MEETING OF THE BOARD OF DIRECTORS AGENDA. Wednesday 25 th March Conference Room 1 Homerton Hospital

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MEETING OF THE

BOARD OF DIRECTORS

AGENDA

Wednesday 25

th

March 2015

Conference Room 1

Homerton Hospital

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MEETING OF THE BOARD OF DIRECTORS IN PUBLIC OF

HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST

Wednesday 25

th

March 2015 at 8:30 a.m.

Conference Room 1

Education Centre,

Homerton Hospital

AGENDA PART ONE

No.

Item

Attachment time

1. Chairman’s welcome and introduction

TM-R

08:30

2. Apologies for absence

TM-R

3. Declaration of interests regarding items on the agenda

TM-R

4. Minutes of the meeting held on 25/02/2015 and matters arising

TM-R

15/26 08:35

5. Chief Executive’s Report

TF

15/27 08:40

6. Integrated Board Report

SA/MK/DW/JF/DJ

15/28 08:55

7. Quality and Safety

09:25

7.1 Response to the NHS England Clinical Senate Review

TF

15/29

7.2 Nurse Staffing Update

SA

15/30

7.3 Quality Accounts Priorities 2015/16

SA

15/31

8. Corporate Governance

10:05

8.1 Board Assurance Framework

TF

15/32

8.2 Freedom to Speak Up Review

DW

15/33

8.3 Monitor Quarter 3 2014/15 Results Notification

JF

15/34

8.4 Staff Survey Results

DW

15/35

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- 2 -

9. Committee Reports

10:25

9.1 Audit Committee

MS

10. Any Other Business

10:30

11. Questions from Public

10:35

Dates of forthcoming meetings

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BOARD OF DIRECTORS

Meeting date: 25

th

March 2015

Agenda Item: 4

Paper: 15-26

Title:

Minutes of the Meetings held 25

th

February 2015

Summary

This document records the items discussed at the Board of

Directors meeting in public, held on 25th February 2015.

Action:

The Board is asked to approve the minutes as a correct

record of the meeting.

Prepared by:

Presented by:

Sam Armstrong Interim Head of Corporate Governance

Tim Melville-Ross, Chairman

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Meeting of the Board of Directors

Wednesday 25

th

February 2015

Part 1 - Public

Present: Tim Melville-Ross CBE Chairman

Sir John Gieve Non-Executive Director Martin Smith Non-Executive Director Vanni Treves CBE Non-Executive Director Susan Osborne CBE Non-Executive Director Jude Williams Non-Executive Director Polly Weitzman Non-Executive Director Tracey Fletcher Chief Executive

Sheila Adam Chief Nurse & Director of Governance Dylan Jones Chief Operating Officer

Dr Martin Kuper Medical Director

Daniel Waldron Director of Organisation Transformation Jo Farrar Director of Finance

In Attendance:

Sam Armstrong Head of Corporate Governance (minutes) Four members of the public were in attendance.

1.0 Welcome and Introduction

The Chairman opened the meeting and welcomed all present.

2.0 Apologies for absence

There were no apologies.

Declaration of interests regarding items on the agenda

There were no declarations of interests.

3.0 Minutes of the previous meeting held on 28th January 2015 and matters

arising

The minutes of the previous Board of Directors meeting were agreed as a correct record of the meeting with one amendment:

to correct the date relating to winter funding from 2105 to 2015. The actions log was noted with the following updates:

• staff update of flu vaccinations was on the agenda;

• staff turnover was covered in the performance report and the staff survey would be an item at the next Board meeting;

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• Martin Kuper had provided information on sickle cell readmissions to Polly Weitzman;

• the GP Federation has been requested to provide information;

• it was agreed to close the complaints related actions as they would be covered at the Board meeting in June;

• the deep dive schedule circulated earlier was noted;

• the governors had been engaged in the annual plan process at their recent Council of Governors meeting

• the presentation of readmission rates for the performance report was being progressed.

It was agreed to close completed actions and progress against other actions was noted.

5.0 Chief Executive’s Report

The Board received the report for noting.

The recent maternal death was formally reported to the Board, having been previously briefed on the matter. The case had been referred to the Coroner and outcomes from the external review would be presented to the Board in due course. The Trust had requested a review into four previous maternal deaths and it was expected that this would be presented to the Board in March 2015. It was noted that the deep dive session for the Trust’s maternity services was scheduled for May 2015. In response to a question, it was noted that the panel conducting the external review of previous maternal deaths would be supplied directly by the Clinical Senate of NHS England and they would decide the format of the review; dates of their availability would be determined and communicated in due course. In response to a follow up question it was noted that it would not be appropriate for the Trust to present its internal review of the recent case to the Board before the external review had been completed. It was advised that, nationally, there was no simple rule of whether a pregnant woman should be treated for a medical condition by maternity services or A&E. In response to a question, it was confirmed that lessons from the latest case would be immediately implemented where possible and appropriate. In answer to a question it was noted that there was no current consensus as to whether ambulances should deliver a pregnant patient to either the nearest, or their nominated, hospital. It was noted that while the Board was anxious to receive the reviews of the latest case, that it was appropriate to wait until all related reviews were completed.

It was reported that the Trust and GP Federation had decided not to submit an application to be a Vanguard site. The different models for the application were noted. The Trust would, however, continue to explore ways to work with the GP Federation and other local service providers in a mutually beneficial way. It was expected that a second round of applications would be offered in the future. In answer to a question it was noted that local authorities outside the Trust’s area had submitted applications, however the London Borough of Hackney had not. It was added that the Trust had featured in the London Cancer’s application as part of their general vision for cancer services across north and east London. It was suggested that the Trust write to the appropriate leadership explaining the Trust’s decision not to apply. It was agreed that the approach taken by the Trust in not submitting an application was the correct decision.

The Board noted the updates to PACs, RiO, Fetal Medicine and Obstetric Services and recent staff appointments.

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06. Integrated Board Report

The Board received the Integrated Board Report for noting, which was presented by the executive team.

It was noted that the Trust had declared a retrospective ‘never event’ from October 2014, which was discovered through the Trust’s review process. The case would be discussed within the Serious Incident report to the Board. The Trust had its first MRSA case for seven months; a review was underway and results would be reported to the Board in due course. There had been two grade three pressure ulcers. Safe staffing levels had recently improved. In answer to a question it was clarified that the patient survey data demonstrated prevalence at a given time rather than the number of incidents, which was presented in other sections of the Board report. To a follow up question it was noted that 90% of falls involved no harm. In response to a question it was noted that it had been difficult to recruit and retain staff in elderly care, however the Trust was recruiting to its values to ensure the most appropriate applicants were appointed. To a follow up question it was opined that recruitment and retention to elderly care did not appear to be pay related. To another question it was noted that the Trust was working to increase the numbers of registered nurses. In response to a question, it was noted that a paper to update nurse staffing, with funding, would be presented to the March Board meeting. It was pointed out that in the last 12 months staff had been increased on two wards and for night shifts. It was acknowledged that the Trust was yet to achieve the level of recruitment it wanted, which was a concern, however continued work was underway to improve on this. It was agreed to present an update on actions to achieve recruitment to a future Board meeting.

