Agenda - swast.nhs.uk · JW 29/01/2015 Update 02/02/15: Patient Experience Report did not go to January 2015 Board, therefore, carried forward to March 2015 Board. Update 18/03/2015:

Trust Public Board of Directors Meeting 26 March 2015 (M:\Board of Directors\Board Papers\2014-15\26 March 2015\Public\0. Agenda\FINAL Trust Public Board Meeting Agenda 26 March 2015 V1.docx)

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Agenda Trust Public Board of Directors Meeting Thursday 26 March 2015 – 10.00am Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Exeter EX2 7HY Chair Mrs H Strawbridge- Chairman Administration Mrs J Smalley – EA & Business Manager to Chairman and Chief Executive Members: Mrs H Strawbridge HS Chairman Mr K Wenman KW Chief Executive Mr R Davies RD Non-Executive Director Mr T Fox TF Non-Executive Director Mr H Hood HH Non-Executive Director Mrs V James VJ Non-Executive Director Mr C Kinsella CK Non-Executive Director Prof. M Watkins MW Non-Executive Director Mr F Gillen FG Executive Director of IM&T Mrs J Kingston JK Deputy Chief Executive/Executive Director of

Finance Dr A Smith AGS Executive Medical Director Mrs J Winslade JW Executive Director of Nursing and Governance Mrs E Wood EW Executive Director of HR & OD Non Members: Mr N Le Chevalier NLC Director of Operations Mr M McAuley MM Trust Secretary Lord P Tyler PT Advisor to the Board of Directors Mrs C Warner CW Head of Communications and Engagement Circulation: All of above and in addition: Dr Harriet Lupton HL Public Governor – Bristol and Bath & North East Somerset Mr Bob Deed BD Public Governor - Devon Mr Torquil MacInnes TM Public Governor - Wiltshire & Swindon Mr C Nelson CN Joint Branch-Secretary, Unison Ms J Fowles JF Joint Branch-Secretary, Unison _______________________________________________________________


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Item Topic

Format Presenter

1.0 Welcome, Introduction & Apologies

Verbal HS

2.0 Declarations of Conflicts of Interest

Verbal All

3.0 Patient Story

Verbal HS

4.0 Report from the Chairman

Verbal HS

5.0 Report from the Chief Executive

Verbal KW

6.0 Questions from the Public, Council of Governors and Staff

Verbal HS

7.0

Action Point Register

Paper 1

HS

8.0 Performance 8.1 8.2

Integrated Corporate Performance Report (ICPR) Draft Regulatory Framework 2015/16

Paper 2

Paper 3

JK

JW

9.0 Governance 9.1

Register of Interests & Declarations of Independence Paper 4 MM

9.2 9.3

Final Board Assurance Framework 2014/15 update Data Quality Report – Quarter 3

Paper 5

Paper 6

KW

FG

9.4 Information Governance Toolkit - Level 2 Compliance 2014/15

Paper 7 FG

9.5

Board Assurance - Monitor Corporate Governance Statement and Update on Quality Governance Requirements in the Annual Report

Paper 8

JW

9.6 9.7 9.8 9.9 9.10

Dementia report update – Impact of SME Training Learning and Development Report Patient Safety and Experience Report 2014/15 – February 2015 Use of Emergency Powers Corporate Risk Register

Paper 9

Paper 10

Paper 11

Paper 12

Paper 13

EW

EW

JW

MM

KW


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9.11 10.0

Committee Assurance Report

Quality & Governance Committee 12 March 2015

Minutes of Previous Meeting 02 February 2015

Paper 14

Paper 15

MW

HS

11.0 Any Other Business

Verbal HS

12.0 12.1

Identification of New Risks (incl. Health & Safety) Care Quality Commission Inspections – The New Approach

Verbal Paper 16

All JW

13.0 Identification of New Legislation

Verbal All

14.0 Identification of Exception Reporting Triggers

Verbal All

15.0 For information-committee meeting final minutes

Quality and Governance Committee Meeting 08 January 2015

Paper 17

MW

It is also to be noted that the following committee meetings have been held since the last meeting of the Board of Directors (2 February 2015)

Quality and Governance Committee -12 March 2015

Date of MeetingMinutes

Reference

Agenda Item

(Topic)Action Allocated To Deadline Progress Date Completed

29 May 2014 10.2.2Corporate Risk

Register

The Board of Directors approved the proposed

changes to the Corporate Risk Register. HS added

that the Board of Directors should undertake Risk

Training and a review of Directorate Registers.

JP/MM 30/10/2014

Update 26/01/2015 Risk Session

was deferred from December

seminar agenda

31 July 2014 8.1.5

Presentation from

HealthWatch

Gloucestershire

HS reported that a Memorandum of Understanding

had been agreed between SWASFT and

HealthWatch and suggested it would be beneficial to

receive a presentation to the Council of Governors.

AR welcomed this.

MM 29/01/2015 Action complete Complete

31 July 2014 10.5.2 Duty of CandourHS advised that she had received some guidance

from Mills and Reeve which she would share with JW. HS 18/12/2014

Update 26/01/2015 Session was

deferred from December seminar

agenda. To be added to future

Seminar.

25 September 2014 3.2 Patient Story

RD asked if this had been classified as a Serious

Incident, JW advised that it had not, but that it was

being dealt with as a case of moderate harm. JW to

report the outcome of the investigation at the next

meeting.

