (reported one month in arrears).

The stroke target of 80% of stroke patients spending 90% of their time on the stroke unit was again achieved in October and November, the fifth consecutive month.

All three 18 week RTT targets were achieved for October and November

3.2 Operational Performance

The following sections detail the Trust performance against a number of key indicators. The report is divided into:

Clinical Indicators Clinical Pathways Emergency Access Elective Access Patient Flow

3.3 Clinical IndicatorsThis section analyses the clinical indicators which directly influence operational performance.

3.3.1 Emergency Readmissions

An emergency readmission is defined as an unplanned readmission within an identified time of leaving the hospital. The ideal readmission rate is zero however this is not always possible as patients can have multiple co-morbidities or long-term conditions which require frequent medical attention. Monitoring emergency readmission rates is important to the Trust as it can help to prevent or reduce unplanned readmissions to hospital. The Trust monitors emergency readmissions within 14 days and 30 days. As demonstrated in Figure 19 performance improved between October and November.

Figure 19:

October November October November TrendPlanned Care 3.80% 2.80% 6.00% 3.10%Emergency & Urgent Care 10.90% 7.50% 14.30% 8.60%Trust Total 7.20% 5.10% 9.90% 5.80%

14 Days 30 Days

Trust Action:

The Trust will continue to assess every emergency readmission to the Trust on a monthly basis. When an avoidable emergency readmission is identified, the details are sent to the lead clinician of the managing specialty to undertake a review and share any learning with their teams.

3.3.2 Average Length of Stay

The average length of stay (ALOS) refers to the average number of days that patients spend in hospital. The Trust strives to have a length of stay below the Trust target as it demonstrates proactive planning of the whole process of care, as well as active discharge planning. As demonstrated in Figure 20 the Trust continued to have a length of stay below the Trust target for four consecutive months.

Figure 20:

The Trust also monitors the percentage of patients with a length of stay (LOS) over 10 days. Figure 21 demonstrates that in October and November the Trust experienced a static position in keeping with the average length of stay.

Figure 21:

Trust Action:

With partners OR International, the Trust is focussing on improving patient flow and has developed the work stream to focus on five distinct areas:

1. Discharge - ‘Home by 11am’2. Pharmacy Process Improvement3. Physiotherapy Process Improvement 4. Discharge Summaries5. Multi-Disciplinary Ward Rounds.

Each area has been reviewed in detail by international specialists with robust actions plans developed alongside the teams. Project management support is in place to ensure that actions are completed by agreed dates and the Performance team are ensuring that this is having the desired impact on performance. These projects will directly have an impact on ALOS and LOS over 10 days which are consistent and within target since the programme started.

The Trust has developed its winter plan and has implemented the new services using the national ‘winter funds’ allocated to North Somerset alongside local health and social care partners. Performance of the system is monitored daily on system wide calls underpinned by a shared performance scorecard.

3.3.2 Delayed Transfer of Care

A delayed transfer of care is defined as when a patient is ready for transfer from acute care, but is still occupying an acute bed. Patients can be delayed for the following reasons:

Further assessment required before their discharge destination can be decided; Lack of capacity in local nursing/residential homes; They may require a specialist placement; Patient or their family/carer needs more time to make a decision about a long-term

placement.

The Trust monitors performance against delayed transfers of care as high levels can have a big impact on the daily numbers of discharges, causing delays in allocating beds for emergency admissions or planned operations. In October the Trust experienced a huge

increase in delayed transfers of care to 16.67%, but actions put in place in November led to performance improving to 4.35%.

Figure 22:

Trust Action:

As a result of Octobers performance the Trust agreed with health and social care partners in North Somerset to introduce the ‘Green to Go’ list. This list is produced at ward level and provides the details of all patients on the ward who are signed off by the consultant in charge of the patients care as medically fit, but require further support to be discharged from the Trust. This list is sent out daily with partner organisations feeding back progress. The health and social care community has agreed a target to reduce the numbers of patients on the list, supporting the Trust to reduce the level of delayed transfers of care, improving patient experience and flow.

This patient group is also targeted by the ‘Home by 11am’ programme which aims to improve the discharge process for patients by improving the management of their care pathway. As part of the new initiative patients will be communicated to at the start of their stay regarding their discharge home. This gives patients the time to prepare and for support to be arranged prior to discharge, enabling a smooth and safe transition from the Trust, reducing delayed transfer of care.

3.4 Clinical Pathways

This section sets out performance indicators related to key clinical pathways, including cancer, stroke and fractured neck of femur.

3.4.1 Cancer Services

The Trust strives to achieve the national cancer waiting times as they are important to patients clinical outcomes, are a measure of how the Trust is responding to demands for services, and highlights where there are delays in the system. Figure 23 provides the levels

of breaches against each target for September and October by specialty, with each target individually reviewed in the following sections.

Figure 23

Two Week Wait Standard Speciality No of breach

es

No of breach

esPercentage patients seen within 2 weeks for all urgent referrals

BreastColorectal

GynaeHaematologyHead & Neck

LungSkin

Upper GIUrology

062002212

142012703

Percentage patients seen within 2 weeks for referrals for breast symptoms

89.58% 97.44%

62 Day StandardPercentage patients treated within 62 days from GP Referral

BreastColorectal

GynaeHaematologyHead & Neck

LungSkin

Upper GIUrology

0211

0.50.50

1.51

01.52.500

0.50

1.53

Percentage patients treated within 62 days from Consultant Upgrade

75% 80%

Percentage patients treated within 62 days from Screening Programme

NIL NIL

31 Day StandardPercentage of patients receiving first definitive treatment within 31 days of a cancer diagnosis

NIL 50%

Subsequent TreatmentPercentage of patients receiving subsequent treatment for cancer within 31 days where that treatment is Surgery

100% 100%

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

NIL NIL

3.4.1.1 Cancer Two Week Wait

The two week wait target was achieved in September and October for the fourth consecutive month. However, in September the Trust did not achieve the breast symptomatic two week wait target. This was mainly as a result of patient choice for the second consecutive month. This was discussed with the referring GP Practices and the CCG, raising awareness of the need to ensure patients are available to attend if place on a fast track pathway and fully understand the importance of being seen in this short time frame. As a result the target was

achieved in October and further work is taking place with the local GP’s regarding the cancer access policy.

Trust Action:

The Trust has appointed a new Cancer Manager who will be monitoring performance on a daily basis and link with the booking team to ensure patients are seen within the nationally defined timescales.

The cancer access policy is being reviewed and plans are in place to jointly agree the process with the referring GP Practices.

The cancer targets are a standing item on the weekly Waiting List Forward Planning meeting agenda to ensure any potential issues are highlighted early and escalated appropriately to ensure there are no avoidable breaches of the target.

3.4.1.2 31 Day Target

The Trust achieved 97% and 98% in September and October respectively against a target of 96% for all patients following a cancer diagnosis having their treatment within 31 days.

Trust Action:

Daily monitoring of performance by the MDT Coordinator and cancer team leader.

Weekly monitoring at the Waiting List Forward Planning meeting.

Monthly monitoring of performance at the Performance Assurance Framework meetings.

3.4.1.3 62 Day Target

In September and October the Trust did not achieve the 62 day standard or the 62 day upgrade standard.