Actions: Present update on actions to achieve recruitment (DW, April 2015)

It was noted that the Trust had commenced declaring Friends and Family (F&F) response rates from its community-based services: the rate was initially low, however the Trust had only recently begun collecting data. In response to a question it was reported that the Trust was acquiring more tablets and kiosks to improve response rates. In response to a question, the Board was advised that the observed reduction in rates from the previous year was most likely related to the change in methodology of the test; current tests were now more detailed, which provided a higher quality of feedback, albeit with a lower quantity, which the Trust continued to work to improve. In response to a question, it was reported that the focus on collecting F&F data declined recently in A&E, mostly due to winter pressures. It was suggested that local targets be set for each clinical area. It was noted that the Trust had received funding to recruit an additional volunteer coordinator to support more volunteers to collect data from patients. It was requested that community related response data be highlighted rather than added into the whole numbers, however the overall position was important and would still need to be presented. It was noted that the PALs data was now presented in more detail and that a glossary of terms would be included in the next report. In answer to a question it was noted that the improved results of the complaints data was a combination of substantive improvements and presentation methodology change; clock-stop instances were noted. It was clarified that the clock-stop data represented the number that commenced in-month and was not cumulative. The Board discussed the information to be included in the complaints department review and it was agreed that the executive would consider how best to present individual examples for further understanding and to demonstrate quality as well as how complaints, PALS, staff and patient feedback data interrelates and whether any themes or conclusions could be observed. In answer to a question it was noted that responses to complaints are initially reviewed by either the

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chief nurse and director of governance or medical director and further reviewed and signed by the chief executive.

It was noted that VTE assessment remained above 95%. In answer to a question about not achieving 100%, it was clarified that the issue was not that patients weren’t being tested; rather it pertained to a small number not completing the assessment in the first 24 hours. SHMI remained constant at 0.8, which was below the expected. In response to a question it was reported that the Trust was investigating whether it could produce its own HSMR output to obtain quicker feedback than that determined by waiting for the nation figures. In response to a follow up question, it was noted that all hospital deaths were reviewed and that an end of life board was being established at the Trust.

It was noted that January had been a challenging month, however the Trust had achieved all national performance targets, including the 4-hour A&E wait target. Bed utilisation had increased in the last month. It was known that other trusts had found the recent period challenging with some declaring internal major incidents. Cancer targets for the last quarter had been achieved and it was expected that the Trust would achieve them in January as well. The Board was warned that the A&E target might drop below 95% for the current month and perhaps for the quarter. The Trust was working hard to achieve the target, however it was a challenging and long winter; delays to bed availability created additional pressure in the Trust. Overall activity remained flat over the last 15 months, however variations within services were noted. Length of stay had reduced over that period. Further analysis of the factors contributing to bed utilisation was underway and an away day with clinicians was planned in post winter to discuss further. In answer to a question, it was noted that vacancy in discharge had not appeared to cause significant problems; the discharge team managed complex discharges and vacancies had predominately been for roles to coordinate simpler discharges. Instances of delayed discharge had increased significantly in the last month and it appeared most likely to be driven by a lack of supply rather than lack of funds or effort from social services. The median age of patients had increased from the winter of 2013/14 to 2014/15 and anecdotally it appeared that cases had become more complex. In answer to a question, it was noted that beds tended to be available at the end of the day, however there was real pressure for bed places in the middle of the day. A solution to this was not easy to establish, however, an audit on bed use was planned. A continuing issue was that a coordinated plan in Hackney had not been developed. In answer to a question it was noted that paediatrics, which was under-utilised, did drive some of the overall flat effect to bed utilisation. There had been a significant investment in paediatrics to improve bed turnover, which had been successful. It was noted that the Trust was concerned about outcomes in such a challenging winter period. In answer to a question it was noted that better engagement with the local authority and the recruitment of a social worker had assisted with discharge, however the closing of a council building with 25 social care beds had added to the challenges for this winter.

It was noted that bank and agency spend had increased by £192k last month of which £171k had been funded from the winter plan. Projects to reduce spend on medical and nursing locums were underway and it was expected they would yield savings of approximately £40k per month. E-rostering had been re-established. It was noted that on preliminary review of the recent staff survey that staff ‘feeling discrimination’ from staff and patients had increased. A report on the national staff survey, including the issue of ‘feeling discriminated’ would be presented to the Board. Environment and corporate divisions continued to underperform on appraisal rates, however the new online appraisal system, linked to pay progression, would hopefully improve all areas. It was noted that some skewing in results occurred as the input was from a finance system and some places were held, although vacant. There had been some positive results in recent

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recruitment: the first overseas exercise was recently held on-site and 12 of the 15 applicants were appointed; it was acknowledged that some turnover of overseas staff would be expected. Both fire and information governance training rates had improved. In answer to a question it was noted that high turnover of school nurses reported was due to the service being moved to a different provider and Trust staff were TUPE-ed across to the new provider. In response to a couple of questions regarding disciplinary actions in the divisions it was noted that the numbers differed due to the relative size of the divisions as well as a particular focus; most issues were related to poor performance that was not rectified in early attempts.

It was noted that the Trust had reported a year-to-date surplus of £670k, which was year-to-date £1.5m behind plan. The cost of agency was still a pressure. Capital expenditure was below plan due to an underspend on the maternity project and slippages in IT costs and delay to the pathology project, as well as the achievement of the bed project being deferred into next year. QIPP delivery was behind plan due mostly to shortfalls in the environment directorate. The Trust was forecasting a year-end £2m profit. The cash balance was on plan and the Trust had received assurances that debtors would pay outstanding amounts. In answer to a question it was noted that the positive position on depreciation had occurred due to the reduction on planned capital spend throughout the year. It was agreed to provide analysis of non-NHS debtors to the Board.

Action: Non-NHS debtors to be presented to the Board (JF, April 2015)

In response to a question it was noted that according to Monitor, over 50% of foundation trusts were in debt and the proportion of acute trusts in debt was higher.

7.0 Quality and Safety

7.1 Dementia Care Audit CQUIN

The Board received the report for noting.

It was noted that the Trust had been working to better understand the needs of carers for dementia patients. A different process for collecting information had been developed as initially it had been difficult to obtain data from carers. The Trust had also recently appointed a dementia care nurse and subsequently appointed two dementia care assistants. Data collected in the last six weeks was presented and an action plan was being developed; some feedback was being acted upon immediately. The Alzheimer’s Society had indicated they were pleased with developments at the Trust. In answer to a question it was noted that plans to achieve improvements for dementia carers would be replicated across the Trust and that it did not appear that staffing issues had affected issues with dementia carers.

7.2 Infection Prevention and Control Quarter 4 Report

The Trust received the report for noting.