JW 27/11/2014 Action complete Complete

25 September 2014 10.5.3

Patient Safety and

Experience Report

2014/15 Period 2

VJ commented on the correlation between the

number of incidents and Duty of Candor cases and

suggested that it would be appropriate for this to be

included in this report, JW agreed

JW 27/11/2014

Update 20/11/2014 JW advised

this would be included in the

January 2015 report. Update

02/02/15: Patient Experience

Report did not go to January

2015 Board, therefore, carried

forward to March 2015 Board.

Updated 18/03/2015: Included

within the report for the March

Board

Trust Public Board Meeting Action Point Register - 2014/15

At each Trust Public Board Meeting action points are recorded throughout the meeting to note items which need further development, additional work or raise other issues which need to be considered or discussed. This

document has been created to keep a record of these action points. This will be a yearly document and incomplete action points will be reported to each meeting along with action points which have been completed since the

last meeting.

Page 1 of 4 M:\Board of Directors\Board Papers\2014-15\26 March 2015\Public\1. Action Point Register\Paper 01a - TrustPublicBoardMeetingActionPointRegister2014-15 updated 06 03 15

25 September 2014 10.5.3

Patient Safety and

Experience Report

2014/15 Period 2

Regards the availability of advocacy services. JW

advised that more work would need to be done

around what was available to both staff and patients.

JW 27/11/2014

Update 20/11/2014 JW advised

this would be included in the

January 2015 report. Update

02/02/15: Patient Experience

Report did not go to January

2015 Board, therefore, carried

forward to March 2015 Board.

Update 18/03/2015: advocacy

services are not provided by the

Trust directly for patients or staff

27 November 2014 6.3

Questions from the

Public, Council of

Governors and Staff

Response: HS did not feel that there were

inconsistencies within the report and sections could

not be isolated. HS hoped that the discussion on

performance reporting which would take place later in

the meeting could be fed back from those governors

present. NLC also offered to contact Craig Holmes to

discuss his concerns. HS welcomed this.

NLC 29/01/2015

Update 02/02/15: Brian Jarvis,

Clinical Support Desk Manager

has made contact with Craig

Holmes.

Completed.

27 November 2014 10.2.3Corporate Risk

Register

HH asked whether, if the mitigating action did not

affect the risk rating, why the mitigating actions were

being taken. JW accepted the feedback and agreed

to discuss this further with the Risk Group at their next

meeting.

JW 29/01/2015

Update: Risk Watch to discuss at

meeting on 26/01/2015. Update

02/02/15: JW and MM are

regenerating the Risk Register

and Board Assurance alongside

the Head of Governance and Risk

and Litigation Manager. Risk

Watch is scheduled monthly but

this had been cancelled and

December 2014. HS asked that

JW check to ensure that there is

full understanding.

27 November 2014 10.4.3

Patient Safety and

Experience Report

2014/15 Period 3

HS asked that when it stated ‘outside the agreed

timeframe’ that the required timeframe was added.

JW confirmed this would be done for future reports.

JW 29/01/2015

Update 02/02/15: Patient

Experience Report did not go to

January 2015 Board, therefore,

carried forward to March 2015

Board. Update 18/03/2015:

included within the report for

27 November 2014 10.4.4

Patient Safety and

Experience Report

2014/15 Period 3

JW advised that a negative ‘word cloud’ had been

introduced as requested. MW commented that this

illustrated how important pain management was, as

this was highlighted in the negative report but ‘pain

free’ did not feature in the positive report. KW asked

that the word clouds were published in the bulletin.

CW/JW 29/01/2015 Action complete Complete


27 November 2014 10.4.5

Patient Safety and

Experience Report

2014/15 Period 3

KW suggested that there may be an opportunity for

green calls for First Responders to provide support,

assurance and comfort to the patient whilst liaising

with the ambulance crew, adding that First

Responders could discharge in liaison with the

Clinical Supervisors or if they were staff who also

respond. NLC to take forwards.

NLC 29/01/2015

Update 02/02/15: NLC has

picked up stop the clock on staff

responders. Responders sent to

green calls are followed up with

an ambulance. KW advised that

the question was where there are

longer back-ups could

responders go and wait for back

up. NLC advised that he is

picking up the governance issues.

It was agreed that KW and NLC

should discuss this outside the

meeting.

Complete

27 November 2014 10.6.2Committee

Assurance Reports

HS suggested that CK, MW, EW, MM and herself

should meet with all papers which go to committees

on sickness to identify any gaps in reporting to be

addressed and reported to the next meeting, which

satisfied the recommendations.

CK/MW, MM/HS 29/01/2015

Update 02/02/15: It was noted

that this meeting had not yet

taken place but would be

scheduled in due course.

02 February 2015 8.1.5

Communications

and Engagement

Strategy

HS commented that is was good to see the

assurance given and requested that the Strategy is

presented to the Quality and Governance Committee.

ACTION: CW to submit the Communications and

Engagement Strategy to the next Quality and

Governance Committee in March 2015. CW 12/03/2015

Update: Comms & Eng strategy

approved by the B.O.D on 2 Feb

2015. Quarterly reporting on

progress to Q&G to begin _____

02 February 2015 9.1.13 ICPR

HS noted that activity had increased and asked

whether the calls come from Health Care

Professionals (HCPs) or other members of the

public. ACTION: JK would request this data for

the next Integrated Corporate Performance

Report produce detail for next time.JK 26/03/2015

Action complete Completed.

