General Meeting Of The Council Of Governors 5.30-7.30pm, 06 August 2015

Transcript

GENERAL MEETING OF THE COUNCIL OF GOVERNORS OF BARNSLEY HOSPITAL NHS FOUNDATION TRUST 5.30-7.30PM, 06 AUGUST 2015 IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL AGENDA 1. Apologies & Welcome 2. To invite comments from members of the public 3. To review the Register of Interests and receive any declarations for interest for the meeting Enc 3 4. To approve Minutes of the meeting held on 11 June 2015 Enc 4 5. To consider any matters arising from the Minutes of the last meeting 6. To receive and consider the External Auditor’s report on the Quality Account for 2014,15 and consider planning for 2015/16 – Ms M Liskiewicz, Manager, PricewaterhouseCoopers LLP 7. To consider the aims and objectives of Listening Into Account – Ms E Parkes, Director of Marketing & Communications & Ms T Rastall, Head of learning & Development 8. To receive and note latest Membership report – Ms E Parkes, Director of Marketing & Communications Enc 8 9. To receive a report from the Trust’s Chairman, Mr S Wragg Enc 9 10. To receive a report from the Lead Governor, Mr J Unsworth Enc 10 11. To receive an update report from the Trust’s Chief Executive, Ms D Wake Enc 11 Enc 6 & presentation Presentation 12. To receive and approve the following reports from the Nominations Committee: a) outcomes of the Non-Executive Directors’ performance reviews for 2014/15 b) outcomes of the Chairman’s performance review for 2014/15 c) annual review of the Terms and Conditions of Service for the Non-Executive Directors and Chairman Enc 12a Enc 12b Enc 12c 13. To receive latest update report from the Council of Governors’ sub-groups – Mrs Carol Robb (Vice Chair, Quality & Governance) and Mr D Brannan (Chair, Finance & Performance) Enc 13 14. To receive and note reports from the Board of Governors – latest Board agenda and Minutes (meetings held in public) – latest monthly integrated performance report Enc 14 15. To consider issues raised by Governors – items highlighted in pre-meeting 16. Any other business, including – matters raised by the public – date of the next General Meeting, 1st October 2015, 5.30-7.30pm Signed: ………………….. Chairman 03 COUNCIL OF GOVERNORS – AUGUST 2015 REF: CG/15/08/03 REGISTER OF INTERESTS 1. INTRODUCTION In accord with statutory guidance and our Constitution, the Trust is required to maintain and regularly review a Register of Interests for the Council of Governors. In addition, Governors are invited to make a declaration of any interests – which should include any changes to the Register – at each general meeting. Whilst every effort is made to assist Governors’ declarations, it is the responsibility of each individual Governor to ensure that his or her interests are declared in a timely and appropriate manner. 2. REGISTER OF INTERESTS A copy of the Register of Interests for the Council of Governors is attached for reference, reflecting latest known changes. If anyone has any other changes/amendments/additions they should record on the Register, would they please ensure the details are declared at the meeting or advised in writing to the Chairman as soon as possible. The Register, together with the Register of Interest for the Board of Directors, is available to the public on request at any time. 3. RECOMMENDATION Governors are asked to: • note the Register of Governors’ Interests attached • advise any amendments, additions or deletions required to ensure that their personal entries comply with Clause 12 and Annex 7 of the Trust’s Constitution Carol Dudley SECRETARY TO THE BOARD August 2015 CoG Aug 2015: 03 Register of Interests BARNSLEY HOSPITAL NHS FOUNDATION TRUST REGISTER OF GOVERNORS’ INTERESTS – MAY 2015 Entry No* 92 Mr Paul Ardron Constitutency: Partner Org Sheffield Hallam University & University of Sheffield (shared seat) 7 Mr David Brannan Constituency: Partner org Voluntary Action Barnsley (VAB) 68 Mrs Pauline Buttling Constituency: Public Barnsley Public 84 93 94 85 * GOVERNOR (& CONSTITUENCY) Mr Tony Conway Constituency: Staff Volunteers Mr Antony (Tony) Dobell Constituency: Public Barnsley Public Mrs Joan Gaines Constituency: Public Barnsley Public Mr Tony Grierson Constituency: Public Barnsley Public Entry numbers to run consecutive by date order Start date of Term End date of Term 01 August 2013 INTERESTS Date entry reviewed 05 February 2015 None 01 January 2005 1. Chairman & Trustee of Voluntary Action (31 December 2007) Barnsley (31 December 2010) rd 2. Member, Independent Remuneration Panel, 3 term to Barnsley Council 31 December 2013 01 January 2010 (31 December 2012) Barnsley HealthWatch champion (volunteer) 2nd term to 31 December 2015 01 January 2013 Union representative, GMB to 31 December 2015 01 January 2014 None to 31 December 2016 01 January 2014 Non Executive Director, Berneslai Homes to 31 December 2016 01 January 2013 Member, Labour Party to 31 December 2015 Signed: Date Interest registered 01 January 2005 (Chair Nov 09) 03 January 2008 05 February 2015 04 February 2015 05 February 2015 08 October 2014 05 February 2015 08 January 2014 05 February 2015 08 January 2014 05 February 2015 October 2014 05 February 2015 ____________________________ ** Hard copy of all updates will be required to be initialled by updating officer and retained in the office of the Chief Executive or Nominated Officer Secretary to Board Dated: May 2015 Page 1 of 4 Entry No* Start date of Term End date of Term INTERESTS Date Interest registered Date entry reviewed 100 Mrs Rachel Hewitt Constituency: Staff Clinical Suppport 01 May 2014 to 31 December 2016 None 05 February 2015 59 Mr Martin Jackson Constituency: Partner Org Joint Trade Unions Committee January 2008 (December 2010) 2nd term to 31 December 2013 None 05 February 2015 102 Ms Annie Moody Constituency: Public Barnsley Public None 05 February 2015 55 Mr Bruce Leabeater Constituency: Public Barnsley Public None 05 February 2015 None 05 February 2015 None 05 February 2015 79 101 95 103 67 86 * GOVERNOR (& CONSTITUENCY) Ms Gwyn Morritt Constituency: Staff Nursing & Midwifery Mrs Dianne Murray Constituency: Partner Org Barnsley College Mrs Jacky O’Brien Constituency: Public Barnsley Public Mr Harshad Patel Constituency: Public Barnsley Public Councilllor Jenny Platts Constituency: Partner org Barnsley Metropolitan Borough Council (BMBC) Mr Jordan Ramsey Constituency: Staff Non Clinical Support 01 January 2015 to 31 December 2017 01 January 2008 (31 December 2010) (31 December 2013) 3rd term to 31 December 2016 01 January 2012 to 31 December 2014 01 October 2014 01 January 2014 to 31 December 2016 01 January 2015 to 31 December 2017 November 2009 (31 October 2012) 2nd term to 31 October 2015 01 January 2013 to 31 December 2015 None 08 January 2014 05 February 2015 None a) Governor, Athersley South Primary School b) Member, Labour Party c) Member, Barnsley Health & WellBeing Board 08 February 2012 08 October 2014 ** Hard copy of all updates will be required to be initialled by updating officer and retained in the office of the Chairman or Nominated Officer 05 February 2015 05 February 2015 None Entry numbers to run consecutive by date order 05 February 2015 Signed: Dated: ____________________________ Secretary to Board May 2015 Page 2 of 4 Entry No* 74 39 97 104 73 98 * GOVERNOR (& CONSTITUENCY) Mr Ray Raychaudhuri Constituency:Staff Medical & Dental Mrs Carol Robb Constituency: Public Barnsley Public Mrs Lisa Sanderson Constituency: Staff Nursing & Midwifery Mr Frank Skorrow Constituency: Public Barnsley Public Mr Trevor Smith Constituency: Public Barnsley Public Mr Luke Steenson Constituency: Public Consituency O (out of area) Start date of Term End date of Term 01 September 2010 (31 December 2012) 2nd Term to 31 December 2015 01 January 2006 (31 December 2008) (31 December 2011) (31 December 2014) 4th term to 31 December 2017 01 January 2014 to 31 December 2016 01 January 2015 to 31 December 2017 Date Interest registered Date entry reviewed a. Director of Yorkshire Women’s Health 21 March 2011 b. Member of Yorkshire Clinical Senate 24 Feb 2015 05 February 2015 INTERESTS None 05 February 2015 None 05 February 2015 Member, Hoyland Medical Practice Patient Reference Group a) Member of the Royal British Legion, Branch Chairman & Honorary Poppy Appeal organiser b) School Governor, Netherwood Advance Learning Centre c) Magistrate (Supplementary List), Barnsley 01 September 2010 Bench (31 December 2012) d) Member, Friends of Darfield Churchyard 2nd term to Group 31 December 2015 e) Owner, Florida Villas Home Rentals f) Member, Chartered Institute of Builders g) Member, Association of Building Engineers h) President & Member, Rotary International - Stainborough 01 January 2014 to 31 December 2016 a) Employee, Calderdale & Huddersfield NHSFT West Yorkshire audit consortium b) Tutor, West Yorkshire RoSPA Advanced Drivers and Riders c) First Aider, St John Ambulance d) Steward, UNISON Entry numbers to run consecutive by date order ** Hard copy of all updates will be required to be initialled by updating officer and retained in the office of the Chairman or Nominated Officer May 2015 31 January 2015 02 September 2013 05 February 2015 ____________ 31 January 2015 08 January 2014 Signed: Dated: 05 February 2015 ____________________________ Secretary to Board May 2015 Page 3 of 4 Entry No* 106 Mr David Thomas Constituency: Public Barnsley Public 34 Mr Joseph Unsworth Constituency: Public Barnsley Public 105 Mr Zubair Warraich Constituency: Public Barnsley Public 66 i * GOVERNOR (& CONSTITUENCY) Mr Stephen Wragg Trust Chairman Start date of Term End date of Term INTERESTS May 2015 to 31 December 2015 01 January 2005 (31 December 2007) (31 December 2010) (31 December 2013) 4th term to 31 December 2016 01 May 2015 to 31 December 2015 a) Member, Labour Party b) Member, Penistone Town Council c) Chair, Penistone Grammar School Foundation Trust d) Councillor, Barnsley MBC 01 January 2009 (31 December 2011) (31 December 2014) 3rd term to 31 December 2017 i a) Non Executive Director, Barnsley Premier Leisure Trading b) Sole Director, Wragg Consulting Limited c) Labour Party, Member d) Director, 360 Engagement Ltd e) Governor, Darton College f) Chairman & Trustee, Barnsley Civic Date Interest registered 01 January 2005 26 September 2005 May 2014 Date entry reviewed 05 February 2015 None 7 January 2009 20 May 2010 29 June 2011 18 October 2011 12 December 2011 15 December 2011 05 February 2015 Subject to annual review/renewal Entry numbers to run consecutive by date order ** Hard copy of all updates will be required to be initialled by updating officer and retained in the office of the Chairman or Nominated Officer Signed: Dated: ____________________________ Secretary to Board May 2015 Page 4 of 4 04 COUNCIL OF GOVERNORS – AUGUST 2015 REF: CG/15/08/04 MINUTES OF A GENERAL MEETING OF THE COUNCIL OF GOVERNORS HELD ON 11TH JUNE 2015, 5.30PM IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL Present: Mr P Ardron Mr D Brannan Mrs P Buttling Mr A Conway Mr A Grierson Ms R Hewitt Mr P Lleshi Mr C Millington Ms G Morritt Ms A Moody Mrs J O’Brien Mr H Patel Cllr J Platt Mr R Raychaudhuri Mrs C Robb Mr F Skorrow Mr H Spence Mr T Smith Mr L Steenson Mr D Thomas Mr J Unsworth Mr Z Warraich Mr S Wragg Partner Governor, Sheffield Universities Partner Governor, Voluntary Action Barnsley Public Governor, Barnsley Public Constituency Staff Governor, Volunteers Public Governor, Barnsley Public Constituency Staff Governor, Clinical Support Services Partner Governor, Barnsley Together Partner Governor, Barnsley Clinical Commissioning Group Staff Governor, Nursing & Midwifery Public Governor, Barnsley Public Constituency Public Governor, Barnsley Public Constituency Public Governor, Barnsley Public Constituency Partner Governor, Barnsley MBC Staff Governor, Medical & Dental Public Governor, Barnsley Public Constituency Public Governor, Barnsley Public Constituency Public Governor, Barnsley Public Constituency Public Governor, Barnsley Public Constituency Public Governor, Public Constituency O (out of area) Public Governor, Barnsley Public Constituency Lead & Public Governor, Barnsley Public Constituency Public Governor, Barnsley Public Constituency Trust Chairman In attendance: Mr S Diggles Ms C Dudley Mrs K Kelly Mr N Mapstone Ms R Moore Ms D Wake Interim Director of Finance & Information Secretary to the Board Director of Operations Non Executive Director Non Executive Director Chief Executive Apologies: Public Governor, Barnsley Public Constituency Public Governor, Barnsley Public Constituency Partner Governor, Joint Trade Unions Committee Public Governor, Barnsley Public Constituency Partner Governor, Barnsley College Staff Governor, Non Clinical Support Staff Staff Governor, Nursing & Midwifery Public Governor, Barnsley Public Constituency Mr A Dobell Mrs J Gaines Mr M Jackson Mr B F Leabeater Mrs D Murray Mr J Ramsey Mrs L Sanderson Mr A Scattergood CG/15 38 APOLOGIES & WELCOME The Chairman welcomed Governors, Directors, and senior managers to the meeting. Particular welcomes were extended to Mr Warraich and Mr Millington, attending their first General Meeting since being appointed to the Council of Governors, and to Mr Thomas, recently re-appointed to the Council. A member of the public was also welcomed. Action Apologies were noted as above, including Mr Scattergood, the third of the newly appointed Public Governors. Governors looked forward to meeting him shortly. CG/15 39 COMMENTS FROM THE PUBLIC None. CG/15 40 DECLARATIONS OF INTEREST Mr Skorrow declared that he had recently joined his local patient participation group. No other declarations were received. CG/15 41 MINUTES OF LAST MEETING (Enc 3) The Minutes of the General Meeting held on 16 April 2015 were received and reviewed. One typing error was noted and corrected, and it was noted that Mr Grierson’s comment about having observed staff introducing themselves to patients, had related to BHNFT (Minute CG/15 33). Subject to these amendments, the Minutes were accepted as a true record. CG/15 42 MATTERS ARISING The following updates were noted: • CG 15/25 – Matters Arising: Hospital Newsletter The Chairman confirmed that, as agreed, the letter explaining the change to the newsletter distribution had been finalised and would be sent out to all members shortly. It would offer the opportunity for members to continue to receive their copies by post and would also invite them to join the new Barnsley Hospital Charity Lottery, leaflets about which were available at the meeting. • CG 15/25 – Matters Arising: Car Park The Chairman advised that the Estates team had looked into the reported concerns further and work was planned to repaint lines and improve signage shortly. Mrs Bevis, volunteer and member of the public who had first reported the issue, advised that she had observed three cars entering car park the wrong way very recently. It was hoped that the planned work would improve the situation. • CG 15/26 – Business Plan The Chairman advised that the 2015/16 Annual Plan was now published; copies were available at the meeting or on request. • CG 15/27 – Quality Account As agreed, Governors’ comments on the (then draft) Quality Accounts for 2014/15 had been completed through the Finance & Performance Subgroup. A copy of the final response was appended to the Minutes. • CG 15/30 – Chairman’s report Lead Governor Mr Unsworth reminded members of the annual review of the Trust’s Constitution. A working group would be established, led by the Associate Director of Corporate Affairs. Expressions of interest from Governors to be involved with the group were welcome, Mr Unsworth and Mr Grierson had already affirmed their intent to join the group. CoG Aug 2015/ 06_June Mins 2015 page 2 of 7 CG/15 43 2015/16 BUDGET Mr Diggles, Interim Director of Finance & Information, presented an overview of the Trust’s budget for 2015/16, as submitted to Monitor: -c£11million. He explained the variance against the figures presented previously, largely reflecting factors outside of the Trust’s remit, including the impact of drivers such as the larger than anticipated national pay award for staff (tough on the budget but good news for staff) and increased insurance premia, as well as local factors including the current gap in funding for 7-day services and lack of funding for winter resilience. The £6.7million cost improvement programme, income and activity projections, planned continued service improvements and forecast capital spend were also highlighted. Governors appreciated Mr Diggles’ clear explanation of how the budget had been built and the challenges and risks ahead for the Trust in 2015/16. The pressures on the budget were discussed at length. In response to a question from Mr Steenson, Mr Diggles confirmed that the Trust had built its plans based on downside risks, taking account of all factors currently identified. In response to queries and comments from other Governors, the Chairman, Mr Diggles, Mrs Kelly and Ms Wake outlined the current status of negotiations with the local Clinical Commissioning Group (CCG) to reach agreement on the main commissioning contract. There was broad agreement on the majority of the contract with the exception of some key issues that remained unresolved, including the gap on 7-day funding and lack of winter resilience funding. In view of service improvements already identified from the 7-day services rolled out to date (eg mortality ratios, support for waiting lists, consistency of services), the Board of BHNFT had agreed to continue 7-day services - at financial risk - pending conclusion of the contract negotiations. Mr Conway commented that, as a volunteer on site Saturdays/Sundays, he had witnessed the positive impact of 7-day services and the increased levels of activity at weekends. Ms Wake advised that the Trust had been asked to identify what services it could stop if needed, to help lessen the funding gap; the Trust had reviewed its service delivery and had reduced costs by a further £0.6 million but this still left a significant shortfall. In terms of any service cessation, it would be for the CCG to identify which services it no longer wished to commission from the Trust. Mr Diggles also reported that the CCG’s recent change to its payment schedule had been unexpected and contrary to the payment systems operated by most neighbouring trusts; it had triggered the need for an earlier than projected drawdown of funding support to project the Trust’s cashflow position but this continued to be closely managed. Mr Smith advised that he had attended the latest public meeting of the CCG and had raised a question regarding the funding gap; the CCG had stated that no more funding would be available. Governors and Board members were conscious that the CCG commissioned services from other providers too. Mrs Kelly affirmed the Trust’s awareness that regional resilience funding was not intended solely for the hospital but to support wider work in the community too, with the aim of providing services nearer to home and reducing avoidable attendances at A&E. Unfortunately there was little evidence that investments to date had been effective, resulting in the Trust’s continued need for further funding support, as had previously been agreed with the CCG’s Governing Body. CoG Aug 2015/ 06_June Mins 2015 page 3 of 7 Ms Wake advised that she and the Chairman would ensure the local MPs were kept appraised of the contract position through their regular briefing meetings. Mr Unsworth suggested, and it was agreed, that it would be useful for Governors to raise their concerns with their local MPs too; it was also agreed that Governors should continue to share news about the hospital with the members they represented. Mr Smith stated that he would continue to attend CCG meetings and encouraged others to attend as well. He would like to receive a note of other public meetings available in the local community and the protocols for attending and, if possible, speaking. ALL CED It was agreed that the CCG’s support in previous years had been greatly appreciated and it was important that both organisations continued to work together for the benefit of Barnsley patients. The Chairman, CEO and Executive Team would continue to make every effort to build better relations with the CCG. Ms Wake advised that the Executive Team would be meeting with NHS England soon, who had offered to convene a meeting subsequently (but not mediation) between the CCG and BHNFT to progress discussions. The Chairman would also be meeting shortly with the Chair of the Health & Wellbeing Board (H&WBB), as the H&WBB had overall responsibility for commissioning in Barnsley. It was noted that Monitor was supportive of the current stance and negotiations would continue. Governors would be kept advised of progress, as discussions progressed. CG/15 44 NOMINATIONS COMMITTEE (Enc 7) The Chairman presented the latest report from the Nominations Committee, which included the proposed timeline for the next Non-Executive Director appointment, a copy of the Trust’s plans to ensure compliance with Fit & Proper Person Requirements – “FPPR” – (already in place based on good practice and would be reinforced with the formal process outlined) and deferral of the 2014/15 year end reviews for the Non Executive team (including the Chairman) pending outcomes from the ongoing external review on governance. Governors endorsed the timelines for the next NonExecutive Director appointment and noted the planned process for FPPR. Governors were also pleased to record a note of sincere thanks to Mrs Christon, Mrs Brain England and Mr Patton for the additional support they had all provided since the start of 2015, when the Non Executive team had not been at full strength. CG/15 45 DIRECTOR OF OPERATIONS Mrs Kelly