There had been no instances of MRSA in quarter three, although the Trust had more recently experienced one case. There were two cases of C.difficile in quarter, however the Trust had had very low number of cases in previous years and subsequently been assigned a ceiling of two cases for the year. The CCG had reviewed the cases: one had been thought of as occurring due to a problem with the care in that particular case, however the other case was considered virtually unavoidable.

The surgical site infection (SSI) surveillance from quarter 1 2014/15 found two instances of SSI in hip replacements, of which one was considered to have had inherent high risks.

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The quarter 2 un-benchmarked data indicated one deep SSI associated with a total knee replacement.

There were no themes identified with seven incidents. An audit of isolation room use demonstrated 98% compliance with Trust policy.

The Board agreed that although further work was needed, the Trust appeared to be satisfactorily progressing the issues associated with SSI.

8 Corporate governance

8.1 Board Assurance Framework (BAF)

Updates to the BAF were noted. The risk associated with the 62-day cancer wait target was downgraded from a risk rating of 16 to 12.

The Board approved the updated Board Assurance Framework.

8.2 Flu Shots: Increasing Staff Uptake

The Board received the report and noted the recommendation to further the campaign approach to increase uptake in favour of either of the two options presented for mandating an annual flu vaccination.

The Board debated the proposal and noted the challenges and opportunities to introducing mandatory vaccinations to new staff contracts. The Board drew general consensus on leaving existing staff contracts as they were, however it divided on the issue of a mandatory approach to new contracts. Contractual issues did not appear to be an obstacle, however the Board was divided on whether it would be considered an issue of human rights for staff and whether or not recruitment would be affected by the introduction of a mandated vaccination requirement. The cultural aspects of compulsion were discussed and noted.

It was agreed to defer any decision on mandatory vaccinations being introduced to new staff contracts and to allow more time for the campaign approach to increase uptake of the annual flu vaccination. It was also agreed that further legal advice would be needed before any revisiting of a proposal to mandate flu vaccinations for staff.

8.3 Use of the Seal

The Board received and noted the use of seal report. The Board ratified the use of the seal as presented.

9.0 Committee Reports

9.1 Council of Governors

The Board received a verbal report on the recent meeting of the Council of Governors. It was noted that the attendance had been very good at the meeting. There had been a long discussion about the recent maternal death and the governors had accepted that reviews were underway and that they would receive a final report in due course. They also discussed the on-going issues relating to the anonymous group known as the ‘unhappy midwives’ and would receive an updated report on this. The Quality Account mandatory indicators for auditing were discussed and the governors agreed on readmission within 28 days and surgical site infections as their two preferred indicators. The annual plan was discussed and a governor focus group would meet to provide feedback on the production of the annual plan. It was recognised by the Board that the governors had become a strong performing group and that their meetings were of a high quality.

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10.0 Any other business

The Board discussed the possibility of adopting the practise of paperless meetings. Issues around perceived equality in providing tablets to Board members and the difficulties of using board papers in electronic form were weighed against expected cost savings and the positive effects on the environment of adopting a paperless approach. There was in-principle support for the idea of paperless Board meeting, however work would be needed to demonstrate the benefits and mitigate any challenges.

Action: Investigate feasibility of paperless board meetings (SAr, May 2015)

12.0 Questions from the Public

A public governor, in attendance with members of the public, asked a number of questions, which elicited the following responses:

• the Trust agreed that people, including its staff, should receive a flu vaccination every year, however it was questionable whether that should be mandatory for staff rather than encouraged;

• the Trust would take on notice a question related to it committing to the comprehensive water supply to patients, especially those in patient transfer lounges;

• the Trust had not received a letter from Francis Maude MP proposing the notion of trusts becoming mutual, however it was aware of the issue in a briefing email received from him;

• as it had only announced that morning, the Trust was not yet aware of the details around the Greater City of Manchester’s devolvement on acute and social care, however it was pointed out a similar approach had been in operation in Belfast for some time.

In answer to a question from a member of the public it was clarified that neither ‘never event’ cited in the meeting were associated with significant patient harm. The October 2014 ‘never event’ had been discovered in recent weeks through the Trust’s own review process and had not been detected by the patient. It was difficult to comment in detail in public at this stage, however the incident involved a prosthetic element that was

incorrect and subsequently replaced. The December 2014 ‘never event’ was reported at the last Board meeting and involved a retained swab. Both events were under

investigation.

The meeting concluded at 11.20 a.m. Date

Arising

Action For By Status

June 2014 Staffing Capacity and Capability Board Report SA Jan & July 2015

Jan: C June: P Sept 2014 Presentation on the patient experience strategy and related

processes to be made to the next joint meeting of the Governors and Board of Directors.

DW Revised July 2015

P

Nov 2014 SA and MK to review 24-hour meeting process, and name, and report to Board MK& SA Revised March, 2015 P

Dec 2014 Provide detailed indictors for needle stick injuries SA/ AC

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Date Arising

Action For By Status

Dec 2014 Place charts back in the Infection Prevention and Control Report SA/ AC

May 2015 P

Dec 2014 Confirm if additional costs could result from the new cleaning contract being negotiated

SA/ AC

May 2015 P Dec 2014 Future reports to include qualitative comment on MSSA SA/

AC

May 2015 P Dec 2014 Review of SSI instances to be presented to the Board SA/

CA

June 2015 P Jan 2015 Information on the GP Federation to be provided to the Board TF Revised

Mar 2015 P Jan 2015 Present readmission rates in more detail in future reports MK Revised

April 2015 P Feb 2015 Present update on actions to achieve recruitment DW April 2015 P Feb 2015 Non-NHS debtors to be presented to the Board JF Mar 2015 P Feb 2015 Investigate feasibility of paperless board meetings SAr May 2015 P

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BOARD OF DIRECTORS

Meeting date: 25

th

March 2015

Agenda Item: 5

Paper: 15-27

Title:

Chief Executive’s Report

Summary

The report provides an update on key activities and events in

the Trust, which are not already covered in the agenda.

Action:

The Board is asked to note the report.

Prepared and

Presented by:

Tracey Fletcher, Chief Executive

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Board of Directors – 25th March 2015 Chief Executives Report

1. CQC unannounced inspection visit – Maternity Services

The Care Quality Commission (CQC) paid an unannounced visit to the Trust, specifically the Maternity services on Tuesday 17th March. This was precipitated by the recent maternal deaths and the NHS England Clinical Senate report. This involved seven clinical experts and CQC officers spending the day within the maternity services as well as requesting a significant amount of

documentary evidence to be submitted. At the time of writing, the inspection is still ongoing and the CQC have ten days to conclude their investigations.

2. CCG Quality Summit – Maternity services

A Trust team comprising of executives, divisional management team and clinicians attended a Quality Summit convened by City & Hackney CCG to review the recommendations made within the NHS England Clinical Senate report. The meeting was also attended by London Borough of

Hackney (Public Health), Care Quality Commission and NHS England. A second similar meeting will be convened in the near future to review the investigation report into the fifth maternal death.