02 February 2015 9.1.14 ICPR

Monitor compliance focuses on minor injuries

and learning disabilities. HS on behalf of the

Trust Board asked that the Quality and

Governance Committee has a deep dive into

learning disabilities. ACTION: JW to add this to a

future Quality and Governance Committee

Agenda. JW 26/03/2015

02 February 2015 10.1.2

Board Assurance

Framework 2014/15

ACTION: It was agreed that HS would ask the

Audit Committee to go through some of the

strands of the Board Assurance Framework in

depth and report back to the Trust Board. HS 09/04/2015


02 February 2015 10.3.3

Information

Governance

Quarterly Report

The IG Toolkit had undergone an internal audit

review. FG stated that the challenge is to get all

staff to do the IG training. ACTION: MM to send

out the links to the Non Executive Directors to

complete IG training as required yearly.MM 26/03/2015 Circulated. Completed. Completed.

02 February 2015 10.6.12 Training Report

ACTION: The Trust Board of Directors noted that

a brief on Training is being submitted to the

Quality and Governance Committee in March

2015 and the Trust Board of Directors requested

a report following that meeting. EW to forward.EW 26/03/2015

Update: Report included on

March Public Board Agenda -

26/03/2015 Completed.


Trust Board of Directors Meeting 26 March 2015

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Title: Integrated Corporate Performance Report (ICPR)

Prepared by: Jessica Hodgman, Director of Planning and Performance and Paul Quick, Performance Manager

Presented by: Jennie Kingston, Deputy Chief Executive/Executive Director of Finance

Main aim: For the Board of Directors to receive the Integrated Corporate Performance Report for assurance

Recommendations: For assurance

Previous Forum: N/A

This report references:

Board Assurance Framework

BAF 05-14 to BAF 08-14 Directorate Business Plans

Finance

Implications

(including Statutory or Legal References)

Reports performance against the Trust statutory and contractual targets

Integrated Corporate Performance Report

February 2015

Title of originator/author: Paul Quick, Performance Manager

Jessica Hodgman, Director of Planning and Performance

Name of responsible director: Jennie Kingston, Deputy Chief Executive/Executive Director of Finance

Date issued: 17 March 2015

SWASFT Integrated Corporate Performance Report

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1. Introduction

1.1. The South Western Ambulance Service NHS Foundation Trust (SWASFT) monthly Integrated Corporate Performance Report (ICPR), reports performance by exception and focuses on action being taken by the Trust to address off plan performance.

1.2. The Integrated Corporate Performance Report is structured as follows:

Reported in the ICPR Monthly Reported in the Confidential

Addendum

• A Performance Dashboard summarising performance across all metrics;

• Ambulance National Quality Measures, covering Patient Safety, Effectiveness and Experience;

• Ambulance National Clinical Quality Indicators;

• Local standards and thresholds agreed with NHS Commissioners;

• Internal Trust Key Performance Indicators (KPIs);

• Resource Performance Measures, covering REAP level, service line activity, financial position and capacity and capability metrics;

• A&E and PTS activity levels are reported within this report;

• Trust performance against the Monitor Compliance Framework (and subsequently Risk Assessment Framework);

• Analysis of the Trust Carbon Footprint (including vehicle carbon emissions);

• Right Care 2.

• The position against the A&E, OOH and NHS 111 commissioning contracts;

• CQUIN performance;

• During 2014/15, the Trust will report on progress against the Acquisition Pledges and Acquisition Benefits from the Acquisition of GWAS;

• Performance ‘deep dives’ as appropriate.

Mapping to the 2014/15 Trust Corporate Objectives, Acquisition Pledges and the NHS

Outcomes Framework

1.3. Appendix A shows how the performance metrics included within the ICPR map to the Trusts

Corporate Objectives, the nine pledges governing the Acquisition of Great Western Ambulance service NHS Trust (GWAS) and the five domains of the NHS Outcomes Framework.

1.4. For each of the five domains, the Trust has identified the metrics best placed to provide

assurance of delivery. The NHS Commissioning Board document ‘Everyone Counts: Planning for Patients 2013/14’ sets out the principles behind the new approach to planning clinical led commissioning from April 2013. This guidance states that NHS outcomes will inform NHS planning and Commissioners will be expected to prioritise improvements against all domains.

1.5. The five domains are as follows:

Domain 1: Preventing People from Dying Prematurely;

Domain 2: Enhancing the Quality of Life for People with Long Term Conditions;

Domain 3: Helping People to recover from periods of Ill Health or following Injury;

Domain 4: Ensuring that People have a Positive Experience of Care;

Domain 5: Treating and Caring for People in a Safe Environment and protecting them from Avoidable Harm.

SOUTH WESTERN AMBULANCE SERVICE NHS FOUNDATION TRUST

INTEGRATED CORPORATE PERFORMANCE REPORT

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2. Performance Exceptions

2.1. The ICPR focuses on exceptional performance and aims to provide the Trust with an early warning of deteriorating performance.

2.2. The four reporting categories assigned to individual performance metrics contained within the ICPR are as follows:

No Concerns: Performance in the reporting period is on or above target and there are currently no predicted risks to the Trusts quarterly or forecast year end performance;

Early Warning: Performance in the reporting period could be on or above target but there is evidence that performance is deteriorating or moving off trajectory AND/OR a metric has been escalated by a Directorate as part of the Trusts Performance Management arrangements. This indicates to the Trust that there is a perceived risk to performance regardless of whether this is evident in the reporting period;

Improvement Expected: Performance in the reporting period is below target but there is evidence that performance is improving AND/OR there is confidence in the action(s) being taken by the Trust. The forecast outturn position is therefore expected to be on or above plan if a performance metric is reported in this category;

Real Concerns: Performance in the reporting period is significantly off plan and there is currently no action plan in place OR there is insufficient evidence of improvement as a result of actions already agreed and being taken by the Trust in order to improve performance.