gave an informative presentation, which outlined her role and the wide scope of her responsibilities as Director of Operations at BHNFT. Essentially, she was responsible for directing, administering and coordinating all of the internal activities through the six Clinical Business Units (CBUs), with ultimate accountability for delivery. Her presentation expanded on the remit of each of the CBUs and how they interlinked with other areas across the Trust. Governors thanked Mrs Kelly for the presentation, which gave a useful insight into her role and clearly demonstrated her awareness of issues across the whole organisation. Mr Millington advised that he had seen evidence of Mrs Kelly’s role and effectiveness from his observation of Board meetings regularly; this was endorsed by other Governors present. CoG Aug 2015/ 06_June Mins 2015 page 4 of 7 CG/15 46 CHAIRMAN’S REPORT (Enc 9) The Chairman’s report was received and noted. It provided commentary and updates on a range of activities, items of interest and Board discussions since the last General Meeting. The Chairman highlighted the event held for the HEART Awards on 4th June. It had been another very successful evening, well attended (and well sponsored) and a great opportunity to recognise some of the Trust’s magnificent staff. Mr Millington commented that the increased sponsorship reflected very positively on the Trust; this was appreciated. CG/15 47 LEAD GOVERNOR’S REPORT (Enc 10) The Lead Governor’s report on activities since the last meeting and items of interest for the Council was received and noted. Mr Unsworth added his thanks to those of the Chairman regarding the HEART Awards – a very good evening and a welcome chance to congratulate staff on their valued contribution to the Trust’s progress. He would like to see more Governor involvement in the award process next year if possible. Only a small number of Governors had been able to attend the shortlisting and it might be useful for the Lead and Deputy Governors and the sub-group Chairs to have more direct involvement with the Governors’ Award. Mr Unsworth was also pleased with the continuing success of the informal sessions for Governors before each General Meeting. These had been instigated at a Governor’s suggestion and were proving to be very useful. CG/15 48 CHIEF EXECUTIVE’S REPORT (Enc 11) The Chief Executive’s report was received and noted. Ms Wake expanded on several issues and provided further updates on: • recent changes to the portfolios of the Executive Team, to ensure continued good oversight, direction and management across all areas. This would be supported by continued plans for the recruitment of a substantive Director of Finance; cessation of Mrs Kelly’s part-time secondment to a neighbouring Trust (the role had not been as expected and Mrs Kelly’s return to full time at BHNFT had supported continued full focus on current pressures), and appointment of Mr José Fernandez as Associate Director of HR&OD, to provide cost savings by not filling the post of Director of HR&OD (to be reviewed in six months). • performance for April (and May) – as detailed in the Integrated Performance Report provided under agenda item 13, with achievement of most targets, particularly cancer and quality issues, despite continuing pressures on Emergency Access, and plans to close the escalation ward as soon as possible (had remained open longer than expected due to the continued pressures); • current challenges in outpatients and with DNAs (did not attends), management of outcomes etc – work on which was ongoing to drive improvements; • continued partnership working to ensure optimum services available at Barnsley for patients, with current focus on urology, cardiology and endoscopy services CoG Aug 2015/ 06_June Mins 2015 page 5 of 7 • work ongoing in readiness for the Care Quality Commission (CQC) visit w/c 13th July. Governors would be involved with the visit, the date and time of a focus group meeting between Governors and the CQC inspection team would be confirmed shortly. The Chairman advised that Governors would be able to be involved by other routes too, including a meeting open to the public hosted by the CQC on 13th July; details would be published in the local media. Ms Wake also expanded on the Trust’s commitment to Listening into Action (LiA) and undertook to provide more information about it at the next General meeting. She confirmed that LiA would the encompass and build on the progress achieved to date from a range of good work already undertaken, including the Carnegie programme mentioned by the previous Director of HR&OD. DW Referring back to the performance report and in response to a Governors’ question, Ms Wake provided further information on the sickness absence rate, which had increased slightly month on month (seasonable trend). She advised that Mr Fernandez was giving close focus to some of the underpinning systems (both in terms of reporting and support for staff) and it was expected that this would result in a positive impact on the statistics shortly. Mr Grierson referred to section 11.1 and the Trust’s commitment to the “Hello my name is…” campaign, which he was pleased to note. CG/15 49 SUB-GROUP REPORTS (Encs 12a&b) a) Regular update report The report on the latest meetings of the Governors’ sub-group – Finance & Performance (FPSG) and Quality & Governance (QGSG) was received and noted. The meeting Chairs briefly expanded on a number of key points, including review of the Terms of Reference for the sub-groups and the role of the Lead & Deputy Governors, as requested by the Council of Governors in April. No material changes were recommended and this was accepted by the wider Council. Mrs Buttling highlighted the request for comments on the work of the external and internal auditors and the audit plans shared with FPSG, to be directed to Mr Dobell as soon as possible. As nominated Audit Liaison for the Governors, Mr Dobell would be meeting with the Audit Committee Chair shortly to discuss these further. Governors also noted and reviewed the suggestion that the Council of Governors should write to the Secretary of State, to request consideration of the statements raised during the General Election regarding reduction of ‘red tape’. It was acknowledged that this was a valid point but was complex, particularly in the light of recent announcements regarding administrative changes in the NHS (around referral to treatment times), which could prove helpful to acute trusts. The Chairman read out a brief draft prepared by Mr Dobell. Ms Morritt and Mr Grierson suggested, and it was agreed, that Governors could use the draft as a basis to write to their MPs or the Secretary of State individually if they so wished, rather than as a letter from the Council as a body. The latter would have required more formal consideration, to be submitted by the Chairman on behalf of the Council. CoG Aug 2015/ 06_June Mins 2015 ALL page 6 of 7 b) Appointment of sub-group leads and Lead/Deputy Lead Governor It was noted that four expressions of interest had been received for the six leading appointments in the Council of Governors: Chairs and Vice Chairs for FPSG and QGSG respectively, and the roles of Lead and Deputy Lead Governors. In accordance with the terms of reference for these appointments, the Chairman recommended that the four candidates be accepted and that he would meet with them subsequently to determine who would take which role. This was approved. The outcomes would be reported at the next meeting. CG/15 50 BOARD OF DIRECTORS SW (Enc 15) The agenda (June), Minutes (May) and latest integrated performance report as presented to the Board of Directors meeting held in public on 11th June 2015 were received and noted. CG/15 51 ISSUES RAISED BY GOVERNORS Mr Unsworth confirmed that matters raised at the Governors’ pre-meeting had all been raised and addressed in discussions during the General meeting. CG/15 52 ANY OTHER BUSINESS • Public Comments Mrs Bevis thanked the Governors and the Trust for enabling her to attend the HEART Awards evening on 4th June. She had not been aware of the annual event previously. She had enjoyed it immensely and believed it was something the Trust should be justly proud of. CG/15 53 DATE OF NEXT MEETING There being no further business the meeting ended at 7.30pm. The date of the next meetings was confirmed for 6th August, 5.30-7.30pm. CoG Aug 2015/ 06_June Mins 2015 page 7 of 7 06 COUNCIL OF GOVERNORS – AUGUST 2015 REF: CG/15/08/06 QUALITY REPORT 2014/15 1. INTRODUCTION 1.1. In accordance with Department of Health requirements and Monitor’s Foundation Trust Annual Reporting Manual for 2014/16 (the “ARM”), all Trusts are required to provide a report on the quality of care they provide within their annual report. 1.2. Monitor’s guidance also requires Foundation Trusts (FTs) to include a limited assurance report from the external auditors on the content of the quality report and certain mandated indicators. The limited assurance report gives the auditors’ view on whether anything has come to their attention that leads them to believe that the content of the quality report has not been prepared in line with the guidance or is consistent with other referenced information sources. 2. OUTCOMES 2.1. Barnsley Hospital’s latest quality report and the auditors’ limited assurance report are both included within the Annual Report & Accounts 2014/15, copies of which have been provided to Governors under separate cover and will be available on the Trust’s website (www.barnsleyhospital.nhs.uk) shortly. The Annual Report & Accounts will be presented formally to Governors and members at the Trust’s Annual General & Annual Public Members meeting to be held on 24th September 2015. 2.2. As usual our auditors, Pricewaterhouse Coopers (PWC), have also prepared a fuller report (copies attached for Governors). Additionally, senior representation from PWC will be attending our General Meeting to expand on the report, provide further information and welcome any questions or comments from Governors. 3. RECOMMENDATION The Council of Governors is asked to receive the attached report and further information to be provided by Pricewaterhouse Coopers at the meeting. Stephen Wragg CHAIRMAN August 2015 CoG Aug 2015: 06_i Quality Account 08 COUNCIL OF GOVERNORS – AUGUST 2015 REF: CG/15/08/08 MEMBERSHIP UPDATE REPORT 1. OVERVIEW This report provides Barnsley Hospital NHS Foundation Trust Council of Governors with an update on the Trust’s membership and summarises the work underway to secure membership to ensure that it is representative of those eligible to be members. It also highlights what has been happening across the Trust since the last report and forthcoming activities. 2. MEMBERSHIP MANAGEMENT 2.1. The post of membership officer ended on 10th February 2015 as the Trust was regrettably unable to fund the creation of a new post. 2.2. As the recruitment and retention of members is a requirement of a Foundation Trust and reportable to Monitor, membership has subsequently been managed in the following ways: • Continuous recruitment the Capita membership as using the Trust’s downloadable form is submitted via Freepost. • Membership is Everyone’s Business – a staff campaign is planned for September, to coincide with the Annual General and Public Members Meeting, to be held on 24 September 2015. The campaign will engage our staff in a recruitment drive by asking them to become membership ambassadors by engaging patients, their families and friends and the wider community. • To ensure departing staff are not lost to the membership, we have worked with human resources to change the exit interview forms to enable staff to retain their membership by converting to public membership on departure. • Raising Awareness – A revised membership registration leaflet now enables us to better capture demographic data including some protected characteristics and to reduce our costs and widen our reach we have captured the email addresses of almost 15% of our members • Barnsley Hospital News - a membership application form/website link in every issue to promote recruitment. CoG August 2015 / 08_Membership through the website via an online form, linking directly to database to signpost visitors from the home page as well Facebook and Twitter accounts to drive traffic. A also available which can be completed by hand and (page 1) 3. MEMBERSHIP SUMMARY AND ANALYSIS 2014/15 3.1. Annual Membership Summary 3.1.1. As at 31 March 2015, we had 12,325 eligible members comprising of 8,792 public members and 3,533 staff members. 3.1.2. Overall public membership levels had decreased by under 0.5% and staff membership levels had increased by less than 0.5% compared to 2013-14 year end data. 3.1.3. The table below sets out the movements in membership as at 1 April 2014 to 31 March 2015. At 1 April 2014 New members Members leaving At 31 March 2015 9049 286 543 8792 3436 731 634 3533 Public Constituency Staff Constituency 3.2. Annual Membership Analysis 3.2.1. The table below provides analysis of actual membership, compared against the eligible membership for age, ethnicity, gender and socio-economic groupings. Public Constituency Age (years) 0-16 17-21 22+ Unknown Ethnicity White Mixed Asian or Asian British Black or Black British Other Unknown Gender Male Female Unknown Socio-economic Groupings AB - upper/middle class C1 - lower middle class C2 - skilled working class DE – working/casual class Unknown 31 March 2015 Actual Members 31 March 2015 *Eligible Membership 6 75 8,707 8,521 12,184 202,156 8,423 15 68 20 8 258 218,148 1,571 1,589 1,145 408 0 3,330 5,456 6 110,761 112,100 0 407 3,184 1,411 3,680 110 23,741 38,724 32,287 72,347 55,762 * Eligible members are those that fall within the allowed age range in the defined geographical membership areas. CoG August 2015 / 08_Membership (page 2) 4. ELECTIONS 4.1. As a number of Governors will be stepping down at the end of their current term of office in December 2015, elections to the Council of Governors will be held in accordance with the draft timetable below. Once the dates are finalised they will be recirculated. 4.2. Seats available will include: • Six Public Governors (includes 2 appointed mid year) • Three staff governors 4.3. Candidate workshops will be held in October, led by the Chairman and the Lead Governor, supported by UK Engage. Dates are in the process of being finalised and will be circulated once agreed. Draft timetable for 2015 Elections Event Suggested publication of Notice of Election Thursday 24 September 2015 Last possible publication of Notice of Election Thursday 15 October 2015 Deadline for Receipt of Nominations Monday 2 November 2015 Publication of Statement of Nominations Tuesday 3 November 2015 Deadline for Candidate Withdrawals Thursday 5 November 2015 Notice of Poll / Issue of Ballot Packs Tuesday 17 November 2015 Last possible date for Notice of Poll/ Issue of Ballot Packs Close of Poll – 5pm Declaration of Result 5. Suggested date Thursday 19 November 2015 Thursday 10 December 2015 Friday 11 December 2015 ANNUAL GENERAL AND PUBLIC MEMBERS MEETING The Trust’s Annual General and Public Members Meeting 2015 will be held at 10am on Thursday 24 September, in the Lecture Theatres within the Education centre at the Hospital. 6. RECOMMENDATIONS Governors are asked to receive and endorse this report, noting progress to date. Emma Parkes Director of Marketing & Communications August 2015 CoG August 2015 / 08_Membership (page 3) 09 COUNCIL OF GOVERNORS – AUGUST 2015 REF: CG/15/08/09 CHAIRMAN’S REPORT 1. INTRODUCTION 1.1 This report is intended to give a brief outline of some of the work and activities undertaken as Trust Chairman over the past month and highlight a number of items of interest. 1.2 The items reported are not shown in any order of priority. 2. TRUST POSITION 2.1 As is reported in other papers in this and at Board meetings, our turnaround plan continues to progress and we are now in the second year of the plan. I have no doubt that this year will be more difficult than the first, but we must push hard to deliver the savings and work towards the future sustainability of the Trust. 2.2 We must continue to give confidence to the population of Barnsley and our key stakeholders that care will not be compromised and we will turn this current situation around. I will keep reiterating this message as I think it should be constantly in people’s minds. Whilst we are bringing about our return to stability, we must not compromise on quality of care and patient safety. 2.3 We must also give confidence to our staff that the Trust is doing everything it can to improve patient experience and the quality of care our patients receive. In addition we have to pay tribute to all our staff for the work they are doing to conceive new ideas to deliver better care, but also the work that they have done to bring our transformation to life. 2.4 At our recent meeting with Monitor they indicated that they would be prepared to recommend the removal of our Section 111 licence condition, which marks further progress on our recovery. 2.5 However it does appear that CIP delivery is becoming more difficult and we must keep this on track to return to financial balance as soon as possible. 3. COUNCIL OF GOVERNORS 3.1 Governors will recall that Mr Alan Scattergood was appointed to the Council of Governors in May. Unfortunately, due to unforeseen circumstances, Mr Scattergood had to step down shortly thereafter without any real opportunity to fulfil the role. The vacancy will be carried forward to the forthcoming elections, starting in September. CoG August 2015:09_Chairman (page 1 of 3) 3.2 As reported at the last meeting, expressions of interest were received from four governors for lead roles within the Council of Governors and sub-groups. The Council endorsed my recommendation to accept these expressions and, as agreed, I subsequently met with the four governors - Joe Unsworth, David Brannan, Jordan Ramsey and Trevor Smith - to review and finalise who would take which role in the Council for 2015/16. I am pleased to report the outcome as follows: o Lead Governor – Joe Unsworth (final year) o Sub-group Chair for Finance & Performance – David Brannan o Sub-group Chair of Quality & Governance – Jordan Ramsey o Deputy Lead Governor and deputy Chair for both sub-groups – Trevor Smith Joe also extended an open invitation for any governor with an interest in standing for Lead Governor in 2016/17 to shadow him sometime during the course of this year to get more insight into what the role entails. My thanks again to Joe, David, Jordan and Trevor for taking on these lead roles. 3.3 On behalf of the full Council of Governors may I also record a note of thanks to Pauline Buttling and Carol Robb, as they step down as vice-Chairs for the sub-groups. Their support and leadership since the introduction of the new reporting structure in January 2015, and the different sub-groups they supported previously, has been much appreciated 4. NEWS & EVENTS 4.1 On 6th July I attended the Working Together Chairs and Chief Executive meeting along with our Chief Executive and Director of Strategy. The discussion was robust and new ways of moving the programme forward around a vanguard bid were discussed. We also agreed that the Governance of the programme needs to be reviewed which the CEO’s were taking away to respond to a proposal from the Chairs. 4.2 14th July as you will know saw the start of our CQC inspection and I joined the Chief Exec and Director Colleagues to give the opening presentation to the CQC team. I’m sure all of us are looking forward to their report. 4.3 27th July saw the CEO, Interim Finance Director, Medical Director, Senior Independent Director and I attend our performance meeting with Monitor. It was a very good meeting with much of the excellent work we have been doing highlighted by Monitor and as already reported we have been told that they will be recommending the removal of another of our licence conditions. In addition there is also a suggestion that these meetings will become less frequent and our financial issues will be managed in the standard fashion. 5. BARNSLEY HOSPITAL CHARITY 5.1 At the time of writing, the donations for July are £30,500.56. CoG August 2015:09_Chairman (page 2 of 3) 5.2 The Tiny Hearts Appeal is continuing to grow and I have received cheques presentations in the last quarter of:  £18,000 from Perrigo Foundation  £3,125 from Stainborough Rotary Club  £1500 from TK Maxx 5.3 We have also had four local fundraisers (one of them is a staff member) taking part in physical events, with the latest being at Castle Howard last weekend – they have raised over £1,500 so far. 5.4 Text Giving – There have been no text donations made to the general purpose fund. However, this is not publicised well currently, but is incorporated onto all future publicity for Barnsley Hospital Charity. 6. RECOMMENDATIONS The Council of Governors is asked to receive and note this report, Stephen Wragg CHAIRMAN August 2015 CoG August 2015:09_Chairman (page 3 of 3) 10 COUNCIL OF GOVERNORS – AUGUST 2015 REF: CG/15/08/10 LEAD GOVERNOR’S REPORT 1. INTRODUCTION This is my usual report on my activities and the activities of other governors since the last Council of Governors meeting. The last two months have typically shown the broad range of governor activities. 2. SUB-GROUP AND COMMITTEE MEETINGS 2.1 The Finance and Performance Sub-group was again well attended, as was the Training meeting on 2nd July which I chaired. The Training session was on dementia awareness and the staff survey. 2.2 The Nominations Committee met on 8th July, and the Senior Independent Director, Francis Patton, and myself as Lead Governor, met the Chairman on 17 July to give feedback on his end of year appraisal. Reports from the Nominations Committee are on the Council of Governors’ agenda. 