3. Care Quality Commission ratings display requirements

The Government has introduced a regulation requiring providers to display their CQC rating. This regulation is part of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and becomes a legal requirement from 1st April 2015. Ratings must be displayed legibly and conspicuously at the organisation’s premises and on the organisation’s website.

The guidance document produced by the CQC includes details of where the information should be displayed including;

- At any location that is visited or may be visited by members of the public

- On the main homepage of the website, or the appropriate landing page where as many people as possible looking for information about the service will see it.

This information will need to be provided for the Trust’s community based services as well as Mary Seacole Nursing Home and the hospital site.

4. False and Misleading Information Regulations

As a Trust we need to be aware of the changes to Section 92 of the Care Act 2014 (the Act) that comes into effect on 1st April 2015 and that has put in place a new criminal offence which applies to NHS provider organisations and in certain circumstances to individuals who work in provider

organisations. The Act specifies that organisations that supply, publish or otherwise make available certain types of information, that is determined to be false or misleading, commit an offence. The offence applies to commissioning and other data sets and other specified information including information in quality accounts, cancer outcomes and services data set, hospital and community health services complaints collection, national cancer waiting times monitoring data set, national diabetes audit and national maternity services data set.

5. Director of Finance appointment

The Trust was unable to make an appointment to the post of Director of Finance through the recent recruitment process. An interim has been secured to provide cover for the post over the

forthcoming six months.

Tracey Fletcher Chief Executive March 2015

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BOARD OF DIRECTORS

Meeting date: 25

th

March 2015

Agenda Item: 6

Paper: 15-28

Title:

Month 11 Integrated Board Report

Summary

The attached paper is the integrated report covering the Trust’s

position with respect to Quality, Workforce and Human

Resources, and Financial performance. The report is

presented in a number of sections, each addressing the five

key questions posed by the CQC of the care the Trust

provides:

1. Is it Safe?

2. Is it Effective?

3. Is it Caring?

4. Is it Responsive?

5. Is it Well Led?

The finance report is included within the Well Led section, and

sections are preceded by a summary of the key points of note.

Action:

The Board is asked to receive the report to monitor the Trust’s

position against key indicators and note the performances.

Prepared and

Presented by:

Executive Team

Compliance:

NHS Provider Licence

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Is Care Safe?

(p.5) The Trust has seen an reduction in the level of harm-free care

for the second month in a row. New harms have not increased so

this reflects patients with harms already in place on admission.

(p.6)The incidence of new pressure ulcers reduced this month to 10.

However, 3 of these were grade 3 pressure ulcers. Of the 2 hospital

acquired grade 3 pressure ulcers, one was on Elderly care and one on

Thomas Audley. Both wards have been asked to put action plans in

place to enhance preventive measures. The community acquired

grade 3 pressure ulcer occurred in cluster 4.

(p.8) IV line HII performance fell again in February. Failures included

labelling of the administration sets, VIP score in 1 patient, and 1

patient without intact dressings.

The infection control team are working with the wards as above to

ensure lessons are learnt and performance is improved.

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Is Care Safe?

(p.9) The single clinical incident associated with major or

above harm was a patient in A&E where there was a failure

to identify a significant fracture on the initial radiology

report. This was picked up later when further imaging

occurred

(p.11) Safe staffing – overall levels of staffing have improved

in February, with further staff being recruited and taking up

post.

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BOARD REPORT | SAFE | HARM FREE CARE

90% 92% 94% 96% 98% 100% Dec 2013

Jan 2014 Feb 2014 Mar

2014

Apr 2014 May 2014

Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov

2014 Dec

2014

Jan 2015 Feb 2015

HARM FREE CARE (ALL) (PATIENT SAFETY THERMOMETER)

Trust National Homerton Bedford Lewisham North Middlesex Northern Devon Salisbury Whittington Salford 0 200 400 600 800 1,000 Dec 2013

2014

Apr 2014 May

2014

2014 Dec 2014 Jan 2015 Feb 2015 656 819 835 766 ₇₄₄ 757 777 707 716 841 629 765 770 782 ₇₄₂ PATIENTS SURVEYED

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BOARD REPORT | SAFE | HARM FREE CARE

0% 2% 4% 6% 8% 10% Dec 2013

2014

Apr 2014 May 2014

2014 Dec

2014

Jan 2015 Feb 2015

NEW HARMS (PATIENT SAFETY THERMOMETER)

Trust National Homerton Bedford Lewisham North Middlesex Northern Devon Salisbury Whittington Salford

BOARD REPORT | SAFE | PRESSURE ULCERS

0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5% Dec 2013

2014

Apr 2014 May 2014

2014 Dec

2014

Jan 2015 Feb 2015

NEW PRESSURE ULCERS (PATIENT SAFETY THERMOMETER)

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BOARD REPORT | SAFE | PRESSURE ULCERS

0 5 10 15 20 Dec 2013

Jan 2014 Feb 2014 Mar 2014

Apr 2014 May 2014

Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 17 19 8 15 11 12 18 21 10 22 10 11 13 16 10 PRESSURE ULCERS

Hospital acquired grade 3+ Hospital acquired grade 2-Community acquired grade 3+ Community acquired grade

2-BOARD REPORT | SAFE | FALLS

0% 1% 2% 3% 4% 5% 6% Dec 2013

2014

Apr 2014 May

2014

2014 Dec

2014

Jan 2015 Feb 2015

ALL FALLS (PATIENT SAFETY THERMOMETER)

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BOARD REPORT | SAFE | HIGH IMPACT INTERVENTIONS

90% 92% 94% 96% 98% 100% Dec 2013

2014

Apr 2014 May

2014

2014 Dec 2014 Jan 2015 Feb 2015 98.4% _98.2% 99.2% 99.7% _99.0% 99.4% _99.0% 99.3% 99.4% 97.9% 98.1% 99.1% 98.5% 98.5% 99.5% Target (98%) HAND HYGIENE

BOARD REPORT | SAFE | NEVER EVENTS

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

Total Never Events

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BOARD REPORT | SAFE | HIGH IMPACT INTERVENTIONS

86% 88% 90% 92% 94% 96% 98% 100% Dec 2013

2014

Apr 2014 May

2014

2014 Dec 2014 Jan 2015 Feb 2015 100.0% 100.0% 97.3% 97.8% 89.4% 100.0% 98.3% 100.0% 99.1% 98.2% 95.9% 97.5% 100.0% 99.1% 100.0% Target (98%)

CATHETERS - ONGOING CARE

90% 92% 94% 96% 98% 100% Dec 2013

2014

Apr 2014 May

2014

2014 Dec 2014 Jan 2015 Feb 2015 98.5% 100.0% 100.0% 98.0% 100.0% 99.1% 100.0% 100.0% 100.0% 99.2% 97.7% 98.5% 99.2% 99.3% 93.8% Target (98%) IV LINES

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BOARD REPORT | SAFE | INCIDENT REPORTING

