SWFT Board of Directors Agenda

SWFT Board of DirectorsWed 02 March 2022, 14:00 - 16:00

Agenda

1. Going the Extra Mile Awards (GEM)

2.00 - 2.05 pm

Emma Evans, Nursery Nurse (Clinical Winner for Autumn 2021)Tracey Evans, Specialist Palliative Care Nurse (Clinical Winner for Autumn 2021)

Bereavement Care within Midwifery (Team Winner)Amanda Price, MidwifeMaria Pearman, Deputy Head of MidwiferyRebecca Talbot, Clinical Governance Midwife

2. Apologies of Absence

Fiona Burton, Chief Nursing Officer (Rebecca Moore deputising)

3. Declarations of Interest

4. Minutes of the Meeting held on 2 February 2022

2.00 pm - 2.05 pm

Agenda Item 4 - Public Board Minutes 2 February 2022.pdf (12 pages)

5. Matters Arising and Actions Update Report

2.05 pm - 2.10 pm

Agenda Item 5 - Public Board Actions Update 02.03.22.pdf (1 pages)

6. ITEMS FOR APPROVAL

2.10 pm - 2.30 pm

6.1. Appointment of Senior Independent Director

Russell Hardy

Agenda Item 6.1 - Appointment of SID.pdf (2 pages)

6.2. Board Schedule of Business 2022/23

Sarah Collett

Agenda Item 6.2 - Board of Directors' Schedule of Business 2022-23.pdf (3 pages)

6.3. Final Trust and Foundation Group Annual Objectives 2022/23

Glen Burley

Agenda Item 6.3 - Final Annual Trust and FG Objectives 2022-23.pdf (4 pages)

7. PERFORMANCE REVIEW AND ASSURANCE

2.30 pm - 3.15 pm

7.1. Chief Executive's Report

Glen Burley

Agenda Item 7.1 - Chief Executive's Report.pdf (5 pages)

7.2. Integrated Performance Dashboard (including Mortality Update)

Anne Coyle

Agenda Item 7.2 - Integrated Performance Dashboard (including Mortality Update).pdf (57 pages)

7.3. Monthly Safe Staffing Report

Rebecca Moore

Agenda Item 7.3 - Monthly Safe Staffing Report.pdf (21 pages)

7.4. Maternity Governance Report Quarter 3 2021/22

Dilly Wilkinson, Associate Director of Operations for Family Health DivisionLinda Ward, Acting Associate Director of Midwifery

Agenda Item 7.4 - Maternity Governance Report Q3.pdf (24 pages)

7.5. Freedom to Speak Up Guardian's Report

Deepa Masani

Agenda Item 7.5 - Freedom to Speak Up Guardian's Report.pdf (5 pages)

7.6. Report from Council of Governors Meeting held on 10 February 2022

Russell Hardy

Agenda Item 7.6 - Council of Governors Report 10 Feb 2022.pdf (3 pages)

7.7. Digital Health Board Quarterly Update

Adam Carson

Agenda item 7.7 - Digital Health Board Quarterly Update.pdf (4 pages)

7.8. Audit Committee Report for 9 February 2022 - Open Meeting

Rosemary Hyde

Agenda item 7.8 - Audit Committee Report for 09.02.22 - Open Meeting.pdf (5 pages)

7.9. Clinical Governance Committee Report for 9 February 2022

David Spraggett

Agenda item 7.9 - CGC Report for 9 February 2022.pdf (6 pages)

8. ITEMS FOR NOTING AND INFORMATION

3.15 pm - 3.25 pm

8.1. Summary of Ratified Policies

Anne Coyle

Agenda Item 8.1 - Summary of Ratified Policies.pdf (2 pages)

8.2. Summary of Reports for Noting and Information

Harkamal Heran

Emergency Preparedness Annual Report

Agenda Item 8.2 - Summary of Reports for Noting and Information - Emergency Preparedness Annual Report.pdf (7 pages)

8.3. Estates Strategy Summary

Sophie Gilkes

Agenda Item 8.3 - SWFT Estates Strategy Summary.pdf (9 pages)

8.4. Updated Register of Directors' Interests

Sarah Collett

Agenda Item 8.4 - Updated Register of Directors' Interests.pdf (6 pages)

9. Board Committee Minutes

3.25 pm - 3.30 pm

Agenda Item 9 - Board Committee Minutes - Open Meetings Front Sheet.pdf (1 pages)

9.1. Audit Committee Meeting held on 8 December 2021

Rosemary Hyde

Agenda Item 9.1 - Audit Committee - 08.12.2021 - OPEN MEETING.pdf (8 pages)

9.2. Clinical Governance Committee Meeting held on 12 January 2022

David Spraggett

Agenda Item 9.2 - CGC Minutes 12 January 2022.pdf (8 pages)

10. Any Other Business

3.30 pm - 3.35 pm

11. Questions from Governors and Members of the Public

3.35 pm - 3.40 pm

Adjournment to discuss Matters of a Confidential Nature

CONFIDENTIAL AGENDA

12. Apologies for Absence

3.50 pm - 3.55 pm

Fiona Burton, Chief Nursing Officer (Rebecca Moore deputising)

13. Declarations of Interest

14. Minutes of the Meeting held on the 2 February 2022

3.55 pm - 4.00 pm

15. Matters Arising and Actions Update Report

4.00 pm - 4.05 pm

16. ITEMS FOR APPROVAL

4.05 pm - 4.15 pm

16.1. Draft Annual Financial Plan and Contracts including Draft Capital Programme 2022/23

Kim Li

16.2. Additional Share Capital Requirement for Innovate Healthcare Services Ltd

Kim Li

17. ITEMS FOR NOTING AND INFORMATION

4.15 pm - 4.25 pm

17.1. Host Provider Verbal Update

Anne Coyle

17.2. Employee Relations Report

Gertie Nic Philib

17.3. Sensyne Update

Kim Li

18. Board Committee Confidential / Closed Minutes

4.25 pm - 4.30 pm

18.1. Audit Committee Meeting held on 8 December 2021

Rosemary Hyde

18.2. Clinical Governance Committee Meeting held on 12 January 2022

David Spraggett

19. Any Other Confidential Business

4.30 pm - 4.35 pm

20. Date and Time of Next Meeting

The next meeting will be held on the 6 April 2022

Agenda item 4SOUTH WARWICKSHIRE NHS FOUNDATION TRUST

Minutes of the Board of Directors Meeting Held onWednesday 2 February 2022 at 2.00pm via Microsoft Teams

Present:Russell Hardy (RH) Chairman (present from Minute 22.010) Charles Ashton (CA) Chief Medical OfficerGlen BurleyFiona BurtonAnne Coyle

(GB)(FB)(AC)

Chief Executive Chief Nursing OfficerManaging Director

Rosemary Hyde (RHy) Non-Executive Director (NED)Kim Li (KL) Chief Finance OfficerSimon PageDavid Spraggett

(SP)(DS)

NED – Acting Vice Chair (until Minute 22.010)NED

Sue Whelan Tracy (SWT) NED

In attendance: Yasmin Becker (YB) Associate NEDSarah CollettPablo Garcia De Paso Sophie Gilkes

(SC)(PG)(SG)

Trust SecretaryAssociate Medical Director for Governance (until Minute 22.015)Chief Strategy Officer

Rebecca Moore (RM) Head of NursingGertie Nic Philib (GP) Chief People OfficerMary Powell (MP) Head of Strategic CommunicationsDawn Spencer (DSp) Board Administrator

There were five Governors and two members of public also in attendance.

MINUTE ACTION22.001

22.002

22.003

22.004

APOLOGIES FOR ABSENCE

Apologies for absence were received from the Chief Operating Officer.

Resolved – that the position be noted

DECLARATIONS OF INTEREST

There were no declarations of interest.

Resolved – that the position be noted.

MINUTES OF THE MEETING HELD ON 1 DECEMBER 2021

Resolved – that the Minutes of the meeting held on 1 December 2021 be confirmed as an accurate record of the meeting and signed by the Chairman.

MATTERS ARISING AND ACTIONS UPDATE REPORT

Actions Listed as Complete

The actions listed as complete in the Actions Update Report were noted and would now be removed from the report.

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SOUTH WARWICKSHIRE NHS FOUNDATION TRUSTMinutes of the Board of Directors Meeting Held Wednesday 2 February 2022

MINUTE ACTION

22.004.01


Clinical Governance Committee (CGC) Reports for 9 December 2020 and 13 January 2021 (Minute 21.370.02 refers)

The Chief Executive advised that the Coventry and Warwickshire Pathology Service (CWPS) would continue to be in a national framework financially, until the middle of next year due to the ongoing demands of Covid-19. Arrangements would then revert back to pre-existing plans. There would be a formal joining of colleagues from Herefordshire and Worcestershire Health and Care NHS Trust and the Chief Executive would bring back details to Board when available.


22.004.02

22.004.03

Monthly Safe Staffing Report (Minute 21.374 refers)

The Chief Nursing Officer advised that the Chairman had been briefed on the monthly usage of bank and agency hours and that they were split as follows:

(a) 90% Bank(b) 7-10% Agency

Work was in progress to ascertain the number of whole time equivalent (WTE) staff that this split would equate to.


Clinical Governance Committee Report for 10 November 2021 (Minute 21.375 refers)

The Chief Executive advised that discussions had been held around staffing pressures in Domiciliary Care and Care Homes and was covered within the Annual Trust and Foundation Group objectives which were considered in the confidential section of the meeting (Minute 22.030 refers).


22.004.04 Board Assurance Framework (BAF) 2020/21 and Risk Quarterly Report (Minute 21.104 refers)

The Managing Director advised that Risk Appetite training had been undertaken at the Board Workshop session in the morning. The Risk Management Strategy would be launched at April 2022 Board meeting with training scheduled to take place in May 2022 in order to align to the refreshed Risk Management Strategy and would incorporate Black Swan training.


22.005 APPOINTMENT OF VICE CHAIR

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MINUTE ACTION

22.006

22.007

22.008

The Chief Executive presented this report on behalf of the Chairman which recommended that Mr Simon Page (NED) be appointed as Vice Chair of the Trust to replace Mr Bruce Paxton following the end of his term of office. The recommendation had been considered by the Governor’s Nominations and Remuneration Committee and a recommendation would be made to the Council of Governors meeting on 10 February 2022 for approval.

The Chief Executive invited questions and perspectives, but there were no further comments.

Resolved - that:(A) the proposed recommendation of Mr Simon Page (NED) for the

role of the Trust’s Vice Chair be considered, and(B) a recommendation be made to the Council of Governors meeting

on 10 February 2022 to approve the appointment.

RECOMMENDATION FOR SENIOR INDEPENDENT DIRECTOR

The Chief Executive presented this report on behalf of the Chairman and advised that the recommendation was to appoint Mrs Sue Whelan Tracy (NED) as the Trust’s Senior Independent Director (SID). The recommendation would be considered by the Council of Governors at its meeting on 10 February 2022 and then submitted to the Board Meeting on 2 March 2022 for ratification.

The Chief Executive invited questions and perspectives, but there were no further comments.

Resolved - that:(A) the proposed recommendation of Mrs Sue Whelan Tracy for the

role of Trust’s SID be considered;(B) a recommendation be made to the Council of Governors meeting

on 10 February 2022 to consider the appointment, and(C) a recommendation to appoint Mrs Sue Whelan Tracy as the

Trust’s SID be submitted to the Board meeting on 2 March 2022 for ratification.

REVIEW OF POLICY REVIEW GROUP TERMS OF REFERENCE

The Managing Director introduced the revised Terms of Reference for the Policy Review Group. It was noted that there was a change to the Deputy Chair role and an update to all job titles where appropriate.

The Acting Vice Chair invited questions and perspectives, but there were no further comments.

Resolved – that the review of the Policy Review Group Terms of Reference be approved and ratified.

GREEN PLAN

The Chief Strategy Officer advised that the Plan had been discussed in detail at the Board Workshop session held earlier that morning. The Chief Strategy

RH/SC

RH/SC

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MINUTE ACTION

22.009

Officer presented a brief background to the Green Plan which had been produced to a tight deadline and thanks were given to the Sustainability Manager and other leads involved in producing the Plan. The ambition of the Green Plan was to achieve net zero carbon by 2040 and to ensure that it was aligned to the Estates Strategy.

The Acting Vice Chair invited questions and perspectives, and of particular note was the following point.

The Chief Executive was very supportive of the Plan which would evolve over the next couple of years. It was important to note any future opportunities or innovations that would enable the organisation to achieve the milestone set out in the Green Plan.

The Chief Strategy Officer agreed to bring back updates on the Green Plan to the Board on a regular basis.

Resolved – that (A) the Green Plan, recognising the ambition set out to achieve net

zero carbon by 2040, be approved and ratified, and(B) the Chief Strategy Officer bring back updates on the Green Plan

to the Board on a regular basis.

CHIEF EXECUTIVE’S REPORT

The Chief Executive presented this report and highlighted the NHS England (NHSE) Annual Planning Guidance for 2022/23, new standard NHS Contract terms, National Discharge Taskforce, Covid-19 update, Getting it Right First Time (GiRFT) Analysis and the integrated Single Point of Access (iSPA) and integrated Care Co-ordination (iCC) Team sections.

The Acting Vice Chair invited questions and perspectives, and of particular note were the following points:

Mrs Hyde (NED) enquired on the position of the roll out of SMART technology and sought clarification around whether the roll-out was still at a pilot stage or had it been rolled out extensively and was the technology in nursing homes or private homes only. The Chief Executive responded that there had been an extensive roll-out of technology across Warwickshire. Docobo (monitoring device) supported individuals in Care Homes and the data provided from the devices had been reported nationally. This data was collated from Care Homes in North Warwickshire and some Care Homes in South Warwickshire. The roll out now would be to cover all Care Homes in South Warwickshire which would be moved forward on. MySense was being trialled with respiratory patients in their own homes. These technologies were being evaluated for their benefits through the Digital Hub at Stratford Hospital. Also, the organisation was looking at Herefordshire and Worcestershire Health and Care NHS Trust working alongside the Trust to monitor Docobo either by implementing South Warwickshire NHS Foundation Trust (SWFT) best practice or with SWFT supporting Hereford and Worcester. The Chief Executive would like a further Board Workshop on SMART technology to review work undertaken so far.

SG

SG

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MINUTE ACTION

22.010

Resolved – that:(A) the Chief Executive’s Report be received and noted, and(B) the Managing Director of Innovate Healthcare Services Ltd be

invited to a future Board Workshop to review the SMART technology evaluations and to the work undertaken so far.

INTEGRATED PERFORMANCE DASHBOARD (INCLUDING MORTALITY UPDATE)

The Managing Director presented this report and in turn the Chief Nursing Officer, Chief People Officer, Chief Finance Officer and Chief Medical Officer gave updates on their respective areas. The Managing Director presented the Chief Operating Officers section in her absence.

The Chairman invited questions and perspectives, and of particular note were the following points.

Mrs Hyde (NED) spoke about two Serious Incidents that had occurred over the last couple of months and requested an explanation to what they related to with the outcomes. The Chief Nursing Officer explained that the incidents related to a guidewire and an implant and the outcomes had been submitted to the Clinical Governance Committee for review. The guidewire incident was due to human error and, as an outcome, more guidance had been issued concerning the different types of equipment in the Intensive Care Unit (ICU) which would be included in inductions for new staff. The implant was not the correct size used in a knee replacement but had not caused any harm to the patient and had not affected their mobility.

Dr Spraggett (NED) advised that the results for the Friends and Family Test (FFT) were higher from patients in the community than the acute and sought clarification around what learning could be gained to improve the results for the acute. The Chief Nursing Officer explained the differences and methodology used by each service. Dr Spraggett (NED) also asked about the caesarean section rate and that the Trust was higher than the national rate and sought assurance around what was being done to address the rates. The Chief Nursing Officer explained that an ongoing audit was undertaken and presented to the Clinical Governance Committee on a regular basis. The Chief Nursing Officer explained that, on balance, a caesarean section was the best solution for the safety of the mother and the baby. There was also a percentage of women who elected to have a caesarean section which was higher than the population.

Mrs Hyde (NED) highlighted the cancer faster diagnosis challenges within the Chief Operating Officer’s section. She noted that it would appear that University Hospitals Coventry and Warwickshire NHS Trust (UHCW) was ahead of SWFT and George Eliot Hospital NHS Trust (GEH) and sought clarification around whether this was due to control in the Trust or links to tertiary providers and if there were system discussions in place to improve the position. The Managing Director replied that there were three services, in terms of referrals, that were struggling with the 28 day standard faster diagnosis target. A lot of work was underway with regard to pathway redesign, collaboration within the system and primary care colleagues and, there had

DSp/ACa

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MINUTE ACTIONbeen investment in the pathways by both the Trust and the system. The Managing Director advised that the combination of the increase in referrals from primary care and the access to diagnostics had an effect on the overall Trust performance. The Chief Executive explained that the success factors had been the level of diagnostic activity that the Trust had been able to recover and there was continuing high volumes of diagnostic activity being undertaken by the organisation. Mrs Whelan Tracy (NED) noted that she would welcome a forward view of the 28 day cancer diagnosis target.

The Chief Executive highlighted that the sickness levels in the Trust were the lowest in the region throughout Covid-19 and that the organisation had a dedicated workforce which had kept the levels so low.

The Chief Executive spoke about the non-recurrent Cost Improvement Plans (CIPs) being presented alongside the recurrent CIPs and that the Trust was operating within the resources that had been allocated to them. Systems like the one the Trust was placed in was working in deficit due to the challenging recovery target. Historically, the organisation was one of the most cost effective organisations in the NHS and to be given the same recovery targets as NHS trusts who had large deficits was a discussion to be had the Integrated Care System Board.

22.011

The Chairman asked how often the Trust could assess its reference costs. The Chief Finance Officer advised that the plan was to work on a quarterly basis rather than on an annual basis as it was at present.

Resolved – that the Integrated Performance Dashboard (including Mortality Report) be received and noted.

MONTHLY SAFE STAFFING REPORT

The Chief Nursing Officer presented the report and highlighted the position on staff vacancies and the increased demand, particularly around adult mental health patients, who were staying for lengthy periods of time in Warwick Hospital. The Chief Nursing Officer advised that on reflection there was a need to improve operational planning. A large percentage of the temporary workforce recently had been working in new services or had provided cover for winter annual leave. A better strategy was needed for forward thinking to avoid high cost agency usage.

The Chairman invited questions and perspectives, and of particular note were the following points.

Mrs Whelan Tracey (NED) advised that with regard to the operational planning there was a piece of work that was being undertaken in maternity services regarding workforce levels and sought clarification around whether this work was still on track. She also noted that with regard to clinical support workers there was an upward trend of them leaving the organisation and asked whether there was a strategy Trust-wide to address this. The Chief Nursing Officer advised that the maternity work was on track and a meeting was arranged with the Associate Director of Midwifery to discuss the workforce capacity demand. The step change to date was for clinical support workers (CSW) apprenticeship

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MINUTE ACTION

22.012

22.013

22.014

schemes. National funding had been received and recruitment was underway; refreshing and improving the career progression for those in care services. The Chairman queried whether there was any evidence of CSWs leaving who had not wanted the vaccinations. The Chief People Officer replied that she had not seen any significant number of staff leaving the Trust because of refusing vaccinations but this had affected CSWs who were in social care and domiciliary care.

The Chairman queried whether the costs incurred for Children in Crisis had been identified and whether the Trust had informed Coventry Warwickshire Partnership NHS Trust (CWPT) of these costs. The Chief Nursing Officer advised that it was her understanding that CWPT had been notified of the costs as SWFT’s financial teams had analysed the costs involved. It was noted that some of the costs had been invoiced to social care.

Resolved – that the Safe Staffing Report be received and noted.

PATIENT EXPERIENCE QUARTERLY REPORT

The Chief Nursing Officer presented the report and advised that there was good levels of patient experience with low levels of complaints. The patient portal had been included in the report for the first time and had empowered patients to manage their own health. The FFT had not always been successful in gaining public feedback so a public engagement session had been held. This session was successful and would be rolled out as a method of triangulating feedback.

The Chairman invited questions and perspectives, but there were no further comments.

Resolved – that the Patient Experience Quarterly Report be received and noted.

CAPITAL PROGRAMME UPDATE REPORT

The Chief Strategy Officer advised that the multistorey car park would be opened on 14 February 2022 which would help support the workforce. The capital programme was on track and the capital spend in the last quarter would be looked at carefully to ensure that the organisation was in a good position for the next financial year. The risk around the Cath Lab was being mitigated and there was work starting on Macgregor Ward to improve the environment.

The Chairman thanked Mr Roger Lloyd (Public Governor for West Stratford and Borders) and the governors for their sterling work over the years who had helped push the multistorey car park project forward.

Resolved – that the Capital Programme Update Report be received and noted.

6 MONTHLY UPDATE ON TRUST’S PERFORMANCE AGAINST NATIONAL GUIDANCE ON LEARNING FROM DEATHS

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MINUTE ACTION

22.015

22.016

22.017

The Associate Medical Director for Governance presented the report and advised that the Trust was in a reassuring position. The mortality indicators remained well within the control limits and the Medical Examiner role was expanding. Appropriate advanced care planning was the theme that emerged from regional and national mortality reviews in order to provide better experience for patients and families.


Resolved – that the Six Monthly Update on the Trust’s Performance against National Guidance on Learning from Deaths report be received and noted.

CARE QUALITY COMMISSION (CQC) UPDATE INCLUDING INSIGHTS REPORT

The Chief Nursing Officer presented this report which was taken as read. The Chief Nursing Officer explained that the Trust was in an improving position despite the current pressures.


Resolved – that the CQC Update including Insights Report be received and noted.

AUDIT COMMITTEE REPORT FOR 8 DECEMBER 2021

Mrs Hyde (NED) presented this report which was taken as read and noted that all the Internal Audit reports that were received had all been given significant assurance of the general systems in place in the Trust. Mrs Hyde (NED) highlighted that an external review earlier in the year had found that the Trust did not meet the standard required for Cyber Essentials Plus (CE+) accreditation. Innovate Healthcare Services Ltd was recruiting 3 additional cyber security roles to mitigate the current cyber security risks. It was recognised that CE+ accreditation would not be achieved in time for the Data Protection and Security Toolkit (DPST) submission in June 2022. Cyber security was a growing threat for all organisations and that the Trust remained at risk despite the growing investment.


Resolved – that the Audit Committee Report for 8 December 2021 be received and noted.

CLINICAL GOVERNANCE COMMITTEE REPORTS FOR 8 DECEMBER 2021 AND 12 JANUARY 2022

Dr Spraggett (NED) presented the report which was taken as read. He noted that the meeting held in January 2022 had been abridged due to the Covid-19

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MINUTE ACTION

22.018

22.019

22.020

situation which meant no formal reports had been received and verbal updates only had been given.


The Chairman thanked the NEDs for their hard work and diligence.

Resolved – that the Clinical Governance Committee Reports for 8 December 2021 and 12 January 2022 be received and noted.

BOARD ASSURANCE FRAMEWORK AND RISK QUARTERLY REPORT

The Managing Director presented this report and advised that it did not highlight any particular concerns but it flagged the highest current risks including the financial challenges faced by the Trust.

The Chairman invited questions and perspectives, and of particular note was the following point.

Mrs Hyde (NED) commented that there was no reference to cyber security risks in the report. The Managing Director explained that as part of the refresh for the risk management strategy, the infrastructure around implementation had been examined which had led to the recasting of the Corporate Risk Group. It would be with that group where the cyber risk and system based risk would be held and become more visible.

Resolved – that (A) the Board Assurance Framework for Quarter 3 2021/22 update be

received and noted, and (B) the Red (15-25) risks on the Divisional Risk Registers be received

and noted.

SUMMARY OF RATIFIED POLICIES

The Managing Director presented the report which included the summary of SWH 05676 - Corporate Records Policy and SWH 00306 - Development and Control of Trust Documents Procedure.


Resolved – that the Summary of Ratified Policies report be received and noted.

SUMMARY OF REPORTS FOR NOTING AND INFORMATION

The Board received and noted the Summary of Reports for noting and information which included a summary of the Registration Authority Annual Report.

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MINUTE ACTION

22.021

22.022

22.023

22.024

22.024.01


Resolved – that the Summary of Reports for Noting and Information be received and noted.

UPDATED REGISTER OF DIRECTORS AND REGISTER OF DIRECTORS’ INTERESTS

The Trust Secretary presented the report which was taken as read. She noted that the changes reflected that Bruce Paxton’s term of office had ended as a NED and that Harkamal Heran had transferred into the Acting Chief Operating Officer role.


Resolved – that the Updated Register of Directors and Register of Directors’ Interests be received and noted.

BOARD COMMITTEE MINUTES – OPEN MEETINGS


Resolved – that the Board Committee Minutes – Open Meetings for the Audit Committee meeting held on the 13 October 2021 and the Clinical Governance Committee meetings held on 10 November 2021 and 8 December 2021 be received and noted.

ANY OTHER BUSINESS

There was no further business raised.


QUESTIONS FROM GOVERNORS AND MEMBERS OF THE PUBLIC

Question from a Public Governor (West Stratford and Borders)

The Public Governor referred to the Chief Operating Officer’s section of the Integrated Performance Dashboard (Minute 22.010 refers) and asked the following question:

‘Whilst the 28 day Cancer Treatment and the 31 day Diagnosis to Treatment cases are below the target values, is the direction of travel acceptable and consistent with an upward trend and how does SWFT’s performance rate in our system?’

The Managing Director explained that the 28 day Cancer treatment performance had been covered under the Integrated Performance Dashboard (Minute 22.010 refers). The 31 day Diagnosis to Treatment performance had

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MINUTE ACTION

22.024.02

22.024.03

22.025

22.026

22.027

22.028

22.029

22.030

22.031

22.032

been more variable in delivery although there had been an upward trend since July 2021 and that the forecasting for January 2022 indicated that the standard would be met. The Trust was delivering more treatments than before which had placed the Trust as one of the fastest recovering cancer services in the West Midlands.

Resolved – that the position be noted


‘Is the Chief Medical Officer content with the state of the pathology turnaround times?’

The Chief Medical Officer responded that there had been considerable improvement, staff had been retained in the laboratory and the latest turnaround times for the latest figures were within the standard. It was to be noted that the histopathologists employed by SWFT undertook the work although the laboratory was within the Coventry and Warwickshire Pathology Network.



‘With Cost and Productivity Improvement Plans (CPIP) appearing to be far below the required values, does the Chief Finance Officer have plans in place to mitigate for the absence of CPIPs to achieve a surplus in 2021/22?’

The Chief Finance Officer assured the Board and the public that schemes and plans were in place to achieve a break-even position if not a surplus position at the end of the financial year.


ADJOURNMENT TO DISCUSS MATTERS OF A CONFIDENTIAL NATURE

APOLOGIES FOR ABSENCE


CONFIDENTIAL MINUTES OF THE MEETING HELD ON 1 DECEMBER 2021

CONFIDENTIAL MATTERS ARISING AND ACTIONS UPDATE REPORT

DRAFT ANNUAL TRUST AND FOUNDATION GROUP OBJECTIVES 2022/23

SWFT ELECTRONIC PATIENT RECORD (EPR) OUTLINE BUSINESS CASE

ESTATES STRATEGY

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MINUTE ACTION

22.033

22.034

22.035

22.036

22.037

22.038

22.039

22.040

22.041

ELECTIVE HUB DEVELOPMENT

REPLACEMENT OF CATH LAB EQUIPMENT

APPOINTMENTS AND REMUNERATION COMMITTEE REPORT FOR 9 DECEMBER 2021

SWFT CLINICAL SERVICES LET QUARTERLY UPDATE REPORT

HOST PROVIDER UPDATE

AUDIT COMMITTEE REPORT FOR 8 DECEMBER 2021 – CLOSED MEETING

BOARD COMMITTEE MINUTES – CONFIDENTIAL/CLOSED MEETING

ANY OTHER CONFIDENTIAL BUSINESS

DATE AND TIME OF NEXT MEETING

The next meeting would be held virtually on Wednesday 2 March 2022 at 2.00pm.

Unfortunately, due to national guidance around the COVID-19 pandemic, members of the public would be unable to attend in person but would be able to register to join virtually and would be invited to submit questions in advance. The meeting would be recorded and published on the Trust’s website following the meeting.

Signed ______________________________ (Chairman) Date _______________Russell Hardy

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Agenda Item 5

1

SOUTH WARWICKSHIRE NHS FOUNDATION TRUST

ACTIONS UPDATE: PUBLIC BOARD OF DIRECTORS MEETING – 2 MARCH 2022

AGENDA ITEM ACTION LEAD COMMENT

ACTIONS COMPLETE22.005Appointment of Vice Chair(02.02.22)

To ensure a recommendation be made to the Council of Governors meeting on 10 February 2022 to approve the appoint of Mr Simon Page as the Trust’s Vice Chair.

RH/SC Complete and appointment approved.

22.006Recommendation for Senior Independent Director(02.02.22)

To ensure a recommendation to appoint Mrs Sue Whelan Tracy (NED) for the Trust’s Senior Independent Director (SID) be considered by the Council of Governors at its meeting on 10 February 2022 and then submitted to the Board Meeting on 2 March 2022 for ratification.

RH/SC Complete – recommendation supported by CoG and submitted to Board for ratification.

ACTIONS IN PROGRESS

REPORTS SCHEDULED FOR FUTURE MEETINGS22.008Green Plan(02.02.22)

The Chief Strategy Officer bring back updates on the Green Plan to the Board on a regular basis.

SG Frequency to be determined.

22.009Chief Executive’s Report(02.02.22)

The Managing Director of Innovate Healthcare Services Ltd be invited to a future Board Workshop to review the SMART technology evaluations and to the work undertaken so far.

DSp/ACa To be confirmed

ACTIONS REFERRED TO BOARD OF DIRECTORS SUB-COMMITTEES

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Meeting Board of Directors Date 2 March 2022

Subject Appointment of Senior Independent Director

Agenda Item 6.1

For informationFor approval

Nature of item

For decision

Decision required

The Board is invited to ratify the appointment of Mrs Sue Whelan Tracy, Non-Executive Director, as the Trust’s Senior Independent Director (SID), as supported by the Council of Governors.

Report Author Sarah Collett, Trust SecretaryGeneral Information Lead Director Russell Hardy, Chairman

Meeting 1. Board of Directors2. Council of Governors

Received or approved by

Date 1. 2 February 20222. 10 February 2022

RevenueCapitalWorkforceUse of Estate

Resource Implications

Funding Source

Place/Lead Provider Group Wide SharingRecovery of Services Health InequalitiesUrgent Care Pathways Reducing Delayed DiagnosisHospital Discharge Sustainability

Applicable Quality Improvement Priorities

Electronic Patient Record (EPR) Mobilisation

Confidential (Y/N)(if yes, give reasons)

No

Final/draft format Final

Ownership Trust

Freedom of Information

Intended for release to the public

Yes

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South Warwickshire NHS Foundation Trust

Report to Board of Directors – 2 March 2022

Appointment of Senior Independent Director

1. Background

Monitor’s NHS Foundation Trust Code of Governance requires the Trust to appoint one of the independent Non-Executive Directors to be the Senior Independent Director (SID) for the Trust. This provision is made under The Code’s ‘comply or explain’ approach to governance and the appointment requires consultation with the Council of Governors.

Mr Simon Page was previously the Trust’s SID but as Mr Page has been appointed as Vice Chair, the Chairman recommended the appointment of Mrs Whelan Tracy as SID until the end of her term of office on 8 February 2023. This recommendation was supported at the Board meeting on 2 February 2022 and by the Council of Governors at their meeting on 10 February 2022.

2. The Constitution

Annex 6, Council of Governors’ Standing Orders, of the Trust’s Constitution (paragraph 8 refers) states that:-

‘8.1 The Council of Governors is entitled to be consulted by the Board of Directors on the appointment of the Trust’s Senior Independent Director.

8.2 The role of the Senior Independent Director is as set out in the Trust’s ‘Senior Independent Director job description’, as amended from time to time.’

3. Council of Governors

The Council of Governors received and supported the recommendation of Mrs Whelan Tracy as the Trust’s SID at its meeting on 10 February 2022.

4. Recommendations

The Board is invited to ratify the appointment of Mrs Sue Whelan Tracy, Non-Executive Director, as the Trust’s SID, as supported by the Council of Governors.

Sarah CollettTrust Secretary

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Meeting Board of Directors

Date 2 March 2022

Subject Board of Directors’ Schedule of Business 2022/23

Agenda Item 6.2

Nature of item For information For approval For decision

Decision required

The Board of Directors is asked to approve its Schedule of Business for 2022/23.