3. OTHER GOVERNOR ACTIVITIES 3.1 I am sure all Governors are aware of the difficulties the Trust has in agreeing a contract with our main commissioner, the Barnsley Clinical Commissioning Group (CCG). A number of Governors, including myself, attended the AGM of the CCG on 11 June and some Governors have attended the CCG Board meetings held in public. If you are able to attend a CCG Board meeting please do. It will give you a greater understanding of the local health economy. 3.2 As part of the inspection of the Trust by the Care Quality Commission (CQC), CQC inspectors met a focus group of Governors, for what turned out to be a very lively session, on 14 July. The Lead Inspector and two other members of the inspection team at this meeting had no experience of working in a Foundation Trust, so it was particularly interesting to be able to share our views with them. 3.3 Christine Fisher, from the Infection Prevention and Control Department, asked for Governors to take part in a hand hygiene audit, and half a dozen or so volunteered. To date I have managed to fit one audit in. Governors wishing to take part in such an audit, and also quality visits, must have received training in safeguarding and infection prevention and control. If any Governor would like to join one or both of these programmes but has not yet completed the training, please speak to Carol Dudley and she will make appropriate arrangements for you. 3.4 The next issue of Barnsley Hospital News is due out in September and I will be writing a Lead Governor update. It is important we have Governor input in each edition. If you have any item of news about your role as a Governor please contact Erin Brady from the Communications Department. The deadline for copy for the September edition is 14 August. CoG June 2015: 10_Lead Governor report Aug 2015 4. NATIONAL AND REGIONAL GOVERNOR ACTIVITY 4.1 The minutes of the 19 May meeting of the Governor Policy Board (GPB) of NHS Providers Forum are on the NHS Providers website: www.nhsproviders/members/governor-support. The draft minutes of the meeting of 23 July have, at the time of writing, not yet been published. At the time of the May minutes the Chair of the GPB was a Foundation Trust Chair. The January meeting had agreed that the GPB should be chaired by a Governor, but until 19 May there had been no Governor volunteer for this role. The May minutes do indicate an interest from the GPB in existing regional groups of governors. 4.2 Longer serving Governors will remember the Yorkshire regional meetings. These ran for several years on a twice a year basis, rotating between FTs. We hosted the meeting in October 2011. The last event was in May 2012 at Harrogate and District NHS FT. Since then no FT in our region has volunteered to host a regional meeting. These meetings are not without cost for the host, and the financial pressures on FTs this may be at least part of the reason for their demise. 4.3 Barnsley Hospital FT hosted a meeting of Lead Governors in the region in February 2013. Five Lead Governors attended. We all agreed on the value of the regional meetings and agreed to speak to our Chairs to encourage their revival, but nothing came of this. 4.4 Pauline Buttling tells me that a Governor from Harrogate has spoken to her about a possible return of regional governor meetings. I suggested to Pauline that she advise her contact in Harrogate that the difficulty was getting an FT to volunteer to draw up a programme and arrange a meeting. I have raised this with our Chairman, Stephen Wragg. As we hosted the last regional meeting but one, and Harrogate hosted the last one, it would be unreasonable to expect either Barnsley or Harrogate to kick start a new round of regional meetings. 5. RECOMMENDATIONS The Council of Governors is recommended to: a) receive this report, and b) agree to request the Chairman, Stephen Wragg, to raise the issue of regional governor meetings with other Trust Chairs in the region. J Unsworth Lead Governor August 2015 CoG Aug 2015: 10 Lead Gov 2 11 COUNCIL OF GOVERNORS – AUGUST 2015 REF: CG/15/08/11 CHIEF EXECUTIVE’S REPORT 1. INTRODUCTION 1.1 This report is intended to give a brief outline of some of the key activities undertaken as Chief Executive since the last Council of Governors’ meeting and highlight a number of items of interest. 1.2 The items below are not reported in any order of priority. 2. WORKING TOGETHER PROGRAMME 2.1 The Chief Executive attended the Working Together Programme meetings on 1st June 2015 and 6th July 2015. Agenda items at the meeting included: • review of Progress – areas of the programme that were going well and areas where improvements could be made • key learning points • new models of acute care collaboration • organisational models • the way forward and next steps • Trusts’ clinical strategies (6th July 2015 meeting) 2.2 Chief Executives were requested to share a brief summary with their colleagues prior to the July meeting and then discuss their own Trust Clinical Strategy and how it would link to the proposed overarching Working Together three tiered approach. 2.3 The next meeting of the Working Together Programme is scheduled for 3rd August 2015. 3. NHS CONFEDERATION CONFERENCE 3.1 This year’s Confederation Conference was attended by Stephen Wragg, Chairman; Diane Wake, Chief Executive; Karen Kelly, Director of Operations and Richard Jenkins, Medical Director. The conference was held over three days and key speakers included, Sir Andrew Cash OBE, Deputy Chair NHS Confederation and Sir David Dalton, Chief Executive, Salford Royal NHS Foundation Trust, and the Right Honourable Sir Jeremy Hunt, Secretary of State for Health. 4. NHS PROVIDERS CHAIRS AND CHIEF EXECUTIVE MEETING 16TH JUNE 2015 4.1 The Chief Executive together with the Chairman attended the NHS Providers Chairs and Chief Executives Meeting on 16th June 2015 in London. The agenda for the day included: CoG Aug 2015: 11_CEO Report Page 1 of 4 • Strategic and Policy Update and Dialogue – A presentation from NHS Provider’s Chief Executive, Chris Hopson on strategic and policy issues affecting NHS providers. • Update on the Five Year Forward View – a session facilitated by the Chief Executive of NHS England, Simon Stevens which gave members an update on the Five Year Forward View and the NHS Care Models Programme. 5. START OF THE YEAR CONFERENCE 18TH JUNE 2015 5.1 The Chief Executive together with the Chairman and members of the Executive Team and the Board of Directors attended a Start of the Year Conference on 18th June 2015. The conference had been arranged by Barnsley Clinical Commissioning Group and the aim of the conference was to facilitate the System Transformation Analysis and Redesign Tool as an enabler for a Multispecialty Care Provider model of Care in Barnsley. 6. THE PATIENT REPORTING AND ACTION FOR A SAFE ENVIRONMENT (PRASE) PROJECT 6.1 The Trust is part of an exciting project supported by the Health Foundation called PRASE. Information about patient safety is collected from patients or the patient’s representative using a detailed questionnaire that is administered by volunteers. The questionnaire captures the patient’s perception of patient safety. The results of the questionnaires are then discussed at multidisciplinary ward team meetings and an action plan is produced. 6.2 Wards 17 and 32 are piloting PRASE and this will then be rolled out to other wards. This is an effective way of involving patients in helping to make our hospital safer. 7. BARNSLEY QUALITY IMPROVEMENT INITIATIVE WINS INTERNATIONAL CONFERENCE POSTER PRIZE 7.1 The Surgical Team from the Trust presented four oral presentations and seven poster presentations at the recently concluded Golden Jubilee (50th) Congress of the European Society for Surgical Research Conference held in Liverpool. 7.2 The Barnsley Abscess Pathway, which was presented by Mr Balakumar, CT2 (Core Trainee Doctor), won the Best Poster Award. It showcased the quality improvement initiative from Barnsley aimed at delivering cost-effective patient cantered care without compromising quality and safety. 7.3 Mr Samuel, General Surgery Registrar, along with Mr Balakumar audited management of patients presenting acutely with superficial abscesses to the Surgical Department. The inconvenience (both social and work life to the patient) caused by longer in-patient stay prior to their operation and the cost impact to the Trust was identified through this audit. The Barnsley Abscess Pathway was developed by a working group chaired by Mr Shiwani, Consultant General Surgeon, Dr Butterworth, Consultant Anaesthetist, Mr Samuel, Sue Spencer, Sister-in-charge Surgical Decisions Areas, Jos Vines, Theatre Matron and Lynn Oldfield, Nursing Matron. 7.4 Explaining the pathway to the panel of judges, Mr Balakumar said “Patients with uncomplicated superficial abscesses are assessed by a senior member of the on-call surgical team, who decide whether the patient is clinically well enough to go home and come back the following morning to have their operation done as a day procedure. Following their operation, such patients are discharged home (nurse-led) the same day if clinically deemed fit for discharge: aftercare in the community and follow-up are also organised”. CoG Aug 2015: 11_CEO Report Page 2 of 4 7.5 The initiative has been well accepted by patients who gladly agree to go back to the comfort of their own home and come back the following morning to have the procedure done straight away without too much waiting. This has been explicitly stated by most patients when they have received a follow up phone call from the nurses. The process has saved the Trust over £10,000 by avoiding in-patient hospital admissions. 8. 9. PATIENT INFORMATION LEAFLETS TO SUPPORT INFORMED CONSENT 8.1 The Trust has subscribed to EIDO, the provider of patient information leaflets which support the process of informed consent. All EIDO documents describe accepted clinical practice and provide information on medical conditions or investigations and any associated risks or benefits. The use of patient information leaflets is an important aspect in the process of shared decision making with the patient and in supporting the process of informed consent. All EIDO leaflets are validated by clinicians, proof readers, patients, and external organisations such as the Plain English Campaign and Patient Concern. Each document bears the Plain English Campaign Crystal Mark. 8.2 All of EIDO’s documents are evidence-based and fully referenced. EIDO documents are updated at least once each year, and more regularly if required, based on changes in medico-legal law and clinical practice. There is a full archiving programme of all EIDO documents. 8.3 The 360 EIDO Patient Information Leaflets are available for all staff to use. The leaflets can be found on the Trust’s home intranet page YORKSHIRE AND THE HUMBER DEMENTIA AUDIT AND QUALITY IMPROVEMENT AWARD 9.1 10. On 25th June 2015 the Hospital Dementia Support Service was successful in reaching the final of this regional event and gave an excellent presentation of their project. The presentation was judged to be runner up. Well done to Vicky FaxonWastnage, Dementia Nurse Specialist and the Alzheimer’s Society Team. CARE QUALITY COMMISSION (CQC) INSPECTION 10.1 The CQC carried out their planned inspection on the Trust the week commencing 13th July 2015. The Chief Executive was requested to present to the CQC on Tuesday 14th July 2015 prior to the commencement of the full inspection. 10.2 Preliminary feedback following the initial visit was given and the Trust received a lot of positive feedback. In particular, staff received high praise – caring, committed and passionate were three of the words used to describe staff at the Trust. 10.3 The CQC inspection team recognised that as an organisation, we had undergone a significant amount of change over a short period of time and that staff had undergone this transition whilst delivering high quality patient care. The team also observed that a change in culture throughout the organisation was evident although they were aware that we were still on our journey of development. 10.4 The areas which were highly commended during the feedback session were: CoG Aug 2015: 11_CEO Report Page 3 of 4 • • • • • • Endoscopy Suite and Day Surgery Unit End of Life including the Mortuary Team, Porters and Bereavement Office Maternity Services Critical Care Unit Our approach to the delivery of mandatory training and skills development. The Quality Impact Assessment (QIA) process. It was evident that this was working throughout the organisation at different levels forming a systematic approach • There was evidence of learning from Serious Incidents in Theatres and an example of a good patient story • Complaints, the CQC were impressed regarding the progress made against the complaints performance. Although it was recognised that there was still progress to be made, the Trust was commended on work undertaken to date. 10.5 The unannounced part of the inspection was undertaken during the evening of 26th July 2015 and no immediate concerns were reported. 11. IMPROVING AND SUSTAINING CANCER PERFORMANCE 11.1 In response to the ongoing national challenge faced by most providers in the delivery of the GP 62-Day target, Monitor, the Trust Development Authority and NHS England have jointly notified all Trusts and Clinical Commissioning Groups of changes required to support improvements to cancer standards. The Cancer Waiting Times (CWT) Taskforce has identified eight key priorities to be implemented urgently; designed to achieve sustained delivery of the target – thus improving the experience and outcome of patients. All organisations are required to commence weekly reporting of cancer performance (started in late July) and to evaluate current compliance against the eight key targets. 11.2 Initial self-assessment against each priority identifies compliance against three standards, partial compliance against four standards and non-compliance against one. Fuller detail is outlined in the monthly Integrated Performance Report – cancer section. 11.3 Latest Trust performance for Q1 2015/16 demonstrates compliance against the GP 62-Day target at 85.1% but meeting this target remains difficult; in particular poor shared pathway performance with Sheffield increasingly exposes us to requests for re-allocation of breaches which further jeopardise our position. 11.4 Improving overall performance through the redesign of processes and structure within the cancer services team has been the priority over the last 6 months. Many changes are now embedded and starting to show some impact on CWT (shared pathway performance in Q2 specifically). 11.5 Submission of the Trust’s self-assessment against the key priorities is due by the end of August. In view of the Board’s schedule, members are requested to give delegated authority to Mrs Kelly, as Executive Director responsible for cancer services, to complete and submit the self-assessment by the required deadline on behalf of the Trust. Diane Wake Chief Executive August 2015 CoG Aug 2015: 11_CEO Report Page 4 of 4 COUNCIL OF GOVERNORS – AUGUST 2015 REF: CoG/15/08/12a NON-EXECUTIVE DIRECTORS’ YEAR END APPRAISAL / PERFORMANCE REVIEW (2014/15) 1. INTRODUCTION 1.1 The 2014/15 performance reviews for the Non Executive Directors (NEDs) have been completed in accord with Monitor’s guidance and following protocols previously agreed with the Council of Governors. 1.2 The appraisals comprised of two parts this year: my review, as Chairman, of each member of the team and outcomes from 360° reviews carried out for each of the NEDs in post in 2014/15. The process was further informed by feedback from the second stage governance review completed recently (the latter contributing to the delay in the year end appraisals). The 360 and the governance reviews were carried out by external consultants. 1.3 Whilst this report only provides a high level overview of the appraisals process and outcomes, a more detailed report was provided to, and accepted by, the Nominations Committee in July. I am sure members of the Committee will support the findings outlined in this report. 2. NED PERFORMANCE 2.1 As this report is intended to give a review on the NEDs’ performance in 2014/15, it focusses on the three NEDs in post during that period: Linda Christon, Suzy Brain England and Francis Patton. For completeness, it includes reference to the newer members of the team, Ros Moore and Nick Mapstone – and looks ahead for all of the NEDs in terms of proposed objectives for 2015/16. 2.2 Governors will recall that, due to the delay in the 2013/14 year end appraisals (following the first external governance review), my mid-year review of the NED team for 2014/15 was presented in December 2014, and I affirmed then that all of the NEDs had been working effectively and making valuable contribution to the Board of Directors and business of the Trust. The 2014/15 mid year review also confirmed that the NEDs had a diverse range of skills, strengths and experience, which collectively made them a strong, well balanced and effective team. I considered each NED’s progress against their objectives for the year and confirmed that progress had been good with the expectation that their objectives would be fully delivered in 2014/15. 2.3 I am pleased to say that the year end review for 2014/15 has reinforced this view. 2.4 In terms of development for 2014/15, I urged all of the NEDs to increase their engagement with staff and governors, particularly by greater attendance at Governors’ general and sub-group meetings. I believe the meeting will be able to confirm that this has been pursued by the NEDs and well received by the Governors. 2.5 Individual reviews a) Francis Patton Francis has performed his duties to the highest standard over the year 2014/15. In addition he Chairs Barnsley Hospital Support Services and is the Senior Independent Director; he carries out both roles to the highest standard, and I have no hesitation in supporting his continued engagement as a Non-Executive Director. b) Linda Christon Linda is extremely dedicated to the Trust and carries out her duties to the highest of standards. She chairs the Quality & Governance Committee, which is currently going through some significant changes and Linda will need to lead that committee in its improvement. Her current term of office is complete in December this year and I would support her re-applying. Linda willingly stepped into the breach with her colleagues to pick up gaps in NED presence whilst we were recruiting and continues to show her dedication to the Trust. c) Suzy Brain England Suzy continues to be an asset to the Trust providing a balanced view at Board, and ensuring that her experience is used to the benefit of the Trust. As with Linda, Suzy stepped in to take up extra work when we were recruiting for NEDs, showing her commitment to the Trust. Suzy has performed to the highest standard throughout 2014/15 and delivered all her objectives. d) Ros Moore Ros has begun her engagement with the Board very well and it is obvious that someone with her experience and skill will be an asset to the Trust. This report, however, will not go into detail as she began her first term of office outside the scope of this review. e) Nick Mapstone Nick has also begun to make an impact in his first few months on the Board, and will continue to provide the challenge required, particularly around financial issues. This report will not go into detail as he too began his first term of office outside the scope of this review. 2.6 External reviews The 360 degree and external governance reviews of the relevant NEDs (Francis, Linda and Suzy) fully supported the evaluations reported above. All three NEDs were very open in sharing key details from the reviews with the Nominations Committee. 2.7 Objectives I would propose that, as in previous years, the Non-Executive Directors’ objectives evolve from my own objectives – which are themselves subject to agreement by the Council of Governors at the August meeting. The NEDs will also focus on areas of personal development identified from the external reviews. 3. RECOMMENDATIONS The Council of Governors is asked to: a) note and support the outcome of the Non-Executive Directors’ annual appraisals for 2014/15 b) endorse the approach outlined for the Non-Executive Directors’ objectives for 2015/16 Stephen Wragg CHAIRMAN August 2015 CoG Aug 2015: 12a NED perf review COUNCIL OF GOVERNORS – AUGUST 2015 REF: CoG/15/08/12b CHAIRMAN’S YEAR END APPRAISAL/PERFORMANCE REVIEW - 2014/15 1. INTRODUCTION 1.1 As agreed previously, the annual review of the Chairman’s performance is led jointly by the Senior Independent Director (SID) and Lead Governor and carried out in accordance with Monitor’s guidance, the Trust’s Constitution and the instructions of the Council of Governors. The process is overseen by the Nominations Committee on behalf of the wider Council. 1.2 In undertaking the Chairman’s appraisal for 2014/15, the approach adopted last year with the use of an independent 360 degree appraisal process has continued, enabling views of how the Chairman has developed over the last 12 months. The 360 reviews included contribution from a wide range of stakeholders, including Governors as well as Board members and, of course, the Chairman himself. This has been supplemented by direct feedback to the SID from the Non-Executive Directors (NEDs) and the Executive Directors (EDs) through the Chief Executive. In addition, following the 2-stage governance review the Trust has been through over the last 12 months, the SID has also had access to the 360 degree feedback undertaken by the external consultants leading this work, and again the more recent second review has enabled improvements to be tracked. The SID also obtained and presented views from the NEDs and EDs on the Chair’s performance against the objectives set for 2014/15 (appendix 1). 