2.3. There is a direct link between the exception category assigned to individual performance metrics and the level of detail and assurance provided in the ICPR. Appendix B sets out the Trust approach to reporting performance exceptions and specifies the level of information and assurance required by the Board of Directors.

Table 1: Performance Exception Overview in the Reporting Period

Early Warning

Green 1, Green 2 and Green 4 call performance in February 2015 was below target;

The staff turnover rate remains high at 13.27% at the end of February 2015 (reducing to 13.06% excluding redundancies);

Information Governance Toolkit actions are required to deliver level 2 performance;

Staff Appraisal rates were below the internal KPI target of 85% but this is linked to the Red performance recovery plan.

No Concerns

Green 3 call performance was above (better than) local KPI levels for February 2015;

Percentage of A&E calls abandoned are lower (better) than local thresholds;

Acute STEMI patients receiving appropriate care bundle is above local thresholds;

ROSC following cardiac arrest was above (better than) local thresholds;

Stroke patients receiving the appropriate care bundle is above local thresholds;

Outcome from Stroke, patients receiving thrombolysis at an hyper-acute centre within 60 minutes is above (better than) local thresholds;

Outcome from cardiac arrest, survival to discharge rates, are above local thresholds;

Urgent Care Service QR12: Less Urgent

Consultations at Base Sites were fully compliant against the National Quality Requirement for February 2015 in all three counties against the 95% target;

Tiverton UCC performance against the 4 hour

treatment time was above the 95% target.


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Real Concerns

A&E (999) Activity levels (demand) is higher than contracted volumes and significantly higher than the levels for 2013/14;

Red 2 and A19 performance were below national targets in February 2015 and the Trust is forecasting performance below national targets for the year ending 31 March 2015;

The number of frontline operational

vacancies in the North Division is having a significant and sustained impact on performance;

NHS 111 call anwswering performance is below the 95% national KPI level in February 2015;

NHS 111 call abandonment rates were above (worse than) KPI levels in February 2015;

1,639 of operational resource time was lost to

handover delays at acute hospitals in February 2015;

Sickness levels across the trust are higher than planned.

Improvement Expected

Red 1 performance was below the national target level in February 2015, but is expected to improve in Quarter 4 and recover the year end position;

Time to answer calls were above (worse than) the local threshold measures for the 95

th

and 99th percentile metrics in February 2015;

Re-contact rates following telephone advice and following treatment at scene were higher (worse than) the local performance threshold;

Outcome from STEMI PPCI, patients receiving primary angioplasty commencing within 150 minutes;

ROSC following cardiac arrest (for the Utstein Comparator Group of patients) was below (worse than) local thresholds;

Urgent Care Service QR12: Urgent

Consultations at Base Sites were fully compliant against the National Quality Requirement for February 2015 in the county of Somerset (98.00%), partially compliant in Dorset (91.62%) and non-compliant in Gloucestershire (83.33%) against the 95% target;

Urgent Care Service QR12: Urgent

Consultations at patients’ homes were partially compliant against the 95% target in all three counties, Somerset (92.76%), Dorset (92.24%) and Gloucestershire (90.91%);

Urgent Care Service QR12: Less Urgent

Consultations at Base Sites were fully compliant against the National Quality Requirement for February 2015 in the counties of Somerset (98.56%) and Dorset (95.29%), but was partially compliant in Gloucester (93.02%) against the 95% target;

Some PTS KPIs in the BNSSG contact are below agreed levels but are showing improvement;

Compliance with Infection Prevention and

Control.


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3. Summary of Benchmarked Position based on January 2015 Data 3.1. The following benchmarking data compares the performance of the Trust with other

ambulance services in England. Benchmarking data is only available for January 2015 and not for February 2015.

National Benchmarking Against Other Ambulance Trusts 3.2. Following a very challenging month in December 2014, none of the 10 ambulance services

in England delivered performance above the national target levels for Red 1 and Red 2. January 2015 showed a slight improvement with average Red 1 performance improving from 66.01% to 71.37%, Red 2 performance improving from 61.15% to 68.01% and A19 performance improving from 90.12% to 93.34%.

3.3. Despite the improvements on December performance levels, national averages for all three

performance metrics remained below the national target levels and only 2 ambulance trusts in England delivered Red 1 performance above the national target of 75%.

3.4. Unprecedented levels of demand for ambulance services experienced in the South West

and across England during the winter period continued into January 2015. This unexpected and substantial increase in overall activity volumes made delivery of all three Red performance targets extremely challenging.

National Average Performance Figures 2014/15 by Month

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

Red 1 75.42% 73.31% 72.48% 70.84% 73.21% 72.69% 72.09% 71.80% 66.01% 71.37

Red 2 73.63% 72.54% 70.68% 68.75% 70.92% 69.96% 69.79% 68.38% 61.15% 68.01

A19 95.79% 95.26% 94.81% 94.03% 94.96% 94.40% 93.98% 93.58% 90.12% 93.34

3.5. In January, SWASFT delivered performance above the national average for Red 1 (73.39%

against a national average of 71.37%) and Red 2 performance (68.01% against a national average of 67.95%) but was marginally below the national average for A19 performance (93.34% against the national average of 92.50%).


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Year to Date Benchmarking Against Other Ambulance Trusts 3.6. For the period April to January 2015 the national averages for Red 1 (74.44%), Red 2

(73.00%) and A19 (93.98%) performance for ambulance trusts in England were all below the national target levels. SWASFT is performing comparatively well nationally: performance for the period April to January 2015 was above the national average for all three performance metrics.


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4. Monitor’s Risk Assessment Framework 4.1. Monitor uses the Governance Rating, incorporating information across a number of areas,

to describe their views of the governance of the Trust. Monitor generates this rating by considering a range of information set out in 4.4 below and forms a view as to whether this is indicative of a potential breach of the governance condition. Full details of these areas can be found at Appendix C.