General Information

Report Author Sarah Collett, Trust Secretary Lead Director Sarah Collett, Trust Secretary


Meeting Date


Revenue Capital Workforce Use of Estate Funding Source


Place/Lead Provider Group Wide Sharing Recovery of Services Health Inequalities Urgent Care Pathways Reducing Delayed Diagnosis Hospital Discharge Sustainability Electronic Patient Record (EPR) Mobilisation


Confidential (Y/N) (if yes, give reasons)

No

Final/draft format

Final

Ownership

Trust


Yes

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Board of Directors’ Schedule of Business 2022/23

1. Introduction Each year the Board considers and agrees a Schedule of Business which maps out those items/issues which the Board can expect to consider for the forthcoming 12 months. This schedule does not preclude the Board from considering any other issue it wishes or to vary the schedule if required. 2. Schedule of Business The schedule for 2022/23 is attached for the Board’s consideration and approval. The confidential reports have been shaded in grey for ease of reference. The Board should note that due to the Foundation Group Boards quarterly meetings commencing in August 2022, the Trust’s Board business has been rescheduled as there will be no Board meetings during those months (August and November 2023, and February and May 2023). 3. Recommendation The Board is invited to consider and approve the Schedule of Business for 2022/23. Sarah Collett Trust Secretary

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Board of Directors Schedule of Business 2022/2306-Apr 04-May 01-Jun 15-Jun 06-Jul Aug 07-Sep 05-Oct Nov 07-Dec Jan Feb 01-Mar2022 2022 2022 2022 2022 2022 2022 2022 2022 2022 2023 2023 2023

Items for ApprovalDraft Annual Financial Plan/Contracts (Confidential) x x x x √Final Annual Financial Plan/Contracts √ x x x xAnnual Capital Programme √ x x x xBoard Declaration of Going Concern √ x x x xAnnual Report and Accounts and Annual Governance Statement √ x x x xQuality Report √ x x x xOperational Capacity Plan and Winter Plan 2022/23 x √ x x xWinter Plan look back in April 2022 and Winter Plan Update every other month after considered in September 2022 until March 2023) √ x x √ x x √Winter Flu and Vaccination Plan 2022/23 x √ x x xCompliance Declarations: x x x - Data Security and Protection Toolkit (DSPT) Assessment √ x x x x - FT Code of Governance Review (for inclusion in Annual report) √ x x x x - Compliance Statement for Same Sex Accommodation Standards √ x x x x √Governance Arrangements x x x x - Review of SFIs and Scheme of Delegation √ x x x x - Annual Review of Board Standing Orders √ x x x x - Review of Committee Terms of Reference √ x x x x - Review of Risk Management Strategy (Next review 2027) √ x x x x - Annual Review of Directors' Register of Interests and NED Independence Review √ x x x x - Fit and Proper Persons Annual Declaration √ x x x xAnnual Review of Key Performance Indicators (to include Quality Indicators) √ x x x xBoard Schedule of Business x x x x √Board Calendar of Meetings x √ x x xReview Policy Review Group Terms of Reference x x x x √Annual Board Self Certifications - G6 Licence Condition √ x x x xCorporate Governance Statement and Other Declarations √ x x x xFinal Trust and Foundation Group Annual Objectives x x x x √Emergency Planning Resilience and Response Core Standards Annual Submission x √ x x x

x x x xPerformance Review and Assurance x x x xPerformance Summary Reports (monthly) x x x x

- Integrated Performance Dashboard (to include Mortality) √ √ √ √ x √ √ x √ x x √Committee Reports and Minutes x x x x - Audit Committee (bi-monthly) √ √ x √ x √ x x √ - Clinical Governance Committee (monthly) - to include a positive statement of assurance from Chief Nursing Officer and Chief Medical Officer √ √ √ √ x √ √ x √ x x √ - Appointments and Remuneration Committee (Confidential) √ √ x √ x x x √

- Foundation Group Strategy Committee (Report in public and Minutes in confidential) √ √ x √ x x x √Chief Executive's Report (monthly) √ √ √ √ x √ √ x √ x x √Monthly Safe Staffing Report (monthly) √ √ √ √ x √ √ x √ x x √Capital Programme Quarterly Update Report (quarterly) √ √ x √ x x x √Report from Council of Governors Meeting (quarterly) √ x √ x √ x x √Patient Experience Quarterly Report √ x √ x √ x x √Patient Experience Annual Report (including complaints) √ x x x xAnnual Signing and Sealings Report (Annual) √ x x x xBoard Effectiveness Review (annual) x x √ x xAudit Committee Annual Report (annual) x √ x x xAudit Committee Self-Assessment of Performance √ x x x x

Joint Audit Committee and Clinical Governance Committee Assurance Statement (annual) √ x x x xReport from Infection Prevention Board (6-monthly) - summary to be included in Clinical Governance Committee report √ x √ x x xMedical Revalidation Report (from the Medical Director) x x √ x x6 Monthly Update on Trust's Performance against National Guidance on Learning from Deaths √ x x √ x xFreedom to Speak Up Guardian's Report (6-monthly) x √ x x x √CQC Insights Quarterly Report √ x √ x √ x x √Digital Health Board Quarterly Report √ x √ x √ x x √Annual Sustainabillty Strategy x √ x x xMaternity Services Assurance Quarterly Assurance Report & Ockenden Update √ √ x √ x x x √Host Provider Update (Confidential) √ √ √ √ x √ √ x √ x x √Maternity Governance Report (Quarterly) √ x √ x √ x x √

x x x xStrategic Direction x x x xReview of Trust Strategy (following Roundtable in April and October) √ x x √ x xProgress Report on Annual Trust and Foundation Group Objectives (following Roundtable in October) x x √ x xYear End Report on Annual Trust and Foundation Group Objectives √ x x x x

x x x xRisk Management x x x xBoard Assurance Framework and Risk Quarterly Report (reports in October 2022 and April 2023 to include 6 monthly update) √ √ x √ x x x √

x x x xItems for Noting and Information x x x xSummary of Ratified Policies √ √ √ √ x √ √ x √ x x √Management Reports x x x x - Infection Control Annual Report √ x x x x - Emergency Preparedness Annual Report x x x x √ - Safeguarding Children, Young People, Vulnerable Adults Annual Report √ x x x x - Equality and Diversity Annual Report √ x x x x - PLACE (Patient-Led Assessments of the Care Environment) Annual Report x √ x x x - Summmary of Legal Services Annual Report (confidential) √ x x x x - Senior Information and Risk Officer (SIRO) Annual Report √ x x x x - Health and Safety Annual Report √ x x x x - Security Annual Report √ x x x x - Registration Authority Annual Report x x x x √ - Guardian of Safe Working Annual Report x x x x √SWFT Clinical Services Ltd Update Report (Confidential - report in June to include financial statements) √ x √ x √ x x √Innovate Healthcare Services Report (Confidential) √ x √ x √ x x √Employee Relations Report (Confidential - 6 monthly) x √ x x x √

Draft Trust and Foundation Group Annual Objectives (Confidential) - to be considered by email in February prior to final version submitted to public Board in March x x x

2022/23

Agenda Item 6.2 - BoD Schedule of Business 2022-23 - v1 DRAFT.xlsx

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Subject Annual Trust and Foundation Group Objectives 2022/23

Agenda Item 6.3

For informationFor approval

Nature of item

For decision

Decision required

The Board of Directors is asked to:a) consider and approve the final Annual Trust and Foundation Group

Objectives for 2022/23, recognising further work will be done across the network of Chief Strategy Officers to identify the ones suitable for a group approach, and

b) note the next steps for further development of plans and measures to achieve them.

Report Author Chief OfficersGeneral Information Lead Director Glen Burley, Chief Executive

Meeting Board of Directors - ConfidentialReceived or approved by Date 2 February 2022



Funding Source

Place/Lead Provider Group Wide Sharing Recovery of Services Health Inequalities Urgent Care Pathways Reducing Delayed Diagnosis Hospital Discharge Sustainability




No


Ownership Trust



Yes

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Annual Trust and Foundation Group Objectives 2022/23

Executive Opinion

The Annual Trust Objectives signal the Board’s key priorities for the coming year. These take account of Trust strategy, local priorities, and national planning guidance.

The Chief Executive has met with the three Chief Strategy Officers from across the Foundation Group to agree common themes and areas of potential group working to maximise the benefits available to each organisation from the Foundation Group. An example of this would be the productivity and efficiency objective that all three organisations have adopted.

This year’s objectives have been grouped under the pillars of our strategy and are shown below:

Workforce:

Create a workforce culture that empowers colleagues to contribute to compassionate care and deliver improved outcomes for our population

Develop colleague experience, leadership, and talent management through inclusion and empowerment

Develop our leaders’ capabilities to work collaboratively with partners to deliver better outcomes for our population

Enhance inclusion, diversity, and equity

Continue to develop and implement support for staff health and wellbeing, particularly recognising the impact of COVID-19

Support Recovery and Restoration post COVID-19 to ensure that there is a retained focus on staff wellbeing, staff experience and staff voice

Well-being & Mental wellbeing promotions and support Respond to the national staff survey

Mobilise the new national workforce strategy Enabling new ways of working and planning for the future Work with partners to develop new enhanced blended roles across health and

social care Develop and implement a workforce strategy for maternity

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Sustainability:

Progress plans to reach net zero by 2040 Develop a Green Plan with a commitment to achieving net zero carbon by 2040,

with a specific focus in 2022/23 on local purchasing Investigate and develop financing for an integrated energy solution project that

details how we will reach net zero for our estates related emissions by 2040

Embed the Productivity and Clinical efficiency programme Establish the Group Board structure to share best practice across the Foundation

Group (Wye Valley NHS Trust, George Eliot Hospital NHS Trust and Worcester Acute Hospitals NHS Trust, our associate member) and utilise benchmarking data through the programme to drive best practice at pace

Implement the elective care strategy Finalise plans for an elective hub at Warwick Hospital and strengthen plans to

protect elective capacity Utilise digital solutions to support the redesign of outpatient’s appointments Full implementation of patient initiated follow ups across all services

Realise ambitions set out in the Group Research Strategy Progress University Trust application Develop research programme with Warwick Business School

Digital:

Commence implementation of a new Electronic Patient Records (EPR) System Commence implementation of a replacement for legacy patient records systems Expand use of the patient portal to cover community services and increased

sharing of clinical information, enabling our patients to own their own records Further develop the sharing of clinical information across Coventry &

Warwickshire Providers by implementing Integrated Care Records and exploring opportunities to develop shared pathways and electronic systems to support the EPR

The Digital hub will support the utilisation of technology to ensure that innovation is at the heart of what we do

Wider mobilisation of monitoring technology in homes and care home settings Explore the use of robotics to support delivery of care for our population

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Quality:

Improve the experience, outcomes and safety of patients accessing our services Fully implement Living well with cancer agenda across all cancer sites Work with partners to implement the recommendations of national Autism

strategy Embed improvement methodologies with partners at Place

Improve the experience and mental wellbeing of children and young people accessing our services

Create an environment to support children and young people in a mental health crisis accessing our services

Implement recommendations from special educational needs (SEND) Ofsted and CQC assessment

Integration:

Embed a prevention mindset across all staff groups Use population health data to drive planning and decision making to move

resources that help keep people well for longer and reduce inequalities Utilise the patient portal to support people to live healthy lives

Reduce health inequalities for our local populations Embed a workforce approach to ensure staff recognise and address health

inequalities in their service areas Ensure there is board visibility of inequalities and actions to address them Implement the actions from the ‘Levelling up report’

Implement the national strategy of operating at Place Create capacity and capability to act as prime integrator and facilitator of

Warwickshire Care Collaborative Develop Lead Provider model Develop a financial framework that incentivises changes in behaviours within

Place

Once approved, the objectives will be communicated across the Trust, used to shape the individual objectives of Executive Directors and of teams. Divisional objectives will be developed to support the delivery of the Trust objectives, and these will be approved at Management Board. These objectives will also be used to develop underpinning action plans and measures which will populate our Board Assurance Framework for 2022/23.

Recommendation

The Board of Directors is asked to:a) consider and approve the Final Annual Trust and Foundation Group Objectives for

2022/23, recognising further work will be done across the network of Chief Strategy Officers to identify the ones suitable for a group approach, and

b) note the next steps for further development of plans and measures to achieve them.

Glen BurleyChief Executive

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Subject Chief Executive’s Report Agenda Item 7.1

For information For approval

Nature of item

For decision

Decision required (if any)

The Board is asked to receive and note this report.

Report Author Glen Burley, Chief ExecutiveGeneral Information Lead Director Glen Burley, Chief Executive

MeetingReceived or approved by Date



Funding Source





No


Ownership Trust



Yes

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Chief Executive’s Report

Delivery Plan for Tackling the Covid-19 Backlog of Elective Care

The much-awaited delivery plan was published in early February 2022. The plan sets out ambitions to restore elective activity and performance to pre-pandemic levels, including expanding capacity, a reduction in waiting times, and transforming the delivery of care to reduce the elective backlog. Given the care backlog and demand pressures for services, it is acknowledged that the national elective waiting list is expected to increase in the short term. The Plan also acknowledges the importance of focusing on clinical need and aims to reduce the longest waits by clinical prioritisation, managing long waits, and increasing the number of cancer referrals. It should be acknowledged that the plan focusses on elective recovery and does not set out to tackle care backlogs across mental health and community services.

Key ambitions within the plan include:

Delivering 30% more elective activity by 2024/25 than before the pandemic; Eliminating waits of longer than twelve months for elective care by March 2025; 95% of patients needing a diagnostic test to receive it within six weeks by March

2025; 75% of patients who have been urgently referred by their GP for suspected cancer

having their condition diagnosed (or cancer ruled out) within 28 days by March 2024, and

To deliver on these ambitions NHS England/Improvement (NHSE/I) highlights four key areas of delivery:

Increasing health service capacity by expanding (and separating) elective and diagnostic services

Prioritising diagnosis and treatment Transforming the way, we provide elective care Providing better information and support to patients

The plan also builds on previous funding announcements to support elective recovery including £8bn revenue funding between 2022/23 and 2024/25, £5.9bn in capital funding announced in the October 2021 spending review, and the Targeted Investment Fund (TIF) made available to systems in September 2021.

Local Response to the Plan including Operation Ringfence

As the plan outlined above makes clear, the protection of elective capacity will be a critical enabler to ensure that we deliver the national milestones of elective recovery. All three Trusts in the Foundation Group (Group) have focussed on how we can deliver safer, faster, better urgent care through many innovations and service improvements. By managing urgent care in the right part of the site we not only protect elective capacity, but we also ensure the best and safest urgent care. Patients need to be managed in the right facilities, with the right teams and sites which regularly compromise this have higher mortality and longer lengths of stay. Even though we have a great track record of bed protection we have

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agreed that we will further ramp-up our approach in response to the challenge of the Elective Recovery Plan. We have called our approach Operation Ringfence and included the ambition to excel in this approach in the annual objectives of all three Trusts in the Foundation Group. Our approach will demonstrate that it is feasible to create an Elective Hub on a busy acute site without the demands of urgent care compromising activity. By doing so we will demonstrate the additional benefits of maintaining single site working for clinicians who are involved in both elective and non-elective care as well as the enhanced recovery support which comes from the involvement of physicians, alongside surgeons in post operative care.

All three Trusts have made bids against the national capital funding referred to above and we await the results. South Warwickshire NHS Foundation Trust (SWFT) has a relatively strong waiting list position currently and hence we expect to deliver against the national milestones much earlier than required. This places us in a position where we could offer mutual aid to another provider or system. Our recently approved Estates Strategy identified the relatively pressing need for a capital resourcing plan for the replacement of the Day Surgery Unit. We have therefore proposed a plan which could overlap the replacement of the theatres and hence create additional short-term capacity to deal with waiting times backlogs. When these are cleared it will be important for the NHS to appropriately right size elective capacity to maintain waiting ties equilibrium so that suitable shares of resources can be directed to other health and wellbeing priorities.

Annual NHS Staff Survey

The results of the Annual NHS Staff Survey will be published later this month. The impact on staff morale of the multiple waves of Covid-19 will have taken its toll on the national results with many year-on-year comparators expected to deteriorate. The best way to interpret this year’s results is therefore to look at how we compare to other similar Trusts. The survey was undertaken on behalf of the Trust and the Care Quality Commission (CQC) by Quality Health who are the leading provider of surveys to the NHS. The NHS Staff Survey is the biggest survey of staff views and attitudes undertaken anywhere in the World. In my view it is one of the most important indicators which crosses my desk each year as all of the evidence shows that the feelings of staff drive the experiences of our patients and service users.

Over the years our performance has gradually risen to be one of the best in the NHS and this year’s results follow that trend with over 70% of the individual questions having answers which were significantly better than our peers. Only one was significantly below our peers and this related to staff working unpaid overtime which in itself is testimony to the dedication and attitude of our staff. Having said that, I also accept that the situation is not something that we should condone.

The Foundation Group wide results were equally as impressive demonstrating the improvement journey of all three Trusts. Across the entire Group we only recorded 12 questions from the potential 297 which were worse than our peers with overall staff engagement and morale scores all above average. The individual results indicate the areas where we can make further progress and the aim to do so is already captured in our Annual Objectives for 2022/23.

I would like to thank our staff for their incredible attitude to their work and also recognise the hard work of line managers and corporate teams in delivering such impressive results.

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More from our Great Teams – Community Childrens Nursing Continuing Healthcare (CHC) Model

The Community Childrens Nursing team provides a holistic and integrated service for children with complex needs in the community. This includes general community nursing, specialist community nursing, palliative care, CHC assessments, CHC packages of care and competency-based training for non-registered carers, school assistants and foster carers, along with updates for parents.

The current caseload is 244 children with significant nursing needs. The team’s caseload is highly complex, for example the 15 most complex cases of care could not be provided at home and would require Intensive Therapy Unit (ITU) or High Dependency Unit (HDU) admission in a specialist hospital. There are 35 complex and ongoing palliative care cases and a further 40 CHC children who would need a bed on a specialist children’s hospital ward if care at home broke down. The model of assessment and provision of children’s CHC packages enables children to be fully integrated into existing NHS and Local Authority services. The benefits of this model include rapid discharge, low readmission rate, safe and effective care.

At the start of the Covid-19 pandemic, the Clinical Commissioning Group (CCG) CHC services across England were redeployed leaving a number of children stuck in hospital or in failing care packages at home. In Warwickshire the Community Childrens Nursing team along with the Childrens Commissioner prioritised CHC assessment and provision and became key to multiagency efforts to ensure the welfare of children with complex needs at home. Care packages continued throughout the pandemic, and this along with rapid discharge and low readmission rates demonstrated the strength of this integrated single provider-based model. The team was nationally recognised during the pandemic for their integrated support and for being one of the first areas to get children who require Aerosol Generating Procedures (AGPs) back to school.

Our palliative care services equally were prioritised throughout the pandemic, staff wore enhanced Personal Protective Equipment (PPE) allowing children and families to be mask free in these critical and emotionally charged hours without all the restrictions that they experienced in hospital. 24/7 provision continued despite extensive numbers of shielding and isolating staff by drawing staff from across the wider Community Childrens Nursing team.

Whilst Covid-19 has been far less significant in children, even with the most complex needs, its effect on the mental welfare of families, who struggle to cope in normal times, has been very significant. The team are experiencing high levels of sickness and vacancy currently and therefore a partnership project has been established with an experienced agency to recruit and train carers for the short term to enable substantive recruitment to take place.

Autumn 2021 Going the Extra Mile (GEM) Winners

Clinical Winner: Tracey EvansThe Autumn 2021 Clinical GEM Award was awarded to Tracey Evans, Specialist Palliative Care Nurse, after a member of staff nominated her for being extremely compassionate and supportive to many families, who have said they simply couldn’t manage without her. The

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nominator said Tracey is a source of inspiration and support for her colleagues and went out of her way during lockdown to keep her team positive and reminded them that they were valued. They also said that Tracey is a truly remarkable nurse who has touched the lives of many people over the course of her working life as a Macmillan/Specialist Palliative Care nurse and that Tracey is the driving force behind the Palliative Care Teams. Tracey has now left the Trust, working for Macmillan entirely however we felt it important to recognise the impact Tracey has made on so many of our patients during her time with SWFT.

2nd Clinical Winner: Emma EvansThe second Autumn 2021 Clinical GEM Award was awarded to Emma Evans, Nursery Nurse in the Special Care Baby Unit, after a member of staff nominated her for being passionate about improving care for babies and their families and how she is always looking at ways to make it better. Emma also worked tirelessly to achieve the Bliss Baby charter silver award. The nominator also said that Emma always pulls the team together.

Team winner: Bereavement Care within MidwiferyThe Autumn 2021 Team GEM Award was awarded to the Maternity Bereavement Team. The team were chosen after they received a nomination for always providing a very personalised and caring service, even when they are working in some of the most stressful areas of maternity. A patient emailed to say that in her darkest of days they treated her and her family in the most tender, kind, and thoughtful way and that they could not be more thankful. The patient also said the team were all walking angels.

Glen BurleyChief Executive

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Meeting Board of Directors

Date 2 March 2022

Subject Integrated Performance Dashboard (including Mortality Update)

Agenda Item 7.2

Nature of item For information For approval For decision

Decision required

The Board of Directors is asked to receive this report and note delivery of the month 10 position for 2021/22.

General Information

Report Author Anne Coyle, Managing Director Fiona Burton, Chief Nursing Officer Harkamal Heran, Chief Operating Officer Gertie Nic Philib, Chief People Officer Kim Li, Chief Finance Officer

Lead Director Anne Coyle, Managing Director


Meeting Date







No

Final/draft format

Final

Ownership

Trust


Yes

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Integrated Performance Dashboard

Managing Director’s Commentary In relation to the Chief Nursing Officer’s report, it is pleasing to see the focus on continued improvement across the quality and safety key performance indicators and the professional curiosity shown when matters required investigation and improvement. The Chief Operating Officer’s commentary noted a slight decline in performance of the Trust’s 4-hour performance; in January 2022 performance dipped by 2.5% to 69.9%. Attends to the Emergency Department increased from December 2021 to 209 per day. Covid pressures resulted in a number of bed closures and medical bed occupancy increased to 93.8%. In order to ease operational pressures, our teams are working internally and externally with partners to sustain flow and hold gains in length of stay reduction for example undertaking multi-agency discharge events while managing Covid pathways. January 2022 saw a big improvement in patients waiting over 78 weeks. Our Cancer performance remains stable but below the national standards. The Trust’s Cancer 28-day faster diagnosis performance has remained consistently in the mid-60% with expectations that this will improve to target measure of 75% of patients meeting the standard by end of 2021/22 The Chief People Officer has provided a summary on recruitment activity and staff well-being. A particular concern in relation to appraisal and Core Skills Training Framework (CSTF) compliance is highlighted, with the Divisions asked to provide trajectories through Finance and Performance Executive (FPE) to recover their position. The Chief Finance Officer confirms that at month 10 the Trust has delivered a £24k surplus compared to a break even plan.

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South Warwickshire Foundation Trust Type Item Description

Trust Key Performance Indicators (KPIs)-2021/22 Pass/Fail The system is expected to cons is tently Fa i l the target

Performance Against Target (Status) Pass/Fail The system is expected to cons is tently Pass the target

Meeting Target Pass/Fail The system may achieve or fa l l the target subject to random variation

Not Meeting Target Trend Variation Specia l cause variation - cause for concern (indicator where HIGH is a concern)

Trend Variation Specia l cause variation - cause for concern (indicator where LOW is a concern)

Trend Variation Common cause variation

Trend Variation Specia l cause variation - improvement (indicator where HIGH is a GOOD)

Trend Variation Specia l cause variation - improvement (indicator where LOW is a GOOD)

Regulatory Performance Measures CQC Domain Responsible Director Standard Nov-21 Dec-21 Jan-22 YTD 21/22 Rags Pass/Fail

A&E max wait time 4hrs from arrival to departure Responsive Director of Operations 95% 66.4% 72.4% 69.9% 76.0% ●A&E minors max wait time 4hrs from arrival to departure Responsive Director of Operations 95% 59.4% 66.9% 64.0% 74.7% ●Stranded Patients - average numbers of patients in bed >21 days Effective Director of Operations 109 77 71 97 80 ●Waiting Times - Diagnostic Waits <6 weeks Responsive Director of Operations 99% 98.2% 97.2% 96.3%

Referral to Treatment Times - Open Pathways (92% within 18 weeks) Responsive Director of Operations 92% 80.7% 78.9% 78.4%

Referral to Treatment Volume of Patients on Incomplete Pathways Waiting List Responsive Director of Operations 16234 23159 23184 23376

Referral to Treatment Number of Patients over 52 weeks on Incomplete Pathways Waiting List Responsive Director of Operations 0 322 332 327

Referral to Treatment - Patients over 52 weeks on Incomplete Pathways Waiting List - Admitted Responsive Director of Operations 0 196 194 170

Referral to Treatment - Patients over 52 weeks on Incomplete Pathways Waiting List - Non Admitted Responsive Director of Operations 0 126 138 157

Cancer 62-Day 2WW Ref to treat, all cancers Responsive Director of Operations 85% 59.7% 60.2% 60.3% ●Cancer 62-Day 2WW Ref to treat, all cancers patients waiting Responsive Director of Operations 0 98 67

28 day referral to diagnosis confirmation to patients Responsive Director of Operations 70% 63% 63% 62% ●Effective Occupancy rates Effective Director of Operations 92% 88% 87% 92% 87% ●

Financial Compliance CQC Domain Responsible Director Standard Nov-21 Dec-21 Jan-22 YTD 21/22 Rags Pass/Fail

Liquidity (Days) Well Led Director of Finance 1 C-19 C-19

Capital Service Capacity (Times) Well Led Director of Finance 1 C-19 C-19

Overall Financial Sustainability Risk Rating Well Led Director of Finance 1 C-19 C-19

I&E Margin % Well Led Director of Finance 1 C-19 C-19

Variance in I&E Margin % Well Led Director of Finance 1 C-19 C-19

Agency Ceiling % Well Led Director of Finance 1 C-19 C-19

Financial efficiency

Financial Controls

Responsiveness

Financial sustainabil ity

Activity CQC Domain Responsible Director Nov-21 Dec-21 Jan-22 YTD 21/22 Rags Pass/Fail

A&E Activity Responsive Director of Operations PLAN -2.10% -10.57% -3.70% -1.8% ●Same Day Emergency Care (SDEC) Responsive Director of Operations PLAN 19.8% -7.1% -8.6% 15.0% ●Emergency Ambulatory Pathways - Follow Up Attendances Responsive Director of Operations PLAN 67.6% 160.0% 37.21% 95.1% ●Non Elective Activity - Adult Acute Responsive Director of Operations PLAN 21.6% 29.1% 11.9% 20.0% ●Non Elective Activity - Paediatric Acute Responsive Director of Operations PLAN 5.3% 10.4% 1.0% 19.4% ●Maternity Activity (Deliveries) Responsive Director of Operations PLAN 18.0% 6.3% 10.6% 4.7% ●Maternity Activity (Non Deliveries) Responsive Director of Operations PLAN -14.3% 16.9% -59.1% -7.2% ●Total Non Elective Activity (Exc A&E) 4.7% -0.6% -0.4% 4.9% ●Elective Activity - IP Responsive Director of Operations PLAN -18.6% -9.2% -11.7% -11.0% ●Elective Activity - DC Responsive Director of Operations PLAN -4.0% -1.1% -19.7% -6.9% ●Elective Activity - Total -5.5% -1.9% -19.0% -7.3% ●Outpatient Activity - New OP F2F & Virtual (excl AHP & AEC) Responsive Director of Operations PLAN 14.4% 24.2% 15.7% 15.8% ●Outpatient Activity - New OPP (excl AHP & AEC) Responsive Director of Operations PLAN -24.3% -14.0% -26.0% -27.6% ●Outpatient Activity - Follow Up OP F2F & Virtual (excl AHP, incl AEC) Responsive Director of Operations PLAN 20.6% 14.8% 8.3% 15.74% ●Outpatient Activity - Follow Up OPP (excl AHP, incl AEC) Responsive Director of Operations PLAN -15.9% -10.7% -19.9% -13.50% ●Outpatient Activity - AHP Responsive Director of Operations PLAN -29.0% -29.1% -35.8% -28.93% ●Outpatient Activity - Total -1.0% 0.0% -8.0% 0.7% ●Outpatient Activity - New Virtual Responsive Director of Operations PLAN 23.0% 23.6% 24.0% 26.96%

Outpatient Activity - Follow Up Virtual Responsive Director of Operations PLAN 27.7% 29.9% 29.3% 30.41%

Outpatients Activity - Virtual Total 26.2% 27.7% 27.5% 29.3%

Diagnostic Activity - Computerised Tomography Responsive Director of Operations 2019/2020 Outturn 152.2% 107.8% 130.0% 115.2% ●

Diagnostic Activity - Magnetic Resonance Imaging Responsive Director of Operations 2019/2020 Outturn 155.6% 120.1% 103.6% 167.2% ●

Diagnostic Activity - Endoscopy Responsive Director of Operations 2019/2020 Outturn 118.2% 117.0% 134.7% 124.7% ●

Diagnostics Activity - Total 141.7% 115.7% 120.2% 136.4% ●Community Service Contacts - OOH&CC Responsive Director of Operations 2019/2020

Outturn 13.6% 11.0% 4.0% 10.9% ●Community Service Inpatients - Support Services Responsive Director of Operations 2019/2020

Outturn 12.0% 1.3% -8.0% 1.8% ●Community Service Contacts - Family Health Responsive Director of Operations 2019/2020

Outturn 46.8% 43.0% 19.0% 31.7% ●Community Service Contacts - Support Services Responsive Director of Operations 2019/2020

Outturn 83.4% 77.5% 54.8% 57.3% ●Community Service Contacts - Elective Responsive Director of Operations 2019/2020

Outturn 778.6% 1145.5% 645.5% 717.0% ●Community Service Contacts - Total 19.3% 14.3% 5.8% 13.4% ●

Urgent Care

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Access CQC Domain Responsible Director Standard Nov-21 Dec-21 Jan-22 YTD 21/22 Rags Pass/Fail

A&E - Ambulance handover within 30 minutes Responsive Director of Operations 98% 65.0% 77.8% 77.2% 75.6% ●A&E - Ambulance handover over 60 minutes Responsive Director of Operations 0.0% 10.8% 5.8% 4.7% 6.4% ●A&E - Time to Initial Assessment Responsive Director of Operations - 32 19 20 20

A&E - Time to treatment (median) Responsive Director of Operations - 83 63 58 67

A&E - Mean Time in Department for non-admitted patients Responsive Director of Operations - 173 158 153 153

A&E - Total time in A&E (median) Responsive Director of Operations - 201 186 182 177

A&E - Percentage of patients spending more than 12 hours in A&E Responsive Director of Operations - 1.9% 1.5% 2.2% 1.2%

A&E - Left department before being seen for treatment Responsive Director of Operations - 5.1% 4.3% 4.0% 3.5%

A&E - Unplanned Re-attendance with 7 days rate Responsive Director of Operations - 4.0% 4.1% 4.5% 4.4%

A&E Quality Indicator - 12 Hour Trolley Waits Responsive Director of Operations 0 1 0 0 1 ●A&E - % of admitted patients who are admitted within 4 hours Responsive Director of Operations 90% 37.5% 48.0% 37.6% 52.0% ●Cancer 62-Day National Screening Programme Responsive Director of Operations 90% 62.5% 62.5% 66.9% ●Cancer 31-Day Surgery, subsequent treatments Responsive Director of Operations 94% 78.6% 84.6% 76.3% ●Cancer 31-Day Drugs, subsequent treatments Responsive Director of Operations 98% 97.4% 100.0% 99.6% ●Cancer 31-Day Diag to treat, all new cancers Responsive Director of Operations 96% 91.9% 98.2% 93.9% ●Cancer 2WW all cancers, Urgent GP Referral Responsive Director of Operations 93% 91.1% 89.4% 88.9% ●Cancer 2WW Symptomatic Breast Responsive Director of Operations 93% 85.9% 88.2% 88.2% ●Cancelled Operations on day of Surgery Responsive Director of Operations 0.8% 0.00% 0.00% 0.00% 0.01% ●Over 28 Day readmission following short notice cancelled operation Effective Director of Operations 0 0 0 0 3 ●Outpatient - Short Notice Cancelled Clinics Effective Director of Operations 2% 0.1% 0.1% 0.1% 0.1% ●Outpatient Hospital Reschedules Effective Director of Operations 6% 5.1% 6.8% 5.3% 5.9% ●Delayed Transfers of Care - Acute Effective Director of Operations 2.5% C-19 C-19 C-19 C-19 C-19

Delayed Transfers of Care - Community Effective Director of Operations 7.5% C-19 C-19 C-19 C-19 C-19

Stroke Indicator 80% patients = 90% stroke ward Caring Director of Operations 80% 44.8% 54.3% 43.6% 44.9% ●Stroke Admissions - Admitted to stroke ward within 4 hours of presentation Caring Director of Operations 65% 0.0% 6.3% 2.8% 2.0% ●Stroke Admissions - CT Scan within 24 hours Caring Director of Operations 80% 83.3% 91.2% 100.0% 94.7% ●iSPA call response rate within one minute Effective Director of Operations 80% 86.9% 92.4% 88.1% 87.4% ●iSPA call abandoned rate Effective Director of Operations 5% 2.4% 1.4% 2.0% 1.9% ●Main call centre response rate within one minute Effective Director of Operations 95% 70.4% 71.2% 59.7% 74.9% ●Urgent Response > 1st Assessment completed on same day (facilitated discharge & other) Responsive Director of Operations 80% 90.4% 91.1% 89.8% 91.0% ●Urgent Response > 1st Assessment completed within 2 hours Responsive Director of Operations 50% 32.7% 35.2% 69.1% 65.8% ●Trust Admissions - % recorded within 2 hours Effective Director of Operations 95% 90.9% 92.3% 92.5% 93.7% ●Trust Discharges - % recorded within 2 hours Effective Director of Operations 95% 78.1% 77.4% 79.1% 80.1% ●Trust Transfers - % recorded within 2 hours Effective Director of Operations 95% 80.6% 84.6% 85.8% 86.1% ●

A&E Quality Indicators

Cancer

Cancelled Operations

Responsiveness

Local Performance Targets and Measures CQC Domain Responsible Director Standard Nov-21 Dec-21 Jan-22 YTD 21/22 Rags

Emergency Ambulatory Care - % of total adult emergencies (Ambulatory or 0 LOS) Responsive Director of Operations 35% 41.8% 39.4% 39.9% 39.7% ●ALoS - Adult Emergency Inpatients Effective Director of Operations 6.0 6.8 5.8 6.9 6.2 ●ALoS – Elective Inpatients Effective Director of Operations 2.5 2.1 1.9 1.9 2.2 ●ALoS – D2A Pathway 2 Effective Director of Operations >28 days 23 21 23 23 ●ALoS – D2A Pathway 3 Effective Director of Operations >42 days C-19 C-19 C-19 C-19