Trust Action:

A review of all the breaches is being undertaken by the newly appointed cancer manager to understand the causes with the results to be discussed with the clinicians, MDT coordinators and Access team.

The cancer targets are a standing item on the weekly Waiting List Forward Planning meeting agenda to ensure any potential issues are highlighted early and escalated appropriately to ensure there are no avoidable breaches of the target.

The significant increase in activity across a number of the key cancer sites has put significant pressure on capacity. The clinical divisions as part of business planning are undertaking capacity and demand analysis for all clinical specialties to ensure that the right staff and facilities are in place to ensure that patients are seen within the national timeframes.

3.4.2 StrokeFigure 24 depicts that the stroke target of patients diagnosed with a stroke spending

90% of their time on the Stroke Unit for 80% of patients. The 80% target was met in October and November, for the fifth consecutive month. Figure 24:

Trust Action:

The Emergency & Urgent Care Division continues to hold regular meetings with the Stroke team to monitor performance, work through any issues and agree actions to improve. The meeting also ensures that actions and changes agreed are delivered.

3.5 Emergency Access

Patient arrives via ambulance

Patient arrives at Emergency

Department

ED clinical quality indicators – November 2013

Time to initial assessment99.09% of

Ambulance arrivals were assessed within 60 minutes against a

target of 95%

Time to treatment

On average, patients stayed 37

minutes from arrival to treatment against a target of

60 minutes

Total time in A&EOn average, patients stayed 2 hours and 17 minutes from arrival to

departure

93.28% of patients stayed less than 4 hours

253 patients out of 3,767 ED patients and 698 CAREUK patients waited longer than 4 hours

The average stay for patients not requiring admission to hospital was 2 hours and 3

minutes95% stayed less than 3hours

and 58 minutes against a target of 4 hours

93 patients out of 3,767 waited longer than 4 hours before being

discharged

The average wait for patients who needed to be admitted to hospital was 3 hours and 49

minutes95% waited less than 8 hours

35 minutes against a target of 4 hours

160 patients out of 1,057 waited longer than 4 hours

before being admitted

Left without being seen

6.82% of patients re-attended A&E within 7 days of their original attendance against a

target of 5%

For all patients

For patients admitted to hospital For patients not admitted to hospital

1.9% of attendances this month left the department without

being seen against a target of 5%

Unplanned re-attendances

Overall assessment of performance:Overall assessment of performance:The performance of the Emergency Department in referring patients within 4 hours was not achieved in November with a percentage of 94.4%.

The Emergency Department had 3,767 Type 1 attendances in November against a contracted plan of 4,176. This is a decrease against contract of 2.9%.

There were 698 Type 3 attendances at the CAREUK clinic.

The acuity of patients remains high with a conversion rate from attendance to admission of 25.5% in November.

3.5.1 Emergency Department (ED) PerformanceThe NHS constitution set the national standard wherein 95% of all patients attending NHS Emergency Department’s spend a maximum of four hours in the department before being discharged, referred/transferred to other services or admitted to the hospital and transferred to an inpatient bed. The target was not achieved in October and November with 92.4% and 94.4% respectively (Figure 25).

Figure 25:

As illustrated in Figure 26, attendances were significantly above the contracted plan (17.26% in October and 14.10% November).

Figure 26:

The number of people being admitted to the Trust as emergencies continues reduced across October and November and was 2.5% less than the previous financial year where it peaked. With an increase in attendances compared to the previous period, this demonstrates the impact of the redesigned emergency department in reducing the level of emergency admissions.

Figure 27:

Trust Action:

The Trust has undertaken 19 initiatives using the winter monies to restructure patient flow from the front door to discharge. This will ensure a high quality and efficient experience for patients, and will enable the Trust to more effectively manage the expected increase in acuity and demand. A number of initiatives have been completed with the final initiatives coming on line in the run up to Christmas. The biggest change has been the restructure of the Emergency Department where circa £230,000 has been invested. The new model is now in place and functioning, with only minor building work to be completed (Figure 28).

The Trust participates in two daily system calls, one with North Somerset providers and one covering the BNSSG area. This will enable improved joint working and understanding of the system flows. The impact of these calls will improve as the calls develop and the information available on a daily basis improves.

The Trust has introduced a ‘Green to Go’ list which will capture all patients who are medically fit but awaiting further support to be discharged. This has led to bi-daily calls with social services and the community teams to facilitate swift and seamless discharges to more appropriate settings.

Internal performance management of patient flow has been strengthened with the introduction of an additional patient flow manager and the introduction of daily performance meetings to review the previous day’s performance and set goals and targets for the current day which the teams are monitored against. Finally work has been undertaken to improve the depth, quality and availability of daily information. This is being used by the teams to investigate performance improvements and reductions and also improve their predictions and forward planning.

Figure 28:

3.6 Elective AccessThis section reviews the key elective access targets to understand the effectiveness and the quality of care throughout the elective care pathways.

3.6.1 Referral to Treatment (RTT)The NHS constitution states that patients have the legal right to start their NHS consultant-led treatment within a maximum of 18 weeks from referral, unless the patient chooses to wait longer or it is clinically appropriate to wait longer. For the months of October and November the following sub-sections will review the Trust performance against the three national 18 week targets.

3.6.2 Referral to Treatment (RTT) AdmittedThe 90% target has been achieved for 38 consecutive months as depicted by Figure 29.

Figure 29:

The Trust also achieved the target by specialty in October but did not achieve the target for Trauma & Orthopaedics in November (Table 8). The Trust planned to fail the target in November as a result of a significant growth in the waiting list due to an increase in referrals throughout 2013/14. The Trust is working alongside the CCG and other local organisations to manage the increased activity.

Table 10:

Trust Action:

The Trust will continue to undertake waiting list forward planning meetings where the waiting list for each specialty and the theatre timetable is reviewed on a weekly basis with the Assistant Divisional Manager of Planned Care, Access Manager and Theatre Manager.

Monthly monitoring of performance at the Performance Assurance Framework meetings.

Development of a plan alongside the CCG and other local organisations to manage the increase in activity.

3.6.3 Referral to Treatment (RTT) Non-AdmittedThe Trust significantly improve performance against the non-admitted target which was achieved in both October and November. This was as a result of the reinvigoration of the Waiting List Forward Planning meeting and the resolution of ENT provision with University Hospitals Bristol NHS Foundation Trust (UHB).

Figure 32:

Table 11 illustrates the achievement of the target by specialty. Excluding ENT the specialties that failed varied each month. This is as a result of the very small number of patients treated.

Table 11:

Trust Action:

The Trust will continue to undertake waiting list forward planning meetings where the waiting list for each specialty and the theatre timetable is reviewed on a weekly basis with the Assistant Divisional Manager of Planned Care, Access Manager and Theatre Manager.

Monthly monitoring of performance at the Performance Assurance Framework meetings.

Continue to work with UHB and other provider Trusts of visiting services to ensure that the correct capacity is provided at the Trust to meet current demand.

3.6.4 Referral to Treatment (RTT) IncompleteThe 92% target has been achieved for 14 consecutive months as depicted by Figure 33.