1.3 A comprehensive report on this information has been shared with and reviewed by the Nominations Committee, together with feedback from Governors collated by the Lead Governor. The Committee has considered the collective feedback, an overview of which is presented here for the Council of Governors. 1.4 The outcomes have also been shared and reviewed with the Chairman, at a meeting between the SID, Lead Governor and Chairman, in late July. 2 EXTERNAL REVIEW 2.1 The external 360 reviews each had a slightly differing focus. One used nine key themes – genuine concern for others, accessible and enabling, focuses shared effort and vision, engages effectively with others, enables improvement and change, connects and influences, monitors performance and risk, integrity and consistency and qualities and skills. The other was more closely aligned to the Trust’s governance structure – the efficiency and effectiveness of the Trust’s reporting structure, the Chairman’s understanding of his and others’ roles, his work as an ambassador of the Trust, his effectiveness as a Chair at meetings (including preparation, conduct of meetings and follow up), appropriate levels of challenge and seeking of assurance, and engagement with staff and patients. 2.2 Overall both reports showed an excellent performance – not a top score in every area but certainly above mid-point for most ratings, with continued strengths in key areas and a trend of improvement against last year. 2.3 Both reports also showed that after receiving some fairly difficult messages as a Trust and personally last year the Chairman had taken them all on board and made clear efforts to act on the feedback and use it to develop himself into a stronger Chair. 2.4 Shared areas for further development identified in the two reports included communication (good overall but scope for improvement in some aspects), challenge and level of operational detail. 2.5 In 2014/15, the Chairman developed a personal action plan, with external independent support, and has used that throughout the year to good effect. He will doubtless build on that to take account of the feedback provided in the latest reviews. 3 INTERNAL FEEDBACK 3.1 As a team, the Non-Executive Directors believe that the Chairman has listened to the feedback received to date and modified his behaviours accordingly over the last 12 months. He is passionate about the Trust and actively encourages a Quality culture. He has confidence in the executive team and a good relationship with the Chief Executive and has become a more effective Chair and leader of the Board. In terms of developmental areas he still needs to ensure delivery of the plans submitted, he can still occasionally focus on favoured concerns and he needs to continue working on his communication style at all levels internally and externally. 3.2 Speaking for both herself and the Executive Team, the Chief Executive has affirmed her view that the Chairman has worked hard to meet the challenges and steer the Trust in the right direction, holding her to account for on key issues to ensure delivery of the Trust’s plans. She also agreed that the Chairman has listened carefully to feedback received previously, has taken it on board and incorporated it into his own development. 3.3 Feedback received from Governors was very positive, with universal support for how he deals with Governors and Chairs meetings. From observation at Board meetings, several Governors were also able to confirm the Chairman’s learning and development year on year, as highlighted in the feedback from the external reviews and Board members. 4 OVERALL SUMMARY 4.1 The Chairman has provided another year of good performance, demonstrating valuable learning and development, and his continued and unquestioned commitment to the hospital and the people of Barnsley. 4.2 He needs to take on board the feedback on areas for further development and make better use of his NED colleagues where deemed appropriate. 4.3 The Chairman’s delivery against his 2014/15 objectives has been good (only one noted as partial – all others achieved). Objectives for 2015/16 are attached for the Committee’s consideration (appendix 2), built on the feedback received for 2014/15 and mindful of the Trust’s Five Year Plan, of which 2015/16 is year two. 4.4 The Committee was also mindful that the Chairman has now undergone numerous reviews within the last 12-15 months (both external reviews conducted twice, two internal reviews – at mid-year and yearend review – with input from NEDs, EDs and Governors). Whilst the processes to date have been effective, the current level of review does seem at risk of becoming excessive, that said there will not be another external review and the Real World 360 degree feedback is proving very effective. CoG Aug 2015: 12b CHAIR perf review Therefore the Committee has asked the Trust’s Associate Director of HR&OD to consider this and to propose a way forward building on the systems which have proved very effective to date but pulling back on the risk of putting one person under too much scrutiny. 5 RECOMMENDATIONS The Council of Governors is recommended to: 5.1 receive this report and agree the overall outcomes for the year end review for the Chairman, and 5.2 approve the propose objectives for the Chairman for 2015/16 J Unsworth Lead Governor FOR AND ON BEHALF OF THE NOMINATIONS COMMITTEE July 2015 Appendices 1 – 2014/15 objectives 2 – proposed objectives for 2015/16 CoG Aug 2015: 12b CHAIR perf review Francis Patton Senior Independent Director APPENDIX 1 Chairman’s Objectives 2014/15 1. To ensure delivery of the turnaround plan to programme within the agreed time frames – The Chairman has driven this as hard as he can and we did deliver on budget, the CEO feels that he has held her to account in ensuring the executive deliver. Achieved. 2. To ensure delivery and implementation of the external review recommendations and Independent review of Governance within agreed time frames – – Again the Chairman has driven delivery of the recommendations through the executive and through F&P committee. Whilst we await the final review report internal measurement shows that we have delivered on all but 2 of the issues raised. The CEO feels that he has held her to account in ensuring the executive deliver. Achieved. 3. To ensure delivery of the quality agenda by promoting the QUIP agenda and ensuring delivery of all quality targets this year – Again a clear area of focus for the Chairman this year; that said the CQC inspection will give us a better external viewpoint on this key area. The CEO feels that he has held her to account in ensuring the executive deliver. Achieved. 4. To ensure delivery of improved patient care as measured by patient surveys and ensure that the patient agenda is a central plank of our strategy and board meetings – another clear area of focus for the Chairman with some good results throughout the year. The CEO feels that he has held her to account in ensuring the executive deliver. Achieved. 5. To utilise the independent external feedback to evaluate his role as Chair and put together a personal development plan (using coaching/mentorship where appropriate) and implement it over the next 12 months – The SID has seen the Chair’s development plan and the feedback through the various 360 degree questionnaires would suggest improvement in this area. Achieved. 6. To ensure the delivery of a board development programme over the next 12 months – to some degree this was taken out of the Chair’s responsibility by external consultants following the initial review. There have been a number of Board development sessions and there does seem to be improvement in Board dynamics but more work is needed. Partially achieved. CoG Aug 2015: 12b CHAIR perf review APPENDIX 2 (draft) Chairman’s Objectives 2015/16 1. To ensure the delivery of both the short term (2015/16) turnaround plan and the long term (5 year strategic) plan in the shortest period possible with specific focus on CIP delivery whilst maintaining Patient safety and quality. 2. To develop effective external partnerships with all key stakeholders but with particular focus on the CCG and to make more use of the wider NED team to assist with this where appropriate. 3. To ensure that he works with key external stakeholders to deliver a clear health vision for Barnsley and the wider health community with a clear understanding of the role that BHNFT will play within that vision. 4. To ensure that by the end of the financial year the board has been developed into a fully integrated team with a clear understanding of each other’s roles and the value they can add as measured through an improvement in the 360 degree feedback, a coherent ongoing development plan, unitary working and improved performance. 5. To ensure that he promotes and develops the Working Together initiative through his work with the other chairs delivering tangible benefits for the partnership and the Trust in 2015/16 6. To ensure that the BAF is utilised as a key document at Board and key governance committees and continues to be developed as appropriate to give full assurance to the Board in terms of delivery of the strategic plan 7. To ensure that all outcomes from the CQC visit are appropriately discussed and acted upon thus ensuring improved patient experience and care and a clear focus on the quality agenda 8. To utilise the follow up Real World and external governance review feedback to continue his personal development through an update of his personal development plan and further coaching/mentoring where needed. CoG Aug 2015: 12b CHAIR perf review 12c COUNCIL OF GOVERNORS – AUGUST 2015 REF: CG/15/08/12c REPORT OF THE NOMINATIONS COMMITTEE - ANNUAL REVIEW OF THE TERMS AND CONDITIONS OF SERVICE FOR THE NON-EXECUTIVE DIRECTORS AND CHAIRMAN 1. INTRODUCTION 1.1. In accordance with the Chairman and Non Executive Directors’ service agreements,, the Council of Governors is required to undertake an annual review of their Terms and Conditions of Service to ensure they are remunerated fairly 1.2. This work is led by the Nominations Committee on behalf of the Governors. 1.3. With reference to Monitor’s guidance, market testing of pay levels needs only to be carried out “at least once every three years” (Your statutory duties: a reference guide for NHS foundation trust governors – Monitor, August 2013, updated). 1.4. Monitor’s guidance also requires that any considerations must take account of a range of factors beyond comparable rates, for example economic climate, market conditions, changes in roles and responsibilities. 1.5. Data and advice is also obtained from the Trust’s HR team and the Committee retains the right to seek independent external advice at any time. 2. 2015 REVIEW 2.1. In depth review of the terms and conditions for the Chairman and Non Executive Directors (the NED team) was last carried out in 2013, at which time an uplift was agreed to bring their remuneration more in line with the median for smaller FTs, nationally and locally. 2.2. In 2014, the Committee took account of the latest available reports from the Foundation Trust Network (now known as NHS Providers), Capita’s ‘NHS Foundation Trust Board Remuneration Report’, and national pay awards within the NHS. The Committee also considered the Trust’s position, the economic recovery position in England, and the challenging environment that continues to face the NHS generally. No changes were recommended to the team’s Terms and Conditions in 2014. 2.3. The review outlined in 2.2 was repeated this year; an overview of the comparative salaries is attached at appendix 1. The Committee was mindful of the 2015 pay award for NHS staff and the Chancellor of Exchequer’s latest budgetary announcements of a 1% pay uplift for public sector staff for the next four years. 2.4. The Committee also took account of current pressures on the Trust, the local community and the wider NHS, and the growing demands on the role of members of the NED team at Barnsley Hospital (BHNFT). The Committee was also conscious that some FTs offer enhanced payments for specific roles within NED teams, such as Committee Chairs. 2.5. It was acknowledged that none of the individuals currently appointed to the NED team at BHNFT is motivated to fulfil this important role primarily for monetary gain, rather each has a clear commitment to driving improvements for the Trust’s patients and staff. 3. OUTCOMES 3.1. The data showed that remuneration levels for the Chairman and Non Executive Directors at Barnsley remain below the mean and the lower quartile for the FT sector. 3.2. There is never a good or right time to consider an increase, nor, however, would it be appropriate to allow the gap in remuneration levels to become wider and introducing a risk to recruitment and retention of high calibre candidates to the Trust’s NED team. 3.3. In conclusion the Committee agreed that an uplift should be proposed for consideration by the wider Council of Governors, in line with latest awards for staff on the national pay framework, Agenda for Change. The Committee did not, however, agree that any enhanced payments should be offered for additional duties, as one would expect applicants to anticipate taking on such responsibilities as part of the role of a NED. 3.4. No other changes were proposed to the NED Team’s Terms and Conditions of Service. 4. RECOMMENDATION The Council of Governors is asked to: a) consider the information provided above b) approve the recommendation to make a 1% uplift for the Non Executive Directors and Chairman’s remuneration, effective from 1st April 2015 Joe Unsworth LEAD GOVERNOR For and on behalf of the Nominations Committee, August 2015 CoG Aug 2015: 12c_NomCom T&C review APPENDIX 1 SUMMARY OF SALARY COMPARISONS FOR THE NON EXECUTIVE DIRECTORS ROLE 1. 2. Source: NHS Foundation Trust Board Remuneration Report, March 2015 (Capita) Based on data collated from 2013/14 annual report and accounts for all Foundation Trusts. ROLE BHNFT current Upper quartile Lower Quartile Mean Median NED £12,000 £12,500 £12,500 £12,834 £12,500 Chairman £40,000 £50,000 £42,500 £45,810 £45,300 Source: FTN Remuneration survey 2014 – Chairs and Non Executive Directors. (a) Based on a turnover range of up to £160m, Acute, North of England, 3 Trusts: ROLE BHNFT - current FTN Mean FTN Median NED £12,000 £12,526 £12,000 Chairman £40,000 £44,145 £45,000 (b) Based on Region Trusts only - not available at this point CoG Aug 2015: 12c_NomCom T&C review 13 COUNCIL OF GOVERNORS – AUGUST 2015 REF: CG/15/06/13 STRATEGIC SUB-GROUPS 1 2 3 INTRODUCTION 1.1 This report provides an update on the work and discussions of the Council of Governors’ Quality & Governance sub-group (QGSG) and Finance & Performance sub-group (FPSG) meetings held in June and July respectively, and the latest Governors’ training session 1.2 Changes to the sub-group leadership are also reported. SUB-GROUP LEADERSHIP & MEMBERSHIP 2.1 At the time of the reported meetings, David Brannan and Pauline Buttling (for FPSG) and Jordan Ramsey and Carol Robb (for QGSG) served as Chairs and Vice Chairs. 2.2 Following receipt of expressions of interest for these roles in May/June, and as referenced in the Chairman’s report, the sub-group Chairs remain unchanged for 2015/16, with Trevor Smith taking on the role of deputy to both sub-groups. 2.3 Membership of the sub-groups remains informal. Governors are welcome to attend the sub-group meetings regularly or on an ad hoc basis if preferred. If any Governor wishes to raise an item through either of the sub-groups, the Chairs would be pleased to hear from you ahead of the next meeting’s agenda. WORK OF THE SUB-GROUPS 3.1 One of the primary objectives of the sub-groups is to support the Governors’ role of holding the Non Executive Directors (NEDs) – and through them, the Board – to account for the Trust’s performance. As part of this, the sub-groups continue to review progress against the strategic aims and objectives underpinning the Trust’s business plan. 3.2 In addition to the Chair’s Logs received from the Board’s Finance & Performance and Quality & Governance Committees, Board reports on a range of issues of interest to Governors continue to be shared at sub-group meetings and other information can be presented on request. 3.3 The sub-group meetings also provide a valuable opportunity for Governors to share feedback from their constituencies (public, partners and staff) as well as their own experiences and observations of the hospital’s services. 3.4 Minutes from the sub-groups are shared with all Governors by email. Printed copies are available to Governors on request and key points from each meeting are reported at General Meetings (see below). CoG Apr 2015: 13 Sub-groups report 3.5 As stated previously, sub-group meetings are intended to supplement and support the work of the wider Council of Governors. Other information will also continue to be available to Governors via formal and informal updates from the Chairman and Chief Executive, Governor attendance at Board meetings held in public, the annual joint meeting of the Governors and Board, briefings received at General Meetings, private briefing sessions for Governors, and the Board’s responses to any questions raised by Governors. 4 REPORT ON SUB-GROUP MEETINGS 4.1 Quality & Governance (QGSG) This group’s latest meeting was held on 11th June, chaired by Carol Robb. Key issues discussed are noted below. • Mindful of the (then) impending Care Quality Commission (CQC) inspection, the group welcomed an overview on the background to and role of the CQC as regulator of health and social care for England. The presentation from Ms Keeney, Associate Director of Corporate Affairs, outlined what a Trust should expect from a CQC inspection, the breadth of the data the visiting team would glean from both external and internal parties, the CQC inspectors’ full access to all areas across the site, how the Trust was preparing for its visit and work ongoing to ensure staff and public awareness, and how the Governors could and would be involved too. It was emphasised that the work outlined was not intended just to get ready for the visit but to further embed Trust-wide service and system improvements for the longer term. • An informative briefing was received from Staff Governor Gwyn Morritt, explaining why it was particularly important for in-patients with Parkinson’s Disease to be able to take their medication at times to suit the patients’ needs, even when that does not coincide with wards’ regular drug runs. Gwyn has developed a self-learning guide for staff to raise awareness of these patients’ needs, supported by the use of simple aids such as a plastic clock which could be set by the patient’s bedside to show the next time they would need their tablets. Timeliness of medication is important for all patients in hospital but many Governors had been unaware of the potential impact for those with Parkinson’s when their routines are disrupted, adding to the already difficult experience of being in hospital. • The Chair’s Log from the Board’s Quality & Governance Committee was presented by two Non Executive Directors, Mrs Christon (Non Executive Director and Committee Chair) and Ms Moore (Non Executive Director and Committee member). Key issues discussed included ongoing work on pressure ulcers, the six monthly report on nursing and midwifery staffing, the annual reports on safeguarding for adults and children, improvements in HSMR (albeit with a slight increase reflecting winter peaks), continued good performance in infection rates and the risks to the Trust’s services with the current funding gap. • The Committee also received confirmation that Governors’ feedback from the Quality & Safety visits had been reviewed as part of a recent internal audit. Governors’ input to these visits had been appreciated. Governors were pleased to learn that the audit had also shown how actions identified through the visits were reported and followed up promptly. Ms Keeney undertook to request sharing of the fuller information for Governors. • Two public governors reported on their/their family’s recent experience as patients within ophthalmology. CoG August 2015: 13 sub-group report (2) • 4.3 Public Governor Frank Skorrow also reported that he had recently joined his local Patient Reference Group and encouraged others to consider joining their local groups too. They were a useful way to learn more about health services in our region and to share information about the hospital. Finance & Performance (FPSG) The latest FPGS meeting was Chaired by David Brannan on 7th July and covered a diverse agenda, including: • an update on focussed work on “DNAs” (did not attends), discussions on which included outpatient waiting lists and the need to update the automated message on the phone line for the appointments desk; • review of the Chair’s Log from the Board’s Finance & Performance (F&P) Committee and the latest Integrated performance Report, presented by the F&P Committee’s Deputy Chair, Mr Diggles, interim Director of Finance. Mr Diggles expanded on a wide range of issues discussed by the Committee – from the Trust’s financial position £10,000 ahead of plan (albeit still a deficit position) and performance against key indicators and targets, to approval of print management services to support savings and greater efficiencies. There was considerable discussion around the continuing funding gap for 7-days services too. The Board has agreed that 7-day services should be continued, although this is at financial risk to the Trust; the benefits to patients are evident in areas such as the reduced HSMR (hospital standardised mortality ratio) and achievement of the emergency access target despite current pressures. Governors were keen to support the Trust’s stance around funding for 7-day services and several ways of dong so were explored at the meeting; • the business plan objectives for 2015/16 were noted, as outlined in the Annual Plan, and it was agreed that (a) progress should continued to be monitored through the relevant Governors’ subgroups, (b) achievement against the objectives should also be reviewed by the sub-groups based on the timelines shown in the Annual Plan, and (c) if/when the required information was not apparent from the reports provided at sub-group and General Meetings, the more frequent attendance of Non-Executive Directors (NEDs) at Governors’ meetings would enable us to ask question of them direct to obtain more information. • The group also welcomed feedback from Partner Governor Martin Jackson, representing the Joint Trade Unions Committee, giving feedback on the Trust’s progress from staff’s perspective. Martin highlighted some of the key pressures facing staff – both locally (eg continuing high activity levels and impact of the escalation ward) and nationally, and staff’s appreciation that, despite the savings needed, no major disruptions to date had been imposed on their terms and conditions. Staff had also recognised that Trust continued to face a tough position. • The sub-group started planning for the Governors’ Annual Development Session. A few tentative suggestions for key topics have been noted and it was agreed that other ideas should be invited from all Governors at the August General Meeting. The group also agreed that, rather than try to add another commitment into Governors’ diaries, the November training session should be used for the Development Session. The date could be one of three to be put forward for consideration: 5th, 17th or 19th (5.30-7.30pm). CoG August 2015: 13 sub-group report (3) 5 GOVERNORS’ TRAINING 5.1 A brief overview on training for Governors is included in this report as the programme is largely designed by the sub-groups. 