Elective - Theatre Productivity Effective Director of Operations 75% 93.7% 83.0% 90.5% 91.1% ●Elective - Theatre utilisation Effective Director of Operations 85% 92.4% 83.7% 87.0% 89.5% ●Elective - Daycase rate Effective Director of Operations 85% 90.7% 91.9% 91.8% 89.3% ●BPT - Fracture Neck of Femur Effective Director of Operations 75% 53.1% 54.5% 63.8% ●BPT - Laparoscopic Cholecystectomies Effective Director of Operations 60% 100.0% 84.6% 73.3% 74.8% ●Occupancy Acute Wards Only Effective Director of Operations 90% 86.6% 86.0% 90.8% 85.5% ●Outpatient - DNA rate (consultant led) - First Effective Director of Operations 3.35% 7.0% 7.7% 7.4% 6.8% ●Outpatient - DNA rate (consultant led) - Follow-Up Effective Director of Operations 6% 7.4% 7.4% 7.7% 7.4% ●Outpatient - % OPD Slot Utilisation (All slot types) Effective Director of Operations 95% 76.1% 76.8% 79.7% 77.2% ●Outpatient - % of patients waiting over 6 weeks without a date Effective Director of Operations 30% 62.6% 69.1% 69.3% 65.4% ●Outpatient - % of patients waiting longer than 16 weeks over their due appointment date Effective Director of Operations 9% 47.8% 47.5% 48.3% 49.3% ●Outpatient - Advance Booking (new patients only - excluding patients seen within 3 weeks) Responsive Director of Operations 80% 57.3% 65.8% 61.9% 58.2% ●Maternity - Smoking at Delivery Effective Director of Nursing 8% 3.0% 6.9% 5.9% 5.4% ●Maternity - % of women who have seen a midwife by 12 weeks and 6 days of pregnancy Effective Director of Operations 90% 83.7% 88.2% 81.6% 85.4% ●Maternity - Elective C-Sections Effective Director of Nursing 10% 16.6% 14.5% 16.4% 15.5% ●Decrease the emergency caesarean section rate Effective Director of Nursing 15% 19.0% 19.6% 19.9% 20.3% ●Increase the number of women birthing in a Midwifery Led Unit setting Effective Director of Nursing - 23 28 40 287

Increase Normal vaginal Birth Rate Effective Director of Nursing 60% 53.8% 56.4% 55.9% 53.3% ●Community Family Services - Family Nurse Partnerships - Activity during pregnancy achieving plan Caring Director of Nursing 70% 80.3% 86.6% 78.3% 78.3% ●Health Visitor - Birth to first visit within 14 days - Latest Quarter - Warwickshire (Q3) Safe Director of Nursing 90% 45.3% ●Health Visitor - Birth to first visit within 14 days - Latest Quarter - Coventry (Q3) Safe Director of Nursing 90% 79.7% ●Health Visitor - Birth to first visit within 14 days - Latest Quarter - Solihull (Q3) Safe Director of Nursing 90% 69.1% ●School Nursing - National Child Measurement Program (Reception aged pupils) Responsive Director of Operations 90% Not Started Not Started 8.9%

School Nursing - National Child Measurement Program (Year 6) Responsive Director of Operations 90% Not Started Not Started 9.1%

Maternity

Out of Hospitals (OOH)

Inpatients

Outpatients

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Workforce Measures CQC Domain Responsible Director Standard Nov-21 Dec-21 Jan-22 YTD 21/22 Rags Pass/Fail

Midwife to birth ratio Well Led Director of Nursing 1:27 1:33 1:29 1:30 1:30 ●Overall Sickness Well Led Director of HR 3.8% 5.6% 5.8% 5.1% ●Staff Turnover Rate Well Led Director of HR 10% 1.4% 1.5% 1.2% 1.4% ●Temporary Staffing Rate Well Led Director of HR 0% - - - -

Appraisals - Latest Quarter (Q3) Well Led Director of HR 85% 75.6% ●Qualified Nursing Vacancies - percentage of unfilled posts against budget Well Led Director of HR 8% 15.5% 17.8% 17.6% 15.5% ●

Clinical Outcomes CQC Domain Responsible Director Standard Nov-21 Dec-21 Jan-22 YTD 21/22 Rags Pass/Fail

HSMR - Rolling 12 months Dec 20 -Nov 21 Effective Medical Director 100 107 ●Mortality RAMI (2019) - Rolling 12 months Jan 21 - Dec 21 Effective Medical Director 100 93 ●Mortality SHMI - Rolling 12 months Sep 20 -Aug 21 Effective Medical Director 89-112 96 ●Avoidable Deaths - Rolling 12 months YTD: April 21 (July 21 MSC) Safe Medical Director 0 1 ●Serious Incidents Safe Director of Nursing - 5 3 3

Never Events Safe Director of Nursing - 1 1 0

Sepsis screening - A&E (% screened) - Latest Quarter (Q3) Caring Medical Director 90% 100.0% ●Sepsis screening - Inpatients (% screened) - Latest Quarter (Q3) Caring Medical Director 90% 100.0% ●MRSA Bacteraemia Safe Director of Nursing 0 0 0 0 0 ●MSSA Bacteraemia Safe Director of Nursing 0 2 0 2 17 ●BSI Bacteraemia bloodstream infection Safe Director of Nursing 0 5 5 3 47 ●C Diff Hospital Acquired, Avoidable (Target for Full Year) Safe Director of Nursing 5 3 ●Hand Hygiene Safe Director of Nursing 80% 99.2% 98.8% 98.7% 98.6% ●Combined MRSA Screening Safe Director of Nursing 95% 95.0% 95.0% 95.0% 95.0% ●Maternity - Breast Feeding Initiation Rate (Warwick Hospital) Effective Director of Nursing 81% 91.4% 91.1% 89.2% 89.8% ●Maternity - Breast Feeding at 6 - 8 weeks (Community Midwives & Health Visitors) - Latest Quarter-W Effective Director of Nursing 46% 36.0% ●Maternity - Breast Feeding at 6 - 8 weeks (Community Midwives & Health Visitors) - Latest Quarter-Co Effective Director of Nursing 46% 50.6% ●Maternity - Breast Feeding at 6 - 8 weeks (Community Midwives & Health Visitors) - Latest Quarter-So Effective Director of Nursing 46% 47.8% ●Maternity - Continuity of Care Effective Director of Nursing 51% 29.1% 35.2% 30.1%

Quality - reduce avoidable death rates

Sepsis

Reduce Infection Rates

Maternity

Workforce

Patient Experience CQC Domain Responsible Director Standard Nov-21 Dec-21 Jan-22 YTD 21/22 Rags Pass/Fail

Friends and Family Test Score: A&E% Recommended/Experience by Patients Caring Director of Nursing >96% 100.0% - 50.0% 74.7% ●Friends and Family Test: Response rate (A&E) Caring Director of Nursing >12.8% 0.1% 0.0% 0.1% 0.2% ●Friends and Family Test Score: Acute % Recommended/Experience by Patients Caring Director of Nursing >96% 93.7% 86.8% 91.2% 93.5% ●Friends and Family Test: Response rate (Acute inpatients) Caring Director of Nursing >25% 24.4% 4.6% 34.8% 18.9% ●Friends and Family Test Score: Maternity % Recommended/Experience by Patients Caring Director of Nursing >96% 96.8% - 93.8% 94.6% ●Friends and Family Test: Response rate (Maternity) Caring Director of Nursing >23.4% 10.1% 0.4% 26.8% 13.5% ●Friends and Family Test Score: Community % Recommended/Experience by Patients Caring Director of Nursing >96% 94.2% 91.6% 93.9% 95.3% ●Written complaints rate Caring Director of Nursing 0% - - - -

Catering Surveys (Patients rating food as Good or Excellent) Caring Director of Nursing 90% 99.0% 100.0% 100.0% 99.3% ●Mixed Sex Accommodation Breaches - Confirmed Caring Director of Nursing 0 3 3 0 6 ●Patient ward moves emergency admissions (acute) Caring Director of Operations 2% 0.9% 1.2% 1.6% 1.0% ●

Reduce the proportion of non va lue added time

Experience

Reducing Harm CQC Domain Responsible Director Standard Nov-21 Dec-21 Jan-22 YTD 21/22 Rags Pass/Fail

Falls with harm (per 1000 bed days) Safe Director of Nursing 1.14 0.61 1.45 0.92 1.19 ●Medication Error Incidences Safe Director of Nursing <6% 3.2% 6.4% 4.3% 4.1% ●Pressure sores (Confirmed avoidable Grade 3,4) Caring Director of Nursing 0 0 0 0 1 ●Dementia - Find : Patients 75 or over Admitted as an Emergency Caring Director of Nursing 90% C-19 C-19 C-19 C-19

Dementia - Assess/Investigate : Patients 75 or over Admitted as an Emergency Caring Director of Nursing 90% C-19 C-19 C-19 C-19

Dementia - Refer : Patients 75 or over Admitted as an Emergency Caring Director of Nursing 90% C-19 C-19 C-19 C-19

VTE Risk Assessments Safe Director of Nursing 95% 96.0% 97.3% 95.1% 94.6% ●WHO Checklist Safe Director of Nursing 100% 98.8% 99.6% 98.6% 99.0% ●Patient Safety Alerts not completed by deadline Safe Director of Nursing 0 0 0 0 0 ●Nurse Care /Community Care Indicators Caring Director of Nursing 95% 93.4% 93.6% 94.3% 93.5% ●

Hygiene Cleaning Standards: Acute (Very High Risk) Safe Director of Nursing 95% 98.4% 98.3% 98.3% 98.4% ●Cleaning Standards: Community (Very High Risk) Safe Director of Nursing 95% 98.4% 98.5% 98.4% 98.4% ●

Safety

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Chief Nursing Officer Report 1. Clinical Outcomes 1.1 Serious Incidents (SIs)

There were 3 SIs reported/occurred in January 2022, one definite hospital acquired Covid infection and 2 probably hospital acquired Covid infection. Table 1 below identifies SIs by month they occurred, not the month reported. All SIs undergo a full investigation to identify the root cause(s) as well as any potential learning opportunities. The incidents are discussed at the Clinical Governance Committee. Table 1

Table 2 There was no new Never Events recorded in January 2022.

2. Patient Experience 2.1 iWantGreatCare (iWGC)

In January 2022 a total of 1820 patients submitted a review through the Friends and Family Test (FFT) iWGC survey. This is the highest number of reviews received in a month over the past year and reflects the effort by the teams to increase the number of patients asked to complete the survey.

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The target response rate for acute inpatients is 25% and this month the teams achieved 34%. The Maternity target response rate is 23.4% and the team achieved 26.8%. The Accident & Emergency (A&E) target response rate of 12.8% was not met and the team continue to struggle to give out survey cards to patients. It is expected the implementation of SMS messaging alerts to patient who receive A&E treatment will resolve this problem and work on this is in the final stage and expected to commence during March 2022. The percentage of patients who stated they had a positive experience in January 2022 was 92.5% and the 5 star score was 4.73. Whilst this is a high proportion of patients who received good care it is below the target to achieve 96% of patients who state they had a positive experience. In order to try and meet the target, teams are looking at the negative reviews to see what intervention can be put in place to improve the patient experience. 4.3% of the patients who left a review reported having a negative experience. 120 patients gave a low score for the questions relating to whether they felt involved enough in decisions made and if they received timely information about their care and treatment. 5 patients felt they were not treated in a suitable location. Work is ongoing to improve in these areas and links in with the National Care Quality Commission (CQC) Inpatient survey action plan which is currently in development. 3. Reducing Harm 3.1 Falls with Harm

The number of falls reported in January 2022 was 57, which was similar to November 2021 and December 2021, all of which were low harm. The injury rate per 1000 bed days returned to below threshold of 1.14 at 0.92 having been over the threshold in December 2021 Good reporting of near misses continues despite the work and staffing pressures.

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3.2 Medication Error Incidences

There were 93 incidents reported in January 2022 which is a decrease from 109 in December 2021. There were 4 low harm incidents in January 2022 putting the ratio of harm to no harm at 4.3%, which is above the Trust threshold of 4%, but below the national benchmark of 10% and an improvement of the December 2021 figure (6.48%). There were 3 low harm incidents in the Emergency Division and 1 in the Family Health Division; learning has been shared with all staff involved. There were no harm incidents reported in Out of Hospital Care Collaborative (OOHCC) Division, however there were 6 insulin incidents reported in January 2022 (the same number as in December 2021), although 2 of these were patient related incidents and not directly related to insulin administration. These have been looked in to and assurance received from OOHCC. There was one incident of unaccounted loss of a controlled drug in theatres reported in January 2022; this is currently under investigation with a full investigation report expected by March 2022.

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3.3 National Patient Safety Alerts (NatPSA)

The Patient Safety Team now ensure the Board of Directors is notified to any new NatPSA issued and aware of non-compliance with alerts via the Integrated Performance Dashboard. Five alerts were issued in January 2022; there are no overdue alerts.

3.4 Deteriorating Patient

January 2022 saw the lowest number of 2222 calls in relation to the previous 4 months data. This is pleasing as January 2022 is traditionally a very busy month for 2222 calls. Of the 18 calls, 2 of the 17 patients attended were Covid Positive. From the 2222 data, it was felt there had been a number of missed opportunities with regard to Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) conversations. Of the 17 patients attended it was felt that potentially 9 of these would have benefited from a ReSPECT conversation. One patient that suffered a cardiac arrest had indicated they would not want Cardiopulmonary Resuscitation (CPR) or Intensive Treatment Unit (ITU) to a member of nursing staff, this was escalated to the Doctor in charge of patients care, but not acted upon before the patient deteriorated to cardiac arrest. It is pleasing that there were no incidents raised where patients were discharged without their ReSPECT forms.

3.5 Safe Discharge

There were 29 incidents relating to discharge in January 2022, 28 no harm 1 low harm. The rate of incidents over the last 9 months is fairly static. 5 of the reported incidents were with regards to George Eliot Hospital NHS Trust (GEH) discharges reported by South

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Warwickshire NHS Foundation Trust (SWFT) staff and have been sent to GEH for comment. 11 incidents related to To Take Out (TTO) Medication which is appropriate in proportion to the volume of discharges each month and with no particular theme. The incident with low harm was related to a patient being discharged home without timely referral to the integrated Single Point Access (iSPA) for insulin administrated which led to the patient missing doses of insulin; this is under investigation by the Ward. There were 4 complaints around discharge this month; 3 with concerns raised by family members around the lack of provision of care on discharge, one a complaint following a complication of surgery; all are currently under investigation. The reassuring picture is, despite the increase in activity, extra capacity areas opened and increase in staff sickness, the levels of incidents remain low with in the main no harm.

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4. Chief Operating Officer Report

Performance fell slightly in January 2022 after signs of recovery in December 2021. January 2022 performance was 69.9% (down 2.5%); The month did improve as it progressed with factors keeping the figure below 68% in the first 2 weeks, improving to 71.8% during the second half of the month. Nationally this places SWFT in 31st place amongst Acute Trusts (from 20 December 2021) and on the 75th percentile. Attends to the department picked up from the December 2021 low point; and the primary issue in month was admitted performance which was low in the month at 37.6%. Non admitted performance (82.6%) remained steady and has improved over the past two months. COVID numbers in hospital and related pressures were particularly felt in January 2022 with numbers as they have been since the end on the winter 2021 COVID wave; patients occupied 46 beds mid-month, dropping to less than 20 by month end. COVID forced a number of bed closures during month and bed pressures were a feature across the month. Acute bed occupancy of 91.9% in month, increasing to 93.8% where only Medical Wards are considered.

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Average attends increased from 201 per day in December 2021 to 209 per day in January 2022; though the numbers accelerated as the month progressed. Elderly attends were sustained across December 2021 and increased slightly in January 2022; paediatric attends fell in December 2021 and started to return to prior level more fully towards month end; 18-74 returned to prior levels almost as soon as Christmas ended. Ambulance arrivals were sustained in January 2022 at 1,642 in month; handover delays have improved though some issues remain. Arrivals from people not having a South Warwickshire GP increased in January 2022 after declining in December 2021. Around 20% of arrivals in January were not registered with a South Warwickshire GP. Same Day Emergency Care (SDEC) and short stay areas continue to be utilised as bed capacity and admitted performance could be improved further once it is safe for these areas to be returned for normal use.

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A further slight improvement in the time to assessment in January 2022 despite the drop in performance. Time taken reduced slightly to 32 minutes. No Emergency Department (ED) areas achieved assessments within 15 minutes; though there is a degree of variation between areas.

There was an improvement across areas except for Resuscitation which saw a marginal increase in month.

This is the ninth consecutive month with patients in the department over 12 hours. In previous times, December/January have been the worst affected and this winter October remains ahead of other months. In January 2022 the number increased to 141 patients who were in the department for over 12 hours (2.2% of attends).

• 35 of these patients went on to be discharged (24%) ↓

• 56 Aged 75+ (40%) ↑ • 3 Paediatrics (2.1%) ↓ • Notable increase in Mental Health 17

(12.1%) ↑ • 42 people (40% total) in the department for

12 hours+ arrived between 7pm - 10p

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Stranded took a large step upwards in January 2022; in line with previous years the number started off relatively low but increased as we moved into the second week of January 2022. Multi Agency Discharge Event took place on 18 January 2022 that helped to reduce Stranded numbers towards month end. The learning from that event is being used to shape discharging decision making and improve use of Criteria to Reside and has helped to spread discharging more evenly across the week. In January 2022 70.1% of stranded patients were aged 75+ years.

January 2022 saw the first drop in non-elective spells since August 2021 with 2,474 recorded spells in total. The use of Ambulatory areas for bedding patients meant that fewer patients passed through these beds; the Fraility Assessment Area (FAA) was particularly affected. By Specialty then most areas reflected the slight downturn in Emergency activity, with only a few areas of note showing any significant increase, namely, Diabetic Medicine, Urology and Obstetrics and Gynaecology.

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Elective work remained close to December 2021 numbers in January 2022 with 2,474 spells. January 2019 was one of SWFT’s most productive months for elective activity while January 2022 fell some way short of the comparison – though somewhere in the middle across the year.

Occupancy has increased to 92.2% in January 2022, at the same time Medical bed occupancy has averaged out at 94.1%. This reflects the reality of the situation, and beds have been the most pressing challenge throughout January 2022. Taking this a stage further Occupancy (Medical beds) appears to be a more acute issue earlier in the week:

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A slight reduction at SWFT with performance at 78.4%, though signs that performance is stabilising.

However, it is worth remembering that the main focus around the referral to treatment targets is to increase the number of reported Referral to Treatment (RTT) clock stops and reducing the volume of patients waiting over a year, which is being achieved. Big improvements in those at 78+ weeks.

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A slight reduction in Diagnostic Performance this month with 96.3% of patients seen within 6 weeks. 226 patients were over 6 weeks at month end, 154 of those are Endoscopy related (68%). By area, Imaging is at 99.7%, Measurements at 91.1%, with Endoscopy back a little at 77.3%. Areas with lower performance ratings:

↔

Our 2 week wait performance has continued on a stable trajectory. We are still required to submit our data monthly but the emphasis remains on delivery of the 28 day faster diagnostic standard. Our 28 day performance also remains stable with December 2021 finishing at 63% January 2022 predicted at 61%. February 2022 is predicted to end the month at 73%, noticeable improvements in colorectal. Urology (52%) and Gynaecology (36%) remain the areas of concern, both of these areas have a large impact on the Trust’s overall performance due to the number of patients. Although gains have been made in February 2022 it is unlikely that we will end the year at or above 75% for the 28 day faster diagnostic standard.

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Our 31 day performance has been unstable for the last three months. We are continuing to treat more patients than in 2019, however demand on our theatres and staffing difficulties on oncology units have resulted in delays to treatment. Oncology delays have now been resolved but remains a fragile service based on nursing and consultant staffing. We are predicting a more stable position in January and February 2022. This standard is now incorporated into a single standard with the 62 day pathway.

Again a stable position although well below the national target. Main causes are delays in Gynaecology and Urology diagnostics which impact on the whole 62 day pathway. Prediction for January 2022 sees a decline on the last three months due to diagnostic delays rather than treatments.

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Births at Midwifery Led Unit setting have been on a downward trajectory since June 2021 (n=31) to 24 births in December 2021. However, in January 2022 there were 36 births which shows a significant increase compared to the last 6 months. 22 of these were water births and there were (n = 45) women who started their labour in the Bluebell Birth Centre (BBC) prior to being transferred to Labour ward for higher risk care. 2 homebirths were also facilitated. The number of births in the BBC continues to be directly affected by safe staffing challenges and there were some shifts where both the homebirth and BBC service were suspended, however this is an improving picture with our successful recruitment programme.

The normal vaginal birth rate is consistent with December 2021– January 2022 at 55.9% staying just above the mean. The emergency caesarean section rate was 19.4% in January 2022. A slight decrease from November and December 2021 and just over the mean of 19.6%. The elective caesarean rate is consistent with last month at 15.97 %, all cases are being audited and are reviewed by the Labour ward lead.

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Reporting Urgent Response 2 hours now includes all urgent visits. The target is 70% and in January 2022 performance rose slightly to 69.1%.

There is no cause for concern with the same day Urgent Response consistently above 80% target at 89.8% for the reporting period.

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Pathology Histopathology TATs- January 2022

The SPECIALTY URGENT / CANCER BIOPSIES

ROUTINE CASES ALL CASES

7 DAY 10 DAY 10 DAY

TALL 73% 87% 47% 60%

Breast 82% 95% 42% 78%

Dermatology 58% 79% 38% 48%

General 67% 100% 43% 45%

GIT 96% 98% 57% 63%

Gynaecology 80% 90% 45% 66%

Haematology 48% 71% 94% 82%

Head & Neck 72% 84% 25% 57%

Respiratory 40% 40% n/a 40%

Urology 62% 79% 17% 70%

Histopathology • The Histopathology Laboratory at SWFT

continues to be down one processor, consequently some biopsies are sent to University Hospitals Coventry and Warwickshire NHS Trust (UHCW) laboratory. Such transfers impact on the turnaround times for the Breast and Colorectal specialties, Multi-Disciplinary Teams (MDTs) predominantly, and creates pressure on the reporting Pathologists.

• Staffing shortages, slow backfilling of vacancies/moves and skill mix changes have resulted in backlogs, ranging from 400-800 blocks on average. As these are returned in batches this making management of cases difficult for Pathologists.

• Training for Bare Metal Stents’ (BMS) dissection and cross cover across the Network for specialist BMS dissection continues to be problematic. SWFT Consultants try to support this activity but impacts on reporting turnaround times (TATs).

• Pathologists are trying to prioritise cases for MDT discussions and those likely to breach.

Mitigations Pathologists do their best to address cases required for the MDT discussion and ones that are likely to breach the 2 week wait (2WW)

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Phlebotomy waiting times Warwick Activity 2777 patients bled within 15 mins of appointment 94% Stratford Activity 1859 patients bled within 15 mins of appointment 98% Covid Swabbing Service numbers. Swabbing Figures for 2021 with comparison Figures for 2020 Month 2021/22

Patients Patient Figures 2020

Staff/Index Month 2021/222

Staff/Index Figures 2020

August 1764 - 165 - September 1630 1001 215 452 October 2088 1619 257 214 November 2026 1796 276 235 December 1560 1408 963 889 January 1877 1470 962 727

Swabbing have continued to support wards and department outbreaks, the increased staff and index cases and the resulting contract tracing. Discussions are taking place with Infection Prevention and Senior Managers to understand the future Covid testing requirements.

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Recruitment continues at pace with 88 new starters in January 2022. Sickness absence remains a concern, particularly in the Out of Hospital Care Collaborative and Family Health Division. Staff absences are hoped to have plateaued in January 2022. Appraisal and Core Skills Training Framework (CSTF) compliance both remain disappointingly low having reduced further this month. No Division is achieving 85% compliance for either appraisals or CSTF compliance. These are being addressed through Finance and Performance Executive (FPE) and the Divisions are developing trajectories to recover their position.

5. Chief People Officer Report

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Recruitment

• There were 88 new starters in

January 2022, including 25 registered nurses, 1 registered midwife, 30 Clinical Support Workers (CSWs) and 4 Allied Health Professionals (AHPs).

• There were 61 leavers in January

2022 with no identifiable trend in reasons for leaving.

• There were 245 more starters than

leavers over the rolling 12 month period.

• This SPC chart shows nurse

vacancy trends over the past year. • Vacancy data is currently provided

by Finance and includes those on parental leave or sick leave. The active vacancy rate for nursing is currently 10.98%.

• The increase in CSW vacancies is

being addressed through a system-wide recruitment campaign.

0

50

100

150

200

250

Jan-21 Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22

Permanent Starters and Leavers

Starters Leavers

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Feb-21 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22

Nursing Vacancies Excluding Bank Staff

Registered Unregistered

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Health and Wellbeing

WTE (July 21)

% sickness July 2021

% sickness Aug 2021

% sickness Sept 2021

% sickness Oct 2021

% sickness Nov 2021

% sickness Dec 2021

4289.57 5.66 5.27 5.46 5.63 5.61 5.76

Commentary: • The overall Trust sickness figure for

December 2021 was 5.76%, a small increase on the November 2021 level of 5.61%. The figure for January 2022 is not yet available.

Issues/Risks: • Sickness levels in all divisions

except the Corporate Division remain above the Trust target of 3.8%.

• Sickness rates in Out of Hospital remain particularly high and are still a cause for concern. Sickness levels in Family Health also remain high, and rates in Elective Care have risen.

• Sickness is 8.09% for Clinical Support staff and 7.28% for qualified nursing and midwifery staff which has a significant operational impact.

Mitigation: • Continued support offered to staff

through Occupational Health, Staff Support, Employee Assistance Programmes (EAP) and Well-being interventions

• Targeted interventions in areas of highest sickness absence levels and expedite returns to work.

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Commentary: • Anxiety/stress/depression remains

the highest reason for absence, accounting for 26.9% of all sickness absence. Musculoskeletal (MSK) problems (including back problems) accounted for 11.8% of sickness.

Issues/Risks: • 14.9% of sickness in December

2021 related to infectious diseases. This is a significant increase which reflects the impact of the Covid surge. It is expected that absences as a result of Covid infection will remain high for the next few months.

Mitigation: • Health and Well-being interventions

targeted to support mental health.

Top 10 Sickness ReasonsAnxiety/stress/depression/

Infectious diseases

Musculoskeletal problems

Cold, Cough, Flu

Other known causes

Gastrointestinal problems

Injury, fracture

Unknown causes / Not specified

Genitourinary & gynae disorders

Chest & respiratory

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Appraisals and CSTF Compliance

Staff Group Appraisal Compliance %

CSTF Compliance

% Add Prof Scientific and Technic 77.59 91.36 Additional Clinical Services 72.13 86.08 Administrative and Clerical 75.59 92.27 Allied Health Professionals 83.67 90.17 Estates and Ancillary 79.12 90.16 Healthcare Scientists 80.95 84.25 Medical and Dental 80.65 73.83 Nursing and Midwifery Registered 69.35 86.64 Students 41.38 91.35

Commentary: • Appraisal compliance is poor

across the organisation with no staff group achieving the 85% target.

• CSTF compliance for medics has reduced this month and is now far below the target of 85%.

Issues/Risks: • No division is achieving over

85% compliance for staff appraisals.

• Both appraisal and CSTF compliance have worsened this month.

• Corporate areas have the lowest appraisal compliance at 60%.

Mitigation: • The People & Workforce and

Education teams are working with divisions to improve compliance.

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6. Chief Finance Officer Report Executive Summary To enable the NHS to respond to Covid-19 NHS England/NHS Improvement (NHSE/I) issued guidance throughout last year which included moving to block contract payments ‘on account’ for all NHS and foundation trusts with suspension of the usual Payment by Results (PBR) tariff payment architecture and associated administrative/transactional processes, contracting and planning. The framework for the second half of the year was intended to support the restoration of services with a greater focus on system partnership with systems being issued with funding envelopes and a national requirement to break even. The financial regime for 2021/22 is on a similar basis with the suspension of PBR and a move to block arrangements. A national financial settlement for the NHS was agreed for the first half of the 2021/22 financial year within which included a national requirement for all Sustainability and Transformation Partnerships (STPs) to submit a break even plan for the period April – September 2021. The Coventry & Warwickshire STP submitted a breakeven plan. Within this South Warwickshire NHS Foundation Trust’s (SWFT) share was also a breakeven plan but includes a stretch target of £3m to enable the STP to achieve a balanced plan. The Financial Recovery Fund, Provider Sustainability Fund, Marginal Rate Emergency Rule (MRET) and associated rules have been suspended for this financial year. An Elective Recovery Fund (ERF) has been introduced which is designed to ensure that systems receive appropriate funding to deliver the highest possible levels of recovery activity. Systems will be paid through the ERF for activity delivered above nationally set thresholds compared to 2019/20 activity levels. Any additional income can only be earned if targets are achieved at system level. The Trust has included Income from ERF in its H1 plan as a stretch target in order to deliver a breakeven plan. The estimated ERF payment values for the H1 and have been included in the year to date position but a final reconciliation is required to confirm the final value. For H2 value included is the ERF year to date underwrite value. On 30 September 2021, NHSE/I published the priorities and operational planning guidance for the remainder of 2021/22. Financial arrangements for the second half of the year are broadly consistent with those for the first half of the financial year, although there is an increased efficiency requirement. Systems will continue to receive a fixed system funded envelope based on H1 2021/22 envelopes adjusted for additional known pressures, such as the impact of the pay award.

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The final narrative and numeric submission is required to be submitted (at a system level) by 16 November 2021. This will be a final set of plans covering the second half of the year by using the centrally generated templates covering the key actions set out in guidance documents. From a system level the expectation remains for all systems to deliver a breakeven or surplus plan. The H1 system position was a £5.0m deficit, of which £1.3m relates to Georg Elliot Hospital NHS Trust (GEH) and £2.28m relates to University Hospitals Coventry and Warwickshire NHS Trust (UHCW). The expectation is that the system will deliver a break even plan at the end of the year and therefore will have to deliver a surplus of the equivalent value to ensure at least break even. SWFT had a small surplus year to date at month 6. For the Month 7 return to NHSI submitted on the 15 November 2021 the Coventry & Warwickshire (C&W) system submitted deficit plans to the equivalent of the ERF Income gained in H1 of £24.3m. For SWFT this value was £4m. At month 7 the Trust has reported a £704k deficit compared to a deficit plan of £731k A number of discussions took place with NHSE/I regarding the possibility of underwriting this income and whilst discussions continued with NHSE/I a decision was made as a system along with NHSE/I that we should submit a surplus plan (to the equivalent of the H1 deficit for UHCW and GEH) by including the ERF income of £24.3m as a mitigation to the costs of delivering Elective Recovery. On the 18 November 2021 the C&W STP submitted a surplus plan of £5m. Following submission of the month 7 deficit position on 15 November 2021 and System H1 plan submission on 18 November 2021 we received confirmation from NHSE that the ERF underwrite has been confirmed. The organisational plan submission submitted on 25 November 2021 reflected this agreement and the Trust submitted a breakeven plan. At month 10 the Trust has delivered a £24k surplus compared to a breakeven plan. Key movement in month is the £5.305m reduction in Investments value to £0.672m, which reflects the current fall in share price of the Trust’s Sensyne Health investment. On initial recognition of the Sensyne shares the Board of Directors took the decision to make an irrevocable election under IFRS 9 for equity instruments to reflect Fair Value movements through Other Comprehensive Income (FVOCI). In doing this, any movements in share price will then go through Other Comprehensive Income with increases or decreases in share price being reflected in an equity reserve.

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Statement of Comprehensive Income

Agency Spend

Variance to plan Plan – Break Even

YTD £24k surplus NHSI Cap 21/22: £6.02m Agency spend remains high.

£3.3m YTD (67%) adverse

variance to the NHSI Cap.

Capital Plan 21/22: £22.807m

Capital expenditure as at Month

10 YTD against the plan is

£16.701m

CPIP Target 21/22: £9.04m

Divisions have identified £5.6m

schemes and are working on

quantifying further savings.