Figure 33:

As depicted in Table 10 Urology and Trauma & Orthopaedics consistently failed the specialty level target. Both specialties have been hit by a steep increase in activity in 2012/13 which has put significant pressure on capacity. A review of the Urology and Orthopaedics specialties waiting list has been undertaken with plans in place to reduce the waiting list over the next six months.

Table 12:

Trust Action:

The Trust will continue to undertake waiting list forward planning meetings where the waiting list for each specialty and the theatre timetable is reviewed on a weekly basis with the Assistant Divisional Manager of Planned Care, Access Manager and Theatre Manager.

Monthly monitoring of performance at the Performance Assurance Framework meetings.

Undertake and monitor delivery against the Urology and Trauma & Orthopaedics activity plans to ensure the waiting list is reduced over the next 6 months.

3.6.5 Choose and BookThe Trust did not achieve the 96% National target for Choose and Book slot availability target in October and November as depicted in Figure 34. Current performance is caused by demand outstripping contracted capacity in a number of specialties, and the use of choose and book by GP’s.

Figure 34:

Trust Action:

The Trust continues to review demand and capacity across all of its specialties and where disparity between the two is identified, the divisions are developing business cases to increase capacity. A recent success was the appointment of an additional colorectal consultant to meet the increase in cancer work being referred to the Trust.

Working closely with providers of visiting specialities to ensure capacity meets demand.

Monthly monitoring of performance at the Performance Assurance Framework meetings.

3.7 Patient FlowTo support the delivery of key operational targets, it is vital that the Trust has good patient flow. An important aspect of ensuring good patient flow is the level of discharges throughout the day and at the weekend.

3.7.1 Morning DischargesThe internal target of 30% of discharges being undertaken in the morning was not achieved by the Trust in October & November. Whilst the Trust has experienced an increase in the level of discharge over the period, the discharges have increased post 17:00 leading to a reduction in the percentage despite the actual numbers staying static.

Trust Action:

The Trust is working on the ‘Home by 11am’ programme which aims to greatly increase the number of discharges before 11. The programme is using the winter funds and the reorganisation of the current workforce to put in place robust processes to ensure patients receive efficient and high quality care in the right setting.

3.7.2 Discharges at NightA ‘discharge at night’ is defined as a discharge between 23:00 and 06:00. The Trust ensures

that all measures are taken to ensure safe and efficient discharges for all of our patients. In September and October XX patients were discharged at night. Discharges at night generally occur due to patient wishes, any discharges during this period are monitored daily by the operational teams.

Section 4 Human Resources4.1 Executive Summary Headlines

The temporary staffing costs in November were 11% of the total pay bill; this includes temporary staffing posts funded through winter funding.

This month’s sickness rate has increased from 3.73% to 3.97%.

The appraisal rate has increased from 80.96% to 81.02%.

The training compliance rate has increased from 81.32% to 82%.

4.2 Workforce

Figure 35 shows the pay expenditure for contracted staff, for agency staff, and for staff funded through winter monies.

Figure 35:

Figure 36 shows the temporary staffing spend across the year, with temporary staffing costs attributed to winter funding identified separately in October and November. When you exclude temporary staffing costs funded through winter monies, the graph shows a decrease in temporary staffing each month since August, which is largely due to the reduction of agency nurses. This reduction correlates with the phasing of the overseas nurse recruitment campaign and the time taken to ensure all newly appointed nurses have been appropriately trained and inducted within the Trust.

Since the Trust has increased its establishment and recruited to the subsequent vacancies there has been a steady decrease in turnover within nursing and midwifery, as can be seen in Figure 37.

Figure36 also demonstrates an increase in the temporary staffing costs for medical locums. There are a number of factors that are attributed to this, an increased level of turnover within the Emergency & Urgent Care Division (Medical Staff), a number of hard to recruit to posts and the removal of some junior doctor’s posts by the deanery have all increased our reliance on medical locums.

Significant effort has been made to reduce the number of vacancies and recently the Trust has appointed a Respiratory Consultant (long term NHS Locum) and two Care of the Elderly Consultants. It is anticipated that with the recruitment of two Care of the Elderly Consultants, the Deanery will reinstate our Care of the Elderly Registrars, although this is yet to be confirmed.

Figure 36:

Figure 37:

4.2.1SicknessSickness over the past two months decreased in October to 3.73% and then increased to 3.97% in November, with 2.33% relating to short term sickness and 1.35% relating to long term sickness (in November). The increase in sickness is mainly attributed to the Estates and Facilities and Planned Care Divisions where short term sickness has increased in both areas. Sickness continues to remain below the national average.

Figure 37:

* Trust standard is ≤ 3.0%

4.2.2 Statutory/Mandatory Training

The divisions have made a concerted effort to release staff and increase their training compliance, which has seen the statutory training compliance increase from 76.92% in September to 81.32% in October and 82% in November; there has now been a steady increase over four consecutive months. Each division has plan in place to achieve the required 90% target by 31st March 2014.

4.2.3 Appraisal

The appraisal rate increased from 80.96% to 81.02%, this again shows a steady increase over a four month period and is now within 4% of the Trust target. Each division has plan in place to achieve the required 85% target by 31st March 2014.

4.2.4 Flu Vaccines

The Trust flu vaccination uptake at the end of November was 45%, which represents a significant increase in the previous flu campaign where the campaign ended on 31%. The Trust continues to use its Trust vaccinators which are attending departments and clinical areas to ensure vaccinations are easily accessible to staff. Clearly there is still a challenge to reach the 75% target and all data is being validated to ensure accurate reporting of the figures.

4.2.5 NHS Staff Survey 2013

The Staff Survey closed at the beginning of December and the Trusts data has been submitted to the Survey Co-ordination Centre for analysis. Our final response rate for 2013 was 49%, which is disappointing and represents a drop of 4% on last year’s figure.

In February 2014 the Co-ordination Centre will provide the trust with the results of our survey responses appropriately benchmarked against national data from Trusts of a similar type. Final national results will be published on the staff survey website at the end of February 2014.

4.2.5 Leadership Programmes

During the autumn, Skills for Health have delivered 3 full day workshops for 12 of our managers who are completing their QCF Level 5 Diploma in Leadership. Feedback to date from course participants has been excellent. Assignments are due to be completed by the end of February 2014.

In addition, fifteen of our supervisors/team leaders are due to start their QCF Level 3 Award in Leadership on the 15th January 2015.

Section 5 Finance Report5.1 Executive Summary Headlines

The financial position at Month 8 is that the Trust is reporting a year to-date deficit of

£2,483k which is in line with the plan.

Overall income is £1,741k above plan at the end of November.

Overall expenditure is £1,750k over plan at the end of Month 8.

The Trust plan for the year is a deficit budget of £4.95m and it is forecast that this will be achieved subject to the satisfactory management of the risks for the remainder of the year.

5.1.1 Statement of Comprehensive Income Position to Date The financial position at Month 8 is that the Trust is reporting a £2,483k deficit which is in line with the annual plan.

Revenue from patient activity is £1,277k above plan for the 8 months to November 2013. Other sources of income have generated £464k more than plan. The activity plan has been profiled, in agreement with the commissioners’, using the monthly average of the last two financial years.