62 73 56 49 50 56 77 76 36 59 61 43 49 48 45 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 69 61 73 64 67 68 70 71 64 61 50 63 61 78 57 0 1 0 0 0 0 0 0 1 1 0 1 0 0 0 572 642 565 545 479 550 526 579 450 511 523 521 493 520 423 1 4 1 2 3 1 4 3 2 3 5 2 1 1 1 1 5 5 3 7 3 9 9 10 10 9 3 2 6 2

All Medication Errors

Medication Errors (Resulting In Major Harm or Abo… All Falls

Falls (Resulting In Major Harm or Above) All Clinical Incidents

Clinical Incidents (Resulting In Major Harm or Above) Serious Incidents

Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15

Indicator 27 27 26 21 18 Delivery Suite Patients Home Acute Care Unit Elderly Care Unit Graham Ward

Total Incidents Location

1 Accident and Emergency - Majors

Clinical Incidents resulting in major harm

Location

LOCATIONS WITH HIGHEST NUMBER OF INCIDENTS (FEB 2015)

LOCATIONS WITH INCIDENTS RESULTING IN MAJOR HARM (FEB 2015)

LOCATIONS WITH HIGHEST NUMBER OF INCIDENTS (YTD)

476 380 355 315 312 Delivery Suite

Acute Care Unit Patients Home Intensive Therapy Unit Elderly Care Unit

Total Incidents Location 3 3 3 2 2 2 1 1 1 1 1 1 1 1 1 Thomas Audley Ward

Delivery Suite

Accident and Emergency - Majors Patients Home

Theatre - Main Theatre One Elderly Care Unit Priestly Ward

Neonatal Intensive Care Unit Lloyd Ward

Intensive Therapy Unit Accident and Emergency - General Mary Secole Nursing Home Acute Care Unit Theatre - Main Theatre Five Endoscopy

Clinical Incidents resulting in major harm Location

(25)

BOARD REPORT | SAFE | INFECTION CONTROL

0 2 0 1 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 1 1 1 1 0 0 0 0 2 0 2 1 1 0 0 1 0 1 1 1 1 0 0 2 3 1 2 2 2 1 5 2 2 1 1 3 4 9 10 14 14 11 10 10 6 12 10 8 13 10 9 13 MRSA CDIFF MSSA ECOLI Trust Attributable Non-Trust Attributable Trust Attributable Non-Trust Attributable Total Total

Dec 2013 Jan 2014 Feb 2014 Mar 2014 Apr 2014 May 2014 Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015

Infection Attributable Month

BOARD REPORT | SAFE | MRSA SCREENING

80% 85% 90% 95% 100% 0 200 400 600 800 Dec 2013

2014

Apr 2014 May 2014

2014 Dec 2014 Jan 2015 Feb 2015 97.1% 97.2% 95.8% 98.2% 95.8% 97.3% _96.8% _96.9% 95.4% 94.5% 97.6% 95.4% 96.1% 96.6% _94.9% 96.3% 95.3% 93.6% 95.8% 94.5% 94.9% _94.0% 95.5% 91.8% 92.7% 96.0% 94.0% 94.4% 95.7% 93.4% Target (98%) MRSA SCREENING % Screened In Time Not Screened Screened % Screened

(26)

Less than 90% of planned staffing Between 90-95% of planned staffing More than 110% of planned staffing Red

Amber Yellow

BOARD REPORT | SAFE | SAFER STAFFING (FEB 2015)

100% 101% 97% 100% 107% 102% 108% 100% 83% 106% 100% 102% 94% 88% 92% 83% 98% 100% 100% 96% 100% 77% 101% 104% 101% 100% 104% 98% 100% 83% 100% 100% 100% 100% 100% 100% 100% 117% 100% 100% 100% 100% 100% 67% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 75% 100% 100% 108% 100% 108% 100% 108% 121% 133% 100% 100% 100% 100% 100% 100% 100% 100% 121% 133% 133% 171% 108% 133% 100% 135% 67% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 69% 100% 79% 100% 100% 100% 69% 83% 119% 100% 76% 100% 100% 100% 100% 144% 83% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 150% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 200% 100% 100% 100% 38% 100% 100% 100% 100% 100% 100% 130% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 200% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 200% 100% 100% 100% 100% 100% 100% 100% 100% 100% 143% 143% 86% 100% 100% 100% 86% 100% 100% 129% 100% 114% 129% 129% 100% 100% 114% 100% 129% 100% 100% 86% 86% 86% 100% 86% 100% 86% 130% 100% 100% 100% 125% 125% 100% 125% 100% 100% 125% 100% 100% 100% 100% 100% 75% 100% 100% 100% 125% 100% 100% 100% 100% 100% 100% 100% 125% 125% 125% 163% 120% 150% 138% 113% 88% 100% 100% 100% 133% 88% 113% 100% 100% 88% 138% 100% 100% 100% 95% 83% 100% 100% 145% 113% 100% 75% 150% 150% 100% 100% 100% 150% 125% 125% 100% 130% 150% 150% 150% 100% 125% 100% 100% 100% 125% 125% 100% 100% 100% 100% 100% 100% 100% 83% 100% 100% 100% 80% 100% 100% 100% 83% 100% 100% 93% 86% 108% 83% 83% 80% 80% 93% 100% 100% 98% 100% 100% 98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 101% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 67% 100% 100% 100% 100% 100% 105% 133% 100% 100% 62% 100% 62% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 79% 76% 69% 100% 100% 100% 100% 87% 100% 100% 109% 100% 100% 100% 100% 100% 100% 79% 100% 100% 91% 100% 106% 95% 94% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 84% 100% 100% 100% 100% 138% 121% 100% 100% 100% 100% 100% 100% 100% 100% 100% 105% 100% 100% 112% 100% 131% 117% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 67% 100% 100% 100% 100% 100% 100% 100% 100% 100% 133% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 86% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 90% 100% 100% 90% 90% 100% 100% 100% 100% 100% 100% 86% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 89% 100% 100% 100% 100% 100% 90% 90% 100% 106% 75% 106% 100% 89% 75% 139% 98% 100% 116% 125% 100% 100% 91% 100% 100% 116% 100% 75% 98% 73% 75% 106% 117% 100% 114% 106% 93% 100% 99% 100% 126% 99% 103% 100% 99% 74% 99% 101% 100% 102% 101% 100% 99% 99% 100% 99% 74% 101% 76% 100% 100% 100% 74% 100% 99% 100% 132% 76% 100% 88% 94% 94% 114% 92% 100% 76% 100% 100% 100% 95% 100% 100% 100% 94% 94% 87% 114% 95% 83% 118% 99% 107% 83% 100% 100% 100% 96% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 96% 100% 100% 100% 196% 100% 100% 100% 100% 100% 100% 49% 100% 83% 110% 71% 90% 125% 124% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 128% 100% 100% 100% 100% 72% 100% 83% 100% 100% 100% 100% 100% 100% 133% 133% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 133% 100% 133% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 138% 100% 100% 100% 100% 100% 100% 100% 100% 100% 114% 100% 100% 100% 100% 100% 100% 100% 83% 156% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 100% 100% 100% 100% 100% 150% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 150% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 101% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% 105% 126% 106% 101% 107% 99% 102% 115% 110% 101% 87% 93% 98% 98% 106% 94% 106% 84% 104% 98% 87% 99% 94% 93% 98% 99% 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 78% 90% 98% 93% 93% 113% 94% 100% 109% 109% 93% 101% 110% 94% 89% 107% 98% 109% 94% 104% 94% 100% 104% 96% 89% 103% 99% 83% 78% 94% 94% 89% 100% 100% 94% 94% 94% 94% 94% 94% 109% 106% 94% 100% 94% 100% 83% 94% 94% 94% 94% 72% 78% 78% 78% 89% 100% 165% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 165% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% - 100% 100% 100% 100% 100% 100% - 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 129% 100% 100% 75% 100% 100% 86% 100% 80% 100% 75% 82% 83% 82% 86% 100% 100% 75% 83% 83% 86% 84% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 75% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 150% 100% 100% 100% 100% 100% 50% 100% 100% 50% 100% 50% 100% 100% 100% 100% 91% 100% 100% 100% 150% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 200% 200% 100% 100% 100% 100% 100% 100% 200% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 107% 100% 75% 100% 100% 100% 81% 100% 100% 100% 100% 100% 100% 75% 100% 100% 57% 100% 83% 100% 67% 88% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 89% 100% 100% 111% 100% 100% 96% 106% 100% 65% 121% 100% 100% 107% 96% 100% 88% 100% 100% 100% 89% 71% 82% 96% 82% 107% 107% 100% 100% 100% 67% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 121% 100% 100% 113% 100% 100% 100% 100% 100% 116% 75% 100% 100% 75% 81% 100% 100% 100% 100% 125% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 67% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 67% 67% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 86% 97% 100% 100% 100% 86% 97% 100% 97% 86% 114% 100% 93% 114% 100% 83% 91% 100% 100% 105% 100% 100% 100% 100% 100% 100% 100% 117% 100% 100% 100% 100% 83% 100% 100% 100% 100% 100% 100% 100% 117% 117% 100% 100% 117% 117% 100% 100% 100% 100% 83% 100% 100% 125% 101% 95% 95% 115% 100% 120% 143% 125% 121% 121% 114% 100% 87% 100% 100% 70% 89% 73% 91% 100% 120% 100% 125% 111% 100% 75% 120% 100% 100% 100% 100% 100% 100% 150% 100% 100% 100% 100% 100% 150% 100% 100% 100% 100% 150% 100% 150% 100% 100% 100% 100% 150% 100% 100% 100% 100% 100% 100% 80% 100% 100% 80% 80% 100% 100% 100% 100% 100% 100% 75% 98% 100% 100% 100% 88% 103% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 75% 75% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 67% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Feb-15 ACU Cardiology ECU Edith Cavell Graham ITU Lamb Lloyd Mary Seacole NICU Priestley RNRU Starlight Templar Thomas Audley Qualified Unqualified Qualified Unqualified Qualified Unqualified Qualified Unqualified Qualified Unqualified Qualified Qualified Unqualified Qualified Unqualified Qualified Unqualified Qualified Unqualified Qualified Unqualified Qualified Unqualified Qualified Unqualified Qualified Unqualified Qualified Unqualified Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Day Night Night Day Night Day Night Day Night Day Night 1 SUN 2 MON 3 TUE 4 WED 5 TH… 6 FRI 7 SAT 8 SUN 9 MON 10 TUE 11 WED 12 TH… 13 FRI 14 SAT 15 SUN 16 MON 17 TUE 18 WED 19 TH… 20 FRI 21 SAT 22 SUN 23 MON 24 TUE 25 WED 26 TH… 27 FRI 28 SAT Month Ward Grade Period