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2021/22 Financial Control Total April – March 2022 H1 A national financial settlement for the NHS was agreed for the first half of the 2021/22 financial year within which included a national requirement for all STPs to submit a breakeven plan for the period April – September 2021. The C&W STP submitted a breakeven plan. Within this, the Trust’s share was also a breakeven plan but includes a stretch target of £3m to enable the STP to achieve a balanced plan. H2 On 30 September 2021, NHSE/I published the priorities and operational planning guidance for the remainder of 2021/22. Financial arrangements for the second half of the year are broadly consistent with those for the first half of the financial year, although there is an increased efficiency requirement. Systems will continue to receive a fixed system funded envelope based on H1 2021/22 envelopes adjusted for additional known pressures, such as the impact of the pay award. H2 envelopes are a broad continuation of the H1 financial regime with:

• a requirement for the system to breakeven • an increased general efficiency requirement from H1 of 0.82% for the six month period • a targeted reduction in system top up funding for some systems based on their distance from their 2021/22 financial improvement

trajectory funding envelope • a reduction to the COVID19 fixed allocation • A reduction in non-healthcare income support of 75% • Uplifts for the 3% Agenda for Change (AFC) pay award • Funding available for additional winter pressures

Provider Sustainability Funding (PSF), MRET and Top up Funding The Financial Recovery Fund, Provider Sustainability Fund, MRET and associated rules have been suspended for the 2021/22. Current Funding arrangements To enable NHS to respond to Covid-19 NHSE/I issued guidance throughout last year which included moving to block contract payments ‘on account’ for all NHS and foundation trusts with suspension of the usual PBR tariff payment architecture and associated administrative/transactional

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processes, contracting and planning. The framework is intended to support the restoration of services with a greater focus on system partnership with systems being issued with funding envelopes and a national requirement to break even. H2 Plan submission The Final Narrative and Numeric Submission is required to be submitted (at a system level) by 16 November 2022. This will be a final set of plans covering the second half of the year by using the centrally generated templates covering the key actions set out in guidance documents. From a system level the expectation remains for all systems to deliver a breakeven or surplus plan. The H1 system position was a £5.0m deficit, of which £1.3m relates to GEH and £2.28m relates to UHCW. The expectation is that the system will deliver a break even plan at the end of the year and therefore will have to deliver a surplus of the equivalent value to ensure at least break even. SWFT had a small surplus year to date at month 6. For the Month 7 return to NHSI submitted on the 15 November 2021 the C&W system submitted deficit plans to the equivalent of the ERF Income gained in H1 of £24.3m. For SWFT this value was £4m. At month 7 the Trust has reported a £704k deficit compared to a deficit plan of £731k A number of discussions took place with NHSE/I regarding the possibility of underwriting this income and whilst discussions continued with NHSE/I a decision was made as a system along with NHSE/I that we should submit a surplus plan (to the equivalent of the H1 deficit for UHCW and GEH) by including the ERF income of £24.3m as a mitigation to the costs of delivering Elective Recovery. On the 18 November 2021 the C&W STP submitted a surplus plan of £5m. Within this, SWFT’s share was a breakeven plan which included:

• An automatic roll forward of the H1 stretch target of £3m to enable the STP to achieve a balanced plan • An explicit reduction of 6% in covid income • A fair shares allocation of Winter Funding of £1.1m • A significant efficiency of 0.82% built into the envelope • A further efficiency application for the system Financial Improvement Target of £1.6m • Share of the system contingency reserve of £0.5m

Following submission of the month 7 deficit position on 15 November 2021 and System H1 plan submission on 18 November 2021 we received confirmation on 19 November 2021 from NHSE that the ERF underwrite has been confirmed. The organisational plan submission due on 25 November 2021 will reflect this agreement. At month 10 the Trust has delivered a £24k surplus compared to a breakeven plan.

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The Elective Recovery Fund The Elective Recovery Fund (ERF) is designed to ensure that systems receive appropriate funding to deliver the highest possible levels of recovery activity. Systems will be paid through the ERF for activity delivered above nationally set thresholds compared to 2019/20 activity levels in value terms. The thresholds, as a percentage of the value of the 2019/20 activity, originally set out were:

• 70% for April 2021 • 75% for May 2021 • 80% for June 2021 • then 85% from July to September 2021

For valued activity delivered between the target thresholds and estimated funded activity within the envelopes systems will receive an additional payment at 100% of tariff. Additional valued activity above 85% will receive the equivalent of 120% of tariff. The thresholds have been reviewed, taking into account progress to date and Quarter 2 plans, income earned, actual costs incurred and expectations about staff availability in the next few months. As a result, the thresholds for earning ERF are being adjusted to 95% of 2019/20 activity levels from 1 July 2021. ERF will be paid at 100% above the 95% and at 120% of tariff above 100% of 2019/20 activity. Any additional income can only be earned if targets are achieved at system level. The Trust has included Income from ERF in its H1 plan as a stretch target in order to deliver a breakeven plan. The estimated ERF payment values for the H1 and have been included in the year to date position but a final reconciliation is required to confirm the final value. For H2 value included is the ERF year to date underwrite value. H2 Elective Recovery Fund (ERF) and Targeted Investment Fund (TIF) For the second half of 2021/22 there is £1bn of revenue and capital funding above that funded within core envelopes that has been made available to support the continued recovery of elective activity and cancer services. There will also be a £700m TIF available to support elective recovery. Systems were asked to propose by 14 October 2021 to their regional teams a shortlist of targeted investments for elective recovery reforms that can have a material impact on activity in 2021/22 or in future years. The Trust submitted our return via the C&W Health and Care Partnership (HCP) in accordance with the guidance requirements.

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In addition, systems that achieve completed Referral to Treatment (RTT) pathway activity above a 2019/20 threshold of 89% will be able to draw down from the ERF. This however is different to the measure used in H1, which was total cost weighted activity. For H2 this will be focused on completed RTT pathway activity rather than cost weighted activity used in H1. Part of the ERF will also be used to centrally fund Independent sector activity above 2019/20 levels. Changes to the threshold from 85% to 95% 2019/20 activity levels that impacted from July 2021 significantly reduced the financial benefit to the Trust and although the costs have not exceeded the Income gained this has resulted in a significant reduction in the anticipated income earned. The Trust’s current forecast of ERF Income for H1 is £4.06m. It should be noted that the ERF gains and losses are calculated as a system and are influenced predominantly by UHCW who account for 60% of elective activity and who have been impacted by an unplanned switch from elective to critical care in response to rising Covid-19 caseload and as a result the system did not earn any ERF in August 2021 and September 2021. As detailed above NHSE/I have confirmed agreement to the Elective Recovery Income underwrite of £24.3m.

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Expenditure by Expense Type The table below details the expenditure run rate for the Trust by expense type. Costs exclude SWFT Clinical Services Ltd (SWFTCS) and will not reconcile exactly to the Statement of Consolidated Income on Page 2. Pay costs for 2020/21 Month 12 have been adjusted to remove the technical adjustment for the additional 6.3% pensions contribution paid centrally by the Department of Health. The 3% NHS pay award for 2021/22 was paid in September 2021, with backpay to April 2021, resulting in a spike in substantive and bank pay expenditure. Both pay and non-pay have been increasing with the Elective recovery work and pressures of maintaining services with very high levels of activity. Agency remains high, reflecting difficult operational pressures. In Month 1 2021/22 there were significant increases in Clinical Negligence insurance premium, consistent with other Trusts, and depreciation because of capital spend in recent years. The apparent decrease in supplies and services expenditure in Month 5 is related to accounting for the ERF.

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Covid-19 Costs The table below details the run rate expenditure associated with Covid-19. Some pay spend was identified as Covid-19 and consequently re-categorised in Month 11 2020/21, which, together with the second Covid-19 wave, led to a peak in expenditure. After a drop in June 2021, Covid-19 pay spend increased in July and August 2021, mostly agency nursing.

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Cost and Productivity Improvement Plan (CPIP) (Efficiency) As a result of Covid-19, the 2020/21 Cost Improvement Plan (CIP) target was much lower than previous years at £1.65m, of which £1.29m was delivered, non-recurrently. The target for 2021/22 is a challenging £9.04m, or 3% of baseline budgets. The table on the right shows the breakdown of the target by Division. Approximately £5.4m of in year budgetary reduction schemes have been identified. As in previous years, schemes are predominantly non-recurrent, with ~ 1/4 of schemes identified being recurrent (£0.7m).The main schemes are vacancy slippage and ERF budget relief being set against the target. The CPIP target is forecast to be delivered through other non recurrent income and productivity gains. .

Division 2021/22 Budget reduction CIP Target £000

Emergency Division 1,638 Elective Care Division 2,155 Support Services Division 1,360 Corporate Division 1,354 Out Of Hospital Care Collab 1,590 Family Health Services 939 Total 9,036

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New Use of Resources Metrics (UoR) NHSI Single Oversight Framework (SOF) assesses the financial performance of providers via the “Use of Resources Metrics (UoR)” comprising the following five metrics:

• Liquidity Ratio • Capital Servicing Capacity • I&E Margin • I&E Distance from Plan • Agency

Historically providers were scored 1 (the highest / best score) to 4 (the worst / lowest score) equally weighted metrics. The average across the metrics then determined the Trust’s Use of Resources (UoR) score. The UoR score is not being measured in the April – September 2021 period. NHSE/I published proposals this week that describes their approach to oversight for 2021/22. This details that the existing statutory roles and responsibilities of NHSE/I in relation to trusts and commissioners remains unchanged for 2021/22 with the accountabilities of NHS organisations remaining unchanged. The oversight framework provides clarity to Integrated Care Systems (ICSs), trusts and commissioners how NHSE/I will monitor performance Further the framework details the

• main areas of focus in overseeing trusts • how information will be collected from trusts • how potential concerns with a trust’s performance will be identified • how the trust sector will be segmented according to the level of challenge each trust faces

The Trust has received confirmation that it has been placed in segment 1.

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Agency Expenditure (excludes direct engagement) The Trust has been issued with an agency spend ceiling value of £6.018m for 2021/22, which is consistent with previous years. Total agency expenditure (excluding medics engaged through direct engagement) continues to increase with September 2021 and now January 2022 spend hitting the £1m in month mark, this is more than double the in-month agency ceiling. January 2022 represents 5.81% of total staff costs compared to 3.62% in January last year. Year to date (YTD) agency amounts to £8.4m, this is £3.3m (67%) more than the YTD ceiling and £2.4m above our annual ceiling There have been significant operational pressures due partly to Covid-19 (self-isolation and increase in Covid-19 patients) on top of managing annual leave through the summer, maintaining elective recovery and underlying vacancy pressures. Nursing, Theatres, IT, Clinical Coding are the main staff groups using agency

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Nursing Cost Run Rate The chart below shows the rolling run rate of nursing costs from April 2020. Nursing agency spend is mostly on Registered Nursing. Temporary nursing spend overall reduced significantly during the first Covid-19 peak because of reduced shift numbers but has continued to rise since elective work restarted. Temporary workforce costs hit a peak during the second Covid-19 wave over December 2020 (Month 9) through to February 2021 (Month 11) due partly to increased shifts covering staff sickness and self-isolation and partly to cost - incentive rates were paid to encourage staff to work bank shifts between 23 December 2020 and the end of February 2021. The 2021/22 NHS pay award was paid in September 2021, including back pay to April 2021. Temporary shift numbers remain high in 2021/22, due to a combination of:

• increased activity, both Covid-19 and non-Covid-19, with high levels of emergency activity and elective recovery and accelerator work; and

• staff shortages due to the ping-demic, covering annual leave and underlying vacancies. The Trust has had to resort to expensive off framework agencies with increasing frequency

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Medical and Dental Cost Run Rate The chart below shows the rolling run rate of temporary Medical Staff costs from April 2020. Medical spend has been steadily increasing during the year date due to restoration and recovery work and the impact of the Covid-19 second wave between December 2020 and March 2021. Direct Engagement and Agency medical costs are grouped together as they are both premium cost. Whilst direct engagement and agency cost reduced at the beginning of 2021/22, there was an increase in July 2021 with the introduction of incentive payments related to the elective accelerator work. The Health Education England (HEE) allocation of Junior Doctors from August 2021 was lower than expected and there will be increased rota gaps later in the year, causing further expected cost pressure on medics. The NHS pay award was made in Sept 2021 including back pay to April 2021.

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Productivity and Efficiency Measures The NHS Model Hospital is a benchmarking tool identifying key performance and productivity measures across the dimensions of care settings, clinical service lines, clinical support services, corporate services and people. It introduces a measure of “weighted activity unit”, designed to allow comparison of Trust’s performance across other Trusts despite providing different services and having different case-mix. The key productivity measure within the Model Hospital is Cost per Weighted Activity Unit (WAU), which is based on trusts’ annual national cost collection. Because this collection is annual, and not published until the February after collection, by the time it is published in the Model Hospital, it can be quite out of date, particularly when there have been significant changes affecting trusts activity and costs, such as the Covid-19 pandemic. We have developed an in-year proxy cost per WAU trend analysis below. Cost per WAU follows weighted activity closely, with the first and second Covid-19 waves being clearly reflected by drops in weighted activity and spikes in cost per WAU. Cost per WAU had been improving since the second Covid-19 peak earlier in 2021 but deteriorated in August 2021. This was due to a reduction in weighted activity, partly due to reduced activity in the summer holidays and partly due to a backlog in coding for A&E attendances reducing the apparent complexity of activity and hence WAUs. Coding for A&E in August 2021 has now been updated. The spike in September 2021 is due to the pay award and arrears.

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Total Cost per WTE

Income per WTE

Pay Cost per WTE

Cost and Income per Whole Time Equivalents (WTE) Cost per WTE does not show quite the same relationship with Covid-19 as cost per WAU, as the cost increases were more gradual (Although March 2021 costs have been adjusted for impairments and pensions costs, there remain other year-end accounting adjustments that may impact on the cost per WTE). Increases in pay per WTE are related to incentive payments and increased numbers of staff self-isolating and on sick leave in the second surge as well as having to go out to more expensive agencies for cover. Pay cost per WTE has now increased outside of control limits due to very high levels of agency nursing and bank incentives. Back pay for the AFC Pay award was be paid in September 2021 leading to the sharp rise in pay cost per WTE in September 2021.

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Point of Delivery Productivity A&E

A&E cost per attendance and cost per WTE mirror the Covid-19 waves quite closely. A&E Spend increased by 50% in February 2021 due to an increase in additional Locum and Agency for both Medical and Nursing staff, impacting on cost per A&E attend. The Sept 2021 spike in £ per attendance and per WTE is related to the pay award and back pay. Although £ per attendance remains within control limits, a delay in coding of A&E activity led to an apparent reduction in complexity in August 2021, impacting on overall WAU. This has now caught up, but September 2021 coding appears low.

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Consultant Episodes

Acute cost per consultant episode and consultant episode per Acute WTE mirror closely the activity trends with the Covid-19 waves. Elective and Daycase activity dropped in August 2021, probably related to the summer holidays.

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Outpatients

As with consultant episodes, the acute spend per outpatient attendance mirrors quite closely the attendance pattern in the first Covid-19 wave. Outpatient activity did not deteriorate as much in the second wave but increased temporary staffing costs mean there was a bigger increase in cost per Outpatient attendance than reduction in outpatients in the second wave. Outpatient attendances, attendances per acute WTE and cost per outpatient attendance had been recovering following the second Covid-19 peak but have deteriorated in the last couple of months.

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Statement of Financial Position

The statement of financial position reflects a consolidated position with the inclusion of SWFTCS Ltd. Key movement in month is the £5.305m reduction in investments value to £0.672m, which reflects the current fall in share price of the Trust’s Sensyne Health investment. On initial recognition of the Sensyne shares, the Board of Directors took the decision to make an irrevocable election under IFRS 9 for equity instruments to reflect FVOCI. In doing this any movements in share price will then go through Other Comprehensive Income with increases or decreases in share price being reflected in an equity reserve.

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Cashflow The graph opposite shows the actual cash position, together with the monthly cash balance forecast for the year. The cash balance at the end of January 2022 was £28.911m for the Foundation Group. The 12 monthly rolling cash forecast is shown in the graph below.

A reduction in the Trust’s cash balances over the next 12 months is forecast due to internal resources used to fund the capital programme.

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At January 2022, the value of invoices on the Sales Ledger was £8.642m across 2,044 invoices (December 2019 was £9.303m across 1,989 invoices). The trend line reflects an improving position.

At January 2022, the value of invoices on the Purchase Ledger was £11.836m across 3,500 invoices (December 2021 was £11.198m across 3,738 invoices). An increase in the number of 0-30 days invoices is currently driving a deteriorated trend line, the new monthly £1.4m unitary payment invoices to Innovate Healthcare Services Ltd (Innovate) are now appearing in the monthly 0-30 day base line.

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The Better Payment Practice Code (BPPC) target is 95% of invoices to be paid within 30 days by number and value. The YTD performance by number is 86.3% (83.3% 2020/21).

YTD performance by value is 88.9% (82.8% 2020/21). Payments to NHS suppliers is also an area the Trust is now focusing on, with purchase orders now being raised to local providers to help improve the approval time of invoices.

TOTAL 30/04/2021 31/05/2021 30/06/2021 31/07/2021 31/08/2021 30/09/2021 31/10/2021 30/11/2021 31/12/2021 31/01/2022 TOTAL2020/21 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 YTD

By Value £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Non NHSTotal bills paid in the period 172,360 19,482 14,593 15,062 17,003 13,869 18,091 15,367 17,231 16,336 18,545 165,579 Total bills paid within target 154,004 17,542 13,837 14,076 16,030 13,654 16,594 15,004 15,911 15,781 16,652 155,081 Percentage of bills paid within target 89.4% 90.0% 94.8% 93.5% 94.3% 98.4% 91.7% 97.6% 92.3% 96.6% 89.8% 93.7%NHSTotal bills paid in the period 26,776 1,021 2,688 488 2,181 948 1,523 595 3,299 822 696 14,261 Total bills paid within target 10,793 774 942 477 529 195 127 588 341 290 551 4,814 Percentage of bills paid within target 40.3% 75.8% 35.0% 97.7% 24.3% 20.6% 8.3% 98.8% 10.3% 35.3% 79.2% 33.8%TOTALTotal bills paid in the period 199,136 20,503 17,281 15,550 19,184 14,817 19,614 15,962 20,530 17,158 19,241 179,840 Total bills paid within target 164,797 18,316 14,779 14,553 16,559 13,849 16,721 15,592 16,252 16,071 17,203 159,895 Percentage of bills paid within target 82.8% 89.3% 85.5% 93.6% 86.3% 93.5% 85.3% 97.7% 79.2% 93.7% 89.4% 88.9%

Better Payment Practice Code (BPPC) by value

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Capital Programme The Trust’s planned capital programme spend for 2021/22 is £22.807m, (January 2022 report £22.700m), an increase of £0.107m. The increase relates to £100k for the MacGregor playroom following a successful Public Dividend Capital (PDC) bid and a £7k increase in donated assets. The Trust has also recently been successful in a £1.273m Digital Aspirant Programme IT PDC bid. As this relates to IT the capital spend will be undertaken by Innovate, with the Trust using the £1.273m PDC to fund Innovate via a share/loan issue. A business case identifying the best use of this funding is currently being completed and will ensure the necessary Trust internal approvals are obtained before Innovate undertake any capital spend. The £1.273m is not shown within this report. The Trust has £4.357m remaining of its STP Out of Hospital (OOH) Digital Public Dividend Capital (PDC) allocation remaining and has just received written confirmation from Department of Health and Social Care (DHSC) for £2.909m of this funding to be rephased to next year, so that it can be used on the Ellen Badger Development Scheme. Actual spend in January 2022 was £1.655m, year to date £16.701m. Capital budget leads are committed to achieving the forecast outturn spend of £22.807m, with the largest area of risk being the ability at this stage in the year to spend all of the £1.6m of the Elective Hub TIF PDC funded scheme by yearend (the current associate risk is circa £0.5m). Recommendation

The Board is asked to note delivery of the Month 10 position for 2021/22.

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Data refreshed 04/01/2022

Completed mortality reviews for inpatient deaths (Dec 2020- Dec 2021) Completed mortality reviews for LD/MH/maternal/child deaths

Mortality Reviews - Trust-Wide (to Dec 2021)Lead: Associate Medical Director Governance

Deaths Assessed as “Avoidable” Sept ‘20 – Sept ‘21 4 avoidable deaths have been confirmed:

December 2020 – x3 Hospital acquired Covid (Oct MSC)April 2021 – x1 failure to treat hypothyroidism (July MSC)

All deaths undergo a screening mortality review by the Medical Examiners and are selected for more detailed reviews in accordance with the National Guidance on Learning from Deaths, in summary (in line with pause during Level 4 alert):• Consider discussing preferred place of care if patient deteriorating • To call outreach/ITU for early support • Escalation to medical team for patients who become acutely delirious • Consider early discharge particularly for patients from nursing homes. • Very clear documentation of regular discussion with NOK in last few days of life as patient

deteriorated. • Aggressive fluid resuscitation when treating sepsis is paramount to avoid cardiovascular

compromise. • Advanced care planning and support for RH in caring for the dying patient.

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Mortality Reviews/Medical Examiner (ME) Data (July-December 2021) – Trust-wideLead: Associate Medical Director (AMD) Governance

The patient safety team have reconciled December 2021 Lorenzo Mortality and ME data.

December 2021: 107 Deaths (including 8 ED death) which underwent an initial ME office review. 83 deaths proceeded to ME screening. 24 were not screened as they met Coroner referral criteria and so fall outside the ME remit (family support still provided)

• 11 - following review the Coroner agreed SWFT could issue the death certificate• 13 - cause of death to be determined at post mortem and/or the Coroner

1 not screened as it was a paediatric death (reviewed by the Child Death Overview Panel (CDOP) and the Coroner instead of MEs).

Of the 83 deaths screened by MEs, 4 were passed to the AMD for Governance to request Structured Judgement Reviews (SJR): • 1 with Learning Disability (SJR awaited, review to be sent to CCG as part of LeDer review process) • 1 with Severe Mental Health (SJR requested and awaited)• 2 Concerns raised regarding care:

• 1. Delay in antibiotics (awaited SJR) and • 2. Suspected accumulation of beta-blocker (reviewed by AMD – deemed unavoidable)

Of the 83 deaths, to date 0 has had a Mortality review completed by the speciality. No issues of concerns or learning identified.

It is planned to automate the reconciliation process if possible and also to expand this to include learning as identified by the Medical Examiners and reasons for Coroner referrals (in particular if there are family/clinical concerns). A meeting arranged by the AMD for Governance took place November to discuss a better IT solution. 54/57 81/193

Mortality - Trust-Wide (deaths data to December 2021)Lead: Associate Medical Director Governance

Summary Hospital-level Mortality Indicator (SHMI)

Latest available quarterly SHMI is for Nov 2020 - Oct 2021 and stands at94.27 (local) and 97.08 (Peer).

Learning from mortality reviewsis shared widely throughout theTrust via, for example, Audit andOperational Governance Groups,Grand Rounds, MultidisciplinaryMortality Meetings, SpecialityGovernance Meetings, ePulse,Patient Safety Monthly Reports,Newsletters, Safety PracticeAlerts, screensavers, andInvestigation reports. ThePatient Safety team monitorfollow up of actions and progressreported at the relevant AOGG.

Recent learning (from mortality reviews received in January 2022)• Due to multiple ward moves and multiple different consultants there

was a lack of 'step-back' and recognition of recurrent frailty decompensations, infection and progression of frailty.

• Unclear what determined this lady being admitted under T&O rather than frailty as non-operatively managed fracture.

• Consider RESPECT decisions early on in each admission. Assess during these decisions whether readmission should be avoided considering patient’s wishes and co-morbidities.

The Chief Medical Officer has confirmed that routine sampling specialty mortality reviews to be paused during Level 4 alert.

Learning from deaths of patients with learning disability (LeDeR):A national report into Learning from the deaths of people with a learning disability) 2018-2020 has recommendations for national bodies such as NHS England, DHSC, the Chief Coroner and NHS Improvement, Royal Colleges etc.. There were no direct recommendations for the Trust. The report will be sent to the learning disability team for local learning and knowledge and to the Mortality Surveillance Committee for information and discussion.

Autism – LeDeR reviews for deaths for patients diagnosed with autism is expected to start shortly, following release of a provisional definition by NHSE. Further details awaited.

1 death was reported to LeDer in January 2022 & a mortality review requested, which will be shared with the CCG.2 mortality reviews from November & 1 from December still awaited – responses have been delayed due to Level 4 Covid pressures on Clinicians, CCG are aware.

Learning themes from Coventry/Warks LeDer reviews include: completing MCA/DOLs assessments, considering safeguarding referrals for patients at risk of self-neglect, listening to familyand ensuring sepsis pathways are started promptly

2. HSMR Rolling month/average - Peer WVT and GEH

1. HSMR Rolling month/average – Peer Small acute Trusts

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SWFT Mortality Dashboard – HSMRNovember 2020 – November 2021

National Comparison

SWFT compared with Foundation Group

Rolling monthGEH SWFT Wye

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SWFT Mortality DashboardSWFT Compared with Foundation Group

Monthly Radar chart

SPC Chart CuSum chart

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Subject Monthly Safe Staffing Report Agenda Item 7.3


Nature of item

For decision

Decision required


Report Author Rebecca Moore, Head of Nursing Emergency Division

General Information

Lead Director Fiona Burton, Chief Nursing Officer




Funding Source




Confidential (Y/N)(If yes, give reasons)

No


Ownership Trust



Yes

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Monthly Safe Staffing Report

Executive Opinion

This report is an update to the Board of Directors regarding safe staffing in relation to Nursing, Maternity and Allied Health Professionals (AHP). Assurance remains that the organisation has oversight of these different disciplines and specialities, and this is monitored on a regular basis at Divisional level with mitigating actions being taken when gaps exist. Fiona Burton Chief Nursing Officer

Executive Summary

This report provides information related to the safe staffing across inpatient and out of hospital Nursing, Family Health, Maternity and AHP services. It provides information about gaps against planned rosters, incidents, sickness, vacancy, and parental leave and mitigating actions being taken to address any risks. It provides a summary of recruitment for these groups.

Recommendations

Continue senior Corporate Nursing monitoring of Nurse Staffing (Corporate Nurse of the day Rota) as an assurance, supporting anticipated challenges and keeping oversight of risks to quality, safety and wellbeing and the mitigations in place.

Human Resources to ensure managers are supported to manage sickness and absence in all areas to facilitate return to work in a timely and supportive manner.

Continue the recruitment activity, prioritising those teams with the highest vacancy risk.

Continue the recruitment, arrival and induction of international recruits including good pastoral care.

Operational and clinical managers to ensure they work to rostering principles and Key Performance Indicators (KPIs) to staff their area safely and effectively with available resources.

Divisions to continue to monitor Staffing Risks on their registers, review mitigation measures and update regularly.

Continue to promote career development for our workforce, supporting opportunities for talent management as part of a retention strategy.

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1.0 Introduction

This report is an update to the Board of Directors regarding safe staffing in relation to Nurse and AHP staffing in the Emergency and Elective Division, Maternity Service, Family Health Division, and the Out of Hospital Care Collaborative (OOHCC) based on the whole month data for January 2022.

2.0 Inpatient Nurse Staffing

Graph 1 indicates the overall gap in relation to planned Nurse staffing levels versus actual Nurse staffing levels in inpatient areas for January 2022.

Graph 1

In November 2021, the data indicated average staffing levels were 1% below planned for all areas across all shifts. In December 2021 this was 4% increasing further to 5% in January 2022.

Further detail is provided in Graph 2 with associated narrative for wards above or below planned staffing levels.

As an average figure, this should be viewed in context. The staffing levels during the day demonstrated a 6% gap for registered staff and 14% gap for unregistered staff. The night staffing was 8% above planned for registered staff and 4% below planned for unregistered staff.

The demand has continued to rise due to the sustained use of extra capacity beds on Squire Ward and additional use of our assessment areas overnight.

95%

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The increase in expected staffing overnight can also be attributed to patients requiring 1:1 care or increased acuity in an area.

Staffing above a template would always be done in agreement with the General Manager (GM) and in discussion with the Matron or Head of Nursing (HoN).

Graph 2 and 2a indicate areas shown in red, where there is a difference in percentage of either being staffed above or under the planned template for January 2022. Staffing above the expected template is apparent in those wards that have needed to provide one to one care for patients with high risk of falls or self-harm. This is done in conjunction with a patient risk assessment and is monitored by the Matrons and GMs.

Graph 2

Graph 2a

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Over the month of January 2022 Charlecote Ward required 124 Registered Mental Health Nurse (RMN) shifts to provide one to one care to one patient. Two RMNs 24/7 is equivalent to another 4.3 Whole Time Equivalent (WTE) Nurses being needed in addition to their funded template of 13.05 WTE Registered Nurses (RNs) hence the continued unusual appearance of the overstaffing over the last 4 months.

Charlecote Ward had one long stay patient with complex and challenging mental health needs who resided 4 months on the ward and who has required 2 RMNs day and night to manage the patient’s risks. This individual had been escalated to System level due to multiple organisational involvement in their placement. The patient has now been discharged on 8 February 2022.

Greville Ward, Beaumont Ward and Squire Ward appear to have a gap for staff on the graphs; however, over this period there were times when there were fewer patients and therefore rostered staff were redeployed to other areas. As these shifts are not optional, this will show as a gap and influence the overall figure reported.

Avon Ward continues to run the Covid Medicines Delivery Unit which is additional to their current template.

Ellen Badger Rehabilitation Ward moved over to Campion Ward in Leamington on 5 January 2022. There was a phased approach to increasing the bed base and staffing levels across the month which resulted in the appearance of a gap.

The Corporate Nursing Team continue to work closely with the wards, Operational Managers and Site Capacity team to manage staffing safely in accordance with the agreed Procedure for Nurse Staffing Escalation. This includes the Corporate Nurse of the Day for Staffing rota to provide senior nursing oversight and support to the Site Capacity Team and Wards.

The Clinical Lead for Provisional Nursing and AHP Staffing is assisting on a daily basis particularly in areas with high levels of temporary staff or extra capacity. The Chief Nursing Officer (CNO) remains confident in the ongoing scrutiny and responsiveness to maintain safe staffing.

3.0 Staffing Related Incidents

Graph 3 shows the spread of the incidents by area for January 2022.

In January 2022 there were 46 incidents reported in regards to inadequate staffing levels this saw a reduction from 79 in December 2021. This includes non-clinical and medical staff.

Maternity services including Antenatal, Bluebell, Swan, Labour and Special Care Baby Unit (SCBU) combined accounted for 24% of all staffing incidents. This is lower than in previous reports but still reflects the high acuity and gaps due to parental leave, vacancy and sickness. This is also indicative of a positive reporting culture. Shortfalls in maternity were managed through redeployment of staff from other areas in Maternity, specialist Midwifes or on call Maternity Managers. Further detail of mitigations are in section 7.0 Maternity Services.

All of the incidents were no harm, however it is accepted that some are likely to have impacted on both patient and staff experience.

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The consistant theme was high acuity, complexity of the patients and those requiring increased supervision due to confusuion or a mental health crisis. Shortfalls caused by sickness and self isolation at short notice across all disciplines increased over this period.

Graph 3

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Non-Clinical Staff Shortages

Inpatient Nurse/HCA staffing below establishment/acuity levelStaffing/acuity below the minimum level in all maternal/neonatal settings

Staffing Incidents by Category & Sub-category (January 2022)

Category

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Graph 4 describes the category of incident, the most common reporting being amongst Nursing and Midwifery staff.

Incidents relating to safe staffing, themes and risks are reviewed by the Head of Nursing and Matrons in Maternity and Nursing and support and feedback offered to staff as appropriate.

4.0 Breaches in 1:8 Staffing Ratio Nursing

Once validated with the Matrons and the rosters, data which compares unplanned breaches in the 1:8 ratio indicated a total of 78 shifts in January 2022. This is an increase on previous months which is reflective of the staffing challenges due to short term sickness, maternity leave and staff needing to self-isolate at short notice.

There was no correlation between the areas with the highest number of breaches and staffing related incidents.

Where breaches have occurred, it is often by a narrow margin i.e. 1:9 or 1:10 and on analysis there are usually other staff present on a ward that mitigate any risk such as Band 4 Associate Practitioners, students and therapists, and ward managers on management days.

It has been agreed that wards will be supported to recruit against vacancies caused by parental or other long-term leave and the Trainee Nurse Associates and Apprentices.

5.0 Vacancy Position

Graph 5 shows the registered and unregistered nursing vacancy gap for January 2022 18.05% excluding Bank Staff. Which showed a small decrease from 18.25% in December 2021. The figure is 9.60% including Bank Staff. This is an overall figure and should be noted that this includes those on parental leave and sick leave so the vacancy rate for positions we can actively recruit to is 10.98%.

A new risk has been added for Beauchamp Ward for the Nurse staffing which sees a 78% registered nurse vacancy and 80% unregistered staff vacancy. This sees a heavy reliance on temporary workforce and moving substantive staff from other wards to ensure safety. The ward are advertising for a variety of roles and are signed up to the Band 1 Clinical Support Worker (CSW) Apprenticeship Programme and have some international nurses starting in the coming months.

The Central England Rehabilitation Unit (CERU) is also on the Support Services Risk Register for staffing. Vacancies are across both wards. Two Band 5s recruited and currently advertising for Band 5s and Band 4 Nurse Associates. CERU recently held a nurse recruitment meeting with the multidisciplinary team. Ideas for recruitment were discussed and an action plan is in place. This included meeting with Coventry University to discuss possibility of joint roles across both organisations. Recruitment events are to be arranged and promotional filming of roles is to be arranged.

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Graph 5

Graph 6 shows starters and leavers over a rolling 12-month period.

There were no specific trends with permanent leavers in January 2022 and it was consistent with previous months. The highest number of permanent leavers were CSWs with 17 leavers and Nursing and Midwifery Staff with 20 leavers. These two staff groups consistently have the highest levels of leavers each month. The bank office also continued with the data cleanse to remove bank staff who haven’t worked for the Trust in a considerable amount of time. This is to cleanse the database and ensure the Trust are targeting bank staff who wish to work for the Trust..Please note the large spikes in leavers in June 2021 and August 2021 relate to the Junior Doctor Rotation and the addition of the Information and Communication Technology (ICT) leavers in November 2021 when staff transferred to Innovate Healthcare Services Ltd (IHS).

It is worth noting that there were 245 more starters than leavers over the rolling 12-month period (excluding the ICT transfer to IHS). It demonstrates that while recruitment is healthy, retention rates need to be considered in order to reduce the number of voluntary leavers as this will help the overall staffing numbers. This is particularly the case with the retention of CSWs and Nurses.

Of the 88 new starters in January 2022 there were 25 registered nurses, 4 AHPs, 1 Registered Midwife and 30 CSWs.

Graph 6

The Trust is currently running a number of Recruitment Campaigns in order to promote roles across all staff groups. We are running social media campaigns to attract passive and active

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job seekers. In addition to this we are holding more events (in line with Covid guidelines) in order to attract as many candidates as possible. There is a plan to hold a Trust wide Recruitment Open Day in the Spring. This is to have a big push in recruitment in order to offset potential leavers and reduce our vacancies. There is obviously a focus on nursing staff in both Acute and Community teams, however we are always actively targeting AHPs and all other roles to the Trust.

The challenges remain similar to previous months in that we are still trying to recruit and attract staff into areas of concern. These areas are concentrated in Acute Wards across the Trust.