4.2. Within the Integrated Corporate Performance Report each month an internal assessment, based on the forecast quarter end performance figures, is reported for the Access and Outcomes Metrics element of this overall assessment.

4.3. Where the Trust breaches a target(s), Monitor uses the sum of each metric’s weighting to calculate a Service Performance Score. Where this score is 4.0 or greater, this represents a governance concern. Where the Trust breaches a target systematically (i.e. a national performance breach for three consecutive quarters) this also triggers a governance concern as shown in the table below, an extract from Diagram 15 in Monitor’s Risk Assessment Framework:

Indicator Driver of Governance Concern

Ambulance Response Times

Breaches:

Either category A 8-minute response time targets (Red 1 and Red 2) for a third successive quarter; or

Category A19 minute response time target for a third successive quarter

4.4. The overall Governance Risk Rating includes:

Service Performance Score (based on a score of 0.0 to 4.0 with 0.0 representing strong performance and no concerns)

CQC Information;

Third Party Reports: Adhoc reports from GMC, the Ombudsman, Commissioners, Healthwatch England, Auditors, Health & Safety Executive, Patient Groups, Complaints, Whistle-blowers, etc;

Quality Governance Indicators: Patient metrics, staff metrics and cost reduction plans;

Financial Risk: Continuity of Services Risk Rating is provided under the financial section of this report (based on a score of 0.0 to 4.0 with 4.0 representing the strongest financial performance).

Quarter 3 2014/15 Performance 4.5. SWASFT has received a Continuity of Services Risk Rating of 4.0 and a Governance Risk

Rating of Green for Quarter 3 of 2014/15.

Quarter 4 2014/15 Forecast Performance 4.6. Based on additional actions being taken in Quarter 4, the Trust is still forecasting delivery of

Red 1.

4.7. Following the challenging start to the Quarter for all Red performance metrics, the Trust has

identified a risk to delivering the national performance standards for both Red 2 and A19 for Quarter 4 of 2014/15. The Trust is therefore forecasting an indicative Service Performance Score of 2.0 for Quarter 4 of 2014/15.


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5. Accident and Emergency (999) Performance

Accident and Emergency (999) Activity Levels 5.1. Within the A&E contract for 2014/15 the Trust has moved to a single contract currency

covering all operational areas of the Trust. The new contract currency is ‘Incidents’. 5.2. Incident volumes during the month of February 2015 were 4.19% above contract and 3.29%

above contract for the Year to Date (1 April 2014 to 28 February 2015). Further information on the incident numbers can be found in Section 10 of this report. High activity levels have a direct impact on performance.

Table 1: Comparison of Activity against Contract in the month of February 2015

Actual Activity

February 2015

Contract Activity

February 2015

% Variance

Actual vs

Contract

West Division A&E Incidents

23,345 21,502 +8.57%

East Division A&E Incidents

17,571 17,358 +1.23%

North Division A&E Incidents

26,646 26,768 -0.46%

Total A&E Incidents

68,378 65,628 +4.19%

5.3. Activity levels set out in Table 2 below show a 10.82% increase on the incident numbers compared with the month of February last year.

Table 2: Activity in the month of February 2015 compared to February 2014

Actual Activity

February 2015

Actual Activity

February 2014

% Variance

Actual vs Last

Year


23,345 20,484 +13.97%


17,571 15,936 +10.26%


26,646 25,281 +5.40%

Total A&E Incidents

68,378 61,701 +10.82%

5.4. Compared to the incident numbers in the same period (1 April 2014 to 28 February 2015)

last year the Trust has seen a 10.06% increase. This increase has been evident across all divisions within the Trust.

Table 3: Comparison of Actual Activity 2013/14 and 2014/15 (April to February)

Actual Activity

April 2014 to

February 2015

Actual Activity

April 2013 to

February 2014

% Variance

Actual vs

2013/14


270,495 243,664 +11.01%


207,248 191,208 +8.39%


310,266 305,010 +8.54%

Total A&E Incidents

793,223 720,726 +10.06%


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5.5. One of the contributing factors has been higher than forecast activity over the winter period.

The Trust experienced unprecedented levels of demand during a six week period starting at the end of November 2014 through to mid January 2015. Whilst weekly incident numbers in February 2015 have reduced slightly, they are still above last years levels.

5.6. This has significantly increased the pressure on frontline operational resources. Weekly activity volumes increased throughout November and December 2014, with total incident numbers moving from circa 16,200 incidents per week during September and October 2014 to over 19,000 incidents per week during December 2014.

5.7. The activity increases continued into the first week of January 2015, with activity during the

New Year week peaking at 19,190 incidents over the seven day period. The activity on 1 January 2015 was 15% higher than the same day last year at 3,334 incidents - the highest ever activity volume recorded for any single day in the South West. Following the peak in activity volumes at the beginning of January 2015, activity reduced fro the remainder of the month, however during February 2015 activity levels again increased, returning above 17,000 incidents per week for the final three weeks of the month.

5.8. The graph below shows the direct correlation between activity volumes and Red performance. It should be noted that the performance figures represented in the graph are combined Red 1 and Red 2 performance.

5.9. The significant increases have been experienced across all areas of ambulance activity and are not isolated to specific incident types or patient groups. The graph below reviews the source of the incidents managed by the ambulance service split into three categories:

Incidents received by the ambulance service via the 999 emergency number;

Incidents referred to the ambulance service via the NHS 111 service;

Incidents referred to the ambulance service from another Healthcare Professional (including GPs).