D D

(27)

Is Care Caring?

(p.14 -15) Response rates fell across the Trust due to very poor ED

and maternity rates. ED have been under significant pressure and

are still using paper response forms as the kiosks have not yet been

installed. However, their ratings remain good with a 95% would

recommend rate.

(p.16) Inpatient response numbers remain good and this had

resulted in a very steady state of rating. Unfortunately only 90%

would recommend although many comments remain very positive.

Two areas of particular concern remain food and noise at night.

Scores for each are below. We are piloting the sleep well, walk well

initiative on Lloyd and Lamb ward which offers ear plugs, and eye

masks plus non-slip socks for patients.

(28)

Is Care Caring?

(p.19) The PALS report extended category list means that issues and

concerns are now broken down into greater detail. PALS contacts

which progressed straight to a complaint have reduced this month

and compliments remain at a higher level for a second month.

(p.19) The upturn in the number of complaints responded to by 25

days has continued with 45% for January in spite of a significant

increase in the number of complaints received. The number of more

complex complaints requiring a meeting with patients and family also

increased.

(29)

BOARD REPORT | CARING | FRIENDS AND FAMILY TEST

% 0% 20% 40% 60% 80% 100% Dec 2013

Jan 2014 Feb 2014 Mar 2014

Apr 2014 May 2014

2014 Dec 2014 Jan 2015 Feb 2015 94% 95% 94% 94% 95% 95% 95% 95% 96% 96% 90% 93% 93% 95% 93%

FRIENDS & FAMILY RESPONSE RATE & SCORE (TRUST)

Response Rate % Would Recommend % Would Not Recommend

The trust figures now include Community responses for Jan15 onwards. 0 500 1,000 1,500 Dec 2013

2014

Apr 2014 May 2014

2014 Dec 2014 Jan 2015 Feb 2015 1270 1620 1361 1489 1398 1224 1368 1235 1178 1099 861 774 988 1588 958

FRIENDS & FAMILY RESPONSE TYPE (TRUST)

Response Don’t know Extremely Unlikely Unlikely

Neither likely nor unlikely Likely

Extremely Likely

The trust figures now include Community responses for Jan15 onwards.

(30)

BOARD REPORT | CARING | FRIENDS AND FAMILY TEST

% 0% 20% 40% 60% 80% 100% Dec 2013

2014

Apr 2014 May 2014

2014 Dec 2014 Jan 2015 Feb 2015 94% 95% 94% 95% 95% 95% 95% 95% 96% 97% 92% 96% 95% 97% 95%

FRIENDS & FAMILY RESPONSE RATE & SCORE (A&E)

AVG Response Rate % Would Recommend % Would Not Recommend

0 200 400 600 800 1,000 1,200 Dec 2013

2014

Apr 2014 May 2014

2014 Dec 2014 Jan 2015 Feb 2015 990 1123 927 999 1063 932 1002 952 ₉₁₃ 784 505 461 681 847 314

FRIENDS & FAMILY RESPONSE TYPE (A&E)

(31)

BOARD REPORT | CARING | FRIENDS AND FAMILY TEST

% 0% 20% 40% 60% 80% 100% Dec 2013

2014

Apr 2014 May 2014

2014 Dec 2014 Jan 2015 Feb 2015 94% 94% _92% _92% 97% 94% _93% 94% 90% 94% 89% 92% 90% 90% 90%

FRIENDS & FAMILY RESPONSE RATE & SCORE (INPATIENT)