There are positives in that we are still having large numbers of people apply to the Trust and are seen as an Employer of choice across the region. The Trust had 1696 applications in January 2022. This is a large increase on the previous month where we had 1026 applications in December 2021. This had been expected as January 2022 is generally seen as a month where we receive increased numbers of applications.

It demonstrates that while recruitment is healthy to the Trust as a whole a relatively small improvement in retention will have a huge positive effect on overall vacancies within the Organisation.

6.0 International Nurse Recruitment

The Trust is recruiting from India in line with ethical responsibilities as per the NHS People Plan. There was a pause earlier in the year to international nursing recruitment due to Covid travel restrictions. 10 nurses were recruited in January 2022, 3 started within the month and an additional 20 international nurses will be recruited by the end of March 2022.

The Trust has a robust induction and support process for these candidates and will continue to offer the high standard of pastoral care and support all new starters need to settle.

7.0 Maternity Services

The midwifery service recruited 3.93 WTE CSWs in January 2022 leaving a vacancy of 0.31. Of the 3.4 WTE vacancy, 3.0 WTE Midwives are currently in the recruitment process and due to start shortly with 0.4 to be carried over with posts currently in Approval to Recruit (ATR) process. There are plans to commence the recruitment process in February 2022 for possible recruitment of our student midwives and any external candidates that may apply. SCBU have successfully appointed 2 international nurses one to commence in February 2022 and another in March 2022.

Safe staffing is being maintained through the use of bank staff and the redeployment of midwives to different clinical areas and use of specialist midwives if required. The midwifery manager on-call is no longer providing clinical support during night shifts and to date no additional presence has been required during on-call periods.

Chart 8 shows the trend of vacancies over the last 3 months and Charts 9 and 10 shows the challenges faced with Midwifery and SCBU staff unavailable to work due to sickness and absence. The division has been allowed to recruit into the vacancies created by parenting leave.

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Chart 8

Vacancy WTE

%

November 2021

Midwives 2.59 2.2%CSW’s 2.27 9.1%

December 2021

Midwives 1.97 1.67%CSW’s 3.87 15.5%January 2022Midwives 3.4 4%CSW’s 0.3 2.5%

Chart 9

Sickness & Parenting Leave

November 2021 WTE %Midwives 7.22 6.04%Parenting 10.12 8.46%CSW’s 3.02 12%Parenting 2.51 10%December 2021Midwives 7.23 6.04%Parenting 11.05 9.24%CSW’s 3.06 12.2%Parenting 1.99 7.9%January 2022 WTE %Midwives 3.66 6.5%Parenting 3.38 5.9%CSW’s 1.69 13.3%Parenting 0.96 7.5%

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SCBU

Chart 10

November 2021

Sickness Registered 11.2%

Unregistered 4.5%

Total 9.7%

Parenting Leave 3 WTE 15.6% of registered staff

Long term sick 1.5 WTE 8% of registered staff

December 2021Sickness Registered 11.72%

Unregistered 14.06%

Total 11.61%Parenting Leave 3 WTE 15.6% of registered staffLong term sick 1.5 WTE 8% of registered staffVacancies Band 5 36 hours (0.96 WTE)

January 2022Sickness Registered 2.09 WTE 9.8 %

Unregistered 0.36 WTE 8.31%

Total 2.45 8.8%Parenting Leave 2.98 WTE 15.6% of registered staffLong term sick 1.5 WTE 8% of registered staffVacancies Band 3 27 hours (0.72 WTE)

Work on the current way birth to midwife ratio is calculated so in line with the Local Maternity Network. Chart 11 shows the birth to midwife ratio over the last 3 months where you can see there has been a drop in January 2022 in line with the increase in vacancy and unavailability. The staffing risk has now been added to the Maternity Risk Register - Risk ID 1630.

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Chart 11

November 2021 99.7%

December 2021 99.6%

January 2022 97.8%

Birth to Midwife Ratio: November 2021 1:33

December 2021 1:29

January 2022 1:29

The team have received support from the CNO and Divisional Associate Director of Operations (ADO) and have agreed for parenting leave to be back filled with 5 WTE substantive posts plus an additional 2.68 WTE to enable the number of midwives on a night shift on Swan Ward to increase from 2 to 3 which have now been now appointed to.

The ward Coordinators are to report incidents on Datix when unable to be supernummery on shift to ensure robust reporting and to evidence the inability to meet Clinical Negligence Scheme for Trusts (CNST) requirement with current staffing allocations and establishments.

The following measures are in pace to support safety:

1. Sickness is being managed proactively by the maternity managers with the support of Human Resources (HR) and in liaison with Occupational Health.

2. Some of the long term sickness have an anticipated date of return 3. Escalated to CNO for additional support who is also our Maternity Safety Champion4. Recruitment to South Warwickshire NHS Foundation Trust (SWFT) bank pool from local

maternity services5. Utilisation of independent agency staff (SCBU)6. Redeploying specialised Midwives to cover essential clinical shifts7. Reducing the number of management hours of Midwives in managerial positions8. Non-essential training cancelled – CNST risk to the organisation. 9. Non-essential Maternity Services rescheduled/cancelled e.g., parent education/tours of

the unit10.Daily staffing meeting with the Ward Managers to review staffing, vacant shifts and

identification of flexibility within the rosters e.g., training, management time11.Recruitment support enhanced to augment the process12.Bank staff requested for support roles e.g., CSW, Ward Clerks and administrative staff13.Sharing and communication of the actions being taken with the senior team to support

and address the concerns raised from the clinical area

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14.Monthly HR meetings now in place with Matrons and Managers to monitor and manage staff absences

15.Use of the maternity escalation policy, suspending the Bluebell Birth Centre (BBC) and homebirth service.

8.0 AHPs

Theatres

Staffing continues to be a monitored risk within Theatre Services. Meeting service needs on a day-to-day basis is complex with the present junior / inexperienced workforce. Staffing is managed daily to accommodate changes.

Vacancy Factor

Registered: 29% down from 33.3%Unregistered: 39% up from 33.2%

The demands are met by senior staff undertaking a high percentage of clinical activity and substantive staff agreeing to work overtime. Many of these have retired and under present arrangement have no restrictions on hours worked having a financial impact on their pension. However, if as planned the cap is re-introduced in April 2022, this will dramatically reduce the hours they are able to work. This has been raised with HR to see if there can be a local solution to this national change. 12 WTE agency Practitioners are working regularly and being block booked for consistent cover.

Theatre Services have a number of positions from Band 7 to Band 2 being advertised and an external company is coming on site in February 2022 to make a promotional recruitment video to include staff interviews and role play demonstrating roles available within the department.

There were 2 new appointments in January 2022, a Band 5 Operating Departmental Practitioner (ODP) and a Band 5 Registered Nurse.

In addition, 3 Trainee Assistant Practitioners have successfully completed the course and commenced as Band 4 Assistant Practitioners and are following Scrub Induction within Elective Orthopaedics/Urology/Laparoscopic Colorectal. A Band 4 Nurse Associate commenced presently following Recovery Induction. Over the same period, 3 unregistered staff have left for alternative careers or progression.

The department have plans for an open morning in April 2022 to showcase the opportunities available in Theatre services.

Occupational Therapy

In Occupational Therapy (OT) and Wheelchair Services, they have a current risk assessment in place for difficulty in recruiting to Band 5 rotational posts. OT has had long standing vacancies of more than 28% of rotational Band 5’s, this month reduced to 18% which is positive to see.

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Short term projects/additional bed capacity creates gaps in staffing as unable to fill fixed term contracts or agency posts. OTs rely on existing staff for bank shifts as no other bank resource available.

OT currently has 3 level 6 OT Degree Apprenticeships with Coventry University, 1 in year 1, 2 and 3 and this is working well. There is a plan is to progress with 2 x 2 year OT Master’s Degree Apprenticeships as supernumerary to support workforce and ensure our own growth for the future workforce.

As Divisions expand their services or capacity, the demand impacts on AHP capacity accordingly and as it tends to be the Band 5’s who are promoted this results in internal staff moves and a gap elsewhere. There is a national shortage of newly qualified OTs resulting in a gap in the workforce.

Physiotherapy

Physiotherapy were currently holding a new risk for lack of Band 6 Physiotherapists to run the Musculoskeletal (MSK) and Inpatient Services. With 13.1 WTE Band 6 vacancies for either permanent or fixed term positions, the team are scoping international recruitment for these posts.

There is a new Lead for AHPs due to start soon who will sit in the Support Services Division providing much welcomed leadership, support and guidance for our diverse AHP services.

9.0 OOHCC and Community Care

North PlaceBudgeted = 173.57 WTE Vacancies = 19.56WTE – 11.26%

Rugby PlaceBudgeted = 124.70 WTEVacancies = 13.3 WTE – 10.66%

South PlaceBudgeted = 325.03WTE Vacancies = 41.95WTE – 12.90%

Successes

All Place Based Teams (PBT) Roster Reviews completed with the Professional Lead, Locality Manager and Quality Matron

New Physio Ward Manager commenced and Ellen Badger moved to Campion in January 2022

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Sickness Absence at Place

Top 3 Sickness reasons

Anxiety/Stress/Depression/Other Psychiatric Illnesses Infectious Diseases Other Musculoskeletal problems

There are currently 11 formal Sickness Absence Management cases ongoing within Adult Services. 8 are at Stage 1, 3 at Stage 2 and 0 at Stage 3 (Capability Hearing).

Professional Leads, Locality Managers, Quality Matron and GMs are working hard on supporting staff. Psychological support is also regularly accessed and HR support for long terms sickness cases with alternative ways of managing and working to help support an earlier return to work.

Wellbeing and Self Care sessions have been organised by the Quality Matrons with SWFT Wellbeing Officer for February 2022 for all Band 6 staff as a pilot and will be extended to all staff on rolling months.

% WTE Days Sickness NOVEMBER 21 DECEMBER 21

North PLACE 8.36% 7.42%

Rugby PLACE 9.39% 9.27%

South PLACE 8.12% 8.65%

Division 8.36% 8.31%

Parenting leave North Place 6.14%Rugby Place 1.14%South Place 3.23%Division 3.49%

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TurnoverNOVEMBER 2021 DECEMBER 2021 JANUARY 2021

North Place 2.62% 1.52% 2.50%Rugby Place 1.5% 2.67% 0.66%South Place 1.46% 1.57% 2.38%Division - - 1.99%

Starters Headcount Leavers HeadcountNorth Place 6 North Place 5Rugby Place 4 Rugby Place 1South Place 6 South Place 9Division 16 Division 15

Staffing Risk Assessments

North Place

Atherstone Staffing Risk ID 1064 - Score 12 - Staffing is reduced due to maternity leave, unfulfilled vacancies.

Staffing North Place Based Teams 2-4 Risk ID 1628 – Score 8 - Compromised staffing levels within Place based team’s 2-4 North place due to staff shortages leading to a possible detrimental impact on patient quality of care.

Rugby Place

Rugby Place staff physical and psychological wellbeing. Score 8 to be reviewed at Quality and Performance meeting 17 February 2022. Staff physical and psychological wellbeing and patient safety is at risk due to staff shortages resulting in a possible increase in patient complaints as low priority visits being rescheduled in line with team capacity.

South Place

South Place Urgent Response (Warwick and Stratford) Score 12 - Compromised staffing levels within Urgent Response Team South due to staff shortages resulting in a significantly reduced effectiveness of service delivery and detrimental impact on patient care and staff wellbeing.

Campion Ward – Score 12 – Campion rostered establishment bed state of 19-20 increased to 25 with vacancy factor of 5.95 WTE directly impacting quality and an increase risk of patient harm.

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10.0 Childrens Services, Community Nursing Teams and Health Visiting.

Warwickshire 0-5 yrs and Solihull 0-19 yrs.

There continues to be challenges with recruitment and retention and work is happening within the division to support new starters with the retiring Clinical Leads coming back to supervise the new starters and provide supervision and support. Band 5’s are being recruited to fill Band 6 vacancies with the acknowledgment that they will go onto do the Health Visiting (HV) Apprenticeship and return to Band 6 posts as qualified HVs.

It is being scoped to see if an increase HV students from 4 to 8 can be accommodated and has been requested in Warwickshire and Solihull. Additional recruitment in Breast feeding support workers in Rugby increases both service offer and a release of HV time. Rugby remains a concern with regards recruitment. Workloads are being shared across county for virtual appointments and antenatal universal contacts dropped. Risk register kept locally and at divisional level.

A digital marketing post (part-time) is to be advertised to cover all communications and administer the website.

Current Vacancy position

Sickness

Staff are working with HR to help staff to return to work. Several members of staff have had personal losses recently and 3 members of staff are suffering from long Covid. Health & Wellbeing issues are addressed in all teams with local champions and input from the Perinatal Mental Health Visitors.

Area Band WTE Vacant Recruited To Advert Out

Warwickshire 0-5

Band 6 Rugby

Band 6 Countywide

Band 2

5.06 WTE

4.65 WTE

4.89 WTE

Applicants interviewing for 1.2 WTE

No

No

Yes for the rest/ Band 5 being recruited from WTE vacancy

Yes

Yes

Solihull HV Band 6 2.0 WTE No 1 WTE to start end of February1 WTE to convert to Band 5

Solihull S/N Band 7 1.0 WTE No Yes internal and external

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Coventry Family Health and Lifestyle

Workforce

Data for all Banding within service

HV Service

School nursing Service

Family nurse partnership

Stop smoking in pregnancy service

Infant feeding Service

Be active be healthy Service

Service Total

Head count = 99 WTE

Head count = 26 WTE

Head count = 5.9 WTE




148.2

Overall sickness % 5.28%

Overall sickness % = 9.88%

Overall sickness % = 1.3%

Overall sickness %

= 0%

Overall sickness % =0%

Overall sickness % =14.16%

6.12%

% of workforce currently

on sickness

leave

Mat Leave = 4.6%

Mat Leave = 0.3%

Mat

Leave = 0.6%

sickness Covid-19 related

2 0 0 0 0 0 0

Number of staff Self-isolating

3 1 0 0 0 0 4

Vacancies

0.8 WTE Band 33.6 WTE Band 6

2.6 WTE

Band 50.7

WTE Band 2

0.8 WTE 0 0 0

Sickness

There is currently 10.3 WTE across the whole service on Long term sickness due to Anxiety/Depression, Bereavement, Cancers, Covid and Injury. The short term sickness has reduced overall. All sickness is being managed in line with the Trust Sickness policy with HR support.

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Retention and Recruitment

Health Visiting:

Our 10 Band 5 staff recruited for Health Visiting will all be in post from February 2022, x1 to commence in March 2022. All new Band 5 staff complete 1 month induction process to the service. There are 4 WTE Band 6 HVs commencing in post February 2022, these are newly qualified staff so will require induction for 1 month. Although the recruitment and retention within Health Visiting stabilised slightly over the past couple of months there are an additional 2.7 WTE experienced HVs from April 2022, due to two retirements and two promotions to Multi-Agency Safeguarding Hub (MASH).

School Nursing:

A new post was created and recruited to a new Band 7 Clinical Lead for School Nursing.There is 1 WTE Band 6 School nurse commencing in post February 2022.

All outstanding vacancies are out to advert via NHS Jobs.

Sickness has remained a challenge for January 2022 however has decreased from 8.44% to 6.12%. We have seen an increase for School Nursing sickness with 3 WTE Band 6 staff on long term sick, unfortunately these are serious illnesses for all staff concerned and they will be all on Long Term sick for the foreseeable future.

Risk

Both School Nursing and Health Visiting services are currently held on the Trust Risk register due to capacity issues and is reviewed on a monthly basis.

Community Childrens Nursing Team (CCNT)

The team remain on the risk register for staffing shortages reviewed monthly at Family Health Division Health and Safety meeting

They continue to run a Facebook campaign supported by the recruitment team, for recruitment in all bands of staff which has been much more successful than previous campaigns. Our percentage of vacancies has gone down to 8%.

The current challenge is recruiting Band 6 Nurses, though this has improved since last month, it now only sits at 2 WTE vacancy at present. The team have recruited 1 Nursing Associate registered with an aim to recruit more to supplement the Band 5 gap.

A partnership model working with Acacium Group has been used to try support 1 care package that has been challenging for the team to fulfil, this has enabled support to one family whilst the team recruits into vacancy.

Recruitment are supporting the team to gain funding to undertake a video showcasing the team.

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11.0 Nurse Staffing Acuity Update

As the majority of recommended adjustments from the previous acuity review have been made in the intervening months, and some have taken longer due to the need to align the establishment, budgets and financial ledger it is not recommended that all wards are reaudited in the near future.

There will be targeted acuity reviews in March 2022 for areas where the Heads of Nursing and Matrons have identified the need for further analysis based on their experience of daily staffing management over the last 6 months.

These are Nicol Unt, MacGregor Ward and Feldon Ward. In the meantime, the Clinical Lead for provisional Nursing and AHP Staff has been asked to continue to lead roster reviews across all areas and work with the Matrons and GMs to optimise existing staffing deployment through good rostering practice.

12.0 Conclusion

This report provides assurance that the organisation has good oversight as regards safe staffing across all Divisions and continues to adjust to the changing demands and the challenges across our services. Teams are working together to prioritise patient safety and staff wellbeing with a good and transparent reporting culture.

The vacancy position is being proactively managed, and we remain in a strong position to recruit and retain talented staff who believe in our values. Management of staff unavailability is carried out in a supportive manner.

Our quality and safety data consistently reports our patients to be safe and well cared for and that Divisions have good oversight of risks and so the Board of Directors should be assured that scrutiny and oversight of safe staffing remains robust and responsive to patient needs.

13.0 Recommendations

Continue senior Corporate Nursing monitoring of Nurse Staffing (Corporate Nurse of the day Rota) as an assurance, supporting anticipated challenges and keeping oversight of risks to quality, safety and wellbeing and the mitigations in place.

HR to ensure managers are supported to manage sickness and absence in all areas to facilitate return to work in a timely and supportive manner.

Continue the recruitment activity, prioritising those teams with the highest vacancy risk.

Continue the recruitment, arrival and induction of international recruits including good pastoral care.

Operational and clinical managers to ensure they work to rostering principles and Key Performance Indicators (KPIs) to staff their area safely and effectively with available resources.

Divisions to continue to monitor Staffing Risks on their registers, review mitigation measures and update regularly.

Continue to promote career development for our workforce, supporting opportunities for talent management as part of a retention strategy.

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Recommendation


Fiona BurtonChief Nursing Officer

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Subject Maternity Governance Report Quarter 3 2021/22

Agenda Item 7.4


Nature of item

For decision

Decision required


Report Author Linda Ward, Associate Director of MidwiferyGeneral Information Lead Director Fiona Burton, Chief Nursing Officer




Funding Source

Place/Lead Provider Group Wide Sharing Recovery of Services Health InequalitiesUrgent Care Pathways Reducing Delayed Diagnosis Hospital Discharge Sustainability




No


Ownership Trust



Yes

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Maternity Governance Report Quarter 3 2021/22

Executive Opinion

This comprehensive report provides a high degree of assurance to the Board of Directors that the Maternity Department at South Warwickshire NHS Foundation Trust (SWFT) is safe and the leadership team are fully cognitive of their current position against all safety and quality key performance indicators and are focussed on continuous improvement in terms of the recommendations and requirements of Ockenden, Kirkup, Saving Babies Lives and Continuity of Carer implementation.

Recommendation



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Maternity Governance Report Quarter 3 2021/22October 2021 – December 2021

1. Purpose of Report

This report provides assurance that maternity services have the appropriate oversight and governance arrangements in place to robustly monitor and triangulate a safe, effective, caring, responsive and well-led service.

2. Healthcare Safety Investigation Branch (HSIB) Cases

Cases to date

Total referrals (In year) 16

Total for quarter 1

Referrals / cases rejected 6 (2 lack of family consent, 1 duplicate entry, 1 congenital abnormality, 2 with no harm on MRI and did not meet new HSIB COVID-19 criteria)

Total investigations to date 10

Total investigations completed

8

Current active cases 2

Exception reporting 1 (Case MI-003419, delayed as the PM report was outstanding – draft report now with organisation.

3. Mortality Cases

New cases for the quarter.

Extended Perinatal Deaths

Total for quarter 5

Stillbirth 3

Neonatal deaths 2

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The following cases were reviewed and closed in the last quarter as part of the Perinatal Mortality Review Tool (PMRT) review.

Case 1Case Description: Intrauterine Death (IUD) >24 weeks gestation.Date: 24/07/2021Category: Intrauterine Death (IUD) >24 weeks gestation.Web number: Web 92797Cause of Death: Unknown - The PM results and the maternal investigations were inconclusive and a cause of death was undetermined. DOC completed: Yes Family input: The family did not have any questions. Grading of care up to confirmation the baby had died: A - The review group did not identify any care issues.

Grading of care up to confirmation the baby had died: B - The review group identified care issues which they considered would not have made a difference to the outcome.Issues identified

SUDIC Policy not activated at the time of death/ admission to hospital services.Learning points/Actions Plan:

Full review of the Sudden Unexpected Death in Childhood (SUDIC) policy. Reminder to paediatric and midwifery teams on when a SUDIC review should be

activated.

Case 2Case Description: Intrauterine Death (IUD) >24 weeks gestation.Date: 09/05/2021Category: Intrauterine Death (IUD) >24 weeks gestation.Web number: Web 89871Cause of Death: Unknown - The Post Mortem (PM) results were not available at the time of review so a cause of death has still not be established.DOC completed: Yes Family input: The family provided questions that were answered by the review panel. Grading of care up to confirmation the baby had died: B - The review group identified care issues which they considered would not have made a difference to the outcome.Issues identified

Urine samples were not followed up appropriately. Learning points/Actions Plan:

Reminders to staff about care pathways and documentation of observations.

Case 3Case Description: Intrauterine Death (IUD) 22-24 weeks gestation.Date: 22/07/2021Category: Intrauterine Death (IUD) >24 weeks gestation.Web number: Web 96766Cause of Death: Extreme Prematurity DOC completed: Yes Family input: The family did not have any questions. Grading of care up to confirmation the baby had died: B -The review group identified care issues which they considered would not have made a difference to the outcome.Issues identified

MDT input and pre-term delivery risk counselling not undertaken as per British Association of Perinatal Medicine (BAPM) Guidance.

Learning points/Actions Plan: Guidance to be shared with all staff. Ensure correct prescription of Cabergoline. Improvements in documentation. Update local guidance to reflect BAPM.

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4. Clinical Negligence Scheme for Trusts (CNST) - Maternity Incentive Scheme (MIS) Year 4

MIS – Year 4 runs from August 2021 – June 2022. This is an update and predicted likelihood of meeting the actions and a small summary on progress and issues.

Likely Meet

Possibly Meet

Likely not meet

Not met already

SA 1 – MBRRACE One of the standards to change in October was the initial notification of cases to MBRRACE from 2 days to 7. We had hoped this would make this more achievable

In January we were made aware that we missed a surveillance deadline of 27 December 2021. In view of the paused programme we do not currently know the impact of this on our compliance but it is likely that we do not meet this safety action

This missed reporting has been addressed

SA 2 – MSDS It is likely that this safety action will be met. The data team continue to use the provided tool. There are some issues with data completeness that we are working with Badger net and Wye Valley NHS Trust maternity unit to work out how our data is not meeting the criteria. Looking at the national reports there are no trusts that meet all the reporting requirements within safety action 2

SA 3 – Transitional care

Likely to meet but a large amount of work is required and a clear lead still needs to be identified to lead and help embed the work. A working party has been established and work has commenced.

SA 4 – Clinical Workforce

Unknown – did meet last year – looks as though this is likely to be met

SA 5 – Midwifery Workforce

We are clarifying with the national team if the escalation classes as appropriate action and we can meet this action. Although we have not been able to provide 100% 1:1 care in Labour and 100% Co-Coordinator supernumerary, we have used our escalation process

SA 6 – Saving Babies Lives (SBL)

Likely not meet as the region do not agree our alternative pathways particularly around uterine artery dopplers as discussed above if funding is not established to commence Uterine Artery Doppler (UAD)

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SA 7 – Maternity Voices Partnership (MVP)

Likely meet as most of the work is with the Maternity Voices Partnership (MVP) and longstanding

SA 8 – Training Likely meet however a significant amount of work is required to ensure 90% of staff are trained as we have had to cancel 3 Cardiotocograph (CTG) study days in Q2 dropping compliance to 81%. Extra study days will be explored and staff are being offered bank to attend study days. Will also be at risk if we cancel any PROMPT days and/or Operating Departmental Practitoner (ODPs) become more depleted and cannot be released to attend. In Q3 we have not had to cancel any study days but due to sickness lower numbers than expected have been trained and compliance rates still sit at around 85%. As many self-isolating have been put on training as possible but this still remains at risk. Having a large amount of new starters has caused the numbers to drop as they are booked onto and attend training

SA 9 – Safety Champion

Safety champion walk rounds continue. Maternity Continuity Of Carer (MCoC) paper was seen at board

SA 10 – HSIB Likely meet. We have well established process but we need to make them more robust

5. Ockenden

Work on Ockenden continues with monthly meetings with the Multi-Disciplinary Team (MDT) to work through the action plan as per action plan below. We are making significant progress completing actions at each meeting and identifying priorities for work over the next month. Most direct patient safety actions have been complete and most outstanding are around reporting, process and data.

The funding received through the Ockenden bid was less than expected. The initial funding request totaled £430,933 across midwifery and obstetric work force and MDT training. The final amount awarded was £177,328. A risk assessment has been undertaken to assess the impact on the reduction in funding. The monies were allocated and the midwifery provision has been utilised already, the obstetric allocation is being discussed by the Clinical Director (CD) and Associate Director of Operations (ADO) and the MDT training allocation is being ring-fenced to help support the MIS – Year 4 safety actions.

Our evidence submission was returned with a grading to look at areas we need to improve. The first return was sent back following review and a meeting with the Regional Deputy Chief Midwife. Some of the issues raised were:

Areas where evidence was submitted where identified as lacking evidence Areas where evidence wasn’t submitted were identified as having met Clarity was requested on what evidence was required Inconsistency across the Local Maternity and Neonatal System (LMNS) and accepted

evidence.

The second return was sent back with none of the questions answered and no additional information on subsequent submissions etc. this has been raised as part of the LMNS.

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From the action plan and ongoing actions progress has been made on the highest priority for patient safety. The following is a summary of the progress made and some of the actions that are being worked on as the next level priority.

Consultant ward rounds – progress has been made to implement face to face twice a day during the week and this has been extended to the weekend in the last quarter. The virtual ward rounds continue daily. Full implementation has been affected by the funding gap as mentioned above and forms part of the risk assessment.

Cardiotocograph (CTG) Leads and Saving Babies’ Lives (SBL) compliance – an Obstetric and Midwifery Lead have been identified, although the obstetric is an interim lead. Work on CTG training as per SBL V2.0 has commenced and should be fully implemented by the end of the financial year.

Ward to board reporting – work continues to looking at the dashboard metrics and the reporting formats. This report forms part of that and any feedback on the contents, layout or details are welcomed.

The next steps include: Process for ring-fencing funding for maternity. Bereavement Care and pathways Complex pregnancy and antenatal clinics

(Work on all these has already started in some form).

6. Regional and National Work

NHS England/NHS Improvement and the regional Midwifery team have asked maternity services to undertake 3 different assurance and assessment tools to benchmark if our operation delivery of the service is benchmarked again national standards, guidance and regulatory requirements. Work has started on all 3 and the service meets a significant number of the criteria with evidence readily available.

The Ockenden and Kirkup assurance report looks at progress on compliance with both Ockenden (2020) and Morecambe Bay (2015) reports. This is to provide an update on the progress made against the action plan and evidence return that was submitted last year as the regional teams take over the assurance on progress against implementing the 7 Immediate and Essential safety actions.

See Appendix 1 - Ockenden and Kirkup bench marking.

The second assurance tool we have been asked to complete looks at the progress we have made as a service against the implementing the 7 Immediate and Essential safety actions. This is to help us triangulate the evidence and any actions still outstanding. This is for benchmarking for our Ockendon review visit by NHSE regional team in April 2022.

The service is working on the maternity self-assessment tool and is expected to complete the assessment by the end of February 2022. All 3 tools and action plans will help support the visit with Jackie Dunkley-Bent in March 2022. The current areas of outstanding compliance are as follows and are reflective of the ongoing gaps in the Ockenden action plan:

Director of midwifery in post Standard Operating Procedure (SOP) outlining the perinatal quality surveillance model for

the service Recent co-produced 15 steps and maternity vision with the Maternity Voices Partnership

(MVP) Visual schedule of meetings and learning forums Correct PAs for Obstetric Governance Lead and Obstetric Fetal wellbeing lead

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Maternity specific risk management strategy as currently aligned to the trust overarching strategy

Full compliance with the national bereavement pathway.

7. Workforce Plans A Birthrate Plus (BR+) assessment of maternity services was commissioned in 2019, at SWFT.

The BR+ method analyses the acuity of women receiving maternity care for the purposes of workforce planning and strategic decision making. The Royal College of Midwives (RCM) and Royal College of Obstetricians and Gynaecologists (RCOG) recommend the use of BR+ which was endorsed by the RCM Council in 1999, and in the Audit Commission Report; First Class Delivery (1997). The framework is also recommended by the National Institute for Health and Care Excellence (NICE) and is extensively used by NHS maternity units across the UK.

The BR+ assessment found that to provide safe maternity care to women and their babies 24 hours a day, 7 days a week, inclusive of a 22.5% uplift for annual, sick and study leave, the overall clinical establishment (registered midwifery workforce) should be:

Hospital services (Labour Ward, Postnatal Ward, Theatres) 71.72wte

Midwifery Led Unit (MLU), Community services 39.48wte

Outpatient services 8.32wte

Total clinical establishment 119.52wte

This gives an overall midwife to births ratio of 1:26.

These recommendations were not fully implemented due to significant changes within the senior management team overseeing the department and the unprecedented service pressures caused by the COVID-19 pandemic. It is also believed that the initial interpretation of the recommendations included the managerial roles within the clinical establishment and assumed the upskilling of the Maternity Support Workers with the potential to alleviate 10% of the clinical duties from the midwifery workforce.

Challenges with staffing was flagged as a significant risk by the Acting Associate Director of Midwifery and placed on the local risk register on 4 August 2021, as the escalation policy was regularly enacted with staff being redeployed to support the inpatient service. Due to this, the Chief Nursing Officer requested an internal review of the workforce to seek assurance that the midwifery staffing establishment supported the provision of safe care, at all times, to women and babies, in all settings.

The internal review was conducted in January 2022, and similarly concluded that the overall clinical establishment (registered midwifery workforce) should be:

[a] Hospital services (Labour Ward, Postnatal Ward, Theatres) 71.33wte

[b] Midwifery Led Unit (MLU), Community services 43.88wte

[c] Outpatient services 8.32wte

[d] Total clinical establishment 123.53wte

[e] Overall ratio 25.79 births to 1wte midwife (based on the total births recorded in 2021)

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However, that the internal review found that the establishment [a] could be safely reduced to 64.33wte with the additional of an Operating Theatre Practitioner or Assistant Theatre Practitioner to carry out the role of a scrub practitioner (currently undertaken by a midwife on a higher banding) when an emergency theatre is required in response to an obstetric emergency.

The internal review also considered the role of the Maternity Support Worker in undertaking clinical duties and recommended an overall establishment of 38.70wte.

An investment would support the findings of an internal workforce review carried out in January 2022, which closely mirrors the conclusions of an external assessment, Birthrate Plus, conducted for the Trust and based on the analysis of data from 2019. The service is currently putting a business case together.

8. Maternity Continuity of Carer (MCoC)

Maternity services at SWFT are committed to delivering MCoC and achieving the national target for reducing avoidable harm. The three building blocks required to achieve a default model include:

(1) Safe staffing;(2) Staff engagement; and(3) Staff training.

Delivering MCoC at full scale plan needs to take into account the need to support a further review to uplift midwifery staffing establishment, this work is currently being supported by the National Lead for Continuity of Care, who is due to visit the Trust in March.

At SWFT it is proposed that the Trust continues to work within the team model of MCoC as a preferred option. Where safe staffing allows, and when all three building blocks are in place MCoC should be achieved, with rollout prioritised to those most likely to experience poorer outcomes.

The full detailed report can be shared on request.

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Maternity and Neonatal Quality Improvement Action Plan 2021/22

This action plan is based upon feedback from the annual Care Quality Commission (CQC) Survey, staff SCORE safety feedback, complaints, Individual Peer Reviews (IPRs) formerly known as appraisals, and engagement with staff and women.

Identify area to improve

Score of Evidence

Risk to Service if no improvement made

Actions required to achieve improvement

Monitoring Lead Completion Dates

RAG

ANTENATAL CAREThe new model of care being introduced within the hubs will encourage peer support and the support from other services such as health visiting within the hub setting.

Feedback through service users, MVP, External Service evaluation

Head of Midwifery (HoM)

September2021

Complete for low risk pathway – High risk pathway now needs creatingNov 2020 continuing with mapping

1 Care during pregnancy- choice of birthplace- enough information

on where to give birth

- awareness on medical background

- ask about mental health

- involved in decision making

CQC Survey Results B4, B6, B8, B9, B10, B11, B17

May result in reputational damage.

Increase in complaints.

Transfer of care to another organisation. Implement ‘Pathway to

Parenthood’ Feedback through project lead

Parent Education Lead

July 2021 Currently rolling out throughout teamNov 2020 delay due to COVID – considering virtual options

2 Implementation of Saving Babies Lives version 2

National Recommend-ation

May result in reputational damage.

Risk of not meeting national target for reduction in fetal loss

Fully Implement SBL V2.0 – UAD needs implementing and work on smoking

PSM update. Deputy Head of Midwifery (DHoM)

June 2022

3 Implementation of recommendations from review of Maternity Outpatients Services

Service Review May result in reputational damage.

Poor maternity experience.