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5.10. A direct comparison of two weeks, one in April 2014 and one in February 2015 is provided in the table below:

Actual Activity

Week Commencing

21 April 2014

Actual Activity

Week Commencing

23 February 2015

Variance Variance %

999 Incidents 10,711 11,463 752 +7.02%

NHS 111 Incidents 2,481 2,841 360 +14.51%

Healthcare Professional Incidents

2,416 2,779 363 +15.02%

Total Incidents 15,608 17,083 1,475 +9.45%

5.11. The demand pressures facing SWASFT is replicated nationally with all ambulance services

reporting unprecedented increases in incident numbers. To meet such high peaks in a short timescale is extremely challenging as ambulance trusts have a very limited ability to ‘scale up’ resource levels quickly. Long lead times for additional clinical resources and the non-recurrent nature of resilience (winter) funding in-year places increased reliance on existing staff working overtime shifts and use of bank staff and third party suppliers of ambulance services where this is available.

Dispatch on Disposition Pilot 5.12. SWASFT has been chosen, in partnership with London Ambulance Service, to pilot a new

way for ambulance services to respond to 999 calls. The pilot allows 999 call handlers a small amount of extra time to assess calls before dispatching an ambulance response. This does not include those calls which are immediately life-threatening (Red 1 calls), for which there is no change and an ambulance resource will still be dispatched immediately.

5.13. A large amount of clinical work has already been undertaken to support this pilot and this

has shown that there is significant evidence to suggest that patients will benefit from these changes. Where a call is not immediately life threatening, giving call handlers extra assessment time will ensure that the Trust makes the right decision for patients, therefore providing the best possible care. It is also expected that as a result of the changes ambulance resources will be more appropriately deployed to where they are most needed and allow a faster response time for those patients who really need it.


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5.14. NHS England is working in association with the Association of Ambulance Chief Executives, the College of Paramedics and the two pilot sites and there is strict oversight and monitoring of both services throughout the trial period. The trial will be subject to rigorous and independent external evaluation, the findings of which will be published. The 4-week pilot commenced on 10 February 2015 for both SWASFT and London Ambulance Service NHS Trust. During March 2015 NHS England agreed to extend the trial for a further 4 week period through to the 6 April 2015.

5.15. Initial feedback on the trial has identified a number of benefits to the ambulance service in changing the dispatch process including improvements in Red 1 performance, reduction in inappropriate resource allocations and an improvement in the proportion of incidents resolved with telephone advice or referral to a more appropriate service.

5.16. During the pilot period weekly reporting and conference calls with NHS England have been held to discuss the available data and impact on ambulance service performance in all areas including ambulance response times, Ambulance Clinical Quality Indicators (ACQIs), patient experience and staff feedback.

5.17. Further feedback on the trial will be provided in future Integrated Corporate Performance

Reports.


Page 13 of 64

6. Ambulance National Quality Measures

6.1. This section provides a monthly summary of performance against each of the Ambulance National Quality Measures. The definition and national target for each measure is provided in Appendix C.

Accident and Emergency Service Line: Category A Performance: Red 1 (75%) Performance Exception Status: Improvement Expected: The Trust is still forecasting delivery but performance in February 2015 was below national target levels

Reason(s) for the performance exception category assigned in the reporting period: • The Trust is contracted by NHS Commissioners to deliver performance of 75% at a whole Trust level. Red

1 performance in February 2015 was 74.80%.

• The Trust has extended all additional winter specific resources through to the end of the financial year however at peak periods these additional resources in isolation are not sufficient to meet the significant increases in activity levels.

• A further set of actions have been agreed going into March 2015 to secure the year end position. These have been communicated to Commissioners.

• The Trust is forecasting delivery of 76.41% Red 1 performance in Quarter 4 of 2014/15 which would deliver annual Red 1 performance of 75.00% in line with national performance targets.

Risk Assessment: The Trust is taking additional action to deliver this target in Quarter 4 2014/15 and recover the YTD position.

Actual Performance

Variance to National

Target

Variance to Internal

Trajectory

Month: February 2015 Actual Performance

74.80% (0.30)% (1.18)%

Quarter Four 2014/15 Forecast Performance

76.41% 1.41% 0.72%

Year to Date 2014/15 Actual (1 April 2014 to 31 February 2015)

74.45% (0.55)% (0.89)%

Year End 2014/15 Forecast Performance to March 2015

75.00% 0.00% (0.41)%


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6.1. In February 2015 the Trust responded to 74.80% of all Red 1 incidents within 8 minutes, 80.20% within 9 minutes and 84.66% within 10 minutes. 95.35% of Red 1 incidents received a response on scene within 15 minutes. All Red 1 incidents where the 8 minute response target is missed are reviewed by operational managers to identify any learning or barriers to performance that may be addressed to improve future Red 1 performance.

Red 1 Performance by Clinical Commissioning Group (CCG) – February 2015

February 2015 Red 1 Performance Map

Planned Mitigating Action

being taken by the Trust Timescales for Action

Performance Improvement /

Impact Expected

Introduction of additional

clinical resources into the

Clinical Hubs to improve the

percentage of calls appropriate

to be managed through a Hear

and Treat pathway:

• Introduction of GPs and additional clinically trained staff into the Clinical Hubs.

• Introduction of a new rota for GP cover was established in Quarter 2 of 2014/15 and this cover is continuing throughout the winter period.

• GPs and Senior Clinicians within the Clinical Hub assist call advisors in providing advice and support to patients through telephone advice where appropriate (particularly for the most serious and complex incidents).