5.2 The latest session on 2nd July included training on dementia, with the Lead Specialist Nurse recruiting Governors as Dementia Friends and showing us both what the Trust is doing to help and support patients with dementia and what we can do too as Governors. 5.3 The second part of session provided more information on the outcomes from the latest staff survey and what the Trust is doing in response to support staff further. Several Governors offered to help with future staff surveys to enable more staff to complete and return their survey forms. 6 CONCLUSION & RECOMMENDATIONS 6.1 The notes above are by no means a full reflection of the meetings’ business. Governors are encouraged to come along to hear more and contribute to the subgroups’ discussions and work. 6.2 Governors are asked to: a) note and support this report b) review and agree the date of the Annual Development Session c) put forward any ideas they would like to propose for the 2015 Annual Development session. David Brannan & Pauline Buttling Finance & Performance SUB-GROUP CHAIRS & VICE CHAIRS July 2015 CoG August 2015: 13 sub-group report Jordan Ramsey & Carol Robb Quality & Governance (4) 14 COUNCIL OF GOVERNORS – AUGUST 2015 REF: COG/15/08/14 BOARD OF DIRECTORS 1 MEETING PAPERS & AGENDA 1.1 The Agenda for the meeting of the Board of Directors to be held in public on 6th August 2015, is attached for information. The minutes of the previous meeting, held in July are also attached (nb: these will be subject to approval at the Board’s meeting on 6th August). 1.2 The latest performance report is enclosed too. This is in the developing format, which will be further refined over the next few months. 1.3 Progress against delivery of the strategic objectives for the 2015/16 Business Plan will continue to be monitored through the Governors’ sub-groups. Any questions or comments on the performance report would also be welcomed at the General Meeting. 1.4 Copies of the full reports from all Board meetings held in public are available on the Trust’s website (www.barnsleyhospital.nhs.uk) or on request from the Secretary to the Board (Carol Dudley, 01226 431818 or email [email protected]). 2 FUTURE MEETINGS 2.1 Governors, staff and members of the public are welcome to come along to observe any meetings of the Board held in public. Meeting papers will be provided on the Trust’s website and at the meeting. 2.2 The Board of Directors’ regular meetings are usually held on the first Thursday of every month but there are exceptions – as this month – and Governors are advised to check with the Governors’ Office or on the Trust’s website for further details. 2.3 The next Board of Directors’ meeting to be held in public are scheduled for 3rd September and 1st October 2015, both commencing at 9am. 3. RECOMMENDATION Governors are asked to receive and note this report. Stephen Wragg CHAIRMAN August 2015 CoG June 2015/ 14(i) BoD reports A MEETING OF THE BOARD OF DIRECTORS WILL TAKE PLACE ON THURSDAY 06 AUGUST 2015, 9AM IN THE EDUCATION CENTRE, BARNSLEY HOSPITAL AGENDA No Item 1. Apologies and Welcome 2. To receive any declarations of interests 3. To approve the Minutes of the meeting of the Board of Directors held in public on 02 July 2015 4. To approve the Action Log in relation to progress to date and review any outstanding actions Sponsor Ref S Wragg, Chairman 15/08/P-03 15/08/P-04 Strategic Aim 1: Patients will experience safe care 5. To receive and review latest Patient’s Story 6. To receive and support the Chair’s Log and assurance from the Quality & Governance Committee 7. To receive and endorse the annual report on Infection Prevention & Control 2014/15 8. To receive and endorse the Medical Director’s quarterly report 9. H McNair Director of Nursing & Quality L Christon Non Executive Director & Committee Chair D Gibson Asst Director, Infection Prevention & Control Presentation 15/08/P-06 15/08/P-07 & presentation Dr R Jenkins Medical Director 15/08/P-08 To receive and note the Chair’s Log and assurance from the Audit Committee S Brain England Non Executive Director & Committee Chair 15/08/P-09 10. To review the Chair’s Log on any escalation issues from the Executive Team D Wake Chief Executive 15/08/P-10 11. To endorse quarterly review of the Board Assurance Framework 2015/16 12. To endorse quarterly of the Corporate Risk Register 2015/16 A Keeney Assoc Director of Corporate Affairs 15/08/P-11 15/08/P-12 Strategic Aim 2: Partnership will be our strength 13. To note the monthly report from the Chairman 14. To note and endorse monthly report from Chief Executive S Wragg, Chairman 15/08/P-13 D Wake, Chief Executive 15/08/P-14 Strategic Aim 3: People will be proud to work for us Strategic Aim 4: Performance matters 15. To receive and endorse the Chair’s Log and assurance from the Finance & Performance Committee F Patton Committee Chair 15/08/P-15 16. To review the integrated performance report (month 3) Executive Team 15/08/P-16 Cont/… BoD Aug 2015: 00 Agenda No Item 17. To receive and review first quarterly report on the 2015/16 objectives 18. To receive and review the quarterly report on marketing and communications 19. To note intelligence reporting/horizon scanning for the Board 20. Sponsor Ref R Kirton Director of Strategy & Business Development 15/08/P-17 E Parkes Director of Marketing & Communications 15/08/P-18 15/08/P-19 In accordance with the Trust’s Standing Orders and Constitution, to resolve that representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted. Date of next meeting - 03 September 2015, 9am Signed: ………..…………………… Chairman Please see reference section at back of papers for key to business plan and glossary of terms/acronyms BoD Aug 2015: 00 Agenda REF: 15/08/P-03 REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT MINUTES OF A MEETING OF THE BOARD OF DIRECTORS ON 2 JULY 2015 EDUCATION CENTRE, BARNSLEY HOSPITAL PRESENT: Mrs S Brain England OBE Mr S Diggles Mr N Mapstone Ms R Moore Mrs K Kelly Mrs H McNair Ms D Wake Mr S Wragg IN ATTENDANCE: Mr J Bradley Mrs L Christopher Miss M Dass Ms K Dunwell Ms C E Dudley Mr J Fernandez Miss A Green Miss E Parkes Mr M H Wickham APOLOGIES: Mrs L Christon Dr R Jenkins Mr F Patton 15/112 Non Executive Director Interim Director of Finance & Information Non Executive Director Non Executive Director Director of Operations Director of Nursing & Quality Chief Executive Chairman Director of ICT Associate Director of Estates & Facilities Clinical Director, Obstetrics & Gynaecology External Consultant Secretary to the Board & Governors Associate Director of HR PA to the Director of Nursing & Quality Director of Marketing & Communication Clinical Director, Diagnostics & Clinical Support services and Surgical Services (CBUs 4&5) Non Executive Director Medical Director Non Executive Director APOLOGIES & WELCOME ACTION Members and attendees were welcomed. The Chairman also welcomed Ms Karen Dunwell and colleague from Medworxx, and Miss Alex Green, who was shadowing the Secretary to the Board & Governors. Apologies from Board members were noted as above. It was further noted that apologies had also been received from Ms A Keeney, Associate Director of Corporate Affairs, and Mr R Kirton, Director of Strategy & Business Development, as a courtesy. The Chairman confirmed that members and attendees would be sampling food from the wards, directly after the meeting. 15/113 REGISTERS OF INTERESTS & DECLARATION OF INTEREST (15/07/P-02) The Registers of Interests for the Board of Directors, Executive Team and Clinical Directors, dated July 2015, were received and noted. The Chairman reminded members of the importance in keeping the Registers of Interest up to date and requested that any alterations or additions required at any time be provided to Ms Dudley between meetings. 15/114 MINUTES OF LAST MEETING (15/07/P-03) The Minutes of the last Board of Directors meeting held on 11 June 2015 were reviewed for accuracy and agreed as correct, with the exception of adding Ms A Keeney to the list of attendees and noting Mrs R Moore’s retrospective apologies. 15/115 ACTION LOG (15/07/P-04) The action log, showing progress on matters arising from the last and previous meetings held in public, was reviewed and noted. In addition, with regards to minute reference 15/14 – Integrated Performance Report, Mrs McNair confirmed that she was still awaiting feedback from the CCG regarding the maternity Serious Incident (SI), and a date to meet and discuss. With regard to minute reference 15/48 – roll out of the Interagency Information Sharing Agreement, Mr Bradley advised that he was still awaiting outcomes from the meeting on 23rd June however, the work was on track and he would provide the Board with an update as soon as possible. 15/116 LATEST PATIENT FLOW RESULTS (Presentation) Ms Dunwell presented the results and recommended actions from the Patient Flow Review Project in May 2015, following audits undertaken in January 2014 and January 2015. Ms Dunwell advised that the main objective for the project had been to identify patient journey process changes to date and potential changes for the future to enhance support from and access to primary care, community care and social care services, ensuring patients were receiving the right care in the right place at the right time. Ms Dunwell outlined the scope of the audit, key factors and key outcomes. Over a specified 7 day period, all patients with a length of stay over 2, 3 or 4 days had been reviewed with the exception of patients from mental health primary diagnosis, new-born and paediatric patients and Intensive Care/High Dependent unit patients. A total of 299 patients had been reviewed with 19 avoidable admissions identified, 12 of whom had been assessed ready for discharge throughout their length of stay. This equated to a 6% avoidable admission rate. Ms Dunwell advised that when audited in January 2014, there had been an avoidable admission rate of 4% and in January 2015, 2%. For both prior reviews the Hospital had been on red alert. The audit also showed Sunday-Tuesday as the highest days of ‘avoidable admissions’, possibly reflecting a correlation with fewer support services available at weekends. Looking at discharges, overall 109 patients on wards did not clinically require the beds they were occupying, equating to 36% of the patients audited (Ms Dunwell recommended target of 10%) On review by ward, ward 20 had the highest number of patients ready for discharge, reflecting the higher age range of patients on that ward (70% of the patients aged over 70 years). The latest audit had pointed out some potential gaps within the infrastructure supporting the patient journey process. Only two wards had had a nurse present during regular ward rounds, nor were nurse led discharges a routine process in the hospital. Ms Dunwell advised that a nurse led/alternative discharge process would be effective and help to reduce patient length of stay rather than relying solely on consultants. She also advised that as length of stay reduction strategies became more effective, the acuity level of patients would increase as the number of patients became fewer but their individual care needs became higher, resulting in the need for an increased nurse to BoD August 2015: 03_Bod Minutes (PUM) Page 2 of 8 patient ratio. It was suggested that better use of existing tools could support a reduction in delayed discharges such as the Estimated Discharge Date Tool, currently not established for every patient nor documented within case notes. Other issues that impeded on patient flow were the limited number of Intermediate Care and Rehabilitation beds available within the community to provide step down care for patients, and similar pressures for the Rapid Response Team and Hospital at Home Team. Ms Dunwell suggested too that, whilst the Trust’s integrated performance report was informative, it could be usefully expanded to address the flow of patients, length of stay and discharge problems – service line specific. Mrs Brain England commented that the audit was very detailed and queried how the executives would work with a wide range of services and colleagues to bring the issues together and deal with them collaboratively. Mrs Kelly advised that the Trust was currently working with partners around many of the issues identified; it had been acknowledged that some patients in hospital stayed beyond their need for acute care however their discharge was delayed due to limited capacity within the community and limited options for care at home. Mrs Kelly confirmed that the Trust could operate a step down type ward to support these patients; this had been included in recent discussions with community partners on bed needs for Barnsley but they were currently exploring other options. Where possible, care for patients at home remained the optimum preference and community-wide work continued across multiple pathways for packages of care for patients at home; this would entail changes to criteria for bed sets and support services within the community. Ms Moore praised Ms Dunwell for an excellent presentation, commenting that it reflected information already known to the Trust but it was good to see it presented in such a way. She queried how some of the potential gains highlighted around nursing would be addressed alongside other issues around goals and aims across whole healthcare systems. Ms Wake reported that the Clinical Commissioning Group (CCG) had been informed about the latest review (the outcomes had been shared with them) and she was aware of review work being carried out by the CCG too. Ms Wake confirmed there were still actions the Trust could progress internally to manage patients more effectively and these would be taken forward, including a business case for introduction of a clinical utilisation tool, however that did not lessen the need for collaborative work as a whole health economy. Ms Dunwell had mentioned a proposal for a meeting of all community partners to share and discuss this issue more widely and she would be keen to learn more about this; more co-operative working could also potentially help winter funding allocations in the future. The Chairman invited Mr Millington, Vice Chair of the CCG and present as an observer of the meeting, to comment. Mr Millington noted that the presentation had referred to only six intermediate care beds in the community, when he believed there were 21; it was clarified that the audit had referenced only those beds supporting immediate sub-acute care, not other beds supporting patients with less intensive care needs. Mr Millington had been pleased to hear of plans for a united meeting proposed and undertook to follow this up with the CCG. The Chairman also referred to the Trust’s offer to establish a step-down ward, although Mrs Kelly clarified that this had not been presented formally as a business case, it was acknowledged that it might be timely to revisit this option with the CCG on a more formal basis. In closing the agenda item, Ms Dunwell was thanked for an informative and thought provoking presentation, copies of which would be distributed to Board BoD August 2015: 03_Bod Minutes (PUM) Page 3 of 8 members electronically with the Minutes. Mrs Kelly confirmed that a number of actions highlighted in the presentation were already in place and others being developed and a comprehensive action plan would be drafted to incorporate all actions. It was agreed that the plan should be monitored through the relevant Board Committees. Ms Dunwell and her colleague left the meeting at 10.15 hrs. 15/117 QUALITY & GOVERNANCE (Q&G) COMMITTEE (15/07/P-06) Mrs McNair presented and discussed the Chair’s Log. The report listed key issues escalated to the Board for attention, including: • Ongoing concerns in relation to falls • Timings for production of the Integrated Performance Report. • DNAs (did not attend) – the Committee’s request that quality issues are picked up by the workstream on DNAs alongside financial impact was noted. • Appointment review - work currently ongoing. Mrs McNair also affirmed that the Committee continued to monitor ongoing work to improve palliative care coding, further details on which were included in the report on Mortality. The Board noted the full range of matters outlined in the Chair’s log around assurance and escalation. The annual fire statement for 2014/15 was approved for signature by the Chief Executive, and the Board also noted and ratified the Policies approved by the Q&G Committee policies. 15/118 TRUST’S RESPONSE TO THE SAVILE REPORT (15/07/P-07) Mrs McNair presented and expanded on the “Lessons Learnt” Report from the Jimmy Savile investigations; the report contained 14 recommendations, 13 of which had been accepted in principle by the Secretary of State for Health. She confirmed that the Trust had undertaken a gap analysis against the relevant recommendations and had developed an action plan to address any gaps in assurance. Mrs McNair confirmed that the action plan had been reviewed and supported by both the Executive Team and the Patient Safety & Quality Group, prior to submission to Monitor on 15th June. It had subsequently been signed off by Ms Wake on behalf of the Board prior to submission to Monitor. The Board reviewed and ratified the submitted response. Ms Wake noted ongoing work regarding development of a supporting policy and protocols to support site visits by external parties and questioned the timescales. Mrs McNair advised that on this and other related work would be reported upwards to the Board via the Chair’s Logs. 15/119 TRUST’S MORTALITY RATIOS (15/07/P-08) Mrs McNair presented the Mortality Ratios report on behalf of Dr Jenkins, who was absent from the meeting. Mrs McNair confirmed the latest rolling 12 months Hospital Standardised Mortality Ratio (HSMR) position, including data for March 2015, at 102.24 against a target of 105. She highlighted that the Crude Mortality Rates up until May 2015, showed a significant spike in deaths within the Trust during the winter months, however, levels had now returned to the baseline. She also confirmed that although the 2014/15 mortality target of less than 105 has been delivered, the mortality rate for the majority of the BoD August 2015: 03_Bod Minutes (PUM) Page 4 of 8 year had been static. In order to achieve the Trust’s lower target of 100, additional work was required in 2015/16 and, as shown in the report, would be organised into three domains: care processes, casemix and coding. Mrs Brain England commented that it was beneficial to see next steps flagged within the report. Mr Mapstone queried whether there had been an investigation into the spike in January 2015. Mrs McNair confirmed that this had been a national spike and Ms Wake advised that all of the deaths had been reviewed internally to ensure there were no hidden issues. 