Individual Action Plan create to meet all recommendations

Through action plan – maternity and neonatal safety forum

DHoM December 2020Awaiting recommencement

OngoingNov 2020 some recommendations implemented due to COVID. Now needs re-evaluation

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Score of Evidence




RAG

Possible increase in complaints

Potential safety risk

LABOUR4 Did the staff

introduce themselves?

CQC C13 C19 Lack of trustPoor maternity experiencePossible increase in complaints

Communication and Engagement piece through the multidisciplinary team to highlight the importance of introducing themselves throughout the pregnancy and birth journey.

Feedback through service users and MVP.

Maternity Lead for Inpatients

Continuity Lead

Awaiting recommencement

Nov 2020 Delayed due to COVID

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Score of Evidence




RAG

5 Where you and or you partner left alone by midwives or doctors at a time when it worried you.

CQC C15

Potential safety riskLack of trustPossible increase in complaintsPoor maternity experience

Look at setting up peer breastfeeding supporters.

BFI action plan Infant feeding Lead

September 2020Awaiting recommencement

Nov 2020 delay due to social distancing restrictions

POSTNATAL CARE IN HOSPITAL8 If you needed

attention whilst you were in hospital after the birth where you able to get a member of staff to help you within a reasonable time

CQC D4

I Want Great Care

Informal Feedback

Poor maternity experience, reduction in breastfeeding rates

Implementation of Mum and Another (partners staying on the postnatal ward.

Proof of investment in resource

Maternity Lead for Inpatient Services

July 202Awaiting recommencement

OngoingNov 2020 delay due to social distancing restrictions

FEEDBACK FROM DIRECTLY FROM STAFF

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Score of Evidence




RAG

Use the maternity intranet page to list all conditions in alphabetical order and hyperlink the correct guidelines.

New intranet page

Quality Improvement team

September 2021

In progress15 Increase staff support when involved in an investigation.

Informal feedback through teams

Increased staff sickness and stress

Build dashboard New dashboard Clinical Governance Midwife

Awaiting new Badger platform to commence.

In progress

OCKENDEN REPORT LOW LEVEL ACTIONS

1. IEA 1Q2

Agree process across the LMNS to review cases that neither meet HSIB or full PMRT criteria. ANDEnsure all PMRT cases are peer reviewed from a regional level.

Regional/LMNS

Process agreed at LMNS/Regional level. Requires:

SOP Terms of reference Scope/remit of reviewers

Issues/Barriers:This will require additional resource in terms of MDT time – an estimation of how much time needs to be calculated and funded.It would be helpful to have guidance and clear standards from NHSE in a quality framework to ensure quality and consistency on how Peer reviews should be structured, the methodology to be used. Adequate resource is essential and is currently not in place to achieve this ask at the standard that is required. Options:

TBC Regional TeamHeads of MidwiferyClinical DirectorsSROLMNS Board

Initial discussion across foundation group. To link in with bereavement network.

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HSIB currently review all these. Remain independent.

Use foundation group and cross LMNS.

Review the escalation of maternity risks from ward to board, ensuring maternity expert representation at every level.New draft governance structure agreed within maternity and at divisional level. Approval schedule to be sought at Co-operate level.

Mar 2021 ADMADODoN

Agree templates for maternity reporting at each level.

June 2021 ADM

Identify a non-executive Maternity Safety Champion.

March 2021

DoN

Ensure all reporting pathways are clear.

February 2022

CGM

2. IEA 1 Q1

Increase visibility at Board level of maternity identified risks/issues.

Local

Ensure a robust governance structure, introduction of an 8b governance lead to drive the introduction of the perinatal surveillance, Ockenden, CNST, CQC and future national maternity reviews.

September 2021

ADM Acknowledged but not feasible at present.

3. IEA 1Q4

Bereavement Care and the PMRT

Local Register and work towards the national bereavement pathway.

- Gap analysis- Work with Divisional Team to

ensure bereavement service across pregnancy, including early pregnancy meets the national guidance.

Issue:

January 2022

ADMADOCGM

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- Funded time- Identified lead (early

pregnancy)- Available clinical space

Identify a Consultant Obstetric Bereavement Lead

Issues:

- Funded time- Clear scope of role.

September 2021

GM Faye Newport – Consultant bereavement lead.

Review PMRT pathways and documents to ensure parents are included and updated on the progress of investigations in a meaningful way.

- Template letter to families- Template update letter to

families- Information on PMRT clear to

families at initial discharge from hospital

- Template for family feedback.

January 2022

CGM

TOR for PMRT updated to include reporting to MSC.

January 2022

CGM

National Feedback to national team reporting issues with Badger.

July 2021 CGM4. IEA 1Q5

Submitting to MSDSFull submission occurs however requires data cleansing due to local and national issues with reporting systems.

Local Speak to the local IT team to discuss PAS override on the badger system for ethnicity.

December 2021

CGM

5. IEA 1Q7

Implement the Perinatal Clinical Quality Surveillance Model

Local Gap analysis of Perinatal Clinical Quality Surveillance Model

- Add gap analysis to this action plan.

September 2021

ADM

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Update Dashboard to include appendix 2.

December 2021

Update Safety Champion Oversight organisational chart as per appendix 1.

SOP to outline the reporting requirements of the PCQSM

January 2022

SOP discussed at LMNS January 2022

NED links in with MVP

NED included on exec walk rounds monthly.

Action plan completed and visible for staff following ward rounds

Poster for staff highlighting safety champions

Neonatal safety champions to be identified and added to meeting.

Final TOR agreed and shared for the safety champion meetings.

6. IEA 2Q11

Safety Champion, exec and non-exec. This is also part of CNST SA 9

Local

All above fed into the LMNS.

January 2022

Maternity Safety Champion

7. IEA 3 Q17

The validation of training programmes need to be considered at LMNS Board.

National / LMNS

NHSE in the process of designing a core competency framework and thus the LMNS have agreed that training would be assured against this.

National TBC

The Heads of MidwiferyClinical Directors from the three providers

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LMNS SRO

Add training trajectory to TNA December2021

Increase training compliance to 90% in CTG and PROMPT

MDT attending evening ward round virtually

March 2021

DHoMCD

Additional cost currently being calculated to enable Obstetricians to attend evening round at weekends – and then will be subject to financial approval and constraints of on call rota

November 2021

ADO/GM/CD Applied within new consultant job plans.

From the above implement an ‘in person’ ward round twice a day. 7 days a week.

November 2021

ADO/GM/CD 2nd ward round to start mon-fri at 5:30pm from 1st October.

8. IEA 3 Q18

Formalise in a Standard Operating Procedure (SOP) expectations around ward rounds, common language and record of rounds.

Local

Write an SOP to support and outline the process.

November 2021

AF/JC/CD In draft and ongoing.

9. IEA 3Q19

Confirmation of ring fenced Maternity training budget

Local Agree with Executive Maternity Safety Champion that the Trust develop a clear pathway for maternity training funding so there is an easily accessible audit trail that can be easily accessed and reviewed.

December2021

DHoM

10. IEA 3Q20

Effective system of workforce planning

Local Introduce a clinical midwifery on call rota to support a two-step escalation policy.

FY 2022 ADO Costed. Into budget setting and for agreement.

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Explore an option in Badger to identify if the named consultant has been seen.

April 2022 Digital Midwife

Complete

Work on process for ANC appointments allocation to ensure see named consultant at least once.

April 2022 JC/Continuity Lead

Awaiting comms to midwifery team about planned consultant appointment schedule.

Ensure all ANC have an allocated consultant or regular locum consultant.

April 2022 CD/ADO Consultant clinics covered with new consultants. Last due to start in January.

11. IEA 4 Q25

Complex pregnancies Local

Add Consultant documentation audit to audit plan yearly. Consisting of 1% of notes.

FY 2022/2023

Governance Lead

Completed

Identify lead liaison person for each trust to agree the Local service Level agreements. Agreed ADO, awaiting confirmation of commissioning decisions.

February 2021

ADO

**REMOVED ** Lead complex midwife to audit the co-ordination and outcomes of women who access multiple services across multiple sites – consider Allied Health Professional (AHP). This would require a business case, as not in the establishment. Plan to make a decision to pursue or not by April 2021.

FY 2022/2023

ADM Not achievable in the current climate as MM networks not set up as yet. To address in 2022/2023

12. IEA 4Q29

Clarity needed nationally/regionally around maternal medicine pathways and reporting mechanisms.

National / Regional

Investment is needed at Trust level to purchase the software to be able to perform the uterine artery Doppler’s in addition to training the sonographers to be able to perform the scans as

February 2021

ADOCD

Risk on the risk register. Not all funding achieved by digital bid – to request additional funds with business case.

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well as a lead fetal obstetrician to provide oversight at each provider.

Risk assessments required at booking and at every appointment to ensure that the plan of care remains appropriate.

March 2021

Continuity Lead

Complete

Development of a birth choice clinic that utilises the MDT to help support women’s choice through evidence based information and guidance.

June 2022 Continuity Lead

Staff are developed and supported to provide accurate and contemporaneous evidence based information in-line with national guidance.

September 2022

Transformation Lead, Lead PMA

Risks of birth environment – homebirth information to include minimum time for transfer to an obstetric unit and the impact that could have on the outcome for both mother and baby.

March 2021

Continuity Lead

Complete

13. IEA 5Q30

Information and risk assessment

Local

Add Audit 1% of notes yearly to audit plan.

FY 2022/2023

Governance Lead

Guidance to be shared with staff. PCSP forum to be launched.

TBC TBC Awaiting forms to be completed on MEHR.

Training to be roll out nationally, but can started locally.On-going training programme – Training Plan completed.

TBC TBC Awaiting forms to be completed on MEHR.

Audit of 5% of notes yearly. FY 2022/2023

Governance Lead

14. IEA 5Q33

Implementation of Personalised Care and Support Plans (PCSP), including staff training.

Local

Audit of 1% of notes yearly that women are included in decision making about their care.

FY 2022/2023

Governance Lead

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Ensure engagement with the CQC survey and continue to action any findings.

FY 2022/2023

ADM

Review and discussed and documented intended place of birth at every visit.

December 2021

Outpatient Lead

Trial of idecide tool. (Part of a national trial).

June 2022 AF/JC Started and ongoing.

Named Obstetrician in place. February2022

ADOGM

Ensured that these roles have the training required to undertake them effectively as per Saving Babies Lives (SBL) V2.0.

February2022

GM Obs lead to undertake CTG masterclass.

Support from the LMNS and Maternity Safety Champion to ensure assessment criteria met and effective. Consideration to be given around how to evidence this in the form of an assessment.

April 2021 DoNLMNS Quality and Safety GroupLMNS Board

Adequate time to perform service evaluations to ensure learning is being embedded and sustained.Annual review of training and evidence of updating. Next one due June 2021

TBC TBC National Team Leading on this

15. IEA 6Q34

Defined Obstetric and Midwifery Lead for CTG training.

Local

0.4 FTE has been allocated to the QI team for this role – need to ensure this is supernumerary time and clearly in the job description.

March 2021

Governance Lead

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Increase working with the MVP to ensure consulted on all patient information sheets

Ongoing Governance Lead

Added to the document review group distribution list to support guideline reviews.

Ongoing Governance Lead

Complete 15 steps exercise with the MVP.

TBC ADM (Awaiting COVID restriction reduction.)

16. IEA 7 Q43

MVP working. Local

Submission from MVP chair rating trust information in terms of: accessibility (navigation, language etc) quality of info (clear language, all/minimum topic covered) other evidence could include patient information leaflets, apps, websites.

February2022

ADM

New videos of maternity service uploaded to website. All content reviewed and checked to ensure up-to-date. Maternity Information Leaflet on version 10.

March 2021

ADM16. IEA 7 Q44

Trust website is up-to-date, but would benefit from a refresh to make the pages more modern, as shown in the example above.

Local

Formal request to Communications for refreshed website.

October 2021

Project lead

Midwifery Workforce

Birthrate Plus® assessment undertaken in March 2020

February 2021

ADM Working with the DON to fill our deficit. – Work re done for MIS year 4.

Paper to budget setting.

Paper to Board April 2022 ADM

17. Section 2Q45

Midwifery workforce regularly assessed and recruited to Birthrate Plus®.

Local

Business case for deficit May 2022 ADM

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Midwifery Leadership

Head of Midwifery’s current job description is currently under review.Decision to re-band to Associate Director of Midwifery.

March 2021

ADO

Director of Midwifery Role across the foundation group.

March 2022

ADO/DoN

18. Section 2 Q47

All Trusts should have a Director of Midwifery.

Local

Action plan to meet manifesto gaps. (Strengthening Midwifery Leadership)

March 2022

ADM

NICE Guidance Related to Maternity

Robust system in place to alert maternity to NICE updates.

On-going ADM

Keeping on top of reviewing guidelines is an immense task – we currently have in excess of two hundred guidelines and standard operating procedures across maternity and neonates.

On-going ADM

Ensure ‘Operative Delivery’ guideline is up to date and follows national guidance.

March 2021


19. Section 2Q49

Maternity guidance needs to be kept up-to-date.

Local

Ensure ‘Use of Oxytocin’ guideline is up to date and follows national guidance.

March 2021


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Patient Care indicators

1. All babies have a temperature taken and recorded within an hour of birth

Labour Educate all midwives on the importance of early feeding and thermo-regulation

March 2022

Swan Ward Manager

Babies should feed within an hour of birth

Labour Liaise with BadgerNet midwife to create Badger ‘how to’ guide for new starters – to include all necessary documentation at birth

April 2022 Labour Ward Manager

Baby drug cardex completed correctly:-Allergies recorded-Vitamin K double signed

Labour Liaise with pharmacy to stop routinely using drug cardexes for vitamin K – this would have the added benefit of being a money saving initiative.

April 2022 Swan Ward Manager

Baby management plan completed at birth for all babies

Labour Liaise with BadgerNet midwife to see if the risk assessment and management plan be moved to one box on Badger.


/Labour Ward Manager

Women self-administering medication should have the competency box completed on the drug card

Swan Liaise with Digital Midwife to add box onto postnatal check tab on badger so this can be documented at bedside during postnatal check.

April 2022 Swan Ward manager

All notes to be filed prior to transfer from Labour to Swan ward

Swan Email all midwives explaining importance and impact of this March

2022Swan Ward

Manager

Re launch stickers to put on the beginning of CTGs, these state all information required with appropriate boxes to fill in.

March 2022

LW deputy manager

Ensuring all appropriate information is documented on every CTG

Swan/ Labour

Discuss with quality improvement team to highlight importance of CTG stickers at the beginning of every CTG at CTG study day.

March 2022

Swan Ward Manager

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Ensure CTG stickers are on every machine.

March 2022

LW deputy/Swan Ward

deputy

Epidural catheter removal documented on Badger

Labour Decision to be made, should documentation be on badger or green anaesthetic chart.

April 2022 Labour Ward Manager

Daily VTE completed for all women Swan Question to be removed from PCIs.

Instead, data will come from Information Team.


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Subject Freedom to Speak Up Guardian’s Report Agenda Item 7.5


Nature of item

For decision

Decision required


Report Author Sue Pike, Freedom to Speak Up GuardianGeneral Information Lead Director Gertie Nic Philib, Chief People Officer


RevenueCapitalWorkforce Use of Estate


Funding Source





No


Ownership Trust



Yes

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Report to Board – 2 March 2022

Freedom to Speak up Guardian’s Report

Executive Opinion

This is the latest report (covering 1 November 2021 to 31 January 2022) to the Board of Directors from our Freedom to Speak Up Team (FTSU Team) and provides assurance that the role continues to develop in line with national guidance.

Activity for Reporting Period

This report covers the period 1 November 2021 to 31 January 2022 of the financial year 2021/22. We had 25 cases brought to the attention of the FTSU Team. None of the cases were anonymous however the majority of cases were raised in confidence.

During this time the FTSU Team, with colleagues from workforce and people, has delivered weekly civility sessions across George Eliot Hospital NHS Trust (GEH) and South Warwickshire NHS Foundation Trust (SWFT) reaching around 700 staff. The team have conducted train the trainer sessions and a wider pool of trainers is now available to deliver the introductory sessions. We are planning additional training in line with the civility saves lives work looking at second messenger and working with teams to tackle incivility and poor behaviour. It is hoped that an additional online package can also be developed for those who want to learn more and look at civility in more depth.

The sessions are generating good feedback. Participants are asked about their key takeaways from the session these are the most recent answers:

One of the comments in more detail was: “Staff should have confidence in challenging incivility, just because some people behave in a certain way doesn’t make it right. We all have a responsibility, no matter what position we hold, to address inappropriate behaviours in ourselves and others.”

When asked to rate the session out of 5 (where 1 is poor and 5 is excellent) you can see that 97% of respondents have chosen 4 or 5.

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Figure 1 Divisional spread of speak up cases for this period

Figure 2a

Figure 2b Staff continue to raise concerns around staffing levels and high pressures leading to staff feeling they cannot provide the care they aspire to give, staff feeling unable to meet the demands or needs of patients in a timely manner. Burn out and challenges around fitting in everything that is needed to do the job in a satisfactory way is also thematic throughout this period. Staff feeling the pressure to work on off duty days to complete things like

mandatory training is also becoming more frequent, staff feeling that this is impacting on their wellbeing and feeling fatigued is leading to anxiety that more mistakes may be made.

1

3

1

4 4

3

0

1

2

3

4

5

6

Corporate Emergency Division

Out Of Hospital

Elective Division

Support Services

Family Health

Q3

Q4

Divisional Breakdown

2 21

5

4

1 112 2

12

10

1

2

3

4

5

Patient S

afety

/ element o

f

care

Policies, p

rocedures &

processe

sStaff S

afety

Syste

m /Proce

ss not

followedSta

ffing l

evels

Bullying /

Harassm

ent

Middle man

agement is

sue

Quality

& Safety

wellbeing

Relationsh

ips

Q3

Q4

Primary reason for speaking up November 21 - January 22

11

4

1

110

211

Patient Safety / element of carebullying & Harassment

wellbeing

Quality & Safety

Attitudes & BehavioursStaff Safety

pensions

equality and diversitysecurity

0 2 4 6 8 10 12

secondary reason for speaking up Nov 21 - January 22

Addi

tiona

l iss

ues

number of cases

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Our community based Speak Up, Wellbeing and Inclusion ambassadors have been hearing concerns around changes to service including the Urgent Response teams extending their service provision in line with the national aging well agenda. Staff feeling burnt out, low morale and frustrations around workload with an increased pressure to work longer hours in order to complete digital notes and log into online systems to caseload manage. Ambassadors are also hearing that staff are not able to access all of the wellbeing initiatives that the Trust is trying to support, there are concerns that with the introduction of positive tools like the carers passport, those working in front facing clinical roles may still not be able to access the support they need due to a lack of staff.

Staff continue to raise concerns around behaviours and relationships, with the increasing delivery of civility training we hope staff will feel more comfortable to start tackling issues as they arise and we expect to see a change in the pulse survey and local workplace culture surveys indicating that the training is having a positive impact. As yet we have not seen an increase in the number of cases brought to the FTSU team as a result of the civility sessions.

Four cases were related to an element of patient safety or patient experience, in these instances action plans have been put in place to identify issues and ensure measures are in place to improve, this has been managed through divisional management channels along with People and Workforce, Patient Advice and Liaison Service (PALS), FTSU and, where appropriate, Trades Unions.

Figure 3: Out of the 25 cases the majority were from those identifying as workers / staff, 12 contacted with concerns and 11 wanted advice.

The National Guardian’s Office (NGO) categorises staff based on professional background. The category for Nurses and Midwives this quarter has nine cases, seven from nurses and two from midwifery with the majority of these cases concerning staffing levels and staff safety. Figure 4

11

1

12

1

Advice Staff

Advice manager

Concern Staff

Concern manager

0 5 10 15

Type of contact

3 1 1 32 1

5

1 1 2 14

0123456

Admin, Cleric

al an

d

Maintenan

ce / A

ncillary

Allied Healt

h

Professionals

*

Corporate Se

rvice

s

Estates a

nd Facili

ties

Medical a

nd Dental

Nursing A

ssista

nts or

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Registered Nurse

s and

Midwives

Q3

Q4

Professional Groups

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Next Steps

Business case to maintain the Freedom To Speak Up Advisor post and further enhance the speak up offer across the Foundation Group.

Revise and update the FTSU policy in line with current best practice.

Develop and start to deliver additional tackling incivility in the workplace sessions.

Speak Up, Wellbeing and Inclusion Ambassadors – continue to refresh the Ambassador offer, links to Public Health, Warwickshire County Council, With Staff In Mind and other stakeholders to enhance skills, knowledge base and pastoral care of Ambassadors.

Work in collaboration with the Board Wellbeing Ambassador to understand links between safe speak up culture and wellbeing in the workplace.

Start planning Speak Up Month activities for October 2022.

Board to complete FTSU Self-Assessment

Recommendations


Sue Pike Freedom to Speak Up Guardian (FTSUG)

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Subject Report from the Council of Governors Meeting held on 10 February 2022

Agenda Item 7.6


Nature of item

For decision

Decision required

The Board of Directors is asked to receive and note the report from the Council of Governors meeting held on 10 February 2022.

Report Author Meg Lambert, FT AdviserGeneral Information Lead Director Russell Hardy, Chairman




Funding Source





No


Ownership Trust



Yes

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Report from the Council of Governors Meeting held on 10 February 2022

1. Introduction

The Council of Governors (CoG) last met on 10 February 2022 and below is a report of the substantive items from that meeting.

2. Assurance Items:

The CoG received the following items of assurance:

An update on the recovery of services including elective and cancer services; An update on COVID-19 Vaccines for staff; The Patient Experience Assurance Report from the Chief Nursing Officer; The Clinical Governance Assurance Report; The Finance Assurance Report from the Chief Finance Officer, and The Audit Assurance Report from the Chair of the Board’s Audit Committee.

3. Updates from Governor Representatives on Major Projects

Ellen Badger Hospital Site Re-development Update Report; End of Life Committee Update Report; Car Park Project Board Update; Falls Group Update Report; Patient Experience Group Update Report; Patient Safety Surveillance Committee Update Report; Patient Portal Group Update Report; Governor Induction Working Group Update Report; Wayfinder Project Update Report, and Safer Discharge Group Update Report.

4. Governance Matters

The following Governance matters were considered by the CoG:

Approval of the appointment of two Non-Executive Directors; Approval of the appointment of the Vice-Chair; Support for the recommended Senior Independent Director appointment; Approval of the Governors’ Code of Conduct; Annual review of the Sub-Committee terms of reference; A report from the General Purposes Committee Meeting held on 13 January

2022; A report from the Business Oversight Committee Meeting held on 13 January

2022, and A report on the Resignation and Appointment of Governors.

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5. Confidential Section

The Chief Executive provided a strategic update and the Council also received reports from the meetings of the Nominations and Remuneration Committee held on 16 December 2021 and 27 January 2022.

6. Recommendation

The Board of Directors is asked to receive and note the report from the Council of Governors meeting held on 10 February 2022.

Meg LambertFT Adviser

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Subject Digital Health Board Quarterly Update Agenda Item 7.7


Nature of item

For decision

Decision required


Report Author Adam Carson, Managing Director – Innovate Healthcare Services Ltd

General Information

Lead Director Adam Carson, Managing Director – Innovate Healthcare Services Ltd




Funding Source





No


Ownership Trust



Yes

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Digital Healthcare Board Quarterly Update

Executive Opinion

During the last quarter Digital Health Board’s (DHB) focus has shifted to centre on readiness to implement a new electronic patient records (EPR) system for acute services. This resulted in the approval of the EPR Outline Business Case last month, as well as reviewing ongoing priorities and funding opportunities to support the new EPR. The Digital Health Board continues to provide a successful oversight on the Trust ambitious Digital programme.

Adam CarsonManaging Director – Innovate Healthcare Services Ltd

Executive Summary

During the NHS operational Level 4 period from December 2021 to February 2022, Digital Health Board scaled down meetings and non-priority work to allow clinical and operational services to focus on the immediate needs of the organisation. This period has also coincided with the successful transition of Digital and Technology services into Innovate Healthcare Services Ltd, a Joint Venture between the parties using a wholly owned subsidiary of the Trust.

Priority work has continued, with the main focus being on development of the EPR Outline Business Case, and associated readiness work. ICT teams have also provided support to address operational needs, including improvements to systems to support and enhance flow in the hospital.

Headline Updates

Some of the significant areas of work during the last quarter are highlighted below:-

EPR Business Case

Over the last quarter, the Digital Health Board’s (DHB) primary focus has been on development of Outline Business Case (OBC) for a replacement EPR system for South Warwickshire HNS Foundation Trust (SWFT) and George Eliot Hospital NHS Trust (GEH). DHB members have had a particular role in reviewing and agreeing benefits and providing assurance that the case accurately articulates the needs of the Trust.

Following approval at Board of Directors last month, the OBC has now been submitted to NHS Digital. A three-month timescale for approval has been indicated, and the Trust awaits feedback. In parallel, work has commenced on refinement of the OBC into a Full Business Case, which will include the detailed implementation plan and contractual

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elements with the system supplier. The current timescale sets the submission of the case to Board of Directors by July 2022.

Transition of IT & Digital to Innovate Healthcare Services Ltd. (Innovate)

Innovate took up the provision of Information Technology, Information Governance and Digital Transformation services from 1 December 2021. This involved the TUPE transfer of 147 staff from SWFT and GEH to the Joint Venture.

Innovate is currently undergoing a process to define it’s 3-year business plan, engaging staff from across the service and two Trusts. The immediate priorities are bringing together the former SWFT and GEH services into single teams to provider greater resilience and cross cover for the Trusts and primary care.

Funding Bids

During the final quarter, NHS Digital made available several opportunities to bid for predominately capital funding for technology initiatives. Opportunities were evaluated against our short and medium-term priorities and bids were made resulting in SWFT being awarded £1.9m Public Dividend Capital (PDC) for a number of initiatives. These include:

A bid to the infrastructure fund totalling £1.273m for: The replacement of the Core Network at Warwick Hospital enhancing network

performance and availability and ensuring it is fit for purpose to support the implementation of the new Electronic Patient Records system.

Implementation of a new remote access system to provide a more modern, robust platform for those working away from hospital sites, ensuring it supports our future needs and significantly improves performance.

Implementation of a cyber-security platform to enhance mitigation of risks associated with medical devices connected to the Trust’s network.

A bid to the maternity technology fund for £209k to support networking enhancements and hardware for midwives and other maternity staff, as well as the implementation of a new foetal ultrasound software platform.

A bid to the Diagnostics Digital Capability Programme for £407k to enhance the collection, consolidation, and ability to report on a number of cardiac monitoring solutions, following the completion of a review of cardiac services in our Digital Hub.

Due to the tight timescales for the making bids, in some cases detailed business cases are following, and going through the necessary approval process this month.

Hospices Electronic Patient Record

The Trust has continued to lead the implementation of the EMIS system for Warwickshire Hospices. During the last month the Trust have supported the go-live of the system at Shakespeare Hospice with Mary Ann Evens Hospice planned during March, at which time all hospices will have access to EMIS records. A full go-live at Myton Hospice is being planned to commence during Q1 2022/23.

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Forward look

Some key highlights for the coming months include:

Development of the Full Business Case of the new EPR system, including detailed implementation planning, finalising of collaboration arrangements with University Hospitals Coventry and Warwickshire NHS Trust (UHCW) and completion of draft contractual schedules with the EPR supplier.

Completion of a business case, linked to the EPR, to rollout speech recognition for the capture of clinical information in our electronic systems.

Implementation of the Trust’s Intensive Care Management system, which has previously been delayed by operational pressures during the pandemic.

Completing the implementation of EMIS in hospices, providing a single electronic record for Primary Care, Community Services and Hospices in Warwickshire.

Enhancements to the Trust’s process regarding electronic results acknowledgment, as well as significant enhancements to the Trusts electronic ward management system.

Commencing of a number of a pilot initiatives linked to the Trust’s Digital Hub, including wireless patient monitoring and 3D printing.

Recommendation


Adam CarsonManaging Director – Innovate Healthcare Services Ltd

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Subject Audit Committee Report for 9 February 2022 – Open Meeting

Agenda Item 7.8


Nature of item

For decision

Decision required

The Board is asked to receive and note the key issues raised at the Audit Committee open meeting held on 9 February 2022.

Report Author Rosemary Hyde, Non-Executive Director and Audit Committee Chair

General Information

Lead Director Kim Li, Chief Finance Officer




Funding Source





No


Ownership Trust



Yes

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Audit Committee Report for 9 February 2022 – Open Meeting

Executive Opinion

The Board should be assured by the work of the Audit Committee and that there is a strong focus on audit and governance across the organisation.

Kim LiChief Finance Officer

Reports/Items Considered by the Committee

External Audit Update (Deloitte)

The external audit planning work for 2021/22 has now taken place. Whilst recognising the financially challenged environment under which the Trust operates, the auditors did not raise any Trust specific concerns around the audit. Audit materiality for the financial statements has been set at £7.6m (2% of planned revenue). The audit will focus on the financial statements, the Annual Governance Statement and the Trust’s Value for Money arrangements. External auditor reporting on the Quality Report remains suspended for 2021/22.

Internal Audit Reports (CW Audit)

Progress Report

The Internal Audit programme for the year remains on track and reporting on implementation of Internal Audit recommendations is now in a good position. Based on the results of the work to date, it is anticipated that the cumulative audit opinion for the year will be Significant Assurance.

Patient Access Plans – Follow Up Audit

This follow up audit was commissioned to review the status of implementation of audit recommendations raised following the audit undertaken in January 2020, which had provided Limited Assurance. The follow up audit concluded that of the 13 recommendations raised in the 2020 report, only 4 were now fully implemented, with 6 recommendations partially implemented and 3 recommendations not implemented. Resourcing pressures have slowed progress on implementation. A local action plan has been developed which addresses all the remaining actions, which is due to complete by June 2022. This includes a data cleansing exercise of a backlog of over 7,000 patients’ appointments recorded as “follow up to be booked” dating back to 2016. The key challenge relates to the current lack of standardisation across the Trust, both for recording patients requiring follow ups, and for monitoring levels of patients waiting for follow up.

The key issues that management must address are as follows:

a) Monitor and proactively ensure the outcome of test results received for patients on

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awaiting results / awaiting clinical decision status are updated and Access Plans put in place for follow ups.

b) Ensure that patients on Access Plans linked to Consultants who are leaving the Trust are transferred and monitored.

c) Work with all specialties to ensure a Trust wide process in relation to Access Plans / Follow Ups is followed.

d) Introduce a standard form / process for notifying Patient Access Team (PAT) Outpatient referrals originating from an Inpatient stay.

Payables – Analytics Audit

This audit provided Significant Assurance over the Trust’s payables and reflected an improvement over last year. A small number of recommendations were raised around Masterfile duplicates and amendments, raising of Purchase Orders ahead of goods/services being provided, and timely processing of credit notes. It was noted that the oversight of the new Shared Financial Services arrangements appeared to be working well, with daily KPI reports, action plans and twice weekly team meetings.

Receivables – Analytics Audit

This audit provided Significant Assurance over the Trust’s receivables and also reflected an improvement over last year. A small number of recommendations were raised around the continued need to focus on follow up of outstanding debts, and in particular the significant older debts. It was noted that the Shared Financial Services Team had recently recruited a full time credit controller, which should help strengthen the Trust’s debt recovery process.

Asset Management – Follow Up Audit

This review concluded that good progress had been made since March 2021 when a Moderate Assurance opinion had been given on the financial controls surrounding fixed assets. The Fixed Asset Register had been streamlined (although the transfer to the Integra module has not yet progressed), procedures written, invoices over £5k checked, asset verification exercises commenced and IT verification exercises completed for the transfer to Innovate Healthcare Ltd.

Draft Internal Audit Workplan 2022/23

The Audit Committee approved the internal audit workplan for 2022/23. This is considered to be a balanced plan covering a mix of Strategic, Operational and Information for decision making risks.

Single Tender Waiver Report

The Audit Committee noted the significant reduction in the value of waivers, down 50%, from £2.6m in 2020 to £1.3m in 2021. Notably, there were significantly less IT waivers since the last report, reflecting the addition of an IT procurement manager. It was recognised that whilst significant progress had been made by the Procurement Team, there was still more work to do to reduce the waivers allowed due to tight timescales, or where continuity is deemed to outweigh financial benefits.

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Local Security Management Service (LSMS) Annual Report

The report provided the Audit Committee with good assurance that the LSMS had a good grip on security issues. The biggest challenges this year have arisen on Macgregor Ward with Child and Adolescent Mental Health Service patients.

Gifts, Hospitality, Sponsorship and Conflicts of Interest Reports

The Trust Secretary updated the Audit Committee on declarations made in the six months to January 2022. It was noted the new Electronic Staff Records (ESR) roll out, due for April 2022 will allow for conflicts of interest to be picked up at pre-employment stage. New job planning software is also under development for medical staff, which will include a conflict of interest section as part of the annual job plan process.

Annual Review of Board of Directors Standing Orders

The Audit Committee noted the proposed minor amendments.

Information Governance and Security Quarterly Assurance report

The Information Governance Manager presented an assuring report on progress on tightening controls around information governance and security. The Trust had achieved the 95% target for data security awareness training in December 2021. Recruitment for 3 Cyber Security Specialists has been delayed but is due to commence end February 2022. A workshop is to be held in March 2022 to discuss the overall risk of cyber security to the Trust and agree a risk rating.

Risk Appetite and Risk Management Strategy 2022-27

The Audit Committee reviewed the draft Risk Strategy, prior to approval by Risk Management Board and ratification by the Board of Directors. Discussion covered the need to give Cyber Risk more focus, the Trust’s risk management journey, the distinction between risks and issues, risk reporting mechanisms and the availability of training for risk owners.