• The additional clinical resources in the hub frees up operational resources increasing the opportunity of the Trust to respond to Red 1 incidents.

Clinical

Commissioning

Group

No. of

Incidents

Feb 15

Red 1 %

Feb 15

No. of

Incidents

YTD

Red 1 %

YTD

Kernow 139 70.50% 1,445 74.12%

South Devon & Torbay 75 88.00% 877 82.21%

NEW Devon 226 76.55% 2,264 78.71%

Somerset 103 67.96% 1,264 72.47%

Dorset 246 76.02% 2,300 83.22%

North Somerset 61 75.41% 757 68.82%

Bath & NE Somerset 40 70.00% 532 75.19%

Bristol 148 81.08% 1,878 76.20%

South Gloucestershire 50 60.00% 743 64.47%

Gloucestershire 145 71.72% 2,036 66.36%

Wiltshire 112 71.43% 1,377 64.92%

Swindon 46 84.78% 778 81.11%

TRUST 1,383 74.80% 16,301 74.45%


Page 15 of 64




Impact Expected

Investment in Public Access

Defibrillators (PADs):

• PADs to be located within key geographical locations within the local health community.

• A roll out of Public Access Defibrillators in key locations was completed in Quarter 1 of 2014/15 and completion of the remaining training for each of the sites was completed during Quarter 2.

• The Trust is undertaking a further review of activity levels and potential sites for additional PADs during Quarter 4 of 2014/15 continuing into Quarter 1 of 2015/16.

• Additional investment has been agreed in Quarter 4.

• Providing defibrillation units to key sites along with associated appropriate training provides additional community based equipment to support immediate patient care in the most critical cases.

The Trust continues to work

closely with NHS 111 Providers

across the South West and

NHS Commissioners to

manage and mitigate the

impact of NHS 111 on the 999

ambulance service:

• During peak periods at weekends, up to 40% of the Trusts total A&E service activity is received from the NHS 111 service.

• A relatively high proportion of incidents transferred from NHS 111 providers in the North are categorised as Red.

On-going actions:

• The Trust is meeting with NHS Commissioners in the North as part of a small task group regularly reviewing NHS 111 impact on the local health system.

• Feedback is being provided by the Trust on ‘inappropriate’ incidents transferred to the ambulance service. The focus is on red calls.

• Incidents are passed for audit and further investigation to identify the reasons for transfer.

• The Trust is focusing attention on call volume management and the appropriateness of calls to reduce the number of inappropriate incidents passed to 999 dispatch, identifying actions to manage call volume peaks at weekends.

• As part of Winter plans, the Trust is working with Gloucestershire CCG to undertake a trial to deliver additional triage of Red incidents received from the NHS 111 provider.

• Whilst not delaying the ambulance response, the additional triage is designed to identify any inappropriate incidents at the earliest opportunity to free ambulance resources.

Recruitment of additional

clinical frontline staff to fill

identified vacancies within the

operational establishment:

• Targeting the North Division where vacancy levels are high.

• Plans in place to improve establishment levels.

• Concurrent recruitment plans/cycles introduced.

• An updated application process has been implemented to deliver a rapid interview and selection process.

• Incentive schemes targeted at difficult to recruit to areas.

• Introduction of a new internal Paramedic conversion course to provide a route for Emergency Care Assistants (ECAs) to train and qualify as Paramedics.

• Training plans and other staff abstractions are being targeted.

• Reviewing all areas to identify

• Graduate Paramedics completed their blue light training during September and October 2014 and started work with the Trust in November 2014.

• Further recruitment campaign for Graduate Paramedics was launched in July 2014, with a further program of work underway to secure qualifying paramedics in the summer of 2015.

• Advertisements for paramedic posts, targeting specific locations where vacancies exist have been posted.

• In the past 12 months the Trust has filled 119 Paramedic vacancies, 75 of these new Paramedics within the last six months. A further 14 Paramedics have confirmed starting dates within the next two months and another 12 candidates currently within the recruitment process.

• 60 ECAs are on the first internal Paramedic conversion course. On successful completion of their studies new qualified Paramedics would become operational in January 2016.


Page 16 of 64




Impact Expected

actions required to improve current staff retention levels and reduce turnover.

The Trust is working with

individual CCGs (12 in the

south west) to consider

additional joint actions that can

be taken to improve Red 1

performance locally.

• The Trust met with CCGs during Quarter 1 of 2014/15, with plans to be implemented during the remainder of 2014/15.

This engagement is intended to have a number of benefits including:

• A shared understanding of the current performance and local challenges;

• Agreement of additional actions that can be supported by individual CCGs to assist the Trust in delivering Red 1.

A priority focus on Sickness

Management

• A new Sickness Policy for the Trust has been introduced and training given.

• Central sick line

• The new Trust Sickness Policy is in operation.

• Revision to the current Trust sickness reporting line was introduced during Quarter 3 of 2014/15.

• Targeting sickness increases available operational resources.

Reduction in Operational Time

Lost to Handover Delays at

Emergency Departments

• Enhanced revision to the existing Standard Operating Procedure (SOP) for Handover Delays at Emergency Departments.

• Revised SOP introduced in November 2014.

• To support improvements in Red performance and improve patient safety.

Agency Resources

• Clinical agency support commissioned.

• Additional resources have been extended through to 31 March 2015.

• Mitigates impact of the current operational vacancies.

Increase Operational Resource

Cover on a Daily Basis

• Utilisation of overtime shifts.

• Additional overtime shifts offered to operational staff through to 31 March 2015.

• Mitigates impact of the current operational vacancies.

‘Chose Well’ Campaign

• Local media campaign promoting the use of alternative treatment pathways.