15/120 EXECUTIVE TEAM (ET) CHAIR’S LOG (Tabled) Ms Wake tabled the Chair’s Log, following the latest Executive Team Meeting held on 30th June, confirming that discussions continued to take place with Mid Yorks and Sheffield hospitals around Urology services. Mrs Kelly also advised that following a meeting with Sheffield Teaching Hospital on 1st July, the Trust now had a model for Barnsley to deliver a Urology service and employ its own clinicians. The Trust planned to work in partnership with Mid Yorks for non-malignant work and with cancer pathways continuing to go to Sheffield Teaching Hospital. Discussions were ongoing to finalise these arrangements with both partners. A start date for the new service had been agreed – 1st December 2015, which should give Sheffield Teaching Hospital time to consider how they could support sessions for Barnsley Consultants and align cancer services between the two trusts. If needed, the Trust would work in partnership with Mid Yorks for cancer services too. In readiness for the new approach, the Trust intended to go out to advertise for the two posts (without cancer links) shortly; the remaining two posts (ie four whole time equivalents in all) would be addressed as soon as possible afterwards. Mr Wickham enquired where patients would attend for chemotherapy if the partnership working went forward with Mid Yorks only; Mrs Kelly advised that this would be clarified when the final position was known. Ideally the Trust would continue to work with both Trusts but it was imperative to obtain a more consistent service than had been available over the past 12-18 months. Ms Wake confirmed that the Trust was confident the proposed service would be sustainable with either or both partners going forwards. Ms Wake advised that the Trust had also been approached by West Yorkshire Hospitals to support a vanguard bid and this had been agreed in principle. BHNFT had been similarly approached by Working Together partners and further information around this would follow. 15/121 CHAIRMAN’S REPORT (15/07/P-10) The Chairman’s report was received and noted. The report provided a brief outline of some of the work and activities undertaken by the Chairman in the last month following the last Board Meeting. The report also included a presentation from NHS Providers, giving a brief overview of shared information and service future. The Chairman highlighted that section 5.2 within the report had stated that a third new public Governor, Alan Scattergood, would be taking up his role shortly, however, Mr Scattergood had since had to step down from the post. BoD August 2015: 03_Bod Minutes (PUM) Page 5 of 8 15/122 CHIEF EXECUTIVE’S REPORT (15/07/P-11) The Chief Executive’s report was reviewed and noted, providing a brief outline of key activities undertaken since last month’s Board meeting. There were no further comments to report. 15/123 MINUTES OF THE LAST COUNCIL OF GOVERNORS (15/07/P-12) The Council of Governors’ latest agenda (from general meeting held in June 2015) and approved Minutes (April 2015) were received and noted. 15/124 FINANCE & PERFORMANCE COMMITTEE (F&P) (15/07/P-13) In Mr Patton’s absence, Mr Mapstone presented the Chair’s log from the Committee’s meeting held on 25 June and provided a brief summary of the current financial situation. Mr Mapstone advised that the financial performance for the month and year to date had improved on month one and was currently on target for month two, however, the budget continued to remain very stretched particularly with ongoing concerns around seven day working. In relation to the cost improvement programme (CIP), Mr Mapstone confirmed that this had improved from month one but the Trust was £80,000 behind plan at month two. There would be a more detailed review of the CIP plan at the next Finance & Performance meeting. Mr Mapstone confirmed that a business case for the Managed Print Services had also been presented to the Committee and was recommended to the Board for approval. DNAs continue to remain an area of focus for the Committee and it would also continue to monitor the relationship with the CCG, which remained strained despite Trust efforts to engage positively. With regard to the Reference Cost process, this had been reviewed and approved by the Committee, as it was based on the same approach and guidance principles as applied last year. The final outcomes would be agreed by 30th July and would need Board approval. The Board approved delegated authority to the Finance & Performance Committee for its meeting on 30th July. The Board noted the Log, endorsed the Policies approved by the Committee and approved the business case for Managed Print Services. 15/125 INTEGRATED PERFORMANCE REPORT (IPR) (15/07/P-14) The Integrated Performance Report for month 2 was received and reviewed. Mrs Kelly provided an overview of Quality & Performance against key indicators. Operational Efficiency Mrs Kelly confirmed that the Trust continued to have high DNA rates in several areas; further in-depth task and finish groups had been tasked with examining these. Emergency Access Mrs Kelly advised that performance had not met the target for May however additional support had been put in place and had enabled the Trust to meet the target in June - and Quarter 1 at 95.01%. Mrs Kelly thanked everyone for their efforts but advised that pressures continued in acute medicine and surgery; these areas would continue to be monitored. She also confirmed that the escalation ward, Ward 29, had closed but work was still required to enable bed reconfiguration models to be implemented later in the year. BoD August 2015: 03_Bod Minutes (PUM) Page 6 of 8 F&P Cancer Performance targets continued to be on track. Referral to Treatment Mrs Kelly advised that this continued to be monitored; the Trust was currently at 92% however, work was still required – and was ongoing – around central operational models in terms of patients currently on review lists and missing outcomes from clinics. Staffing Mr Fernandez confirmed that mandatory training continued to be below target but had risen slightly in May. He also confirmed that appraisals continued to be actioned; the Clinical Business Units (CBUs) had confirmed that outstanding appraisals had been diarised for the month of June, which would improve the final outcomes. Ms Moore was pleased to note the improvement in sickness and absence and Mr Fernandez added that figures were in line with year on year trends but also reflected continued focus on this area. Quality & Patient Experience Mrs McNair advised that little improvement had been seen in falls and this now formed part of the Listening into Action Programme. She confirmed that the main issue had been around the falls specialist nurse service, the focus of which had been operational rather than strategic. Agreement had been reached recently to release the specialist nurse from CBU duties to provide more support; a clinical lead had also been identified to support this workstream Finance Mr Diggles provided a brief overview of the current financial position. He advised that the CIP achievement year to date was adverse to plan, due to a slower start of delivery from a number of schemes. CIP delivery would continue to remain adverse to plan for the next 2-3 months but remained on track for full year delivery. With regards to clinical activity based income, the position was currently on target with the main favourable variances being elective, non-elective and planned same day income. The reported risks and penalties were mainly due to RTT (referral to treatment) incomplete pathways and A&E performance in April 2015. Mr Diggles also highlighted that operating costs were adverse to plan due to £0.3m of resilience spend in April 2015, due to continued pressures of additional beds being open to satisfy patient demand and activity. Ms Wake reminded members of the concerns regarding ongoing costs of the escalation ward and risks around the 7-day service funding gap; it was encouraging to note the favourable position at end of month 2. The Chairman highlighted that percentage on pay costs was 1.4% and queried whether it should be RAG rated red/amber instead of green. Mr Diggles agreed and advised he would look into this. The Chairman queried the breaches reported against 6 week wait for Diagnostics in May - due to study leave and annual leave; this was not acceptable. Mrs Kelly assured the Board that any such breaches were minimum and usually due to patient choice however she would look into the report further and confirm the position for May. BoD August 2015: 03_Bod Minutes (PUM) Page 7 of 8 SD KK Mrs Kelly added that in terms of the overall format of the performance report, the Trust was continuing to work with Deloitte to provide a first draft report, which should be available towards the end of July. Mr Mapstone commented that it would be beneficial to include Ms Dunwell’s comments within this report around bed management. 15/126 INTELLIGENCE REPORTING/HORIZON SCANNING (15/07/P-15) At the Board meeting in June, it had been requested that a tracker be added to the monthly report. Ms Wake advised that after discussing this at the last Executive Team meeting it was agreed that due to capacity and work pressures this would be too onerous. It was further agreed that should there be any important actions from this report these would be added to the Board tracker for further development. Ms Parkes presented and expanded on the monthly report, drawing attention to the NHS Choices overall rating of 4*. There were no further comments received in relation to the report. 15/127 ANY OTHER BUSINESS AND DATE OF NEXT MEETING a) Date of next meeting The next meeting of the Board of Directors was confirmed for 6th August 2015, commencing at 9am. In accordance with the Trust’s Constitution and Standing Orders, it was resolved that members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted. BoD August 2015: 03_Bod Minutes (PUM) Page 8 of 8 KK INTEGRATED PERFORMANCE REPORT June 2015 Created By: Management Information Services Title of report: Integrated Performance Report Executive Lead: Karen Kelly Page 1 Contents Page No Title Page 1 Front Page 1 2 Contents Page 2 3 Executive Summary 3 4 Summary 4-5 5 Quality and Patient Experience (QPE) 6-8 6 Monitor 9 7 Clinical Business unit (CBU) 10 8 Emergency 11 9 Elective 12 10 Outpatients 13 11 Cancer 14 - 15 12 Commissioning for Quality Innovation (CQUINS) N/A 13 Activity 16 15 Finance 17 - 20 16 Heatmap 21 - 22 18 Staffing 23 Page 2 Executive summary Domains Operational efficiency Emergency Access Elective Access Cancer Year/Quarter to Date Performance Performance (FYTD) Comments DNA rates continue to be higher than expected for the Trust. The Access policy has been ratified and a roll out training plan in its use is in place. Further indepth task and finish groups have been tasked with examining areas such as physio, T&O and paediatrics which have consistently high DNA rates. Task and finish groups have been established to address specific areas impacting on the ASI position. These groups feed into a steering group which reports to the Operations Group meeting. There are particular areas impacting on the Trust position that currently sit outside the Trust control e.g. Ophthalmology and these are being worked through with the service providers. The ED data in this report is based on actual calendar months which reflects the data reported to Monitor for compliance purposes. NHS England calculated monthly and quarter positions based on the weekly A&E Sitrep. The data used by NHSE to calculate Q1 was Monday 30th March to Sunday 28th June inclusive. This resulted in the organisation failing the Q1 A&E 4 hour wait target with an achievement of 94.81% compared to the calendar position of 95.01%. In line with the Keogh report, NHSE are moving to calendar month reporting, therefore our data will match going forward. Continued additional support in place to provide additional clinical and patient flow support in the evenings. Diagnostics: The Transoesophageal Echocardiogram (TOE) breaches are due to Consultant availability (study leave). Only one Consultant is performing these procedures and there is only one session every two weeks. There is no provision for another Consultant to cover the cancelled sessions as they have other clinical commitments. Theatre Utilisation Rates: Utilisation continues to be monitored and low utilisation highlighted and investigated The Q1 preview position indicates compliance across all key performance indicators. Specifically the GP 62 day Q position is 85.1%. However this does not reflect any re-allocation of shared pathway with the tertiary centre (for those patients referred over after Day 62). Such close compliance with the target will not allow us to accept any reallocations without resulting in failure of the target for BHNFT. The Trust's internal GP 62 day pathway performance is good at 90.2%, but shared pathways show only 59.2% of pathways are compliant. Improved tracking and escalation processes should hopefully start to impact on this and certainly a preview of shared pathway performance for July shows significant improvement. A number of site specific pathways continue to be challenging, with colorectal experiencing regular breaches which are impacting greatly on performance. This has been escalated and a pathway meeting is planned within the next few weeks. Q2 position to date shows non-compliance with the breast symptomatic target but this is entirely due to patient choice. The weekly GP 62 day position is good at 91.7% although the Q position to date is non-compliant at 83.3% reflecting July breaches already experienced. Falls including multiple falls; In June there were 71 in-patient falls reported and 12 multiple falls. There have been 4 incidents resulting in death and 3 incidents resulting in severe harm in the month; please see the patient safety section below for details. All of these incidents have been logged as Serious Incidents and are being investigated under the SI investigation process. Pressure Ulcers: Work continues to ensure that the incidence of pressure ulcers at all grades is reduced. Education and Training continues to be rolled out by the facilitator with a particular targeted focus on Wards 19 & 20. The awareness raising campaign through Listening into Action will be focussing on Heel Pressure Ulcers, with a particular emphasis on prevention during the week of 10th - 14th August. Grade 3 avoidable Pressure Ulcers: Both of these occurred on Ward 19, one being a heel pressure ulcer and the other a sacrum pressure ulcer. Both have been Quality and patient experience subject to root cause analysis (RCA) and actions implemented to prevent reoccurrence. Grade 2 Pressure Ulcers: The RCAs from the 8 Grade 2 pressure ulcers have been reviewed. Three of the pressure ulcers were located on heels although there is no pattern regarding ward location. Four of the Grade 2 pressure ulcers were located on the sacrum, two of which were from Ward 20. Targeted training is being rolled out to the staff on this ward. One Grade 2 Pressure Ulcers was located on the thigh as a result of damage from a drain pipe. Patient Safety Finance Mortality Red 3/4 1/4 28 Days cancellation Green 0/1 1/1 Under 4 hour wait Latest Month Performance (Latest Month) Outpatient DNA Rates Ctte: F&P Area: Summary Page: 4-5 ↔ Ctte: F&P Area: Emergency Page: 11 Under 4 hour wait Med errors causing harm Amber 1/4 3/4 ↔ RTT NonAdmitted 62 UG RTT Admitted RTT Incomplete pathways 14 GP 14 BS 62 SC 31 FDT 62 GP 0/8 31 STC 8/8 14 BS 62 GP 31 FDT ↓ P Ulcers 3&4 MRSA MRSA M falls M falls C Diff C Diff Falls Falls 6/11 VTE4/11 SI's ↓ Serious incidents 1/4 2/4 Cash and Funding 1/1 Sickness absence Serious incidents % incidents causing harm Total income Cash and Funding ↔ Staff turnover Total CIP Appraisals Ctte: F&P Area: Finance Page: 17 - 20 Ctte: Q&G Area: QPE Page: 7 HSMR Sickness absence Staff turnover Mandatory training Appraisals ↑ Mandatory training Ctte: Q&G Area: QPE Page: 6 - 8 ↓ Total CIP 0/1 Never Events Surplus/ Deficit Total income Surplus/ Deficit Green VTE Medication incidents Never Events % incidents causing harm Ctte: Q&G Area: QPE Page: 6 - 8 ↔ SI's % incints Medication incidents Ctte: F&P Area: Cancer Page: 14 -15 31 STS 31 STC 31 STS P Ulcers 3&4 #REF! Ctte: F&P Area: Elective Page: 12 RTT NonAdmitted 62 UG 14 GP0 62 SC Red 6 weeks wait RTT Admitted RTT Incomplete pathways Overall income is £0.8m favourable to plan; increased activity and income on elective, non-elective and day case offset by lower activity and income around outpatients. Pay costs are £0.9m adverse to plan due to the cost of higher activity levels and costs incurred around system resilience and escalation beds which are not fully funded by the wider system. Non-pay costs are marginally adverse to plan. Within this category drugs costs remain favourable which will to some extent relate to the lower activity levels in outpatients. CIP delivery is £0.2m behind plan and relates to the slower start of delivery of a number of schemes and due to differences on the phasing of savings. Deficit is in line with plan at £3.8m. Cash position is £7.4m favourable to plan and results from an additional loan draw down and payments received ahead of plan. Sickness continues to improve since the introduction of the new trigger points for management action in Jan 2015. This has resulted in a reduction of 1.36%. Mandatory training increased by 4.2%. Non-medical appraisals did not meet the target but increased by 75% on April’s figures. Ave LoS Non-Elective 28 Days cancellation HSMR Staffing Committee Location Ave LoS Elective ↔ Ave LoS Non-Elective 6 weeks wait 4 deaths in June 2015/17575 Fall on ward 29 resulting in fractured neck of femur. Patient went to theatre and died shortly after leaving recovery 2015/17590 Patient suffered a cardiac arrest in the x-ray department 2015 /17596 Unexpected death in the Emergency Department 2015 /17598 Fall on AMU resulting in bilateral haemorrhagic contusions; patient subsequently passed away during admission 3 Severe harms in June 2015 /17568 Fall on ward 17 resulting fractured neck of femur 2015 /17576 Fall on ward 33 resulting in subdural haematoma Patient fell and sustained a fracture to pubic rami. The patient had also fallen prior to coming into hospital and it was not clear if the fracture was a result of the inpatient fall. This was not considered to be an SI but a local RCA was undertaken. Mortality rates for the full financial year 2014-15 are 103.4 which has achieved the Trust target. Trend Ave LoS Elective Outpatient DNA Rates Ctte: F&P Area: Staffing Page: 23 Note: The YTD circles are composite indicators based on the individual KPI's listed on the summary sheet. Each indicator is evenly weighted within its domain and a score is given based on the YTD performance with green = 1 , amber = 2 and red = 3. The score is then aggregated to give an overall rag rating for the domain. Example: Operational efficiency has four indicators. A composite score of <5 the circle would be Green,5 -8 the circle would be amber, >8 the circle would be red. the current score is 6 so the circle is amber. Page 3 47 11 10 9 8 7 6 5 4 3 2 1 0 Summary - Performance Reporting Month Executive lead : Jun-15 Karen Kelly Performance Matters Measure Target Set By Year/Qrt to Date Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 RTT Admitted A> 90% National 95.9% 94.9% 94.9% 94.6% 92.4% 94.5% 94.2% 98.3% 95.4% 94.9% 96.9% 96.8% 94.0% RTT Non-Admitted A> 95% National 97.7% 97.7% 97.0% 97.4% 96.7% 100.0% 97.2% 96.6% 96.6% 98.2% 97.7% 97.3% 97.9% RTT Incomplete pathways A> 92% National 92.8% 96.2% 96.2% 95.8% 94.2% 93.2% 94.4% 93.0% 94.5% 92.5% 91.3% 92.5% 94.6% Diagnostics patients waiting more than 6 weeks? A< 0 National 12 194 192 69 20 18 60 84 3 16 2 7 3 14 Day- Cancer Two Week Wait Q> 93.0% National 98.5% 93.8% 91.0% 93.3% 96.7% 97.7% 98.5% 99.6% 98.6% 99.3% 99.3% 98.1% 98.3% 14 Day - Symptomatic Breast Two Week Wait Q> 93.0% National 94.9% 95.3% 97.0% 94.2% 97.0% 95.8% 98.1% 94.3% 98.8% 95.7% 96.3% 93.2% 95.1% 31 Day - First Definitive Treatment Q> 96.0% National 99.5% 100.0% 98.