Overall expenditure including depreciation is £1,750k ahead of plan at the end of Month 8. Pay and non pay expenditure is £3,996k above plan for the 8 months, this is offset by the use of £2,246k of reserves.

The Trust’s Service Improvement Programme (SIP) has a year to date underachievement of £2,109k against the target for the eight months of £2,779k, however £567k of underspends for the period April to November have now been ring fenced as non recurrent savings reducing the underachievement to £1,542k.

The adjusted run rate for expenditure has marginally deteriorated in November by £38k when compared with the October level.

5.1.2 Statement of Comprehensive Income Position in Month Income from patient care activity is £60k less than plan whilst other sources of income generated £181k more than planned.

Pay and non pay expenditure, including the shortfall in savings delivery, is £578k above plan for the month of November. Overall expenditure is £122k above plan, after use of reserves.

5.1.3 Savings Plan The Trust’s Service Improvement Programme (SIP) delivered £121k in November against a target of £430k.

5.1.4 Cash The cash plan for 2013/14 is to hold a balance of £303k at 31st March 2014; this will be delivered through the management of cash and working balances. The cash balance of £2,701k, as at 30th November, is £516k higher than the planned position of £2,185k.

Following the approval by Independent Trust Financing Facility Committee of the £4,950k Permanent Dividend Capital (PDC) Revenue Support the Trust has drawn down a further £1,450k in November leaving the balance of £550k to be received in February 2014.

5.1.5 External Financing Limit The Trust’s External Financing Limit will be achieved through the management of cash and working balances, along with the required level of Public Dividend Capital.

5.1.6 Capital Resource LimitThe capital resource limit for 2013/14 is £3,500k and in addition to this the Trust is due to receive:

£100k for donated assets in connection with the front entrance reconfiguration from the League of Friends

£126k from the NHS Safer Hospital, Safer Wards Technology Fund for the implementation of a new Order Communications system.

Therefore the Trust’s forecast spend on capital projects is £3,726k as 31st March 2014.

As at the 30th November the programme so far has delivered capital expenditure of £2,195k. The Trust will operate within its Capital Resource Limit. Detailed capital programme management will enable this to be achieved along with the Trust’s cash plans.

5.1.7 Capital Cost Absorption rateThe Trust’s Capital Cost Absorption (CCA) rate is forecast as 3.5% and is a technical duty which is a requirement of the Department of Health for all NHS Trusts. The CCA is fixed at 3.5% going forward as the Department of Health rules this will be calculated based on 3.5% of actual balance sheet values at the end of the financial year.

5.1.8 Better Payment Practice Code The Trust’s overall performance as at 30th November is 94.7% on the BPPC. The performance has deteriorated slightly from 94.8% in October and remains marginally below the target. The current forecast assumes that this will improve to the required 95% on the quantity of invoices paid within terms or 30 days.

5.1.9 Forecast outturnThe Trust is forecasting to deliver the plan for the year. The Trust forecasts have been reviewed and show that commissioner income will be higher than planned to reflect forecast contract over-performance. The revenue from patient activity is forecast at £1,360k above plan. Other income is forecast to deliver a further £282k improvement over the plan. Total Expenditure against budgets will overspend by circa £1.6m, mainly due to the under-delivery of savings and the nursing pay overspends experienced in the year so far. There is currently a forecast of £2,208k savings, leaving a shortfall of £2,292k against plan.

In September the Secretary of State for Health announced that WAHT would be one of 53 Trusts to receive additional income to assist with the management of operational winter pressures. The North Somerset Health Economy will receive £4.8m to be distributed by North Somerset CCG following the agreement of each of the schemes. Included in the Trusts forecast is the impact of the Trusts current agreed schemes which amount to £2.746k and £306k has been spent to date.

5.1.10 Risk to delivery of financial planThe major high financial risk is the shortfall in the delivery of a £4.5m savings programme and the current under-delivery is forecast at £2.292m.

The Trust also needs to ensure that all divisions and departments manage the expenditure run rate within the budgets available for the remainder of this year. This includes managing expenditure to deliver the schemes as part of the Winter Plans.

5.2 Financial Dashboards 2013/14: Month 8

Level 1 Financial Indicator Calculation

Annual Target 13/14

Plan / Target Actual

Traffic Light

Variance from Target

Plan / Target Actual

Traffic Light

Variance from Target

Plan / Target Actual

Traffic Light

Variance from Target

Forecast Outturn Actual

Forecast Outturn Traffic Light

Financial duties

Cumulative

Bottom line Statement of Comprehensive Income

Bottom line Statement of Comprehensive Income against plan Surplus/ (Deficit) before impairments -4950 -1705 -1705 Green 0 -1661 -1661 Green 0 -2483 -2483 Green 0 -4950 Green

In month

Bottom line Statement of Comprehensive Income

Bottom line Statement of Comprehensive Income against plan Surplus/ (Deficit) before impairments -4950 -162 -162 Green 0 44 44 Green 0 -823 -823 Green 0 -504 Green

Cumulative

Achievement of External Financing Limit

Cash available against planned cash available 303 2895 1792 Amber -1103 2384 1541 Amber -843 2185 2701 Green 516 303 Green

Cumulative

Achievement of Capital Resource Limit

Capital Expenditure against plan 3500 3500 1754 Green 1746 3500 2057 Green 1443 3500 2195 Green 1305 3500 Green

Subsidiary duties

CumulativeCapital cost absorption rate 3.50% Green Green Green 3.50% Green

CumulativeBetter Payment Practice Code

Year to date performance against the prompt payment policy for Combined NHS & Non-NHS suppliers (by number) 95.0% 95.0% 94.3% Amber -0.7% 95.0% 94.8% Amber -0.2% 95.0% 94.7% Amber -0.3% 95.0% Green

March 2014 (FOT)September 2013 October 2013 November 2013

5.3 The Income and Expenditure Position of the Trust

5.3.1The financial position at Month 8 is in line with the planned deficit of £2,483k.

5.4 Expenditure

5.4.1 The main points are:

The position for month 8 is that overall the Trust has overspent the expenditure budgets by £3,996k at the end of month 8. This is due to the non delivery of Savings (SIP) and overspends on Pay and Non Pay Expenditure.

Pay expenditure is higher than budgeted with an overspend of £366k at the end of November. The main staff category overspent at the end of November was Nursing which was over by £736k. This overspend was offset by underspends on Allied Health Professionals (£254k), Admin and Clerical (£196k) and Medical Staffing (£163k).

Non pay expenditure is £623k over budget at the end November, excluding the underachievement of savings. There are overspends on Drugs (£113k), X-ray expenditure (£94k), Estates Expenditure (£76k), Medical and Surgical Equipment (£73k) offset by underspends on Training (£99k), Blood Products (£98k) and Travel and Subsistence (£25k).

During the month of November Clinical Decision- making Unit and Surgical Assessment Unit were opened as part of the measures taken by the Trust following the award of the winter resilience monies to the North Somerset health community. Against the £2,746k allocated to the Trust, £306k has been spent to date, of which £225k is on Medical locum costs and Nursing.

There has been a substantial increase in budgeted establishment for the nursing workforce linked to the outcome of a safe staffing review concluded at the end of last year and the increased capacity for the winter plans. The recruitment campaign has been successful and will help to offset the financial pressures particularly on agency costs. So far the agency costs amount to £1,323k in the first eight months.