AVG Response Rate % Would Recommend % Would Not Recommend

0 50 100 150 200 250 300 Dec 2013

2014

Apr 2014 May 2014

2014 Dec 2014 Jan 2015 Feb 2015 195 219 209 284 218 218 280 175 113 182 274 277 230 250 269

FRIENDS & FAMILY RESPONSE TYPE (INPATIENT)

(32)

BOARD REPORT | CARING | FRIENDS AND FAMILY TEST

% 0% 20% 40% 60% 80% 100% Dec 2013

2014

Apr 2014 May 2014

2014 Dec 2014 Jan 2015 Feb 2015 96% 96% 98% 93% 97% 99% 94% 95% 96% 92% 98% 97% 96% 92% 92%

FRIENDS & FAMILY RESPONSE RATE & SCORE (MATERNITY)

0 50 100 150 200 250 300 Dec 2013

2014

Apr 2014 May 2014

2014 Dec 2014 Jan 2015 Feb 2015 85 278 225 198 117 74 86 108 152 133 82 36 77 117 75

FRIENDS & FAMILY RESPONSE TYPE (MATERNITY)

(33)

BOARD REPORT | CARING | FRIENDS AND FAMILY TEST

% 0% 20% 40% 60% 80% 100% Jan 2015 Feb 2015 98% _97%

FRIENDS & FAMILY RESPONSE RATE & SCORE (COMMUNITY)

0 50 100 150 200 250 300 350 400 Jan 2015 Feb 2015 374 300

FRIENDS & FAMILY RESPONSE TYPE (COMMUNITY)

(34)

0 0 0 0 0 0 0 0 0 0 0 0 0 12 30 42 0 0 0 0 0 0 0 0 0 0 0 0 0 11 19 30 0 3 0 1 2 1 3 1 2 0 3 8 9 12 5 50 0 0 0 0 0 0 0 0 0 0 0 0 0 1 4 5 0 2 1 0 2 1 2 0 3 3 2 3 3 8 3 33 1 2 4 0 4 17 5 4 6 6 16 4 9 14 14 106 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 4 0 0 0 0 0 0 0 0 0 0 0 0 0 3 5 8 53 73 75 39 57 63 95 77 78 90 100 91 97 14 0 1002 0 0 0 0 1 0 2 7 4 1 1 5 3 24 29 77 1 0 0 1 3 1 0 0 1 0 2 5 7 6 1 28 0 0 0 0 0 0 0 0 0 0 0 0 0 12 10 22 0 0 0 0 0 0 0 0 0 0 0 0 0 1 9 10 0 0 0 0 0 0 0 0 0 0 0 0 0 2 5 7 55 80 80 41 69 83 107 89 94 100 124 116 128 122 136 1424 Access to Care Attitude Clinical Information Communication Complaint Compliment Discharge

Estates and Facilities Issue and Concerns Non-clinical Information Other

Patient Care Safety

Waiting times and areas

Total

Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Total

Indicator

BOARD REPORT | CARING | PALS

BOARD REPORT | CARING | COMPLAINTS

Complaints 0 10 20 30 40 0% 20% 40% 60% 80% 100% Dec 2013

Jan 2014 Feb 2014 Mar 2014

Apr 2014 May 2014

Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014 Dec 2014 Jan 2015 Feb 2015 COMPLAINTS Complaints Received Responded within 25 days (Excl clock stops)

(35)

BOARD REPORT | CARING | COMPLAINTS

Complaints 0 20 40 60 80 100 120 140 Medi cal Car e Nur sing Car e Midwife ry C are Com muni caton with pati ent Disc harg e A rrang ement s Atti tud e o f St aff Del ayed O ut-pt Appt Co mm . wi th P t/GP /Rela tive Com mu nication with re lativ e Wai ting T ime in Out -pts Oth er Canc elled O ut-pt Appt Tran sport Loss of P roper ty (inc l. thef t) Pati ent Man ageme nt/ha ndli ng Harras sment by staf f Com mun icatio n w ith G P Admin istrationCat ering Clean lines s Del ayed In-pt Ad miss ion Attitu de of nurs ing staf f Canc elled In-pt Ad miss ion Safe ty Availab ility of S ervic e Tes t res ults de lay ed/ una vaila ble Clini cal Risk Avail . Equip /Appli ance Inappr opri ate wait ing ar eas Env iron . or Fac ilities Attit ude of Midwif e 119 31 ₂₅ 21 ₁₇ ₁₆ 7 6 5 5 4 4 4 3 3 3 3 3 2 2 2 2 2 2 2 1 1 1 1 1 1

(36)

Is Care Effective?

• (Pg 22) Readmission rates remain generally constant.

• (Pg 23) VTE risk assessment remains good, with well over 95%

created within 24 hours of admission.

• (Pg 23) The rate of VTE remains similar to the national rate.

• (Pg 24) The SHMI remains constant at about 0.8, which is below

that expected.

• (Pg 26) The rate of cardiac arrest spiked in February.

We are producing a ‘shadow’ version of the data items in the CQC’s

intelligent monitoring report. This will include data on mortality and

readmissions that we will incorporate into future Board reports.

(37)

BOARD REPORT | EFFECTIVE | READMISSION RATES

0% 5% 10% 15% 20% 25% Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15

READMISSION RATES WITHIN 30 DAYS

Elective Emergency

(38)

BOARD REPORT | EFFECTIVE | VTE

Forms 1,800 1,900 2,000 2,100 2,200 2,300 2,400 2,500 Rate 80% 85% 90% 95% 100% Dec 2013

Jan 2014 Feb 2014 Mar 2014

Apr 2014 May 2014

Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014 Nov 2014

Dec 2014

Jan 2015 Feb 2015

Target (95% completed within 24 hours)

VTE ASSESSMENTS (TRUST)

VTE within 24 hours rate Not created

Created outside 24 hours Created within 24 hours

0.0% 0.5% 1.0% 1.5% 2.0% 2.5% Dec 2013

2014

Apr 2014 May 2014

2014 Dec

2014

Jan 2015 Feb 2015

NEW VTE (PATIENT SAFETY THERMOMETER)

(39)

BOARD REPORT | EFFECTIVE | SHMI

40 60 80 100 120 0 10 20 30 40 50 60 70 Dec 2013

2014

Apr 2014 May

2014

Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014

Target (100) UCL

LCL

SUMMARY HOSPITAL-LEVEL MORTALITY INDICATOR (SHMI) - IN MONTH

SHMI Deaths

SHMI Score _Deaths

* Data only available up to Oct14 40 50 60 70 80 90 100 110 120 Dec 2013

2014

Apr 2014 May

2014

Jun 2014 Jul 2014 Aug 2014 Sep 2014 Oct 2014

Target (100) UCL

LCL

SUMMARY HOSPITAL-LEVEL MORTALITY INDICATOR (SHMI) - ROLLING 12 MONTH AVERAGE

* Data only available up to Oct14

(40)

BOARD REPORT | EFFECTIVE | HSMR

Scores 50 60 70 80 90 100 110 120 0 10 20 30 40 50 Dec 2013

2014

Apr 2014 May

2014

Target (100) UCL

LCL

HOSPITAL STANDARDISED MORTALITY RATIO (HSMR) - IN MONTH

HSMR Deaths

Deaths

* Data only available up to Nov14 Scores 50 60 70 80 90 100 110 120 Dec 2013

2014

Apr 2014 May

2014

Target (100) UCL LCL

HOSPITAL STANDARDISED MORTALITY RATIO (HSMR) - ROLLING 12 MONTH AVERAGE

* Data only available up to Nov14

(41)

BOARD REPORT | EFFECTIVE | CARDIAC ARRESTS

0.0 0.5 1.0 1.5 2.0 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 1.6 1.0 1.4 1.7 1.2 0.6 _0.6 1.6 0.4 0.8 1.1 0.8 0.8 2.1 National Average (1.6)

(42)

Is Care Responsive?