Ordering and Recycling of Wheelchairs

The Audit Committee received an assuring verbal briefing from the Manager for Adult Occupational Therapy and Wheelchair Services. This is a block contract and provides bespoke wheelchairs to users with long term mobility requirements. As demand, and costs continue to increase, every year is a challenge to meet the budget. However, considerable progress has been made on managing costs down, including negotiating wheelchairs with interchangeable parts, meaning repair costs are lower, and more parts can be recycled. It was noted that it would be advantageous for the Service to work with the Trust’s Procurement Team.

Audit Committee Term of Reference

The Committee considered proposed amendments to its Terms of Reference which were approved, with one further amendment that the Managing Director should attend when the Audit Committee considers the draft Internal Audit Workplan.

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Areas of Concern for the Board’s Attention

None

Decisions Made and Actions to be Taken

None

Committee’s Level of Assurance

The Board should be assured that the Audit Committee has good oversight of the governance arrangements of the Trust and is assured that these arrangements are operating satisfactorily.

Rosemary HydeAudit Committee Chair

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Subject Clinical Governance Committee Reports for 9 February 2022

Agenda Item 7.9


Nature of item

For decision

Decision required

The Board is asked to receive and note the report.

Report Author Dr David Spraggett, Non-Executive Director and Chair of the Clinical Governance Committee

General Information

Lead Director Fiona Burton, Chief Nursing Officer




Funding Source





No


Ownership Trust



Yes

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Clinical Governance Committee Report for 9 February 2022

Executive Opinion

The Chief Nursing Officer agrees that this is an accurate summary of the discussions held at the Clinical Governance Committee meeting on 9 February 2022 and in the areas of concern identified.


Reports/Items Considered by the Committee

1) Matters of Note from Action Log

The Associate Director of Operations (ADO) for the Emergency Division detailed processes the Trust had developed to safely manage patients waiting ambulance offload. The paper with full details of processes will be sent to Clinical Governance Committee (CGC) Chair before the next meeting.

Assurance was received from General Manager of Critical Care that the World Health Organisation (WHO) Checklist performance had been stable throughout Winter.

2) Patient Safety Monthly Report

It was reported that there had been 1057 adverse incidents reported in January 2021 but of those only 9 resulted in significant harm.

It was also very assuring to note that Venous Thromboembolism (VTE) risk assessment data for December 2021 had shown a very positive 97.3% compliance.

The Elected Governor representative expressed considerable concern relating to an insulin medication incident where a patient was given five times the correct dose. It was questioned whether the patient had actually been involved in any conversation regarding the dose prior to administration as most patients would have noticed the dose was incorrect. The Chief Nursing Officer commented that in cases where the patient had capacity this should occur but following a review of this case, the pharmacy team have adjusted the Standard Operating Procedure (SOP) to address this issue. The Committee was also given assurance that on this occasion there was only low harm noted.

The Committee remained concerned over the number of medication incidents reported and requested medication safety training and refresher training should be reviewed and fed back to the Committee to give more assurance.

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3) Falls Deep Dive Analysis

The Falls Lead was unable to attend to present this paper and it was therefore agreed that any issues be raised directly with the Falls Lead by email.

4) Audit and Operational Governance Group (AOGG) Out of Hospital Care Collaborative Quarterly Report

It was good to note that Quality Matrons had completed as many as 140 audits in the previous month and also that there was a 36% increase in responses for iWantGreatCare (iWGC). Of more concern was the increase in insulin medication incidents in November 2021 which has resulted in safety actions now being put in place.

It was also important to note that two of the reported complaints had been incorrectly attributed to Out of Hospital Care Collaborative (OOHCC) along with two Information Governance (IG) incidents, these are all to be reattributed by the Governance Team.

The Committee raised a number of concerns as follows:

The rate of falls taking place in patients own homes are greater than in hospital setting and it was questioned how these patients are monitored and what actions are in place to prevent the falls that may result in hospital admission. It was agreed that a review of Patient Care Indicators (PCI) and falls assessment process should be undertaken. Assurance was given that the process had been improved which included collaboration with Warwickshire County Council (WCC).

An Information Governance (IG) incident where a patient’s communication had been sent to an incorrect email address was raised and it was suggested speeding up the roll out of the Patient Portal should reduce the risk of this occurring. The Head of Nursing for OOHCC assured the Committee that she would be reviewing this.

Clarification was sought relating to workforce recruitment and the Committee was assured that the 34% increase in workforce stated was a new resource to support existing workforce.

5) Coventry & Warwickshire Pathology Service (CWPS) Governance Bi-Annual Report

The Chief Nursing Officer congratulated the whole CWPS team on the successful implementation of rapid testing at South Warwickshire NHS Foundation Trust (SWFT). This has been extremely helpful in reducing current operational pressures.

The Committee put challenge in relating to the pathology element of Cancer 28 day faster diagnosis as to why there is no formal request from SWFT to be actively involved. It was made clear that a forward view on the progress of this was necessary. It was agreed that the CWPS Chief Operating Officer and SWFT Chief Operating Officer would progress this. Further challenge was raised as to why calibration reference tests were not included in the report, specifically relating to oestrogen receptor. The Quality and Improvement Manager of CWPS agreed to take this action away.

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The Committee also made comment that there were barriers on both sides relating to Getting It Right First Time (GIRFT) and what SWFT could do to improve this. The Committee was assured that SWFT was actually leading the way, particularly with the move to paperless.

6) Clinical Audit and Quality Improvement Quarterly Report

This report was well received by the Committee but there is evidently a need to put in place processes to ensure Trust compliance with latest National Institute for Health and Care Excellence (NICE) guidelines. There was particular concern relating to how compliance is tracked within all specialities. It was also noted that this issue was not exclusive to SWFT and the Acting Chief Nurse at Coventry and Warwickshire Clinical Commissioning Group (CWCCG) agreed to review in her organisation and raise at the next System Quality Review Group. The Chief Nursing Officer at SWFT provided assurance by describing the new process within SWFT but there remains concern regarding being able to evidence process compliance with guidelines in some specialities. It was agreed a report will be brought back to a future Committee on this topic.

The Committee also asked for an action plan regarding stroke VTE compliance in the AOGG Emergency Division’s next report to give suitable assurance.

7) Mortality Surveillance Committee Quarterly Report

This was a very assuring report showing evidence that SWFT are well within the limits set.

8) CWCCG Learning from Deaths of People with Learning Disabilities and Autistic People LeDeR Mid-Year Report

The Acting Chief Nurse at CWCCG presented the report apologising that the enclosed data was out of date, but themes raised remain valid.

The Chief Nursing Officer at SWFT made comment that themes were more relating to diagnosis rather than care that could be actioned. The Committee was assured by the Acting Chief Nurse at CWCCG that any gaps in care were picked up in reviews and included in the action plan.

The Committee raised a particular question regarding local themes as although they would be captured as part of the national reporting, they are not clear locally and it is important for this to be the case if we are to improve our care of these patients. It was agreed that the SWFT Patient Safety and Quality Manager meet with the Learning Disability (LD) Lead in SWFT to decide how best this should be reported.

The Chief Nursing Officer at SWFT commented that she had raised with the CWCCG LD lead some time ago that there was a need for an LD Provider Group to be set up within the system and an action on this to be fed back at a future Committee meeting.

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9) Results Acknowledgement Project Update

Dr Chachlani, Consultant Histopathologist, presented the report and stated that a ‘go live’ date for Pathology and Radiology within SWFT is planned for inpatient week in May 2022. This was well received by the Committee.

The SWFT Chief Nursing Officer thanked Dr Chachlani and his team for all their work on this very complex issue. This was echoed by the Committee being specifically positive regarding standardisation and digitalisation.

There was also a comment on the continued reliance of ICE which can be difficult to use and the Managing Director of Innovate Healthcare Services Ltd (IHS) reported that some work was being done using Cerner which may be more efficient.

10) Patient Access Improvement and Best Practice Project Update

The SWFT Chief Nursing Officer presented the report as the General Manager for Patient Access Services has now left the Trust. The report highlighted the complex nature of this work made more difficult by increased waiting lists relating to Covid-19. It was clear that there is a need to change the culture of the workforce and how they work to improve access in the future.

The Committee raised a number of points as follows:

The departure of the General Manager for Patient Access Services means the Trust must ensure the momentum of this project is not lost. In particular, that the Executive Team must not lose ‘grip’ of this work and the need for clarification over how many specialities are using processes outside the standard agreed. The Committee needs this information to understand what degree of risk there exists to achieving the outcome of this project.

Concern was raised that recommendations requested in 2020 had either been only partially implemented or not implemented and the Audit Committee has been challenging on this. Assurance was given that the ADO for the Elective Care Division is now taking responsibility with oversight by the Audit Committee. The Internal Audit of the Patient Access Team will be carried out.

11) Radiation Protection Annual Report

A very well constructed report was presented by the Lead for Radiation and Protection.

12) Annual Self-assessment for Members

The Head of Governance presented this report which showed good/very good functioning of the Committee.

The Discussion was had regarding frequency of this report and content of survey needs review and the Head of Governance agreed to do this.

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13) Patient Safety Specialist Update

It was noted that the SWFT Chief Executive had requested that this Committee be updated on National Patient Safety Strategy and implementation action plan.

The Patient Safety and Quality Manager was praised for her work on this and was requested to present to the System Quality Review Group meeting. All agreed that this needed to be a collaborative piece of work across the whole system to be effective.

There was a comment made by the Committee that there needs to be better communication within the Trust as to who the Wellbeing Guardian was and the Safety Champions as many staff appear unaware.

The Committee Chair agreed to circulate this report to any SWFT Board members if requested.

14) Any Other Business

The Committee Chair thanked the Elected Governor Representative for all his contributions to this Committee as he is now leaving SWFT Council of Governors to take up a role in another health related organisation.

Areas of Concern for the Board’s Attention

The Board should note items 1, 3 and 5 Medication Issues, Falls Rate and NICE Guideline Compliance.

Decisions Made and Actions to be Taken

The Board should note items 1, 3, 5 and 7.

Committee’s Level of Assurance

The Committee was significantly assured.

Dr David SpraggettNon-Executive Director and Chair of the Clinical Governance Committee

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Subject Summary of Ratified Policies Agenda Item 8.1


Nature of item

For decision

Decision required

The Board is asked to receive and note the summary of SWH 05703 – Self Medication Policy.

Report Author Ann Hutton, Deputy Head of PharmacyGeneral Information Lead Director Anne Coyle, Managing Director

Meeting Policy Review GroupReceived or approved by Date 21 February 2022



Funding Source





No


Ownership Trust



Yes

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Summary of Ratified Policies

The following policy was ratified by the Policy Review Group on 21 February 2022.

SWH 05703 – Self Medication Policy

The Trust has recently upgraded the “pod lockers” (patient’s own drugs) and they are being rolled out on all the acute wards. These were purchased with the intention of having a safe system in place for patients to take control of their medication during their hospital stay.

The policy was adapted from one already in existence at George Eliot Hospital NHS Trust (GEH). It has been refreshed and updated in order to be adopted for use at South Warwickshire NHS Foundation Trust (SWFT) as well. As we share on the Drugs and Therapeutics Committee there is an ethos that the approach to medication safety and governance is aligned. The Committee has already approved the policy.

The policy explains the criteria for patient selection, and the prescribing administering and recording process for medication with a patient who is self-medicating. There is associated paperwork for the assessment of the patient, a patient consent form and a patient information leaflet. The patient information leaflet has been approved by the Clinical Practices and Patient Information Group (CPPIG).

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Subject Summary of Reports for Noting and Information

Agenda Item 8.2


Nature of item

For decision


The Board of Directors is asked to receive and note this report which includes the Emergency Preparedness Annual Report.

Report Author Sue Shelton, Emergency Planning LeadGeneral Information Lead Director Harkamal Heran, Chief Operating Officer




Funding Source





No


Ownership Trust



Yes

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Summary of Reports for Noting and Information

Emergency Preparedness Annual Report

Executive Opinion

The Board of Directors should note the considerable work undertaken by the Incident Control Room who continue to provide exceptional support to the Trust and are currently operating under the National Incident Level 4, providing cover 7 days a week. South Warwickshire NHS Foundation Trust (SWFT) has been rated as “substantial” against compliance with the Core Standards for Emergency Preparedness, Resilience and Response (EPRR). There are three areas of partial compliance which have action plans against each area. The final part of this report outlines the workstreams related to the Trust’s planning for the Commonwealth Games.

Harkamal HeranChief Operating Officer

Background

Due to the ongoing Covid-19 pandemic, Emergency Preparedness within the Trust continues to be different to previous years.

The Incident Control Room

The Incident Control Room was set up in March 2020 and has been operational since. It was established when the NHS declared a Level 4 incident and has been stood down at various points throughout the past year in line with the national incident level. The requirement for Level 4 incidents is defined in the EPRR Framework as:

‘An incident that requires NHS England National Command and Control to support the NHS response. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level.’

The Incident Control Room collates all the information coming into the Trust from NHS England, Public Health England (now UK Health Security Agency) and other agencies, to provide a central single point of communication. A designated email address receives all emails, documents and correspondence and the staff ensure that this is filed, ensuring there is a record of information received and the action taken in response. There is also a requirement to submit data on behalf of the Trust in the form of situation reports (Sitreps). Currently data is submitted daily for:

Covid Sitrep – summary of bed usage, numbers of Covid and suspected Covid patients in the organisation, ventilated and patients receiving Continuous Positive Airway Pressure (CPAP), new admissions, discharges, number of patients on oxygen and staffing data

Acute and community discharge summaries Sari-watch – numbers of new admissions and Covid status to UK Health Security Agency

(previously Public Health England) Bi-weekly – Mortuary Reports

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Weekly data on elective cancellations, surgical waiting lists, children, and young people unique mental health conditions.

There was also a requirement to monitor data relating to vaccinations, but this has recently ceased with the closure of the vaccination hub.

Staffing

The requirements for staffing the Incident Control Room have increased and funding for an increase in staffing levels was approved at Management Board to maintain the Emergency Planning cover as part of succession planning for the current post-holder and to enable the team to deliver cover on a long-term basis in the Incident Control Room. Staff have been recruited to the posts and there is now a 1.0 WTE Band 6 and 1.0 WTE Band 3 which will make up the team.

In December 2021, NHS England again raised the incident level to a Level 4 incident in response to the new Covid-19 variant, Omicron, requiring the Incident Control Room to be manned seven days a week.

Training

External training was delivered to the members of Silver and Gold Command (Strategic and Tactical commanders) by a solicitor advocate who trained the staff on presenting their evidence to a Public inquiry. There may be a requirement to hold further sessions, but this will be determined by the date of the Public Inquiry which has not yet been announced.

There has been a considerable effort to update business continuity plans to reflect some of the changes required to services during the pandemic, but this is ongoing. A series of short scenarios to be held in the workplace to test business continuity plans have been developed but have had to be postponed until the team can visit the workplaces.

Due to the limitations of face to face contact, the training programme has been curtailed. Some training was given over Microsoft Teams, but training will be a focus for the coming financial year.

Core Standards for Emergency Preparedness, Resilience and Response (EPRR)

Each year, NHS England require Trusts to complete a self-assessment against several Core Standards for EPRR. This year, the Trust was required to submit evidence against the designated Core Standards. The initial submission resulted in an overall compliance rating of substantial, with 47 out of 48 standards assessed as being met. Prior to submission, there is a meeting between the EPRR leads for the NHS Trusts in Warwickshire and the submissions are challenged and verified by the Head of Resilience for the Clinical Commissioning Group (CCG). This process was followed, and submission made. Four weeks later the Trust received a communication from NHS England which further challenged our submission, and two further standards were marked down. This however did not alter the Trust’s overall submission of substantial.

The completion of the action plan from last year’s core standards submission has been delayed and will be addressed throughout the coming year. Some of the work is planned jointly across all Trusts within Coventry and Warwickshire.

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Core Standards Submission – Action Plan 2019/20 – updated January 2022

An action plan has been developed to address the standards that the Trust is partially compliant with. (see below). The progress will be monitored through the Emergency Planning Group which meets quarterly.

Ref Domain Standard Detail Evidence - examples listed

Self-assessment RAG

Action to be taken

Lead Timescale Comments

20 Duty to maintain plans

Shelter and evacuation

In line with current guidance and legislation, the organisation has effective arrangements in place to place to shelter and / or evacuate patients, staff and visitors. This should include arrangements to perform a whole site shelter and / or evacuation.

Evidence - examples listed belowArrangements should be: • current• in line with current national guidance• in line with risk assessment • tested regularly• signed off by the appropriate mechanism• shared appropriately with those required to use them• outline any equipment requirements • outline any staff training required

Partially compliant

Completion of plan and ratification by Emergency Planning Group required

Emergency Planning Lead

Expected by 31st March 2022

Draft plan is completed – to collaborate with other NHS Trusts to develop a whole site evacuation plan with Local Authority input.

22 Duty to maintain plans

Protected individuals

In line with current guidance and legislation, the organisation has effective arrangements in place to respond and manage 'protected individuals'; Very Important Persons (VIPs), high profile patients and visitors to the site.

Operation Consort updated by WMASHave always referenced the WMAS Operation Consort Plan - can reference this document during review of the Major Incident Plan, to include detail. However, it is unlikely that a VIP would be brought to this ED as it is in the Operation Consort plan to transfer them straight to a Major Trauma Centre not a Local Emergency Hospital.Add amendment to Major Incident Policy when it is reviewed to include management of VIP - to be completed by March 2022

Partially compliant

Amendment to be added to major incident plan during review of plan. -



Completed in draft format – to be approved in final format after consultation within the Divisions

34 Response

Situation Reports

The organisation has processes in place for receiving, completing, authorising and submitting situation reports (SitReps) and briefings during the response to business continuity incidents, critical incidents and major incidents.

Generic e-mail address for all types of incidents has been in use. Not referenced in plan, but included in Strategic/Tactical training for senior managersCurrently managed through Incident Control Room and by telephone

Partially compliant

Section to be added to Major Incident Plan during this year's review re process for Sitreps.



Completed in draft format – to be approved in final format after consultation within the Divisions

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The Commonwealth Games

The Commonwealth Games are being hosted in Birmingham in July and August 2022. The organising committees are in place and there are monthly meetings for Joint Integrated Care System (ICS) Coordinating Group and Training & Exercising Group, both of which have Trust representation.

Briefing papers have been issued and a schedule of events to be held – see schedule below.

Work-streams are in place to monitor the following:

The risk log has been shared with the Risk Management Board and will be reviewed on a regular basis.

The Accountable Emergency Officer (Chief Operating Officer) is the Commonwealth Games Accountable Officer, with the Emergency Planning Lead as the Single Point of Contact (SPOC) through a designated Games email address.

The Incident Control Room will be maintained throughout the Commonwealth Games period, with some extra staff to cover the required opening times. (Likely to include on-call managers)

There is a programme of training and exercising and an exercise is planned for April 2022 to test the ability of the Trust to double its critical care capacity and free 20% of its beds in the event of a mass casualty event.

Lessons learnt from previous sporting events have been distributed and the Emergency Planning Lead is reviewing these to ascertain whether any changes are required to current plans.

There will also be training required for frontline staff to manage members of the Games Family and VIP management, and this will be cascaded to relevant staff when received.

Travel and transport have also been discussed and any road closures during the events will be made public, so that Trusts can discuss the risk to staff, patients, logistics and deliveries.

Details regarding overseas patient processes such as charging for NHS treatment, language problems and safeguarding are also under review.

Recommendation

The Board of Directors is asked to receive and note this report which includes the Emergency Preparedness Annual Report.

Sue SheltonEmergency Planning Lead

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Date Sport Site Spectator Capacity System 28 July 2022 Opening Ceremony Alexander Stadium 31500 Birmingham and Solihull 4 – 8 August 2022 Aquatics – Diving Sandwell Aquatics

Centre 2500 Black Country and West

Birmingham 29 July – 3 August 2022 Aquatics - Swimming &

Para Swimming Sandwell Aquatics Centre

5000 Black Country and West Birmingham

2 – 7 August 2022 Athletics and Para Athletics

Alexander Stadium 31500 Birmingham and Solihull

30 July 2022 Athletics - Marathon Smithfield 50000 Birmingham and Solihull 29 July – 8 August 2022 Badminton The NEC Hall 5 5900 Birmingham and Solihull 29 July – 2 August 2022 Basketball 3x3 &

Wheelchair Basketball 3x3

Smithfield 4000 Birmingham and Solihull

30 July – 7 August 2022 Beach Volleyball Smithfield 2500 Birmingham and Solihull 29 July – 7 August 2022 Boxing The NEC Hall 4 5900 Birmingham and Solihull 29 July – 7 August 2022 Cricket T20 Edgbaston Stadium 23500 Birmingham and Solihull 3 August 2022 Cycling - Mountain Bike Cannock Chase Forest 10000 Staffordshire and Stoke-

on-Trent 7 August 2022 Cycling - Road Race St Nicholas Park,

Warwick 30000 Coventry and

Warwickshire 4 August 2022 Cycling - Time Trial West Park,

Wolverhampton 30000 Black Country and West

Birmingham 29 July – 1 August 2022 Cycling - Track & Para

Track Lee Valley Velopark 5500 North East London

29 July – 2 August 2022 Gymnastics – Artistic Arena Birmingham 8500 Birmingham and Solihull 4 – 6 August 2022 Gymnastics - Rhythmic Arena Birmingham 8500 Birmingham and Solihull 29 July – 8 August 2022 Hockey University of Birmingham

Hockey & Squash Centre 6000 Birmingham and Solihull

1 – 3 August 2022 Judo Coventry Stadium 2300 Coventry and Warwickshire

29 July – 6 August 2022 Lawn Bowls & Para Lawn Bowls

Victoria Park, Leamington Spa

2500 Coventry and Warwickshire

29 July – 7 August 2022 Netball The NEC Arena 9000 Birmingham and Solihull 4 August 2022 Para Powerlifting The NEC Hall 1 2400 Birmingham and Solihull 29 – 31 July 2022 Rugby Sevens Coventry Stadium 32600 Coventry and

Warwickshire

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29 July – 8 August 2022 Squash University of Birmingham Hockey & Squash Centre

2000 Birmingham and Solihull

29 July – 8 August 2022 Table Tennis & Para Table Tennis

The NEC Hall 3 2500 Birmingham and Solihull

29 & 31 July 2022 Triathlon & Para Triathlon Sutton Park 20000 Birmingham and Solihull 30 July – 3 August 2022 Weightlifting The NEC Hall 1 2400 Birmingham and Solihull 5 – 6 August 2022 Wrestling Coventry Stadium 2300 Coventry and

Warwickshire 8 August 2022 Closing Ceremony Alexander Stadium 31500 Birmingham and Solihull

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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Meeting Board of Directors

Date 2 March 2022

Subject Estates Strategy Summary

Agenda Item 8.3

Nature of item For information

For approval For decision

Decision required

The Board is asked to receive and note the summary of the Trust’s Estates Strategy.

General Information

Report Author Mark Jones, Associate Director of Strategic Estates and Capital Estates and Capital Teams Mary Powell, Head of Strategic Communications and Fundraising

Lead Director Sophie Gilkes, Chief Strategy Officer


Meeting Management Board, Board of Directors - Confidential

Date 28 January 2022 2 February 2022







No

Final/draft format

Final

Ownership

Trust


Yes

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Estates Strategy Summary

Executive Opinion For the last 12 months an extensive piece of work has been completed to develop a 10-year Estates Strategy for the Trust. The first stage was to understand our current estate and a series of data metrics were used such as backlog maintenance costs, assessment against modern building standards and qualitative evidence from teams. A series of workshops were then held with Estates and Capital teams, before wider workshops with clinical, operational and finance colleagues. The Trust is also part of the South Warwickshire Local Estates Forum and the Coventry and Warwickshire Estates Group, and both have been considered as part of the Trust’s Estate Strategy. The Strategy has also included direction from local clinical strategies, regional and national policies to understand how the estate will need to respond to future provision of services. The Board of Directors considered the full Estates Strategy document and approved this on 2 February 2022, at its confidential meeting, as a roadmap to ensure future developments are aligned to our strategic direction. The strategy will evolve over time but places the Trust in a strong position to develop a fit for the future estate. It also connects with our partnership approach and other approved strategies such as sustainability. Whilst it focuses on the four main sites that services are delivered from, it acknowledges and includes information on our approach with our community properties. This summary Estates Strategy document highlights the key areas for development to enable our estate to respond to the challenges ahead and to support the delivery of high quality, safe services for our communities. Recommendation The Board is asked to receive and note the summary of the Trust’s Estates Strategy. Sophie Gilkes Chief Strategy Officer

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safe, effective, compassionate, trusted

South Warwickshire NHS Foundation Trust’s

Estates Strategy Summary Document2022/32

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CURRENT ESTATE

The Trust operates from four hospital sites:

• Warwick Hospital

• Stratford Hospital

• Leamington Spa Hospital

• Ellen Badger Hospital

WARWICK HOSPITAL STRATFORD HOSPITAL LEAMINGTON SPA HOSPITAL ELLEN BADGER HOSPITAL

What is an Estate Strategy?The Estate Strategy sets out how the Trust will use our estate and infrastructure to support the delivery of clinical and non-clinical services. Transforming our estate will help create sustainable and accessible services that are appropriately located to support clinical safety and operational efficiencies.

A strategic development of the estate will provide benefits for patients, staff, visitors and partners in the health and social care economy. A cost-effective quality estate, which is safe, sustainable, efficient, and fit for purpose, will enable us to deliver services in the right place, at the right time.

The Estate Strategy will be reviewed continually and refreshed in line with local and national developments and provides a roadmap for us to invest in our estate moving forward.

02 South Warwickshire NHS Foundation Trust’s Estates Strategy Summary Document 2022/23 03

We also have teams in several properties within the community, owned by NHS Property Services and others. The condition of these properties varies significantly. The Trust is looking to reduce the number of properties to ensure that community properties are fully utilised to provide the most efficient, safe, and cost-effective services.

We deliver services across the whole of Warwickshire and in Coventry and Solihull

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Key considerationsFUTURE DIRECTION OF SERVICES

The future direction of services will inform estate planning. The Trust will work with the South Warwickshire Estates Forum and the wider health economy in Coventry and Warwickshire to ensure clinical strategies are considered, identifying future models of care and how the estate can operate differently but in the most cost efficient and sustainable way.

MAKING OUR SITES MORE SUSTAINABLE

Most of the Trust’s emissions (84.3%) come from sources the organisation has little or no control over. 78.3% from the supply chain, and a further 6% from patient and visitor travel.

The remaining 15.7% arise from sources that can be controlled or strongly influenced, with 10.9% of emissions coming from the operation of buildings. Making our sites more sustainable will be a key element of estate planning and all plans will be aligned to our Sustainability Strategy.

CREATING AN ELECTIVE HUB FOR PLANNED CARE

Whilst there is growing support nationally for ‘elective sites’ away from the acute site, it has been recognised by the national Getting It Right First Time (GIRFT) programme team that the Trust has, and continues to demonstrate that, elective care can be protected on an acute site and that the productivity impact of a split site will not deliver the increase in elective capacity required.

Elective care is rarely cancelled at SWFT, and the GIRFT team identified us as an ‘exemplar’ in this regard. National planning guidance has set an ambitious goal to deliver around 30% more elective activity by 2024/25 than before the pandemic, so creating an elective hub is going to be critical.

Condition of our estateTo understand the condition of the estate, a full survey was carried out by external specialists.This non-intrusive survey was undertaken between January and March 2021 on three of the Trust’s hospital sites;

WARWICK, LEAMINGTON SPA AND STRATFORD HOSPITALS.Ellen Badger Hospital was not included in this as it already has a development plan.

Findings from the survey included:

• Parts of Warwick Hospital require substantial refurbishment and modernisation

• Lack of space for development

• Not all areas are serviced with more than one lift for back up in case of failure

• Size of buildings not in line with modern standards

• Several services are delivered from temporary accommodation

•National planning guidance has set an ambitious goal to deliver around 30% more thanpre-pandemic elective activity by 2024/25. Therefore, creating a modern fit for purpose electivehub is going to be critical

• Main corridor at Warwick Hospital needs to be wider and fit to modern standards

• Multiple entrances and exits leads to poor wayfinding

• Inefficient spread of IT data rooms across estate

• The current Day Surgery Unit and Radiology Department are not fit for purpose

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Area of focusWith recent investment in Stratford and Leamington Spa Hospitals and a development in progress at Ellen Badger Hospital,

the focus for a development plan is the Warwick Hospital site.

DEVELOPMENT OF THE WARWICK HOSPITAL SITEAfter considering a range of options a phased development of the Warwick Hospital site is the preferred approach.

Key features of this option are:

• Create a main entrance tosupport better wayfinding

• Develop the centre of the site whichis currently in a poor condition andis not as functional as it could be

• Better flow around the site

• Minimal disruption to day-to-dayactivity as it would be completedin a phased approach

• No reduction to car parking

• Futureproofing by providingspace for future expansion

The Warwick Hospital Strategic Site Development

Plan, as proposed, will enable each phase to progress subject to funding and clinical

strategy.

CREATING A HOSPITAL WITHIN A HOSPITALWith the national emphasis on increasing elective capacity, a dedicated elective hub is needed at Warwick Hospital.

By creating a ‘hospital within a hospital’ to support this activity it will enable the Trust to:

• Meet the national targets

• Offer mutual support

• Eliminate the issues with thecurrent Day Surgery Unit andRadiology Department

✓ ✓

✓✓

✓✓

✓

✓✓

Provide immediate extra capacity by re-providing and expanding the footprint of an existing two ward block, adding space for clinics and minor operations.

Ringfence the Trust’s elective capacity and create a ‘hospital within a hospital’, with greater separation from the main site, while still being within the hospital grounds benefiting from existing support workforce and infrastructure.

Allow the decant and demolition of the existing two surgical wards and other older parts of our accommodation. This then ’unlocks’ space on site to start the development of a purpose built three-storey surgical hub.

Developing in stagesIn the first instance the Trust will explore the development of a modular build to support a three-storey surgical hub. The modular build will consist of two wards with treatment rooms and waiting and clinic areas. This accommodation would:

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Development of other sitesSTRATFORD HOSPITAL

A separate plan will be developed to understand the new requirements of Phase 2 of Stratford Hospital, which will include proposals to develop the Trust’s Community Diagnostic Hub on site at Stratford Hospital.

LEAMINGTON SPA HOSPITAL – including Central England Rehabilitation Unit (CERU)

The refurbishment of Campion Ward has been completed; this has enabled the temporary re-location of the inpatient ward from Ellen Badger Hospital to the site.

Further works to strengthen the hospital’s reputation as a centre for excellence for rehabilitation are planned. This may include some of the rehabilitation services moving from Warwick Hospital.

ELLEN BADGER HOSPITAL

The Trust is currently working with Shipston Medical Centre to progress plans to develop the existing Ellen Badger site and re-locate the medical centre.

The new development is going to offer a wide range of services, including a Health and Wellbeing Centre and create shared spaces. There will also be outpatient and treatment rooms for Physiotherapy, Specialist Nurses and other health professionals including Mental Health Clinicians.

COMMUNITY TEAMSThe Trust continues its efforts to ensure the community estate is high quality, accessible and efficient. Several properties have been identified which can be vacated. Our organisation continues to ensure that the charges for the community properties the Trust operate from are value for money.

Options to develop The Orchard Centre in Rugby are currently being explored and plans to create a new healthcare facility which will replace the Cubbington Road Surgery and the Crown Way Clinic in Lillington are underway.

The Trust will continue engagement with health and care partners across Coventry and Warwickshire to develop a strategy for agile working spaces and staff wellbeing areas, which are accessible to our community teams.

1

3

2

45

6

7

1 New car park with flexible space for mobile diagnostics,e.g. breast screening services

2 Health and Wellbeing Centre* (ground floor) -a flexible space for community use, therapy and activities

3 Woodland walk, including access to the River Stour*

4

Shipston Medical Centre: this new updated facility will increase clinical space by more than 30%, allowing for service expansion and space for other primary care services. The new location will enable closer working with community services and integration with other services and the voluntary sector, which all supports quality patient care and enhancing the health and wellbeing of our community. The design of the new building includes larger waiting areas and will better meet infection control processes

5 Entrance from Stratford Road

6

Shared spaces for Community Nursing and Health Visiting teams as well as Shipston Home Nursing. There will be outpatients and treatment rooms for Physiotherapy, Specialist Nurses and other health professionals including Mental Health Clinicians

7Existing building will initially provide the day hospital, Outpatient clinics and Physiotherapy services, flexibility in the future to be used for other services, e.g. Inpatients

Proposed plans for the Ellen Badger site after completion of the first phase:

* The range of facilities within the Health and Wellbeing Centre and the woodland walk are subject to the level of public fundraising support.

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JAN FEB JULMAR AUGAPR SEPTMAY OCTJUN NOV

This summary estates document highlights the key areas for development to enable our estate to respond to the challenges ahead and to support the delivery of high quality, safe services for our communities.To understand the developments, an extensive piece of work was completed to understand our current estate, and this highlighted a number of risks and significant backlog maintenance to our buildings. Several development options were also considered before the ones highlighted within this document were selected.

Key areas considered:• New models of care and clinical strategy

• An estate that maximises productivity

• Ambition to become Net zero carbon by 2040

• Addressing the risks of back log maintenance and demolishing and developing thepoorest parts of our estate from a quality and sustainable perspective

• Responding to learning from covid

This plan provides the Trust with a roadmap to ensure future developments are aligned to our strategic direction. It will evolve over time but places the Trust in a strong position to develop a fit for the future estate. It also connects with our partnership approach and other approved strategies. Whilst it focuses on the four main sites that services are delivered from, it acknowledges and includes information on our approach with our community properties.


Next steps for the Estate StrategyFull strategy was approved by the Board of Directors in February 2022. A phase 1 development plan for the Warwick Hospital site, Community Diagnostic Hub at Stratford Hospital and continuous development of community estates will be developed.