5.4.2 At Month 8 the main points for the Divisional and Corporate performance are as follows:

The Emergency Division has overspent by £2,054k year to date, of this £470k is on Pay expenditure, £210k is on Non Pay expenditure and SIP is underachieved by £1,483k. The Pay variance is because of Additional bed capacity which cost £198k in nursing staff, the Medical Assessment Unit £202k, Harptree unit’s pay overspend was £148k, and the Uphill ward pay expenditure cost £114k more than budgeted. The Ambulatory care centre underspent its pay budget by £97k, Adult Occupational Therapy pay by £36k whilst the division’s Medical staffing budget was underspent by £88k. The non pay overspend was due to Additional Unfunded beds of £61k, Ambulance Agency £45k, Pathology £79k, Pharmacy £89k and offset by an underspend on Drugs and Blood £76k, Physiotherapy £19k and Medical Staff non pay £17k.

The Planned care Division has overspent by £1,769k, the SIP underachievement is £1,432k, Non Pay expenditure was overspent by £306k and Pay overspent by £32k. The non pay overspend was primarily due to an overspend of £121k on Drugs and Blood, Radiology outsourcing of £57k and Medical Secretaries outsourcing £27k offset by underspends against on the Private Patient Unit (PPU) of £62k. The pay overspend was mainly on the Surgical Medical staff (£127k), Hutton (£56k), Cheddar (£53k) and Steepholm (£27k) offset by underspends on ITU (£43k), Theatres (£27k), Endoscopy (£26k), Radiology Medical staff (£22k) and Medical Secretaries (£22k).

The Estates and Facilities Division has overspent by £354k mainly on Savings non-delivery which accounts for £292k and Non Pay where there are overspends in Property Services (£74K), Catering (£24k), Mailroom (£11k) and Housekeeping (£10k).

The Corporate Departments have underspent by £375k.

Reserves of £2,246k have been deployed to offset where there are agreed plans and also the overall variance to the plan.

In September all Directors, Heads of departments and Divisional Managers were requested to work with their Budget Holders to have in place financial recovery plans. They were also informed that the expectation is that they were to manage expenditure within budget during quarters 3 and 4 and therefore not overspend from 1st October. It has been emphasised that there needs to be an increased drive for efficiency improvements which would lead to recurrent financial savings and that projects should be implemented which would maximise the savings in this financial year. In October there was no overall overspend in the Emergency care Division and Estates and Facilities Management Division, before SIP shortfalls, which is a good response. However the Planned Care Division did manage expenditure within their pay budgets but Non-pay budgets were overspent.

5.4.3 The Trusts expenditure run-rate information has been rebased to neutralise the affect on both expenditure and budgets for variations in monthly NICE funded drugs expenditure which has no overall impact on the net financial position. There have also been some amendments for one-off exceptional items. The Trust’s expenditure run rate is shown in the table below compared to the adjusted expenditure level for each month of 2013/14 as well as 2012/13.

The main points are: The adjusted run rate for expenditure has increased in November by £38k when compared with the October adjusted level. For October it was £7.584m whilst it is £7.622m in November. Of the increase Medical staffing accounted for £84k, Nursing Staff £40k, and Allied Health Professional staffing £17k. Some of these increases were offset by

reductions in following non pay items - Estates expenditure £34k, Drugs £31k, Medical and surgical consumables £19k.

Figure 38:

5. 5 Savings Plans (SIP) 5.5.1 The Trust has a savings requirement of £4,500k for the year which represents 5% of turnover. Savings plans have not delivered as planned; a total of £670k of SIP has been achieved for the year as at Month 8 against the profiled plan of £2,779k. Of the SIP savings delivered to date £514k is from recurrent SIP schemes with the balance of £156k from non-recurrent SIP projects. In addition to this non recurring underspends from the period April to November have been ring fenced to provide savings of £567k. In total the savings for the year to date are £1,237k. The Trusts performance against its monthly SIP savings requirement for the first eight months of the financial year is shown below.

Figure 39:

The year end savings forecast is £2,208k which is a major concern as this would result in a shortfall of £2,292k against the plan of £4,500k. There is also a carried forward recurrent undelivered savings target is attributed to individual departments/divisions for recovery this year and is offset at a corporate level to ensure there is no risk to the overall Trust financial plan for the year.5. 6 Activity and Income 5.6.1 Overall patient activity income is assessed at £1,277k above plan at the end of November 2013. The main points regarding activity are:

Income related to North Somerset CCG contract is £1,184k over plan. Income related to the NHS Somerset contract is £126k over plan. Income related to other patient care activities is £33k under plan. The Trust is operating a variable PBR contract. The Trust and North Somerset CCG are

both planning in their financial plans for the forecast outturn over performance of £1.2m as the likely year end position.

Figure 40:

Annual Plan

YTD Plan

YTD Actual

YTD Variance Variance

£,000 £,000 £,000 £,000 %

Day cases 7,823 5,201 5,477 276 5.3%Elective Inpatients 5,903 3,984 3,932 (52) -1.3%Non Elective Inpatients 25,293 16,678 18,509 1,831 11.0%Ambulatory Care 912 611 0 (611) -100.0%Excess Bed Days 1,160 763 1,159 396 51.9%First Outpatients 5,844 3,975 4,201 226 5.7%Follow up Outpatients 5,665 3,810 3,815 5 0.1%Unbundle OP radiodiagnostic 1,305 870 667 (203) -23.3%ED attendances 5,898 4,020 3,966 (54) -1.3%Critical Care 2,759 1,854 1,854 0 0.0%Rehabilitation 2,308 1,540 1,120 (420) -27.3%Children Services 2,200 1,467 1,653 186 12.7%Direct Access 2,828 1,886 2,178 292 15.5%Maternity Services 3,087 2,058 1,862 (196) -9.5%NICE income 3,355 2,237 2,337 100 4.5%Private patients 738 506 362 (144) -28.5%Other 4,618 3,084 2,899 (185) -6.0%QIPP schemes (878) (585) 0 585

Sub total 80,818 53,959 55,991 2,032 3.8%

Penalties 0 0 (562) (562)CQUINS 1,840 1,227 1,034 (193) -15.7%

Total 82,658 55,186 56,463 1,277 2.3%

8 Months ending November 2013 Activity and Income Report

The contract with North Somerset CCG includes a financial value of minus £878k for QIPP schemes. For Non Elective Inpatients £1,831k of over performance is due to the new recording of the Ambulatory Care Centre (ACC) activity, offset by the £611k in the plan. The activity is included as outpatients and inpatients for non electives. The overall volume increase for non electives against plan for the first seven months, excluding the ACC activity is 1.1%. Other significant volume variations in performance, excluding ACC activity, are shown in the table below:

Significant over & under performance areasVolume variances greater than 5% and more than 10 cases