Operational performance in February was generally strong with the

exception of performance against the 4-hr Emergency Care

standard. Particularly noteworthy in reviewing the Integrated Board

Report is:

• (Pg 28) Full delivery of the 18 week elective care requirements

despite the challenges of maintaining the Emergency Care standard

and high bed occupancy rates throughout the month.

• (Pg 30) Confirmation that all cancer targets were delivered in

January with continuation of compliance with the 2-week standards

in February. Based on the latest information, and assuming no

unexpected adjustments, the Trust is likely to be complaint with the

31-day and 62-day standards for February but with 62-day

performance at or around 85%. The overall Q4 position for 62-day

remains at risk therefore and March performance will be key.

• (Pg 33) Reasonable activity levels across the key areas with

elective and day-case activity mirroring planned levels more closely

than in previous months despite the challenging bed occupancy

position.

(Pg 29) Nevertheless, the Trust’s failure to deliver the 4-hr Emergency

Care standard for the month and the extent of the failure at 93.64%

is disappointing. The primary driver for this was a material increase

in breaches associated with long waits in the Emergency Department

– increasing from 38 in January to 183 in February. At a high level the

key reasons behind this change were the impact of the bed

occupancy position on flow through the department, an increase in

delayed transfers of care, difficulties in filling additional medical

shifts and challenges on occasions, and particularly overnight,

relating to the acuity and complexity of patients.

The immediate operational focus is on correcting the position with a

view to maintaining compliance for Q4 although as discussed at the

previous Board meeting this is now a challenging requirement.

Beyond this an away-day with the Trust’s Consultant Physicians has

been organised for May 8th in order to discuss potential

improvement to the efficient management of inpatient care and

work is underway on a refined SOP for the proactive management of

the 4-hr standard across the organisation.

(43)

BOARD REPORT | RESPONSIVE | ACCESS | 18 WEEKS

86% 88% 90% 92% 94% 96% 98% 100% Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Admitted target (90%)

18 WEEKS REFERRAL TO TREATMENT - ADMITTED PATIENTS

90% 92% 94% 96% 98% 100% Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Non-admitted target (95%)

(44)

BOARD REPORT | RESPONSIVE | ACCESS | 18 WEEKS

90% 92% 94% 96% 98% 100% Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Incomplete target (92%)

18 WEEKS REFERRAL TO TREATMENT - INCOMPLETE PATHWAYS

BOARD REPORT | RESPONSIVE | ACCESS | A&E

90% 92% 94% 96% 98% 100% Dec 2013

2014

Apr 2014 May

2014

2014 Dec

2014

Jan 2015 Feb 2015

95% target

(45)

BOARD REPORT | RESPONSIVE | ACCESS | CANCER

Rate 90.00% 92.00% 94.00% 96.00% 98.00% 100.00% Dec 2013

2014

Apr 2014 May

2014

2014 Dec

2014

Jan 2015 Feb 2015

93% Target

CANCER 2 WEEK (ALL CANCERS)

Rate 88.00% 90.00% 92.00% 94.00% 96.00% 98.00% 100.00% Dec 2013

2014

Apr 2014 May

2014

2014 Dec

2014

Jan 2015 Feb 2015

93% target

(46)

BOARD REPORT | RESPONSIVE | ACCESS | CANCER

80% 85% 90% 95% 100% Dec 2013

2014

Apr 2014 May

2014

Dec 2014

Jan 2015

94% target

CANCER 31 DAY WAIT FOR SUBSEQUENT TREATMENT - SURGERY

80% 85% 90% 95% 100% Dec 2013

2014

Apr 2014 May

2014

Dec 2014

Jan 2015

98% target

(47)

BOARD REPORT | RESPONSIVE | ACCESS | CANCER

90% 92% 94% 96% 98% 100% Dec 2013

2014

Apr 2014 May

2014

Dec 2014

Jan 2015

96% target

CANCER 31 DAY DIAGNOSIS TO TREATMENT (ALL CANCERS)

70% 75% 80% 85% 90% 95% 100% Dec 2013

2014

Apr 2014 May

2014

Dec 2014

Jan 2015

85% target

(48)

BOARD REPORT | RESPONSIVE | ACTIVITY | EMERGENCY

BOARD REPORT | RESPONSIVE | ACTIVITY | ELECTIVE

0 500 1,000 1,500 2,000 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 ACTIVITY - NON-ELECTIVE Activity Plan 0 100 200 300 400 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 ACTIVITY - ELECTIVE Activity Plan 0 500 1,000 1,500 2,000 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15

ACTIVITY - DAY CASE

Activity Plan 0 2,000 4,000 6,000 8,000 10,000 12,000 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15

ACTIVITY - A&E (INCL PUCC)

Activity

(49)

BOARD REPORT | RESPONSIVE | ACTIVITY | OUTPATIENTS

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 0 500 1,000 1,500 2,000 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 ACTIVITY - OUTPATIENT New Attendances Follow Up Attendances OP Procedures OP Procedures Attendances

BOARD REPORT | RESPONSIVE | ACTIVITY | BED DAYS

0 200 400 600 800 1,000 1,200 1,400 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15

ACTIVITY - BED DAYS

ITU RNRU Stroke Rehab General Rehab Neonatal

(50)

BOARD REPORT | RESPONSIVE | ACTIVITY | DELIVERIES

0 100 200 300 400 500 600 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 ACTIVITY - DELIVERIES

(51)

BOARD REPORT | RESPONSIVE | BED UTILISATION

85% 90% 95% 100% Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Target (90%)

BED UTILISATION RATE - GENERAL WARDS

0% 20% 40% 60% 80% 100% Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Target (90%)

BED UTILISATION RATE - STARLIGHT

0% 20% 40% 60% 80% 100% Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Target (90%)

(52)

BOARD REPORT | RESPONSIVE | COMMUNITY DATA COMPLETENESS

40% 50% 60% 70% 80% 90% 100% Dec 2013

2014

Apr 2014 May

2014

2014 Dec

2014

Jan 2015 Feb 2015

Target (50%)

COMMUNITY COMPLIANCE RATES

RTT Referrals Activity