✓

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www.swft.nhs.uk01926 495321 (main switchboard) South Warwickshire NHS Foundation Trust’s

Estates Strategy Summary Document

2022/23

/nhsswft

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Subject Updated Register of Directors’ Interests Agenda Item 8.4


Nature of item

For decision


The Board of Directors is invited to receive and note the updated Register of Directors’ Interests.

Report Author Sarah Collett, Trust SecretaryGeneral Information Lead Director Sarah Collett, Trust Secretary




Funding Source





No


Ownership Trust



Yes

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Updated Register of Directors’ Interests

1. Background

As a Foundation Trust the Trust is required to hold a number of registers and to make them available for public inspection.

2. The Constitution and Standing Orders

The Constitution (paragraph 34 refers) provides that:-

‘The Trust shall have:

34.4 a register of directors

34.5 a register of interests of the directors’

Paragraph 36 provides that:

’36.1 The Trust shall make the registers specified in paragraph 34 available for inspection by members of the public…….’

The Standing Orders for the Board of Directors (SO 7.8 refers) states that:

‘7.8.1 In accordance with the Constitution, the Secretary will ensure that a Register of Interests is established to record formally declarations of interests of Directors. In particular the register will include details of all directorships and other relevant and material interests (as detailed in SO 7.2) which have been declared by both executive and non-executive Board directors.’

7.8.2 These details will be kept up to date by means of an annual review of the register in which any changes to interests declared during the preceding 12 months will be incorporated.

7.8.3 The register will be available to the public and the Chief Executive will take reasonable steps to bring the existence of the register to the attention of local residents and to publicise the arrangements for viewing it.’

3. Registers

The Register of Directors’ Interests was subject to its annual review at the Board meeting on 7 April 2021 with updates received at the Board meetings on 5 May 2021, 2 June 2021, 1 September 2021, 6 October 2021, 1 December 2021 and 2 February 2022.

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An update has been received from Charles Ashton, Chief Medical Officer, and therefore the updated Register is attached at Appendix A (updates in bold text) for the Board’s formal receipt and noting.

The updated Register will be made available to the public via the Trust’s website and will be available for physical inspection through the Trust Secretary.

Directors are reminded of their responsibility to advise the Trust Secretary promptly of any changes to their Register entries.

4. Recommendation

The Board of Directors is invited to receive and note the updated Register of Directors’ Interests.


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Appendix A

The Trust is required to compile a Register of Directors’ Interests (as below), in accordance with the Constitution, and to make the register available for public inspection.

The register is maintained by the Trust Secretary who holds the original signed declaration forms. These are available for inspection by contacting the Trust Secretary on (01926) 495321 Ext. 4248.

Register of Directors’ Interests(February 2022)

Voting Board Members

Name Designation Declared InterestCharles Ashton Chief Medical Officer - Confirmation that Charles does not

undertake any private medical practice

- Small holding of Astra Zeneca shares

- Small holding of Framlington Biotech which invests in multiple Biotechnology companies.

Glen Burley Chief Executive - Chief Executive, Wye Valley NHS Trust

- Chief Executive, George Eliot Hospital NHS Trust

- Spouse is a Practice Nurse at Rother House Medical Centre

Fiona Burton Chief Nursing Officer - No interests declared

Anne Coyle Managing Director - Spouse is Managing Director of Mini Digital Limited

Russell Hardy Chairman - Chairman and majority owner of Maranatha 1 Ltd (trading as Fosse Healthcare Limited and Fosse ADPRAC)

- Chairman of ‘Cherished’- Chairman, Wye Valley NHS Trust- Chairman, George Eliot Hospital NHS

Trust- Son is employed by Deloitte LLP

(Trust’s External Auditors)

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Name Designation Declared InterestHarkamal Kaur

HeranActing Chief Operating

Officer- No interests declared

Rosemary Hyde Non-Executive Director - Director and Shareholder of RPR Consultants Ltd

- Employed by South Warwickshire GP Federation in temporary/part time capacity

- Spouse is Director and Shareholder of Brian Hyde Ltd

- Spouse is Director of RPR Consultants Ltd

- Spouse is a member of the Council of University of Warwick

Kim Li Chief Finance Officer - Director of SWFT Clinical Services Ltd (a wholly owned subsidiary of South Warwickshire NHS Foundation Trust)

- Committee member of the West Midlands Branch of the HFMA

- Trustee of HFMA- Daughter has joined the Trust’s

Administrative and Clerical Bank

Simon Page Non-Executive Director - Owner and Director of Weathervane Consulting

David Spraggett Non-Executive Director - GP Partner at Castle Medical Centre, Kenilworth. David’s partnership is a shareholder of South Warwickshire GP Federation. Practice Manager at Castle Medical Centre is a Director of South Warwickshire GP Federation. Castle Medical Centre is a member of Kenilworth and Warwick Primary Care Network

Sue Whelan Tracy Non-Executive Director - Trustee/Company Director of ExtraCare Charitable Trust

- Lay Member of Nursing and Midwifery Council

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Non-Voting Board Members

Name Designation Declared InterestYasmin Becker Associate Non-

Executive Director- Chief Operating Officer for the

Federation of the Royal Colleges of Physicians

- Trustee and Chair of the Business Development Committee at Solace Women’s Aid

Sophie Gilkes Chief Strategy Officer - Partner is a Fund Manager for NFU Mutual, which includes investments in healthcare organisations

Gertie Nic Philib Chief People Officer - Director of People and Organisational Development for both South Warwickshire NHS Foundation Trust and George Eliot Hospital NHS Trust


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Subject Board Committee Minutes – Open Meetings

Agenda Item 9


Nature of item

For decision

Decision required

The Board is asked to receive and note the following open Board Committee Minutes:

1. Audit Committee 8 December 20212. Clinical Governance Committee 12 January 2022

Report Author 1. Colleen Tooze, Committee Administrator2. Zoe Cox, Committee Administrator

General Information

Lead Director 1. Kim Li, Chief Finance Officer2. Fiona Burton, Chief Nursing Officer

Meeting 1. Audit Committee2. Clinical Governance Committee


Date 1. 9 February 20222. 9 February 2022



Funding Source





No


Ownership Trust



Yes

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Open Minutes of the Audit Committee Meeting

held on Wednesday 8 December 2021 at 9.00am Via Microsoft Teams Present: Rosemary Hyde (RH) Non-Executive Director (NED) and Committee Chair Yasmin Becker (YB) Associate NED Simon Page (SP) NED Bruce Paxton (BP) NED

In attendance: Sarah Collett (SC) Trust Secretary Vicky Dumigan (VD) Information Governance Manager (present from Minute

21.201) Fiona Dwyer (FD) Counter Fraud Specialist, CW Audit Services Ian Howse (IH) Partner, Deloitte, LLP Phil Johns (PJ) Associate Director of ICT Services (present from Minute

21.200 to 21.204) Ruth Mawby (RM) Manager, CW Audit Services Gertie NicPhilib (GP) Chief People Officer (present from Minute 21.192 to 21.198) Mick Sargent (MS) Associate Director of Finance (deputising for the Chief

Finance Officer) Greg Stevens (GS) Associate Director of Information and Performance (present

for Minute 21.199 to 21.201) Sarah Swan (SS) Assistant Director, CW Audit Services Colleen Tooze (CT) Executive Assistant / Committee Administrator

MINUTE ACTION 21.192 APOLOGIES FOR ABSENCE

An apology for absence was received from the Chief Finance Officer.

21.193


There were no declarations of interest. Resolved – that the position be noted.

21.194

MINUTES OF THE OPEN MEETING HELD ON 13 OCTOBER 2021 – OPEN MEETING

Resolved – that the Minutes of the Open meeting held on 13 October

2021 be confirmed as an accurate record of the meeting and signed by the Committee Chair.

21.195

MATTERS ARISING AND PROGRESS MONITORING REPORT

21.195.01 Actions Listed as Complete The items listed as complete in the actions update be noted and removed from the report.

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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Open Minutes of the Audit Committee Held on 8 December 2021

MINUTE ACTION


21.195.02 Internal Audit Report – BEST Wheelchair Ordering / Invoice Process – Review of Process (Minute 21.169 refers) NEDs sought assurance on getting more useful information for the Executive Team in regards to opportunities and costs associated with wheelchair ordering and recycling. The Committee Chair requested for the Manager for Adult Occupational Therapy and Wheelchair Services to be invited to the next meeting for wider challenge and discussion on the topic of wheelchair ordering and recycling. Resolved – that the Manager for Adult Occupational Therapy and Wheelchair Services be invited to the next meeting for wider challenge and discussion on the topic of Wheelchair ordering and recycling.

CT CT

21.195.03 Managing Conflicts of Interest 6 Monthly Report (Minute 21.162.03 refers) The Trust Secretary provided an update in that declarations of interest for consultants would be captured as part of the job planning process as part of the new job planning software. There was a pro-forma in the software to capture declaration of interest details and if declarations were not captured, the job plan would be rejected. The consequence of not finalising the job plan would be that the consultant would not get paid. The Trust Secretary confirmed that declarations of interest would continue to be an annual process and the new job planning software would be implemented from April 2022 together with the Electronic Staff Record (ESR) module. The Trust Secretary would be able to access the declarations of interest information from the job planning software. Training of the new software had already commenced with general managers. Tighter work would continue with the Divisions as an improved compliance rate had been noted. NEDs sought assurance that there were no weaknesses in the system and that staff from Innovate Healthcare Services Ltd were also required to complete declaration of interest forms. The Trust Secretary highlighted that the process was well sighted and would liaise with the FT Adviser to ensure Innovate Healthcare Services Ltd had a process for capturing declarations of interest for their staff. Resolved – that the Trust Secretary liaise with the FT Adviser to ensure that Innovate Healthcare Services Ltd had a process for capturing declarations of interest for their staff.

SC SC

21.196 2021/22 SCHEDULE OF BUSINESS (UPDATE) The Committee noted the 2021/22 Schedule of Business (Update).

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MINUTE ACTION

Resolved – that the 2021/22 Schedule of Business (Update) be received and noted.

21.197 INTERNAL AUDIT REPORT – CONTRACTED OUT PAYROLL The Manager, CW Audit Services presented the Internal Audit Report – Contracted Out Payroll and provided Significant Assurance. The key issues that management must address were as follows:

a) Approval to Recruit (ATR) forms to be fully completed. b) The authorised signatory list should reflect all officers authorising

Payroll documentation. c) Managers should be reminded to ensure key Payroll

documentation was submitted in a timely manner.

The Chief People Officer added that it was best to move away from ATR forms and bring forward the implementation to TRAC as ATR’s got held up in various places. Mr Page, NED, commented that there had been a lot of talk of IT weaknesses in processes. The Chief People Officer responded that it was not just IT but management responsibility to ensure processes were followed and adhered to. Mr Page, NED, still had concerns over several leavers where there were delays in getting IT access withdrawn. Discussion took place on under and over payroll payments. The Chief People Officer responded that there was an agreed process with payroll to address under and over payroll payments. Payroll linked with the Finance Department to arrange payment in the case of an over payment. The Associate Director of Finance confirmed that on average there were 15-20 overpayments a month. He added that they could not be eliminated due to human error but could be greatly reduced. The Chief People Officer confirmed that underpayments and overpayments made up well less than 1% and concluded that the contracted out payroll had a level of over 99% accuracy. Resolved – that the Internal Audit Report – Contracted Out Payroll be received and noted.

21.198 EXTERNAL AUDIT PROGRESS REPORT The Partner, Deloitte, LLP provided an External Audit Progress Update and highlighted the following:

a) the External Audit Plan for 2021/22 including Key Performance Indicators (KPIs) would be presented at the February 2022 meeting;

b) Audit Management was under huge pressures due to COVID however the plan was still achievable;

c) The focus moving forward for the Trust would be on new

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MINUTE ACTION

additional payroll disclosures and IFRS 16 (leased assets) for 2022/23.

The Committee Chair queried the Value for Money (VfM) audit and sought clarification around when it would be signed off. The Partner, Deloitte, LLP confirmed that it would be signed off and aligned with the annual accounts audit. The Partner, Deloitte, LLP explained that there were backlogs in completion of audits in the public sector and if anything came up that would deviate from plan, the Audit Committee would be notified. Resolved – that the External Audit Progress Report be received and noted.

21.199

INTERNAL AUDIT PROGRESS REPORT The Assistant Director, CW Audit Services commented that their work was on track to deliver the plan, however there were a few changes to the plan as follows:

a) Recent discussions with the Managing Director identified that the planned review of the Integrated Care System (ICS) would not go ahead this year. This decision was in line with other Trusts locally who considered the timing to be too early to achieve maximum benefit from the review.

b) The planned review of Consultant Job Plans was not in a position to proceed this year as new software was not yet fully rolled out. A request for a further review of scanning had been received. An independent review was required to satisfy the accreditation and validation requirements.

Recommendations and Outstanding Actions had improved in recent months, however 13 had revised dates. The Assistant Director, CW Audit Services concluded for the Trust to continue closely monitoring the implementation of the recommendations. The Committee Chair thanked the Assistant Director, CW Audit Services for including the National Audit Office’s Cyber Risks Guidance in the report as it was useful and well written and had been circulated to Audit Committee members and the wider organisation. Resolved – that the Internal Audit Progress Report be received and noted.

21.200 INTERNAL AUDIT REPORT – DATA QUALITY – REVIEW OF CANCER WAITING TIME 28 DAY FASTER DIAGNOSIS STANDARD (FDS) The Manager, CW Audit Services presented the Internal Audit Report – Data Quality – Review of Cancer Waiting Time 28 Day Faster Diagnosis Standard and provided Significant Assurance. The key driver was noted

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MINUTE ACTION

to be around communication. The key issues that management must address were as follows:

a) Remind key staff that the letter authorised date must be used as the clock stop date, supporting evidence of communication with the patient of diagnosis or ruling out of cancer must be held in all cases and Lorenzo must record all attended appointments or DNA’s accurately.

b) Liaise with the GP e-referral service (e-RS) to ascertain if the system had the functionality to produce a report of all referrals made to the Trust which could be utilised to perform a reconciliation to referrals input to Lorenzo. Additionally, seek confirmation of the audit trail available within e-RS to support the date referrals were received to ensure FDS guidance regarding clock start dates could be evidenced.

Mr Paxton, NED, commented that the patient portal arena was changing rapidly. He suggested not spending a lot of time with it if it was not going to be measured. The Associate Director of Information and Performance commented that the interface with patients may change. Mr Paxton, NED queried if patient choice was tracked. The Associate Director of Information and Performance commented that it was but emphasised that patients needed to be aware in some cases of why they were being seen. The Assistant Director, CW Audit Services thanked the Associate Director of Information and Performance as well as his team for their efforts and that more mandated reviews were most likely to take place in the future. The Committee Chair queried the completeness of e-referrals. The Associate Director of Information and Performance commented that conversations took place with NHS England/NHS Improvement (NHSE/I) to see if there were reports that could be downloaded, however there were no reports available and at this stage it was a manual process. He explained that it did not take an enormous amount of time and that the manual process was balanced with a patient being missed and concluded that it was time well invested. Resolved – that the Internal Audit Report – Data Quality – 28 Day Faster Diagnosis Standard be received and noted.

21.201 INTERNAL AUDIT REPORT – FINANCIAL LEDGER The Manager, CW Audit Services presented the Internal Audit Report – Financial Ledger and provided Significant Assurance. The key issues that management must address were as follows:

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MINUTE ACTION

a) The Trust should ensure that control account reconciliations were evidenced with the correct date of completion, were undertaken regularly and in a timely manner, including review.

b) The Trust should confirm the date of the completion and review of the SWFT Clinical Services Limited Value Added Tax (VAT) control account reconciliation.

c) Clear the Income Suspense Account as the earliest opportunity. The Manager, CW Audit Services commented that there had been a concerted effort to make improvements and it was in a better position than last year. The Associate Director of Finance responded that the financial ledger was reviewed on a quarterly basis. The Committee Chair emphasised that doing it more often made it manageable and helped to keep on top of things for good housekeeping. Mr Paxton, NED, sought assurance on the Income Suspense Accounts as he felt that the Finance Team was not on top of it. The Committee Chair queried the back office function. The Associate Director of Finance explained that Shared Financial Services across Wye Valley NHS Trust (WVT), George Eliot Hospital NHS Trust (GEH) and the Trust went live on 15 September 2021. The aim was to improve financial standards and best practice. The Manager, CW Audit Services confirmed that the audit covered the end of August 2021 and that the performance of Shared Services would be picked up later in the year with the Internal Audit Reports for Payables and Receivables. Resolved – that the Internal Audit Report – Financial Ledger be received and noted.

21.202 INTERNAL AUDIT REPORT – FINANCIAL GOVERNANCE – ADHERENCE TO NATIONAL PLANNING GUIDANCE (H1 ARRANGEMENTS) The Manager, CW Audit Services presented the Internal Audit Report – Financial Governance to National Planning Guidance (H1 Arrangements) and provided Significant Assurance. The key issue that management must address was as follows:

a) Validation of financial reporting information to the ledger should be performed as standard each month and prior to the release of reports for internal and external communication.

Resolved – that the Internal Audit Report – Financial Governance be received and noted.

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MINUTE ACTION 21.203 INFORMATION GOVERNANCE AND SECURITY QUARTERLY

ASSURANCE REPORT The Information Governance Manager presented the Information Governance and Security Quarterly Assurance Report and highlighted the key points. Of particular note during discussion, were the following:

a) The Committee Chair queried where the Trust fell down on in the Cyber Essentials Audit. The Associate Director of ICT Services commented that it was around keeping software security up to date, and the timely fixing of security patches, particularly on stand-alone machines;

b) The Committee Chair agreed to circulate the Cyber Security Guidance from the National Audit Office to the Associate Director of ICT Delivery and Information Governance Manager;

c) The Committee Chair raised the importance of Risk Management and Risk Appetite;

d) The NEDs were assured that funding was now in place to recruit additional cyber security specialists and noted huge progress in cyber security and information governance over the last 12 months.

Resolved – that

(A) the Information Governance and Security Quarterly Assurance Report be received and noted, and

(B) the Committee Chair circulate the Cyber Security Guidance from Internal Audit to the Associate Director of ICT Delivery and Information Governance Manager.

RH RH

21.204 ANY OTHER BUSINESS

21.204.01 Mr Paxton, NED The Committee Chair informed the Committee that this was Mr Paxton’s, NED, last Audit Committee meeting due to the end of his term of office. She thanked him for his support, challenge and involvement over the years with Audit Committee as well as the Clinical Governance Committee Resolved – that the position be noted.

21.205 REFLECTION ON THE MEETING FOR THE OPEN SECTION Mr Page, NED, commented that it was a good meeting whereby good discussions and debate were had. Resolved – that the position be noted.

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MINUTE ACTION 21.206 21.207 21.208 21.209

SWFT CLINICAL SERVICES APOLOGIES FOR ABSENCE DECLARATIONS OF INTEREST MINUTES OF SWFT CLINICAL SERVCIES HELD ON THE 13 OCTOBER 2021 SWFT CLINICAL SERVCIES MATTERS ARISING AND PROGRESS MONITORING REPORT

21.210 DRAFT ANNUAL REPORT AND FINANCIAL STATEMENTS

21.211 INTERNAL AUDIT PROGRESS REPORT

21.212 INTERNAL AUDIT REPORT – CONTRACTED OUT PAYROLL

21.213 INTERNAL AUDIT REPORT – FINANCIAL LEDGER

21.214 ANY OTHER BUSINESS

CLOSED MEETING

21.215 21.216 21.217 21.218 21.219 21.220 21.221 21.222 21.223

APOLOGIES FOR ABSENCE DECLARATIONS OF INTEREST MINUTES OF THE CLOSED MEETING HELD ON 13 OCTOBER 2021 MATTERS ARISING AND PROGRESS MONITORING REPORT INTERNAL AUDIT REPORT – ELECTRONIC PATIENT RECORD (EPR) PROJECT GOVERNANCE COUNTER FRAUD PROGRESS REPORT ANY OTHER CONFIDENTIAL BUSINESS REFLECTION ON THE MEETING FOR THE CLOSED SECTION DATE AND TIME OF NEXT MEETING The next meeting will be held on Wednesday 9 February 2022 at 9.00 am via Microsoft Teams.

Signed___________________________ (Committee Chair) Date 9 February 2022

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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting held on Wednesday 12 January 2022 at 13.00 hours via Microsoft Teams

Present:

Dr David Spraggett (DS) Non-Executive Director (NED) (Committee Chair)

Dr Charles Ashton (CA) Chief Medical Officer

Fiona Burton (FB) Chief Nursing Officer

Chris Day (CD) Head of Governance

Richard Grimes (RG) Elected Governor Rosemary Hyde (RH) NED

Dr Hannah Webber (HW) Clinical Education Fellow

Sue Whelan Tracy (SWT) NED

In Attendance:

Rebecca Bartholomew

(RB) Acting Chief Nurse, NHS Coventry and Warwickshire Clinical Commissioning Group (CWCCG)

Adam Carson (ACa) Managing Director, Innovate Healthcare Services (IHS)

Anne Coyle (AC) Managing Director

Rose Gardiner (RGa) Associate Director of Operations (ADO) Emergency Care Division Christine Georgeu (CG) Head of Infection Prevention and Control (present from Minute

22.004.08 until Minute 22.007) Ruth Gibson (RG) Patient Safety and Quality Manager Ann Hutton (AH) Deputy Head of Pharmacy Sara MacLeod (SMc) Operational Director of People and Workforce Briony Marshall (BM) PA to Chief Medical Officer and Operational Director of People

and Workforce Dr Noushad Padinjakara

(NP) Consultant Physician and Chair of the Emergency Audit Operational Governance Group (AOGG) (present from Minute 22.003 until Minute 22.006)

Tracey Sheridan (TS) ADO Out of Hospital Care Collaborative (OOHCC) Dilly Wilkinson (DW) ADO Family Health Division Zoe Cox (ZC) Committee Administrator

MINUTE ACTION

22.001 APOLOGIES FOR ABSENCE There were no apologies for absence received. Resolved – that the position be noted.

22.002 DECLARATIONS OF INTEREST There were no declarations of interest made. Resolved – that the position be noted.

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SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting held on

Wednesday 12 January 2022

Page 2 of 8

MINUTE ACTION

22.003 MINUTES OF THE PREVIOUS MEETING HELD ON 8 DECEMBER 2021 Mrs Whelan Tracy (NED) asked if the second paragraph on page 5 of the minutes under Minute No 21.238 Patient Safety Report, be updated to be an action and be reflected as such on the Action Log with an update due to brought back in April 2022. Resolved – that pending the above amendment, that the Minutes of the meeting held on 8 December 2021 be confirmed as an accurate record of the meeting and signed by the Committee Chair.

22.004

MATTERS ARISING AND ACTIONS UPDATE REPORT (INCLUDING OUTSTANDING CLINICAL QUALITY REVIEW GROUP (CQRG) ACTIONS)

22.004.01 22.004.02 22.004.03

Changes to January 2022’s Clinical Governance Committee Due to the current pandemic relating to Covid-19 and the Major Incident declared by the NHS across the country, the decision was made to reduce January 2021’s Clinical Governance Committee’s agenda. Due to this, the Committee chose to discuss only urgent items for approval and verbal updates provided where appropriate. Resolved – that the position be noted. Ambulance Offloading Update The ADO Emergency Division gave an update on managing offloads from ambulances as this had been highlighted previously. A policy had been put in place and agreed at the Silver Command meeting, but since then this has been reviewed and some amendments made as to how to manage those Covid-19 positive and non-positive patients and how they are managed when offloaded. This policy had been amended to reflect the Ambulance Trust’s policy so they are comparable. The Committee Chair advised that he would appreciate seeing this in writing and the ADO Emergency Division advised that a paper was going to Silver Command around enhancing the nursing workforce to help with those departmental pressures and it was agreed to send the Committee Chair the paper to review. Resolved – that the ADO Emergency Division send the Committee Chair the paper that will go to Silver Command around managing ambulance offloads and enhancing the nursing workforce to help with those departmental pressures. Patient Safety Monthly Report (Minute 21.237.01 refers)

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The Managing Director, IHS advised that there were still no timescales for implementation of the Medical Examiner System and the Chief Medical Officer added that there had been a discussion with Dr Rajan Paw – ED Consultant about coming up with something internally as a stop gap, however there were issues that still need to be worked though. The Patient Safety and Quality Manager advised that Datix had been considered for this work but the Bereavement Team were concerned about the amount of duplication this would cause if the national data base was being introduced in April 2022 as all the information would have to be inputted twice. An internal spreadsheet was also being reviewed by the team. The Chief Medical Officer highlighted that if the system was to be implemented by April 2022 that this would be ok, however there was concern around this timeline being met. It was agreed by the Committee to keep this action in progress on the action log. Resolved – that this action be kept on the action log in progress and as soon as an update was available around the Medical Examiner System, one would be brought back to this Committee. Children and Young Persons (CYP) Palliative Care Annual Report (Minute 21.192.09 refers) It was agreed that there would not be an update on where the CYP palliative care sat in terms of the ICS structure until later in the year and keep this on the action log in progress. Resolved – that It was agreed that there would not be an update on where the CYP palliative care sat in terms of the ICS structure until later in the year and keep this on the action log in progress. Clinical Audit and Quarterly Exception Report (Minute 21.219 refers) The ADO Emergency agreed to bring assurance back on the audit outcomes around improvement of assessment and treatment of pain at Triage to the February 2022 meeting. Resolved – that the ADO Emergency agreed to bring assurance back on the audit outcomes around improvement of assessment and treatment of pain at Triage to the next meeting. Results Acknowledgement Project Update (Minute 21.237 refers) The Acting Chief Nurse NHS CWCCG confirmed she had still not received a response from the Quality Lead at University Hospitals Coventry and Warwickshire NHS Trust (UHCW) about the electronic forcing function used for bloods in some tests and would feedback to the Chief Nursing Officer as soon as a response had been received.

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22.004.07 22.004.08 22.004.09

Resolved – that the Acting Chief Nurse NHS CWCCG would feedback to the Chief Nursing Officer around the forcing function used for bloods in some tests once she had received a response from UHCW. Patient Safety Report (Minute 21.238 refers) The Deputy Head of Pharmacy confirmed that it had been agreed to work through a leaflet for patients around the use of insulin pens via the Diabetic Clinics to aid patients and wanted to reassure the Committee that this would be discussed at their next meeting. The Deputy Head of Pharmacy advised that this leaflet would go through the Drugs and Therapeutics Committee and CPPIG. Resolved – that the position be noted. ICT Incident and Risk Management Bi-Annual Report (Minute 21.147 refers) The Managing Director IHS advised that a proposal had been submitted but not been agreed as yet and would share an update as soon as one was ready. Resolved – that the Managing Director IHS bring an update on the data sharing agreement as soon as one was available. Any Other Business (Minute 21.248.01 refers) The Chief Nursing Officer assured the Committee that there was a robust process in place to identify those members of staff who were unvaccinated and the Trust were writing to those individuals. A Standard Operating Procedure (SOP) had been drawn up relating to this and presented at Silver Command as it was a risk to all Health and Social Care across the country, however the Trust did not feel they were in a challenging position as this only related to small areas of the organisation. The information of individuals was of course confidential but there were no hot spots within the organisation that would cause departments to fall over due to non-vaccinated staff and the Operational Director of People and Workforce concurred with this. The Operational Director of People and Workforce added that there were only around 3 members of staff who were adamant they would not be vaccinated and they were front line staff who would be able to be redeployed within the organisation. Mrs Whelan Tracy (NED) commented that she was concerned that the organisation was being a little optimistic with their numbers of staff who did not want to be vaccinated and whilst appreciating the need for confidentiality, wanted to understand the contingency arrangements in place if there were more, however if it was only 3 members of staff then

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22.004.10 22.004.11

she felt sufficiently assured. The Chief Medical Officer confirmed that he also believed it was only small numbers. Resolved – that the position be noted. AOGG – OOHCC Quarterly Report (Minute 21.237.10 refers) The ADO OOHCC advised that the outomes of both the clinical and economical evaluations of the Docobo system being used in South Warwickshire would be reported through the Finance and Performance Executive as it was only live in some areas, however, the ADO OOHCC agreed to send through the presentation on this to the Committee. Resolved – the ADO OOHCC to circulate the presentation on the Docobo system to the Committee members. AOGG Family Health Division Quarterly Report (Minute 21.240 refers) The ADO Family Health Division updated the Committee that the Children in Care (CiC) Team had resolved their email backlog issue and that this had now been reduced from 140 to 4. Resolved – that the position be noted.

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22.005 AUDIT AND OPERATIONAL GOVERNANCE GROUP (AOGG) EMERGENCY CARE QUARTERLY VERBAL UPDATE Dr Noushad Padinjakara presented a verbal update summarising that there had not been much change since the last quarterly update. A Covid-19 Medicines Delivery Unit was now in place and set up to deliver medicines to those Covid-19 positive patients who needed treatment but not hospitalisation. Although incidents within the Division were on the rise they were reported as no harm or low harm and were not of a concern. Mortality Reviews were ongoing but had been slower than expected due to organisational pressures. The Committee Chair invited questions. The Chief Nursing Officer wanted to thank Dr Noushad Padinjakara and his team for their continued work over the past 2 years with Covid-19 and their work on Avon Ward. Resolved – that the AOGG Emergency Care Quarterly Verbal Update be noted.

22.006

INFECTION PREVENTION CONTROL QUARTERLY VERBAL UPDATE

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The Head of Prevention Infection and Control presented a verbal summary for the quarter. The Trust was beneath target for C.Diff, however there had been a spike this year with 28 cases to date and of that 7 were undergoing Root Cause Analysis (RCA’s) and the Trust were working with SWCCG on this. There had been a small Norovirus outbreak on Macgregor Ward which had been difficult to manage due to this being a paediatric ward as the ward needed to be kept open, which it was but with mitigations in place and this outbreak had been managed well. There had been a CPE outbreak on Castle Ward. This was a bacteria that lived in the gut and was a superbug that was resistant to many antibiotics, however most of the time these bacteria were harmless and did not cause infection, it was still important to stop the spread. The Head of Infection Prevention and Control advised that she had been liaising with NHSE about this and that admission screening would be implemented to screen for CPE and thereafter, weekly screening would take place. It was important to add that no one was unwell as a result of this infection. There were a couple of Flu A cases coming out of Warwick University as they had seen a small outbreak. Covid-19 remained the main concern for the team with Omicron variant and cases increasing locally and nationally and this was having a high impact on staff and their families. The team were seeing people being re-infected quickly from having the Delta variant and then developing Omicron. There were increased hospital admissions but most of those patients had been fairly well, with no patients on the Intensive Care Unit (ICU) in the last few weeks. Cepheid Swabbing for Covid-19 had been introduced in ED which was great news as this enabled faster results being seen within 2 hours. There had been some Covid-19 outbreaks over the last few weeks within the Trust, however that was no different to other organisations where some were seeing whole wards going down with Omicron, whereas SWFT were only seeing isolated outbreaks on wards. The Head of Infection Prevention and Control highlighted that the organisation had put in a lot of additional increased protection measures into play alongside the NHS Infection Prevention Guidance to help reduce outbreaks internally. The Committee Chair invited questions. Mrs Whelan Tracy (NED) asked what the updated figure was for the Flu vaccination with staff and the Head of Infection Prevention and Control advised that this was around 67% uptake. Mrs Hyde (NED) asked the Head of Infection Prevention and Control if there were a lot of patients coming into the Trust who were asymptomatic

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and then testing positive for Covid-19. The Head of Infection Prevention and Control advised that this was the case which was why the new Cepheid swabbing was so important to get that early result to make sure the patient ended up on the right pathway. The Committee Chair asked for an update on the Infection Prevention and Control Board Assurance Framework (BAF). The Chief Nursing Officer advised that this was in a draft format and near completion and would come back to the Clinical Governance Committee and Risk Management Board. The Trust was mainly compliant and there were only 2 concerns which was the reporting of staff lateral flow test results as staff were being asked to report these twice through the national system and internal reporting system and the internal system was quite difficult to use and had been causing issues and therefore it had been agreed to switch off the internal reporting and therefore there wasn’t a very robust system in place to identify this in a detailed way. It has therefore been agreed with NHSI that if there was an outbreak at the Trust, that staff would be asked to do a screenshot of their lateral flow results to provide assurance and Managers would be asked to do random spot checks on staff to show evidence that they were carrying out those tests. The other gap in the organisation related to the organisational view of the Fit Testing compliance as each department had a list of that compliance but the Trust’s electronic system did not allow for a report of that compliance to be seen across the whole organisation. The Chief Nursing Officer confirmed she was assured of both of these concerns due to conversations and observations around data capture within the organisation. Resolved – that:

(A) the Infection Prevention and Control Quarterly Verbal Update be noted, and

(B) The Chief Nursing Officer bring the Infection Prevention and Control BAF back to the Clinical Governance Committee.

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22.007

ANY OTHER BUSINESS There was no other business raised. Resolved – that the position be noted.

22.008 ADJOURNMENT TO DISCUSS MATTERS OF A CONFIDENTIAL NATURE

22.009 APOLOGIES FOR ABSENCE

22.010 DECLARATIONS OF INTEREST

22.011 CONFIDENTIAL MINUTES FROM THE MEETING HELD ON 10 NOVEMBER

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22.012 CONFIDENTIAL MATTERS ARISING AND ACTIONS UPDATE REPORT

22.013 SERIOUS INCIDENTS

22.014 PRESSURE ULCERS FOR NOTING

22.015 ANY OTHER CONFIDENTIAL BUSINESS

22.016 DATE AND TIME OF NEXT MEETING

The next meeting will be held on Wednesday 9 February 2022, via Microsoft Teams.

Signed ______________________________ Date 9 February 2022 (Chair of the Clinical Governance Committee)

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