Day cases Elective inpatientsOverallOver performing Haematology 66%

General Medicine 13%Surgery 6%

Under performing ENT -91% Cardiology -40%Paediatrics -53% Surgery -14%

Trauma & Orthopaedics -7%

Non Elective inpatients

Over performing Urology 54%Trauma & Orthopaedics 14%Surgery 8%

Under performing Cardiology -33%Paediatrics -29%Gynaecology -21%

First Outpatient attendances F/U Outpatient attendances

Over performing Cardiology 28% Cardiology 16%Dermatology 17% Dermatology 15%Paediatrics 15% Respiratory medicine 6%General Medicine 11%Trauma & Orthopaedics 8%Respiratory medicine 6%

Under performing Neurology -25% Haematology -18%Haematology -7% Neurology -14%Ophthalmology -6% Clinical Oncology -12%

Urology -12%Gynaecology -7%General Medicine -6%

5.6.2 The following table shows the overall activity for the month ended 30th November 2013:

Volumes including ACC

Annual Activity

Plan

YTD Activity

Plan

YTD Activity Actual

YTD Activity variance

Volume Variance

%

Elective Day Cases 12,255 8,153 8,763 610 7.5%

Elective Inpatients 1,789 1,210 1,106 (104) -8.6%

Non-Elective Inpatients 12,551 8,278 9,812 1,534 18.5%

First Outpatients 38,407 26,130 28,200 2,070 7.9%

Follow Up Outpatients 62,326 41,902 42,153 251 0.6%

Emergency department attendances 53,093 36,211 34,504 (1,707) -4.7%

8 Months ending November 2013 Activity and Income Report

Since April 2013 the ACC activity has been recorded as below and this has not been incorporated in the activity plans as the likely volumes were not finalised during the contractual operating framework.

Ambulatory Care Centre

YTD Activity Actual

Non-Elective Inpatients 1,440

First Outpatients 542

Follow Up Outpatients 2,076

For comparative purposes only the impact of the volumes excluding ACC activity is shown on the table below.

Volumes excluding ACC against Plan

Annual Activity

Plan

YTD Activity

Plan

YTD Activity Actual

YTD Activity variance

Volume Variance

%

Non-Elective Inpatients 12,551 8,278 8,372 94 1.1%

First Outpatients 38,407 26,130 27,658 1,528 5.8%

Follow Up Outpatients 62,326 41,902 40,077 (1,825) -4.4%

8 Months ending November 2013 Activity and Income Report

5.7 Penalties5.7.1 A provision of £562k for fines has been included above as an estimate of the potential penalties in the 8 months ending 30th November 2013 for Referral to Treatment, Cancer access, Emergency Department 4 & 12 hour waits and Ambulance handovers. This continues to be updated as the validation of performance in these areas is finalised. The emerging risk is the penalties that may be incurred should the Clostridium Difficile target be exceeded for the year. Each case would result in a £70,000 fine above the target up to a maximum of 20 cases. The action plan to improve the performance will be critical to mitigate this financial risk.

Weston Area Health Trust

Penalties 2013-14Quarter 1 Quarter 2

Total Jul-13 Aug-13 Sep-13 Total October November Total Comment£ £ £ £ £ £ £ £

Actuals Actuals Actuals Actuals EstimateRTT18 weeks - Admitted 90% General Surgery 979 389 0 0 389 1,368

General Medicine 504 0 0 5040

18 weeks - Non Admitted 95% Ear, Nose & Throat (ENT) 185 142 142 142 426 93 70495% Respiratory Medicine 32 15 15 16 63

General Surgery 345 345 345Neurology 52 52 52 104Cardiology 127 211 0 211 63 401Trauma & Orthopeadics 553 553 553Gastroenterology 376 376 75 451Ophthalmology 21 21 142 163

18 weeks - Incomplete 92% Geriatric Medicine 560 0 560ENT 569 569 569Urology 283 283 283Trauma & Orthopeadics 3,321 3,321 3,321RTT estimate 0 0 0 0 0 0 2,501 2,501

RTT waits over 52 weeks £5000 per patient 100% 0 0 0 0 0 0 15,000 15,000

6 week Diagnostics £5000 per month 99% 5,000 5,000 0 0 5,000 5,000 5,000 20,0000

ED attendances within 4 hrs £27,684 per quarter 95% 27,684 0 0 0 0 0 0 27,684 Assumes Quarter 3 target will be achievedTrolley wait<12 hrs £1000 per event 100% 9,000 0 0 0 0 0 0 9,000Ambulance handovers <15 minutes £200 per event 100% 54,400 5,400 3,600 2,900 11,900 5,325 5,325 76,950Ambulance handovers <60 minutes Additional £800 per event 100% 86,400 14,000 12,000 8,000 34,000 13,825 13,825 148,050

Cancer referral to outpatient appointment<2 weeks £34,000 per Quarter 93% 0 0 0 0 0 0 0 0 Assumes Quarter 3 target will be achievedBreast Cancer referral to outpatient appointment<2 weeks £34,000 per Quarter 93% 0 0 0 0 34,000 11,333 11,333 56,666 Assumes Quarter 3 target will not be achievedCancer- First definitive treatment <31 days £34,000 per Quarter 96% 0 0 0 0 0 0 0 0 Assumes Quarter 3 target will be achievedCancer- Surgery <31 days £34,000 per Quarter 94% 0 0 0 0 0 0 0 0 Assumes Quarter 3 target will be achievedCancer- anti cancer drug regimen<31 days £34,000 per Quarter 98% 0 0 0 0 0 0 0 0 Assumes Quarter 3 target will be achievedCancer-radiotherapy<31 days £34,000 per Quarter 94% 0 0 0 0 0 0 0 0 Assumes Quarter 3 target will be achievedCancer-First definitive treatment<62 days £34,000 per Quarter 85% 0 0 0 0 0 0 0 0 Assumes Quarter 3 target will be achievedCancer-Screening service to first definitive treatment<62 days £34,000 per Quarter 90% 0 11,333 11,333 11,333 34,000 11,333 11,333 56,666 Assumes Quarter 3 target will not be achieved

MRSA Non payment of Inpatient episode 100% 0 0 0 0 0 0 0 0C-Diff £70,000 per case over 11 0 0 0 0 0 0 140,000 140,000 Based on a Trajectory of 1 a month except April

Total 184,923 36,490 28,625 26,345 125,461 47,206 204,317 561,907

5.8 CQUINS5.8.1 A provision of £193k for CQUIN’s under achievement of income has been included due to likely underachievement of the CQUIN during this financial year.

5.9 Statement of Financial Position at 31st July 2013

5.9.1 The Trust’s main accounting statements are shown in the appendices of this report. See Appendix B for the Statement of Financial Position as at 30th November 2013.

Cash

5.9.2 The External Financing Limit will be achieved by in year management of cash and working balances. The cash balance of £2,701k as at 30 th November is £516k higher than the planned position of £2,185k.

Debtors

5.9.3. The figures from the debtors system represent invoices raised for which cash has yet to be received. The total outstanding debt as at 30th November 2013 is £4,370k this is divided between NHS £4,251k, Private Patients £48k and non NHS £71k. Debts over 250 days represent £55k which is 1.3% of the total debt.