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.7% 98.8% 100.0% 100.0% 31 Day - Subsequent Treatment (Surgery) Q> 94.0% National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 31 Day - Subsequent Treatment (Chemotherapy) Q> 98.0% National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 62 Day - GP Referral to Treatment Q> 85.0% National 85.1% 94.5% 88.6% 83.3% 83.5% 91.7% 94.4% 81.4% 82.5% 89.9% 88.0% 84.1% 82.8% 62 Day - Screening referral to Treatment Q> 90.0% National 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 62 Day - Consultant Upgrade to Treatment Q> 85.0% BHNFT 91.9% 100.0% 75.0% 92.3% 75.0% 100.0% 66.7% 100.0% 100.0% 88.9% 100.0% 92.3% 81.8% Total % Patients who waited < 4 Hrs A> 95.0% National 95.1% 97.3% 96.4% 97.1% 96.6% 95.5% 90.3% 93.7% 96.2% 97.3% 91.7% 96.3% 97.2% Average length of stay - Elective A< G <=2.42, A >2.42 to 2.67, R >2.67 BHNFT 2.88 2.34 3.04 2.60 2.40 2.78 2.44 2.72 3.14 2.63 2.46 3.24 2.94 Average length of stay - Non-Elective A< G <=3.44, A >3.44 to 3.69, R >3.69 BHNFT 3.40 3.48 3.50 3.46 3.52 3.57 3.95 3.67 3.53 3.60 3.10 3.62 3.50 Patients admitted within 28 Days following cancellation A< 0 National 1 0 0 0 0 0 0 0 0 0 0 0 1 Outpatient DNA Rates A< 10.0% BHNFT 11.4% 9.7% 9.8% 9.9% 9.9% 12.3% 12.4% 12.1% 10.9% 10.9% 11.2% 11.6% 11.3% Domains KPI Elective Access Cancer Emergency Access Operational efficiency DNA RAG and Measure Descriptions RED AMBER GREEN < > Q A N.B. Revised Average Length of Stay target applicable from April 2015. Failed Target Failed by <5% (This tolerance does not apply to Cancer & A&E targets which will be RED if the target is not achieved) Achieved Target Less is Good More is Good Quarter to date Annual to date Page 4 Trend 11 10 9 8 7 6 5 4 3 2 1 0 Summary - Quality Reporting Month Executive lead : Jun-15 Heather McNair Patients will Experience safe care. Measure Target Set By Year/Qrt to Date Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 MRSA Bacteraemia (Hospital acquired) A< 0 NHS E 0 0 0 0 0 0 0 0 0 0 0 0 0 Hospital Acquired Clostridium Difficile A< NHS E 2 1 2 2 3 1 2 0 1 1 1 0 1 BHNFT 77.7% 94.0% 96.9% 94.5% 96.7% 94.7% 80.6% 88.7% 92.7% 90.3% 89.0% 78.3% 70.6% BHNFT 97.0% 98.0% 97.8% 96.9% 96.6% 95.3% 95.6% 97.9% 93.7% 97.0% 96.7% 97.8% 96.5% BHNFT 92.2% N/A N/A N/A N/A N/A N/A N/A N/A N/A 98.9% 90.0% 91.5% Domains Quality and patient experience Patient Safety Mortality KPI Friends & Family Test % reported extremely likely or likely to recommend a family member ED Friends & Family Test % reported extremely likely or likely to recommend a family member Inpatients Services Friends & Family Test % reported extremely likely or likely to recommend a family member Outpatient areas Friends & Family Test % reported extremely likely or likely to recommend a family member Maternity Q> Q> Q> Q> BHNFT 97.5% 98.2% 98.2% 98.0% 98.2% 97.5% 98.1% 98.1% 97.3% 97.3% 97.1% 99.0% 96.5% National 206 55 73 75 57 58 75 85 86 76 68 67 71 National 42 4 21 8 9 9 11 21 21 19 16 14 12 National 7 N/A N/A N/A N/A N/A N/A N/A N/A N/A 1 0 6 0 National 4 4 4 1 7 1 0 1 1 1 1 1 2 0 NHS E 3 0 0 0 0 0 0 0 0 0 2 0 1 A> 95% NHS E 95.4% 96.9% 96.0% 97.1% 96.1% 95.1% 95.5% 95.6% 95.5% 95.8% 95.1% 95.3% 95.8% Number of Serious Incidents A< 5 per month (66 year) NHS E 20 3 3 2 1 7 4 4 6 7 6 3 11 Incidents - Deaths A< 0 National 4 0 0 1 2 1 0 1 5 0 0 0 4 Incidents - Severe A< 0 National 6 2 1 1 1 0 0 0 1 2 0 3 3 Percentage of Incidents Causing Harm A< 28% BHNFT 7.3% 10.2% 7.2% 7.2% 6.9% 7.4% 7.6% 7.0% 10.6% 6.3% 7.8% 6.1% 8.1% Medication Incidents - Causing harm A< 10 National 4 1 0 0 1 1 0 1 3 1 2 1 1 HSMR (Rolling 12 month) A< 105 National 103.4 103.5 102.7 102.8 102.6 101.7 101.1 102.7 104.7 103.4 N/A N/A N/A SHMI (Rolling 12 month) Q< 105 National 103.2 103.7 BHNFT 9.85% 6.61% 6.86% 7.15% 7.51% 8.09% 7.85% 7.94% 7.93% 8.88% 9.09% 9.66% 9.85% BHNFT 85.84% 90.48% 91.87% 92.55% 92.92% 93.11% 92.59% 92.26% 91.92% 91.47% 87.40% 83.02% 87.16% BHNFT 84.30% 86.40% 85.50% 85.98% 85.38% 84.79% 84.44% 83.40% 82.83% 82.32% 82.24% 84.30% 86.48% BHNFT 3.99% 4.09% 4.28% 4.37% 4.46% 4.69% 5.06% 4.81% 4.62% 3.96% 4.30% 3.99% 3.70% Falls A< Multiple Falls A< Falls resulting in moderate harm or above A< Hospital Acquired avoidable Pressure Ulcers 3&4 A< Never Events A< VTE Screening Compliance Staff turnover (Rolling 12 month) A< Appraisals (Rolling 12 month) A> Mandatory Training (Rolling 12 month) A> Sickness absence (Rolling 12 month) A< Workforce RAG and Measure Descriptions RED AMBER 1 per month (13 year) 85% From April 15 85% From April 15 85% From April 15 85% From April 15 43 per month (515 year) 11 per month (128 year) 1.6 per month (20 Year) G <=10%, A >10%11%, R >11% G >90%, A >=70%90%, R <70% G >90%, A >=85%90%, R <85% G <=3.5%, A >3.5-4%, R >4% Trend 103.2 FFT: There are no National Targets set for FFT for 2015/16. This however has been agreed as a local quality target for 2015/16. The 2014/15 targets were nationally set based on response rates. Failed Target Failed by <5% (This tolerance does not apply to Cancer & A&E targets which will be RED if the target is not achieved) GREEN Achieved Target < Less is Good > More is Good Q Quarter to date A Annual to date Page 5 1 0 46 47 Quality and Patient Experience Falls Dementia Complaints Patient Experience Reporting Month Executive lead : Hand Wash Pressure ulcers Current Qtr FYTD 12 month Trend % reported extremely likely or likely to recommend to a family member ED 85.0% 78.3% 70.6% 77.7% 77.7% Inpatient Services 85.0% 97.8% 96.5% 97.0% 97.0% Outpatient areas 85.0% 90.0% 91.5% 92.2% 92.2% Maternity Services 85.0% 99.0% 96.5% 97.5% 97.5% N/A 9 22 57 57 90.0% 63.0% 88.9% 70% 70% N/A 2 0 5 5 Find/Assess 90.0% 91.0% 95.0% 93.0% 93.0% Investigate 90.0% 100.0% 100.0% 100.0% 100.0% Refer 90.0% 100.0% 100.0% 100.0% 100.0% 67 71 206 206 14 12 42 42 99.6% 98.2% 99.1% 99.1% Total Number of Complaints Complaints closed within target Complaints reopened Falls Multiple Falls Infections Jun-15 Heather McNair / Richard Jenkins Target / May-15 Jun-15 Benchmarking 43 Per Month (515 Year) 11 Per Month (128 Year) Handwashing 100% Completion of WHO Surgical checklist 100% Grades 3 & 4 Post 72 hours 0 1 2 4 4 Grade - 2 Post 72 hours 0 6 8 17 17 Single Sex Breaches 0 0 0 0 0 Hospital Acquired Clostridium Difficile 13 0 1 2 2 MSSA Surveillance 0 0 0 0 MRSA 0 0 0 0 0 Surveillance 3 0 5 5 Ecoli -Total hospital Medicine Reconciliation 90% Notes Falls including multiple falls; The Trust continues to undertake focus ed work on the reduction of falls in hospital. The Head of Nursing, CBU 3 continues to lead on the implementation of the Falls Strategy and Policy which has now been approved and is being monitored through governance processes. A new multifactorial risk assessment has been piloted in clinical areas and it is planned to roll this out to all areas in August 2015 following educationand training of staff. Falls are also one workstream of Listening in Action and aims and objectives for t is work stream have now been set and are being implemented. There was 1 fall resulting in death on Ward 29 (Fractured neck of femur resulting in detah), 1 fall resulting in severe harm on Ward 17, 1 fall on Ward 33 resulting in severe harm (fractured neck of femur), 1 fall resulting in severe harm on AMU (fall resulting in a cerebral bleed). All of these incidents have been logged as Serious Incidents and are being investogated under the SI investigation process. Pressure Ulcers: Work continues to ensure that the incidence of pressure ulcers at all grades is reduced. Education and Training continues to be rolled out by the facilitator with a particular targeted focus on Wards 19 & 20. The awareness raising campaign through Listening into Action will be focussing on Heel Pressure Ulcers, with a particular emphasis on prevention during the week of 10th - 14th August. Grade 3 avoidable Pressure Ulcers. Both of these occurred on Ward 19, one being a heel pressure ulcer and the other a sacrum pressure ulcer. Both have been subject to root cause analysis (RCA) and actions implemented to prevent reoccurrence. Grade 2 Pressure Ulcers: The RCAs from the 8 Grade 2 pressure ulcers have been reviewed. Three of the pressure ulcers were located on heels although there is no pattern regarding ward location. Four of the Grade 2 pressure ulcers were located on the sacrum,643 two of which were from Ward 20. Targeted training is being rolled out to the staff on this ward. One Grade 2 Pressure Ulcers was located on the thigh as a result of damage from a drain pipe. FFT: With effective from 1st April 2015 160 the Trust had to withdraw the token system within ED and revert back to a paper based response methodology. The results of this are apparent in May and June's figures however work is on going to look at how this can be improved going forward. Complaints: There has been an 26% improvement in Junes's performance increasing the average FYTD to 70%. To be developed for inclusion in future reports To be developed for inclusion in future reports Page 6 Patient Safety Reporting Month Executive lead : Jun-15 Heather McNair / Richard Jenkins Target / May-15 Jun-15 Benchmarking Mortality VTE Serious incidents Medication incidents VTE Screening Compliance Prevention of Future Death Reports – Notifications Received Incident grading 103.4 1 0 1 1 95% 95.3% 95.8% 95.4% 95.4% 33 per month (400 Year) 28 27 88 88 63 9 8 25 25 1 Per month (10 Year) 1 1 4 4 0 0 1 3 3 66 (2014/15 Outturn) 3 11 20 20 0 0 4 4 4 Incidence of Medication Errors - All Incidence of Medication Errors Near misses Incidence of Medication Errors Causing harm Never Events Serious Incidents FYTD 0 Death Patient safety Data not available 105 HSMR Current Qtr 0 3 3 6 6 Moderate N/A 6 7 22 22 Low N/A 31 42 116 116 No Harm N/A 617 635 1868 1868 Percentage of Incidents Causing Harm <28% 6.1% 8.1% 7.3% 7.3% 0 0 2017 2017 Severe Not available N/A N/A Surveillance Total (NPSA Reported) 616 (7400 Year) Total (All) 657 692 BHNFT Rolling 12 Month - HSMR Mar-15 Feb-15 Jan-15 HSMR Rolling 12M Notes Mortality: Whilst mortality rates for 2014-15 have achieved the target set, there has been a rise in the mortality over the peak winter months related to the national rise in respiratory death rates. Underlying crude mortality rates for recent months have returned to the baseline levels. Serious Incidents: 2015/17565 Never Event Wrong Prosthesis. A patient having a Right knee replacement had a left knee prosthesis put in. 2015/17568 Fall resulting in a fractured neck of femur 2015/17569 Delayed diagnosis of cancer (Urology) 2105/17571 Fall resulting in fractures (humerus, femoral shaft and pelvis). The fall occurred in 2014 but was not declared an SI at the time. The incident is a complaint and has now been declared as an SI 2015/17575 Fall resulting in fractured neck of femur. The patient went to theatre and died unexpectedly shortly after leaving recovery. 2015/17576 Fall resulting in subdural haematoma 2015/175821 Delay in diagnosing Caecal Cancer. Patient had a laparoscopic Appendicectomy in 2014. The CT scan done prior to theatre showed a Caecal mass that should have been investigated further. This was not done and the patient has re-presented with Caecal Cancer. 2015/17589 Failure to act on a diagnosis of lung metastases in a patient with breast cancer. This SI has arisen from a claim 2015/17590 Unexpected death – patient had a cardiac arrest in the x-ray department. The patient had a raised NEWS a few hours before going to x-ray. The patient arrived in x-ray with no escort and did not have a wrist band on. 2015/17592 Drug incident – a patient was not given some doses of antiepileptic medication during two separate admissions and suffered seizures 2015/19931 Grade 3 Pressure Ulcer Incident Grading Deaths - 4 incidents: Unexpected death in ED (delay in assessment). This was logged as a SI in July 2015. Cardiac arrest in x-ray department (Please see above SI 2015/17590) Fall` resulting fractured neck of femur. 9250 Patient went to theatre and died shortly after leaving recovery -(Please see above SI 2015/17575) Fall resulting in a bilateral haemorrhagic contusions; patient subsequently passed away during admission. This was logged as a SI in July 2015. Severe Harm - 3 incidents: Fall resulting in fractured neck of femur. ( Please see above SI 2015/17568) Fall resulting in fractured pubic rami ( as the patient had also fallen at home prior to admission it was not possible to determine if the inpatient fall {patient lowered himself to the floor} led to the fracture) This was dealt with as a high level incident requiring an RCA. Fall resulting in a subdural haematoma (Please see above SI 2015/17576) Moderate harm - 7 incidents: Failure in referral process to AMAC. Patient was peri-arrest and was transferred to CCU Fall resulting in a fractured wrist Grade 3 hospital acquired pressure ulcer x 4 Delay in going to theatre. This has been logged as an SI in July 2015 Mar-15 Jan-15 Feb-15 Dec-14 Nov-14 Oct-14 Sep-14 Jul-14 Aug-14 Jun-14 May-14 Apr-14 Mar-14 Feb-14 Jan-14 140 130 120 110 100 90 80 Dec-14 Nov-14 Oct-14 Sep-14 Aug-14 Jul-14 Jun-14 May-14 107.6 104.9 102.5 103.5 102.7 102.8 101.6 100.7 100.3 103.4 104.7 103.4 Apr-14 110 100 90 12 month Trend Page 7 Nurse Staffing Fill Rate Reporting Month Executive lead : Jun-15 Heather McNair / Richard Jenkins Notes Nursing staffing table Nursing Staffing Commentary: BHNFT is committed to ensuring that levels of nursing staff, match the acuity and dependency needs of patients in order to provide safe and effective care. Nurse staffing includes: Registered Nurses Registered Midwives Unregistered health care/midwifery care assistants Unregistered nursing/midwifery auxiliaries. The Trust uses an e-roistering system with duty rosters created eight weeks in advance to ensure the levels and skill mix of the nursing staff on duty are appropriate for providing safe and effective care. This allows for contingency plans to be made where the roster identifies that the planned staffing falls short of the minimum requirement, for example where there are vacant nursing posts or staff appointed have not started in post. These contingency plans can include: moving staff from a shift which is above the minimum required level, moving staff from another ward/area which is above the minimum required level, or the use of flexible/temporary staffing from the Trust’s internal bank or via an external nursing agency. The areas that currently have the most vacancies in nursing are in CBU 1 including wards 20, wards 34 and the emergency department. A recruitment campaign is on-going. Page 8 1 0 46 47 Monitor Reporting Month Executive lead : Jun-15 Karen Kelly 12 month Trend This month, Last month ↑ = Got Better ↓ = Got Worse Target May-15 Jun-15 Current Qtr FYTD All Cancer 2 Week Wait 95.0% 98.1% 98.3% 98.5% 98.5% ↑ Breast Symptomatic 93.0% 93.2% 95.1% 94.9% 94.9% ↑ Cancer Reporting 31 Day Diagnostic to 1st treatment 96.0% 100.0% 100.0% 99.5% 99.5% ↔ Subsequent Treatment (Surgery) 94.0% 100.0% 100.0% 100.0% 100.0% ↔ Subsequent Treatment (Drugs) 94.0% 100.0% 100.0% 100.0% 100.0% ↔ ED Referral to Treatment 62 Day Urgent GP referral to treatment 85.0% 84.1% 82.8% 85.1% 85.1% ↓ Screening Programme 90.0% 100.0% 100.0% 100.0% 100.0% ↔ Admitted - % treated within RTT 90.0% 96.8% 94.0% 95.9% 95.9% ↓ 95.0% 97.3% 97.9% 97.7% 97.7% ↑ 92.0% 92.5% 94.6% 92.8% 92.8% ↑ 95.0% 96.3% 97.2% 95.1% 95.1% ↑ 13 (year end) 0 1 2 2 ↑ Notes Cancer Reporting: The Q1 preview position indicates compliance across all key performance indicators. Specifically the GP 62 day Q position is 85.1%. However92.51% this does not reflect any re-allocation of shared pathway with the tertiary centre (for those patients referred over after Day 62). Such close compliance with the target will not allow us to accept any reallocations without resulting in failure of the target for BHNFT. The Trust's internal GP 62 day pathway performance is good at 90.2%, but shared pathways show only 59.2% of pathways are compliant. Improved tracking and escalation processes should hopefully start to impact on this and certainly a preview of shared pathway performance for July shows significant improvement. A number of site specific pathways continue to be challenging, with colorectal experiencing regular breaches which are impacting greatly on performance. This has been escalated and a pathway meeting is planned within the next few weeks. Q2 position to date shows non-compliance with the breast symptomatic target but this is entirely due to patient choice. The weekly GP 62 day position is good at 91.7% although the Q position to date is non-compliant at 83.3% reflecting July breaches already experienced. RTT Non-Admitted - % treated within RTT Incomplete Pathways % still waiting ED - Total Time in ED - 4 hours or less Hospital Acquired Clostridium Difficile Page 9 20 Clinical Business Unit Cancer Reporting - Jun 15 Reporting Month Executive lead : Cancer information below is a month behind reporting schedule Jun-15 Karen Kelly Target All Cancer 2 Week Wait 95.0% Breast Symptomatic 93.0% 1 3 4 6 T Y CBU 1 CBU 3 CBU 4 CBU 6 Trust wide FYTD Trustwide 97.4% 98.2% 98.3% 98.1% 98.7% Cancer Reporting: 94.2% CBU4 - the GP 62 day performance reflects breaches in Urology (x 4), UGI (x2), Head and Neck (x2), ENT (x1) and Colorectal (x1). Breach analysis shows pathway inefficiencies across a number of breaches. This picture is also reflected in June breaches which include Colorectal (x3), Urology (x 5), ENT (x3). 95.1% 31 Day Diagnostic to 1st treatment 96.0% 100.0% 100.0% Subsequent Treatments 94.0% 100.0% 100.0% 100.0% 100.0% 99.3% 100.0% 100.0% 83.7% 83.2% 100.0% 100.0% 62 Day Urgent GP referral to treatment 85.0% Screening Programme 90.0% Consultant Upgrades 85.0% 92.3% 82.1% 100.0% 100.0% 83.3% 100.0% 100.0% 92.3% 96.2% Notes CBU3 - The failure to achieve the locally agreed Consultant Upgrade target relates to a Lung pathway breach shared with Sheffield which was caused by a delay to diagnosis due to patient's fitness to undergo tests. RTT RTT Admitted - % treated within RTT Non-Admitted - % treated within RTT Incomplete Pathways % still waiting 90.0% 97.3% 98.9% 87.7% 94.3% 94.0% 95.9% 95.0% 97.1% 99.5% 96.8% 99.0% 97.9% 97.7% 92.0% 94.1% 97.9% 92.7% 94.3% 94.6% 92.8% Infections Infections Hospital Acquired Clostridium Difficile 13 (year end) 0 0 1 0 1 2 MRSA 0 0 0 0 0 0 0 Page 10 3 1 0 46 50 Emergency Care Pathway Reporting Month Executive lead : Jun-15 Karen Kelly Accident & Emergency Target Emergency Department Attendances Seen within 4 hours 95% May-15 Jun-15 Qtr to date Year End Forecast 6759 6728 20282 81128 96.3% 97.2% 95.1% 95.1% Notes: The ED data in this report is based on actual calendar months which reflects the data reported to Monitor for compliance purposes. NHS England calculated monthly and quarter positions based on the weekly A&E Sitrep. The data used by NHSE to calculate Q1 was Monday 30th March to Sunday 28th June inclusive. This resulted in the organisation failing the Q1 A&E 4 hour wait target with an achievement of 94.81% compared to the calendar position of 95.01%. In line with the Keogh report, NHSE are moving to calendar month reporting, therefore our data will match going forward Ambulance Ambulance to ED Handover Time % Under 15 mins 66.3% 65.7% 62.2% % Between 15 and 30 mins 12.6% 19.1% 15.0% % Between 30 and 60 mins 1.1% 1.7% 1.4% % Between 60 and 120 mins 0.1% 0.1% 0.1% Over 120 mins (SI) 0.0% 0.0% 0.0% % Not Recorded 19.8% 13.5% 20.9% Total Ambulance Handovers 1839 1681 5437 Notes Trend Ambulance Information Summary Table Local Trust Benchmark Page 11 1 0 46 47 Elective Care Pathway Reporting Month Executive lead : Jun-15 Current Qtr FYTD 90.0% 96.8% 94.0% 95.9% 95.9% 95.0% 97.3% 97.9% 97.7% 97.7% 92.0% 92.5% 94.6% 92.8% 92.8% 0 0 0 0 0 0 7 3 12 12 0.0% 0.3% 0.1% 0.2% 0.2% 0.8% 0.3% 0.7% 0.6% 0.6% 0 0 0 0 0 0 0 1 1 1 Theatre utilisation - Day TBC 82.9% 83.6% 85.7% 85.7% Theatre utilisation - Main TBC 95.29% 93.11% 96.0% 96.0% Theatre utilisation - Trauma TBC 94.91% 90.79% 93.6% 93.6% Diagnostic Tests Numbers waiting over 6 weeks (DM01) Diagnostic Tests Numbers waiting over 6 weeks % Cancelled Operations Referral to Treatment May-15 Diagnostics Target RTT -Admitted - % treated within RTT RTT - Non-Admitted - % treated within RTT RTT - Incomplete Pathways % still waiting 0 Tolerance to RTT waits of more than 52 weeks Theatre Utilisation Jun-15 Karen Kelly % Cancelled Operations Urgent Operations - Cancelled Twice Cancelled Operations - Breaches of 28 day Rule 12 month Trend Notes Diagnostics: The Transoesophageal Echocardiogram (TOE) breaches are due to Consultant availability (study leave). Only one Consultant is performing these procedures and there is only one session every two weeks. There is no provision for another Consultant to cover the cancelled sessions as they have other clinical commitments. Cancelled Ops: The percentage Cancelled Operations remains within the target There was 1 breach of the 28 day rule in June. This was a complex case and the patient has now been admitted and had their procedure on 14th July. Theatre Utilisation Rates: Utilisation continues to be monitored and low utilisation highlighted and investigated Admitted, non admitted and incompletes by spec Page 12 1 0 46 47 Outpatients DNA rates GP referrals Reporting Month Executive lead : Jun-15 Karen Kelly Target May-15 Jun-15 QTD FYTD GP Written Referrals - made N/A 3782 4344 12055 12055 GP Written Referrals - seen N/A 3463 4136 11121 11121 NA -217 327 86 86 NA -949 -544 -2416 -2416 10.0% 11.8% 10.9% 11.5% 11.5% 10.0% 11.5% 11.5% 11.3% 11.3% 10.0% 11.6% 11.3% 11.4% 11.4% 0 1283 N/A 2617 2617 4.0% 30.4% N/A 30.7% 30.7% GP referral rate year on year +/2014/15 & 2015/2016 Total referral rate year on year +/2014/15 & 2015/16 New outpatient appointment DNA rate Follow-up outpatient appointment DNA rate Total outpatient appointment DNA rate Appointment slot issues Appointment slot issues % Notes DNAs: 11.00% DNA rates continue to be higher than expected for the Trust. The Access policy has been ratified and a roll out training plan in its use is in place. Further in-depth task and finish groups have been11.00% tasked with examining areas such as physio, T&O and paediatrics which have consistently high DNA rates. 11.00% ASI's: June's ASI report has not been published by HSCIC, this is due to issues following the migration to the new eReferral system. Reports are not expected until August at the earliest. Top 10 Specialties (GP Referrals Received and Seen) Specialty General Surgery ENT Dermatology Gynaecology Cardiology Oral Surgery Trauma & Orthopaedics Gastroenterology Paediatrics Urology GP Referrals GP Referrals Received Seen 881 696 659 495 646 433 438 375 262 313 105 289 295 284 167 221 213 216 173 148 Top ten specialities with highest number of ASI's for current month Apr-15 May-15 Specialty 138 158 Orthopaedics 181 133 Ophthalmology 130 130 Children's & Adolescent Services 145 129 Diagnostic Endoscopy 122 127 GI and Liver (Medicine and Surgery) 83 98 Cardiology 94 85 Urology 67 73 Dermatology 79 70 Surgery - Not Otherwise Specified 6 58 Rheumatology Page 13 Jun-15 N/a N/a N/a N/a N/a N/a N/a N/a N/a N/a Trend FYTD 296 314 260 274 249 181 179 140 149 64 1 0 46 47 Cancer Reporting Month Executive lead : Jun-15 Karen Kelly Target May-15 Jun-15 All Cancer 2 Week Wait 95.0% 98.1% 98.3% 98.5% 98.5% ↑ Breast Symptomatic 93.0% 93.2% 95.1% 94.9% 94.9% ↑ FYTD 12 month Trend This month, Last month ↑ = Got Better ↓ = Got Worse Current Qtr Cancer Reporting 31 Day Diagnostic to 1st treatment 96.0% 100.0% 100.0% 99.5% 99.5% ↔ Subsequent Treatment (Surgery) 94.0% 100.0% 100.0% 100.0% 100.0% ↔ Subsequent Treatment (Drugs) 94.0% 100.0% 100.0% 100.0% 100.0% ↔ 62 Day Urgent GP referral to treatment 85.0% 84.1% 82.8% 85.1% 85.1% ↓ Screening Programme 90.0% 100.0% 100.0% 100.0% 100.0% ↔ Consultant Upgrades 85.0% 92.3% 81.8% 91.9% 91.9% ↓ Breast Screening Screening to Offer of 1st Assessment <=3 weeks 90.0% 91.4% 95.0% 93.6% 92.7% ↑ Screening to 1st Assessment 90.0% 88.6% 75.0% 84.6% 83.6% ↓ Screening to issue of normal results <=2 weeks 90.0% 98.4% 98.1% 98.0% 98.2% ↓ Page 14 Notes The Q1 preview position indicates compliance across all key performance indicators. Specifically the GP 62 day Q position is 85.1%. However this does not reflect any re-allocation of shared pathway with the tertiary centre (for those patients 92.51%referred over after Day 62). Such close compliance with the target will not allow us to accept any reallocations without resulting in failure of the target for BHNFT. The Trust's internal GP 62 day pathway performance is good at 90.2%, but shared pathways show only 59.2% of pathways are compliant. Improved tracking and escalation processes should hopefully start to impact on this and certainly a preview of shared pathway performance for July shows significant improvement. A number of site specific pathways continue to be challenging, with colorectal experiencing regular breaches which are impacting greatly on performance. This has been escalated and a pathway meeting is planned within the next few weeks. Q2 position to date shows non-compliance with the breast symptomatic target but this is entirely due to patient choice. The weekly GP 62 day position is good at 91.7% although the Q position to date is non-compliant at 83.3% reflecting July breaches already experienced. 