Creditors5.9.4 The measure for the better payment practice code is:

5.9.5 Target: pay all NHS and non-NHS trade creditors within 30 calendar days of receipt of goods or a valid invoice (whichever is later) unless other payment terms have been agreed. Compliance: at least 95% of invoices paid (by the bank automated credit system or date and issue of a cheque) within thirty days or within agreed contract terms. As at the end of November 2013 the performance against the target is:

Number Value% %

Non-NHS 95.3 96.7NHS 77.9 92.5Combined 94.7 95.6

5.10 Capital Programme and Performance against Capital Resource Limit

5.10.1 The Trust will operate within its Capital Resource Limit. Detailed capital programme management will enable the capital expenditure to be delivered within resources and the Trust’s cash plans for the year.

5.10.2 As at the 30th November £2,195k of capital expenditure has been spent.

5.10.3 The Capital Planning Committee continues to monitor the capital priorities and projects to ensure these fit within the resources available. The detail of each of the projects is included on Appendix D.

5.11 Foundation Trust Indicative Financial Risk Rating

5.11.1 The financial risk rating for the Trust, if operating as a Foundation Trust, which relates to its overall financial sustainability, is detailed in the table below and as at the 30th November 2013 the score is a 1.

5.11.2 The liquidity ratio year to date is 18.9 days which scores a level 3.

5.11.3 The calculation for the financial risk rating for the plan, year to date and forecast outturn for the Trust remains a 1.

Year to date 2013/14 - Month 8

WeightingPlan

2013/14Monitor Rating

Weighted rating

Year to date 2013/14

Monitor Rating

Weighted rating

Achievement of Plan EBITDA achieved 10% 78.0 3 0.30 (644.3) 1 0.10Underlying performance EBITDA margin 25% 0.3 1 0.25 1.8 2 0.50

Return on assets excluding dividend 20% (6.0) 1 0.20 (2.4) 1 0.20I&E Surplus 20% (5.6) 1 0.20 (4.0) 1 0.20

Liquidity Liquidity Ratio (days) 25% (11.0) 1 0.25 18.9 3 0.75

Monitor weighted criteria 1.20 1.75

1 1Financial Risk rating after applying over-riding rules

Monitor Financial Measures

Financial Efficiency

Plan 2013/14

KeyAchievement of Plan EBITDA achieved (% of plan)Underlying Performance EBITDA Margin (% underlying income)Financial Efficiency Return on asset excluding dividend (%)

I&E Surplus net of dividend (%)Liquidity Ratio (days) Cash plus trade debtors minus creditors expressed in number of days operating expenses. Ratio has been adjusted for 30

working days capital borrowing facility as would be available to a Foundation Trust.

5.12 National reference costs 2012-13

5.12.1 Following the national publication of the 2012-13 Reference Costs on 22nd November 2013, the Trust Reference Cost Index (RCI) overall figure is 100. This indicates that overall costs are in line with the national average for the activity we undertake. This compares to the Trust’s RCI for 2011-12 which was 99.9. In 2012-13 the process for formulating the RCI was nationally changed and using the 2011-12 methodology the RCI would have been 97. Within the overall RCI there are significant fluctuations from the national average for several areas. A breakdown of the RCI by category is provided in the table below.

Category RCIElective / DC 97.6Non-Elective Inpatient 93.7Excess Bed Days 97.2Critical Care Services 157.2Outpatient Services 102.3Other Acute Services 94.7Community Services 132.3Mental Health 105.0A&E 106.5Unbundled 104.0Organisation-Wide Index Including Excess Bed Days

100.4

5.13 Recommendation

The Board is asked to note the Trust’s Month 8 financial performance for 2013/14 regarding the revenue, capital and cash positions.

The Board is asked to note the Trust’s Reference Cost Index overall figure is 100 for 2012-13.

Appendix A – Statement of Comprehensive Income – Accumulated Variances as at Month 8 – November 2013

PERIOD NOV

BUDGET

PERIOD NOV

ACTUAL

PERIOD VARIANCE

Fav/ (Unfav) ANNUAL BUDGET

REVISED ANNUAL BUDGET

YEAR TO DATE

BUDGET

YEAR TO DATE

ACTUALVARIANCE

Fav / (Unfav)

YEAR TO DATE

BUDGET

YEAR TO DATE

ACTUAL

FORECAST VARIANCE

Fav / (Unfav)£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

INCOME

5,115 5,096 -19 CCGs - North Somerset 59,971 60,957 40,545 41,729 1,184 60,957 62,157 1,2001,164 1,177 13 CCGs - Somerset 13,796 13,824 9,192 9,318 126 13,824 14,019 195

249 118 -131 CCGs - Other 2,445 2,444 1,797 1,776 -21 2,444 2,444 0119 122 3 Local Authorities 1,590 1,340 909 941 32 1,340 1,389 49280 380 100 NICE 3,355 3,355 2,237 2,337 100 3,355 3,455 10065 39 -26 Private Patients 738 738 506 362 -144 738 554 -184

6,992 6,932 -60 Revenue from patient care activities 81,895 82,658 55,186 56,463 1,277 82,658 84,018 1,360

263 293 30 Education, Training & Research 3,156 3,156 2,104 2,047 -57 3,156 3,070 -8634 98 64 Road Traffic Accident income 400 400 267 290 23 400 330 -70

352 439 87 Other Income 4,293 8,885 4,427 4,925 498 8,885 9,323 438649 830 181 Other operating revenue 7,849 12,441 6,798 7,262 464 12,441 12,723 282

7,641 7,762 121 Total Income 89,744 95,099 61,984 63,725 1,741 95,099 96,741 1,642 EXPENDITURE

5,644 5,652 -8 Pay Expenditure 64,574 65,180 43,542 43,908 -366 65,180 68,998 -3,8181,915 2,485 -570 Non-Pay Expenditure 20,658 21,496 15,096 18,726 -3,630 21,496 27,267 -5,771

456 0 456 Reserves 5,138 7,999 2,246 0 2,246 7,999 0 7,9998,015 8,137 -122 Total Expenditure 90,370 94,675 60,884 62,634 -1,750 94,675 96,265 -1,590

-374 -375 -1 Earnings before Interest and Depreciation -626 424 1,100 1,091 -9 424 476 52

-302 -301 1 Depreciation -3,630 -3,630 -2,420 -2,411 9 -3,630 -3,653 -230 0 0 Interest Receivable 8 8 5 5 0 8 8 0

-1 -1 0 Interest Payable & Unwinding of Discount -12 -12 -8 -8 0 -12 -12 0-159 -159 0 Dividends Payments on PDC -1,900 -1,900 -1,267 -1,267 0 -1,900 -1,929 -29

0 0 0 Gain/ Loss on disposal 0 0 0 0 0 0 0 00 0 0 Fixed Asset Impairment 0 0 0 0 0 0 0 0

-836 -836 0 Retained deficit for Accounting purposes -6,160 -5,110 -2,590 -2,590 0 -5,110 -5,110 0

0 0 0 Impairments 0 0 0 0 0 0 0 0

-836 -836 0 Net deficit after Impairments -6,160 -5,110 -2,590 -2,590 0 -5,110 -5,110 0

13 13 0 Donated assets 160 160 107 107 0 160 160 0

-823 -823 0 Net deficit for NHS accountability -6,000 -4,950 -2,483 -2,483 0 -4,950 -4,950 0

YEAR TO DATE MONTH 8 ACTUAL MONTH 12 FORECAST AS AT MONTH 8

Appendix B – Statement of Financial Position as at 30th November 2013

As at 31 March 2013 Nov-13

£000's £000's

Non-current assets60,188 Property, plant and equipment 59,929

1,880 Intangible Assets 1,802410 Trade and other receivables 386

62,478 62,117Current assets

1,397 Inventories 1,2052,745 Trade and other receivables 6,0082,213 Cash and cash equivalents 2,3096,355 Total current assets 9,522

Current liabilities(9,765) Trade and other payables (11,174)

(430) Provisions (49)(3,840) NET CURRENT ASSETS (LIABILITIES) (1,701)

58,638 TOTAL ASSETS LESS CURRENT LIABILITIES 60,416

Non-current liabilities(250) Provisions (235)

58,388 TOTAL ASSETS EMPLOYED 60,181

Financed by taxpayers' equity:

57,879 Public dividend capital 62,279(8,954) Retained earnings (11,441)9,556 Revaluation reserve 9,436

(93) Other reserves (93)

58,388 60,181

Appendix C - 12 Month statement of rolling cash flowAPR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR TOTAL

£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000sSummary 2013/14 PlanInflows 7,607 7,988 11,886 7,479 7,454 7,410 7,477 7,467 7,470 7,505 7,477 7,482 94,702

Outflows 9,173 8,503 7,711 7,891 7,291 8,542 7,988 7,666 7,494 7,749 7,655 8,918 96,581

MOVEMENT IN PERIOD ( 1,566) ( 515) 4,175 ( 412) 163 ( 1,132) ( 511) ( 199) ( 24) ( 244) ( 178) ( 1,436) ( 1,879)

BALANCE B/FWD 2,182 616 101 4,276 3,864 4,027 2,895 2,384 2,185 2,161 1,917 1,739BALANCE C/FWD 616 101 4,276 3,864 4,027 2,895 2,384 2,185 2,161 1,917 1,739 303

Summary 2013 14 ActualInflows 7,018 8,545 8,180 9,594 8,399 9,310 8,159 9,488 7,470 7,505 8,027 7,482 99,177

Outflows 8,772 8,509 7,666 8,416 8,519 9,554 8,410 8,328 7,761 8,015 7,922 9,184 101,056

MOVEMENT IN PERIOD ( 1,754) 36 514 1,178 ( 120) ( 244) ( 251) 1,160 ( 291) ( 510) 105 ( 1,702) ( 1,879)

BALANCE B/FWD 2,182 428 464 978 2,156 2,036 1,792 1,541 2,701 2,410 1,900 2,005BALANCE C/FWD 428 464 978 2,156 2,036 1,792 1,541 2,701 2,410 1,900 2,005 303

Difference ( 188) 551 ( 3,661) 1,590 ( 283) 888 260 1,359 ( 267) ( 266) 283 ( 266)

CUMULATIVE CHANGE ( 188) 363 ( 3,298) ( 1,708) ( 1,991) ( 1,103) ( 843) 516 249 ( 17) 266 0

Represented by:

INCOMECCG INCOME 147 274 1,198 322 71 ( 68) 56 56 1,098 549 549 549 4,801SHA INCOME / EXCEPTIONAL PERMANENT DIVIDEND CAPITAL 0 ( 45) ( 4,974) 1,100 ( 22) 1,832 ( 16) 1,438 0 0 550 0 ( 137)OTHER INCOME ( 736) 328 70 693 896 136 642 527 0 0 0 0 2,556

EXPENDITUREPAY COSTS 3 ( 2) ( 41) ( 2) ( 85) ( 75) ( 14) ( 51) 0 0 0 0 ( 267)CREDITORS/ADVANCES 61 ( 183) 334 ( 589) ( 1,004) ( 780) ( 521) ( 609) ( 1,365) ( 815) ( 816) ( 815) ( 7,102)CAPITAL 337 179 ( 248) 66 ( 139) ( 214) 113 ( 2) 0 0 0 0 92LOAN / DIVIDEND 0 0 0 0 0 57 0 0 0 0 0 0 57Total ( 188) 551 ( 3,661) 1,590 ( 283) 888 260 1,359 ( 267) ( 266) 283 ( 266) 0

Appendix D - Capital Programme 30th November 2013Approved

Plan £

In-year allocations

£

Actual spend to 30.11.13

£

Committed(Order raised)

£

Forecast spend to 31.03.14

£FUNDINGInitial capital allocation 3,500,000Safer Wards Safer Hospitals Technology Fund 0 126,000Book value of disposed assets 0 0Donated Assets 0 100,000

3,500,000 226,000

CAPITAL EXPENDITURE

1. Carry forward 2012/13 schemesOutpatients transformation programme 1,100,000 54,620 1,219,165 109,409 1,328,574West switch room upgrade - Linking generators 150,000 (147,000) 2,880 2,880Productive ward 68,000 52,905 68,000Flat Roofs Phase 2 126,517 (26,517) 99,658 99,658PACS/RIS (Phase 2) 82,271 76,313 76,313Data Centre Refurbishment 428,700 49,300 301,009 478,000Wireless network 38,140 38,140 38,140IT Projects 2012/13 17,995 17,995 17,995E-Rostering Implementation 52,120 49,866 52,120Medical Records Relocate Mendip 11,157 11,157 11,157

Sub totals 1,955,488 49,814 1,869,087 109,409 2,172,837

2. Capital Schemes - Estates WorksLift 4 100,000 (90,000) 5,537 5,537Compliance: Fire / DDA 100,000 66,022 100,000Pharmacy enabling works 24,350 35,493 35,493Refurbishment of Rafters Vending Area 20,000 23,172 23,172Front entrance 298,000 75,790 298,000Relocate the Access Team into Dormers 31,500 0 0Refurb Churchill Unit to create a permanent discharge lounge 25,000 2,460 2,460

Reconfiguration of Urgent Care 172,000 660 172,000Sub totals 200,000 480,850 209,134 0 636,662

3. Capital Schemes - Medical EquipmentOther medical equipment 300,000 (50,000) 52,843 58,164 250,000Imaging - room replacement 300,000 (300,000) 0 0Donated 0 0

Sub totals 600,000 (350,000) 52,843 58,164 250,000

4. IM&T - Hardware / systemsIT Projects 2013/14 0 62,708 3,851 62,708Windows 7 Migration 129,699 34,405 129,699Sub totals 0 192,407 38,256 0 192,407

5. IM&T - Software and systems developmentOrder Communications 166,119 85,881 0 252,000Millennium Post 2015 Programme (Phase 1) 481,500 (390,000) 11,997 91,500Prescription tracking system 9,570 7,468 9,570

Sub totals 647,619 (294,549) 19,465 0 353,070

6. Incentive Scheme AllocationPlanned Care - Waterside refurbishment 71,342 6,251 71,342Estates 0 0Sub totals 0 71,342 6,251 0 71,342

Capital funding to be allocated / (reduced) 96,893 76,136 49,682

TOTAL 3,500,000 0 2,195,036 167,573 3,726,000

HIGHLIGHTS1 - Confirmed capital available for 2013/14 £3,500,000.2 - Donated asset £100,000 for the Front Entrance from League of Friends3 - Capital spent to date £2195k4. Expenditure to date is 59% of capital allocation of £3,600k.