1 0 46 47 Cancer Reporting Month Executive lead : Jun-15 Karen Kelly In response to the on-going national challenge faced by providers in the delivery of the GP 62 day target; the Cancer Waiting Times Taskforce have identified 8 key priorities to be implemented urgently to bring about sustained delivery of this target - thus improving the experience and outcome of patients. The Trust will submit a detailed self assessment and action plan against the priorities by the end of August as requested. However a basic initial self assessment against each priority is outlined below: 1. The Trust Board must have a named Executive Director responsible for delivering the national CWT standards. Compliant. Executive Director - Karen Kelly 2. Boards should receive 62 day cancer wait performance reports for each individual cancer tumour pathway, not an all pathway average. Compliant. Site specific tumour pathway information is provided per CBU in the monthly IPR. A wider presentation of these pathways is made by the Associate Director of Cancer Services at the monthly CBU performance meeting. 3. Every Trust should have a cancer operational policy in place approved by the Trust Board. Partial compliance. Each site specific cancer MDT has an Operational Policy which is reviewed and updated annually. However there is no generic Operational Policy for cancer in place. Work will commence immediately in the development of such a policy. 4. Every Trust must maintain and publish timed pathway, agreed with the local commissioners and any other Providers involved in the pathway, taking advice from the Clinical Network for the following cancer sites: lung, colorectal, prostate and breast. These should specify the point within the 62 day pathway by which key activities should be completed. Partial Compliance. The Trust's cancer MDTs work in accordance to a generic timed pathway and escalation process. However, we are yet to develop site specific timed pathways. Work to develop timed pathways was commenced at network level previously but has been delayed by the dissolution of network site specific groups. Internally we are developing a MDT level Preview pathway report which will reflect timed pathways for each tumour group and be utilised by MDTs to drive pathway delivery. 5. Each Trust should maintain a valid cancer specific PTL and carry out a weekly review for all cancer tumour pathways to track patients and review data for accuracy and performance. Compliant. The Cancer Services Team produce a weekly Escalation (PTL) report which reflects the 'tracking status' of all patients on a 62 day pathway. This is shared at CBU level with managers and MDT leads. A weekly meeting between CBU service managers and the Cancer management team is embedded allowing escalation and discussion of individual patient pathway issues; as well as providing a forum to discuss emergent themes and issues. The Trust will also submit a weekly summary PTL to UNIFY as mandated nationally from the week commencing 27th July. 6. A root cause breach analysis should be carried out for each pathway not meeting current standards, reviewing the last ten patient breaches and near misses (defined as patients who came within 48 hours of breaching). These should be reviewed in the weekly PTL meetings. Partial Compliance. All breaches are analysed to determine contributing factors. These are shared with respective teams at CBU level and discussed in the Cancer Performance and Improvement Group (CPIG). A rolling action plan is maintained to address emergent causes. Additionally a RCA is completed for pathways which extend beyond 100 days. This is shared at CBU level and discussed at CPIG to share learning and themes. We will establish a process to review these in the weekly PTL (escalation meetings). 7. A capacity and demand analysis for key elements of the pathway not meeting the standard (1st appointment; treatment by modality) should be carried out. There should also be an assessment of sustainable list size at this point. Partial Compliance. Work has commenced with initial focus on capacity and demand for 1st appointments in order to try and reduce the average day of 1st appointment from 10-14 to 5-7. 8. An Improvement Plan should be prepared for each pathway not meeting the standard, based on breach analysis and capacity and demand modelling; describing a timetabled recovery trajectory for the relevant pathway to achieve national standards. Non-compliant. Work has commenced with site specific teams where breaches are highest to review pathway processes and identify areas for improvement. Detailed improvement plans will be developed for Urology, Colorectal, UGI, Lung and Head + Neck - with work involving the tertiary centre with whom many pathways are shared. Page 15 Activity Reporting Month Executive lead : Jun-15 Karen Kelly 14/15 Actuals 15/16 Plan 15/16 Actual Elective Day cases Elective Inpatients Elective Total 5,630 960 6,590 Variance % 5,706 942 6,648 5,790 1,025 6,815 84 83 167 1.5% 8.8% 2.5% Non Elective Non Elective Total 9,070 9,070 8,676 8,676 9,201 9,201 525 525 6.0% 6.0% Maternity Pathway Other Activity Total 1,470 1,470 1,538 1,538 1,452 1,452 -86 -86 -5.6% -5.6% A&E Attendances A&E Total 20,397 20,397 20,349 20,349 20,288 20,288 -61 -61 -0.3% -0.3% Elective day case spells Emergency spells elective inpatient spells Other activity A&E attendances outpatient attendances 61,178 61,247 57,634 -3,613 -5.9% Outpatients 61,178 61,247 57,634 -3,613 -5.9% Outpatients Total * Please note excess bed days are not included in these figures. Obstetric outpatient attendances are excluded as they are covered by the Maternity Pathways 2015/16 Activity Plan 2015/16 Activity Actual 2014/15 Outturn Elective Inpatients - main overperformance in Urology with 35 spells above plan Non Elective Inpatients - main overperformances are in CDU, Medicine and Paediatrics Outpatients - underperformance is across most specialties. Main underperformances are Endocrinology (-455, -35%), Diabetes (-534, -36%), Paediatric T&O (-102, -30%) and Rheumatology (-601, -22%) Page 16 Finance Reporting Month Executive lead : Jun-15 Stuart Diggles June-2015 Variance Plan YTD Actual YTD Variance % Month Plan Month Actual Variance % 397 2,058 3,285 25,175 6,797 426 1,993 3,518 21,213 6,729 7.3% -3.2% 7.1% -15.7% -1.0% 29 -65 233 -3,962 -68 1,100 5,706 10,078 69,428 20,349 1,213 5,790 11,057 61,334 20,288 10.3% 1.5% 9.7% -11.7% -0.3% 113 84 979 -8,094 -61 11,383 9,056 -20.4% -2,327 31,862 28,118 -11.8% -3,744 49,095 42,935 -12.5% -6,160 138,523 127,800 -7.7% -10,723 Income Pay Non-Pay Total CIP £'000 159 201 129 489 £'000 140 77 105 322 -11.9% -61.7% -18.6% -34.2% £'000 -19 -124 -24 -167 £'000 437 400 382 1,219 £'000 401 229 343 973 -8.2% -42.8% -10.2% -20.2% £'000 -36 -171 -39 -246 INCOME Clinical (Activity) Other Clinical CQUINS Risks & Penalties Business Cases Other Total income £'000 8,810 3,305 274 0 144 1,609 14,142 £'000 9,495 2,941 274 -131 498 1,660 14,737 245.8% 3.2% 4.2% £'000 685 -364 0 -131 354 51 595 £'000 25,697 9,738 822 0 432 4,798 41,487 £'000 26,962 9,264 822 -385 915 4,752 42,330 OPERATING COSTS Pay Drugs Non-Pay Total Costs £'000 -9,695 -1,081 -3,615 -14,391 £'000 -10,092 -1,072 -3,852 -15,016 -4.1% 0.8% -6.6% -4.3% £'000 -397 9 -237 -625 £'000 -29,271 -3,245 -10,777 -43,293 £'000 -30,167 -3,096 -10,996 -44,259 ACTIVITY LEVELS Elective inpatients Day Cases Non-elective inpatients Outpatients A&E 'Clinical' Activity Other (excludes direct access tests) Total activity CIP 7.8% -11.0% 0.0% Variance 111.8% -1.0% 2.0% £'000 1,265 -474 0 -385 483 -46 843 -3.1% 4.6% -2.0% -2.2% £'000 -896 149 -219 -966 4.9% -4.9% 0.0% Page 17 Commentary The RAG rating applied to Variance % is based on the following : • Green equating to 0% or greater • Amber behind plan by up to 5% • Red greater than 5% behind plan The key points derived from this table are as follows: • Activity is behind plan year to date excluding Direct Access. The main driver is a shortfall on Outpatient activity and impacts across all relevant CBUs. Activity levels are favourable to plan for Non-elective inpatients. Direct Access tests were excluded from the Other category because large variances in these figures skew the overall activity variance. • CIP achievment has been validated in month. The overall adverse variance is due to a slower start of delivery from a number of schemes. CIP delivery is expected to remain adverse to plan for the next few months as schemes are driven through to delivery. • Clinical activity based income is £1.3m favourable to plan. The main variance s are non-elective income is £1m favourable to plan, outpatient income is £0.5m adverse to plan. • Business case income is £0.5m favourable to plan due to receipt of resilience funding not included within the plan. There is however a significant adverse cost variance as not all resilience requirements are funded. • Other income is slightly adverse to plan. • Operating costs are adverse to plan. Pay is £0.9m adverse to plan which is driven by resilience spend, which is not fully funded. In addition there are agency costs covering vacant posts. • Non-pay costs total are marginally adverse to plan Finance Reporting Month Executive lead : EBITDA Depreciation Restructuring & Other Financing Costs SURPLUS/(DEFICIT) SOFP Capital Spend Inventory Jun-15 Stuart Diggles Month Plan £'000 -249 -479 -42 -147 -917 Month Actual £'000 -279 -477 -29 -142 -927 £'000 -430 £'000 -101 Variance % -12.0% 0.4% 31.0% 3.4% -1.1% -76.5% June-2015 Variance Plan YTD Actual YTD Variance % £'000 £'000 £'000 -30 -1,806 -1,929 -6.8% 2 -1,433 -1,432 0.1% 13 -126 -29 77.0% 5 -442 -415 6.1% -10 -3,807 -3,805 0.1% £'000 329 Receivables & Prepayments Payables & Accruals Deferred Income Cash & Loan Funding Cash Loan Funding KPIs EBITDA % Deficit % Receivable Days Payable (including accruals) Days Continuity Of Service Rating £'000 -1.76% -6.48% £'000 -1.89% -6.29% £'000 -7.5% 3.0% -0.13% 0.19% Variance £'000 -123 1 97 27 2 £'000 -565 1,678 9,202 £'000 -248 1,204 6,804 -56.1% 28.2% 26.1% £'000 317 -474 -2,398 -14,591 -4,276 -15,072 -7,312 3.3% 71.0% -481 -3,036 £'000 1,121 -21,915 £'000 8,556 -25,187 663.2% -14.9% £'000 7,435 -3,272 -4.35% -9.18% 19.6 75.3 -4.56% -8.99% 14.5 77.7 -4.7% 2.0% 26.1% 3.3% -0.20% 0.19% -509.60% 248.11% 1 1 0.0% 0.00% Page 18 • EBITDA is adverse to plan by £0.1m. • Depreciation, restructuring and finance costs are all slightly favourable to plan. • The overall deficit is to plan. • Capital expenditure is £0.3m underspent to plan. • Inventory is £0.5m lower than plan, £0.3m is due to differences to the opening position assumed in the plan. • Total receivables including prepayments are £2.4m favourable to plan. • Total payables including accruals are favourable to plan by £0.5m, this is due to differences to the opening position assumed in the plan. • Deferred income is £0.2m adverse to plan and is due to differences to the opening position assumed in the plan. • Cash is £7.4m favourable to plan and mainly results from additional loan drawdown, payment received ahead of plan from Barnsley CCG , and improvement to inventory and receivables. • Debtor days are 14.5 year to date, which is 5.1 days favourable to plan. • Payable days 77.7 year to date which is 2.5 days better than plan. • The Continuity of service rating has improved to a 2 at month 3 due to a favourable movement in liquidity days. Finance Reporting Month Executive lead : Jun-15 Stuart Diggles BHNFT income analysis BHNFT income clinical income per day Clinical income per day pay as a % of clinical income Pay as % of clinical income • Income analysis - this graph analyses the split of income on a monthly basis and demonstrates the variability of clinical income. • Clinical income per day - this is broadly in line with plan for June 2015. • Pay as a % of clinical income is slightly adverse to plan for June 2015 and reflects the additional costs incurred due to 'winter' pressures' and covering vacancies. Page 19 Finance Reporting Month Executive lead : Jun-15 Stuart Diggles Agency run rate - Trust Agency run rate CIP achievement CIP achievement Deficit treand analysis Deficit Trend analysis • Agency monthly spend - this graph indicates that the agency costs have been running at a lower rate than in 2014, the March 2015 increase relates to EPR costs being put through the I&E. June 2015 costs are slightly higher than in previous months. • Deficit trend analysis - this graph demonstrates the Trust is on plan year to date. Page 20 Heat Map: Quality Indicators Reporting Month Executive lead : Jun-15 Heather McNair Trend Arrow: Latest Month v Previous Month ↑= Got Better ↓= Got Worse CDU Trust Emergency, Ortho & Care Services Theatres, Anaesth & Critical care General & Spec Med General & Spec Surg Diagnostic and Clinical Support Trust CDU ED Ward 19 Ward 20 Ward 23 Ward 34 Ward 33 Day Surgery ICU SHDU ITU Theatres AMU CCU Ward 17 Ward 18 Chemotherapy Unit Ward 24 Ward 27 Ward 28 SDA Ward 29 Ward 31 Ward 32 Medical imaging Outpatients MRSA C-Dff Number of Serious Incidents occurring in month Incidents Deaths Incidents Moderate Incidents Severe 1↓ 10 ↓ 4↓ 7↓ 3↓ 1↓ 2↓ 1↓ 2↓ 1↓ 1↓ 1↓ Medication Incidents Causing harm Falls Adverse Outcome Multiple Falls Adverse Outcome Pressure Ulcers 2 Pressure Ulcers 3 1↔ 18 ↑ 4 8↓ 2↓ 1 2 2↓ 1 1↑ 2↓ 1↓ 2↓ 1↓ 1 1↓ 1↔ 1↔ 1↓ 1↓ 1↓ 2↓ 1↓ 3↓ 1↓ 1↓ 1↓ 1↓ 2 1↓ 1↓ 1↓ 1↓ 1↓ 1↓ 2↓ 1↔ 1↓ 2↔ 1↑ 2↓ 1↓ 1↓ Labour Suite Womens, Children & GUM Never events Ward 14 Ward 37 Birthing Centre Page 21 1↓ Pressure Ulcers 4 Single Sex Breaches Heat Map: Quality Indicators Reporting Month Executive lead : Jun-15 Heather McNair Indicator Name Serious Incidents Incidents resulting in Death Comment 2015/17568 Fall resulting in a fractured neck of femur - ward 17 2015/17575 Fall resulting in fractured neck of femur. The patient went to theatre and died unexpectedly shortly after leaving recovery - ward 29 2015/17576 Fall resulting in subdural haematoma - ward 33 2015/17597 - OPD appointments not followed up 2015/17590 Unexpected death – patient had a cardiac arrest in the x-ray department. The patient had a raised NEWS a few hours before going to x-ray. The patient arrived in x-ray with no escort and did not have a wrist band on. 2015/17596 - Unexpected death in ED (logged as an SI in July) 2015/17598 - Fall on AMU resulting in a cerebral bleed. (logged as an SI in July) 2015/17601 - delay in going to theatre to repair a hole in patient's caecum - ward 31 2015/22584 - grade 3 pressure ulcer - ward 19 2015/22849 - grade 3 pressure ulcer - ward 19 2015/17575 Fall resulting in fractured neck of femur. The patient went to theatre and died unexpectedly shortly after leaving recovery (logged as an SI) 2015/17590 Unexpected death – patient had a cardiac arrest in the x-ray department. The patient had a raised NEWS a few hours before going to x-ray. The patient arrived in x-ray with no escort and did not have a wrist band on (logged as an SI) 2015/17596 - Unexpected death in ED (logged as an SI in July) Fall resulting in bilateral haemorrhagic contusions; patient subsequently passed away. This has been logged as an SI in July 2015. Incidents resulting in severe harm Fall resulting in fractured neck of femur. ( Please see above SI 2015/17568) Fall resulting in fractured pubic rami ( as the patient had also fallen at home prior to admission it was not possible to determine if the inpatient fall {patient lowered himself to the floor} led to the fracture) - This was dealt with as a high level incident requiring an RCA. Fall resulting in a subdural haematoma (Please see above SI 2015/17576) Incidents resulting in moderate harm Failure in referral process to AMAC. Patient was peri-arrest and was transferred to CCU Fall resulting in a fractured wrist Grade 3 hospital acquired pressure ulcer x 4 Delay in going to theatre. This has been logged as an SI in July 2015 Grade 3 avoidable Pressure Ulcers: Both of these occurred on Ward 19, one being a heel pressure ulcer and the other a sacrum pressure ulcer. Both have been subject to root cause analysis (RCA) and actions implemented to prevent reoccurrence. Pressure Ulcers Grade 2 Pressure Ulcers: The RCAs from the 8 Grade 2 pressure ulcers have been reviewed. Three of the pressure ulcers were located on heels although there is no pattern regarding ward location. Four of the Grade 2 pressure ulcers were located on the sacrum, two of which were from Ward 20. Targeted training is being rolled out to the staff on this ward. One Grade 2 Pressure Ulcers was located on the thigh as a result of damage from a drain pipe. Page 22 Staffing and Organisational Development Reporting as at: Executive lead : Key Issues Sickness Absence Rate Jun-15 Karen Kelly Target May-15 Jun-15 Rolling 12 Months 3.50% 3.99% 3.70% 4.28% 9.85% 7 - 10 % Staff Turnover 1.84% 0.55% Mandatory Training 90% 84.30% 86.48% Appraisal Rates - Medical 90% 93.80% 95.90% (0.58-0.83 %) Appraisal Rates - Non Medical Trend 90% 26.40% 85.30% Recruitment - Medical 76 Days 100.00% 75.00% Recruitment - Non Medical 56 Days 83.30% 100.00% Vacancy levels FTE Budget FTE Contracted Variance Maternity Count Sickness Trust 2,730.11 2,550.03 6.60% 82 3.70% Estates & Facilities 99.39 87.09 12.37% 0 0.24% 483.29 432.45 10.52% 13 3.00% 481.98 422.10 12.42% 10 4.79% Emergencies, Orthopaedics and Care Services CBU Diagnostic and Clinical Support Services CBU 12 Month Trend Comments Review of structure in Estates. High band 5 RGN vacancy rate within CBU1, with 8 vacancies in Care of the Elderly, 11 in ED and 7 in Orthopaedics. Some new recruits have started in July with the remainder due to start when they qualify in September. Also a targeted approach to recent ED leavers to undertake exit interviews is currently underway. Recruitment issues for BMS staff in the laboratories being addressed by immediate locum cover and followed up by a permanent recruitment campaign with appointments being offered to successful applicants. National shortages of laboratory BMS staff and sonographers provide the bigger picture with HR Recruitment working with managers to find innovative solutions to shortages. High Level Summary Sickness - Sickness continues to improve since the introduction of the new trigger points for management action in Jan 2015 . 1st June saw the introduction of the last of the reductions in the management trigger levels to 2%. Sickness absence levels for the Trust have fallen month on month since Dec 2014 when they stood at 5.06%. to the current position of 3.70%. This is a fall of 1.36% . The current 12 months average stands at 4.28%. Out of the 6 CBUs only 2 are RAG rated red for this month. These are Diagnostics and Clinical Support Services CBU and Women’s and Children CBU. Focussed HR support to managers is being provided to reduce levels of absence in these CBUs to improve their performance and match improvements achieved by the other CBUs. Staff Turnover - The rolling 12 months turnover figure in Corporate services is currently 12%. This is higher than the expected level and cannot be explained by any major organisational change. Therefore further analysis of leavers numbers and reasons will be undertaken to identify and understand the cause for this and take appropriate action to address. Mandatory Training - Overall Mandatory training compliance has increased by 4.2% to 86.5% Estates and facilities, Women’s and children’s and theatres and anaesthetics CBU’s have all exceeded the 90% target The remaining CBU’s are all demonstrating over 80% compliance Appraisals Medical CBU 1 (ED, Ortho & Care) = 100% CBU 2 (Theatre, Anaes & Critical) = 85.7% CBU 3 (Gen & Spec Med) = 996.9% CBU 4 (Gen & Spec Surg) = 95.5% CBU 5 (Diagnostic & Clinical) = 93.3% CBU 6 (Women & Child) = 100% 4 x June appraisals were not uploaded in time to be included in June data, giving an overall adjusted figure of 98.6% in date at 30th June. Consequently CBU2 is adjusted to 95.7% and CBU5 to 100%. Appraisals Non Medical - Appraisal compliance non-medical is 82.3% Estates and facilities have exceeded target at 96.7% Trust Sickness: Year V Year Recruitment - General - 19 campaigns were completed for June 2015 and none were outside the timeline target, achieving 100% compliance. Recruitment - Medical—There were 4 consultant recruitment campaigns that successfully completed in June 2015; in orthopaedics, acute medicine, gastroenterology and diabetes and endocrinology. The orthopaedics vacancy breached the timeline due to there being 8 shortlisted candidates and long delays finding 2 consecutive days in panel members’ diaries to interview. Page 23 Page 24