• Focussed media campaign launched during December 2014.

• Aim to mitigate demand.

Winter Plans

• SWASFT has worked closely with NHS Commissioners to develop a number of central and local winter contingency plans for resilience purposes.

• Extended through to 30 April 2015 following letter from NHSE, TDA and Monitor.

• Provided resilience in operational cover.

Maintain and Enhance the level

of Community Responders and

contribution to performance

• As at the end of December 2014 the Trust reported a total of 4,597 Responders covering the various types (excluding the Community Public Access Defibrillators and Staff Responders).

• In the period April to December 2014 the Trust has created an additional 14 Community Responder Groups, 234 new Static Sites and 61 Community Public Access Defibrillator sites.

• This is in addition to the significant exercise to roll out Defibrillators and associated Emergency Aid training to new Static Sites

• Responder groups and defibrillator site locations are registered on the Trust dispatch systems for allocation as part of the response to an incident where appropriate.


Page 17 of 64

Accident and Emergency Service Line: Category A Performance: Red 2 (75%) Performance Exception Status: Real Concerns Performance in February 2015 and the forecast performance for Quarter 4 of 2014/15 are both below the national performance target of 75%.

Reason(s) for the performance exception category assigned in the reporting period: • The Trust is contracted by NHS Commissioners to deliver performance of 75% at a whole Trust level. The

Trust delivered Red 2 performance of 61.59% in February 2015 against the target of 75%.

• The introduction of the Dispatch on Disposition pilot across the South West area on 9 February 2015 has resulted in the prioritisation of responses to Red 1 incidents. As part of the changes to the dispatch processes call handlers are provided with extra assessment time for all other classification of 999 calls (including Red 2 incidents). Performance following this additional assessment time has shown some improvement on January 2015; however the figures reported within this report are based on the current performance metrics for all ambulance trusts in England.

• A full assessment of the performance impact of the pilot changes will be produced at the end of the pilot period in conjunction with NHS England.

Risk Assessment: Whilst the Trust has a recovery plan to deliver some improvements in performance during Quarter 4, the additional performance required to recover the performance drop in Quarter 3 as a result of the unprecedented activity levels experienced is not expected to be delivered. The Trust is forecasting performance of 71.92% for the year ending 31 March 2015, 3.08% below the national target of 75%.

Actual

Performance

Variance to

National Target

Variance to

Internal Trajectory Month: February 2015 Actual Performance

61.59% (13.41)% (16.23)%


66.92% (8.08)% (6.90)%

Year to Date 2014/15 Actual (1 April 14 to 31 February 2015)

72.05% (2.95)% (5.12)%


71.92% (3.08)% (5.31)%


Page 18 of 64

Red 2 Performance by Clinical Commissioning Group (CCG) – February 2015

February 2015 Red 2 Performance Map

Accident and Emergency Service Line: Category A Performance: A19 (95%) Performance Exception Status: Real Concerns Performance in February 2015 and the forecast performance for Quarter 4 of 2014/15 are both below the national performance target of 95%.

Reason(s) for the performance exception category assigned in the reporting period: • The Trust is contracted by NHS Commissioners to deliver performance of 95% at a whole Trust level.

• The Trust delivered A19 performance of 90.52% in February 2015.

• The Dispatch on Disposition trial has also impacted on the performance reported for A19 incidents, the A19 performance relates to Red 1 and Red 2 categories of call and therefore the additional assessment time for Red 2 incidents will also impact on A19 performance.

Risk Assessment: Whilst the Trust has a recovery plan to deliver improvements in performance during Quarter 4, the additional performance required to recover the performance drop in Quarter 3 is not expected to be delivered. The Trust is forecasting performance of 93.58% for the year ending 31 March 2015, 1.00% below the national target of 95%.

Actual

Performance

Variance to

National Target

Variance to

Internal Trajectory Month: February 2015 Actual Performance

90.52% (4.48)% (5.50)%


91.89% (3.11)% (3.87)%

Year to Date 2014/15 April 2014 to February 2015

93.68% (1.32)% (1.96)%


93.58% (1.42)% (2.09)%

Clinical

Commissioning

Group

No. of

Incidents

Feb 15

Red 2 %

Feb 15

No. of

Incidents

YTD

Red 2 %

YTD

Kernow 2,420 55.50% 30,929 70.15%

South Devon & Torbay 1,358 67.16% 17,328 76.72%

NEW Devon 3,791 65.44% 4,7634 76.68%

Somerset 2,005 59.40% 26,293 71.74%

Dorset 3,338 58.90% 4,4078 74.74%

North Somerset 932 61.48% 10,403 68.79%

Bath & NE Somerset 740 65.14% 7,677 72.36%

Bristol 2,140 65.37% 25,589 74.41%

South Gloucestershire 1,068 56.84% 11,038 63.96%

Gloucestershire 2,456 60.99% 27,810 66.54%

Wiltshire 1,836 57.63% 20,532 62.47%

Swindon 961 71.70% 10,742 79.12%

TRUST 23,070 61.59% 28,0866 72.05%


Page 19 of 64

A19 Performance by Clinical Commissioning Group (CCG) February 2015

February 2015 A19 Performance Map

Clinical

Commissioning

Group

No. of

Incidents

Feb 15

A19 %

Feb 15

No. of

Incidents

YTD

A19 %

YTD

Kernow 2,543 84.43% 32,194 91.07%

South Devon & Torbay 1,433 94.56% 18,201 96.20%

NEW Devon 4,004 90.73% 49,634 93.90%

Somerset 2,104 89.45% 27,528 92.92%

Dorset 3,578 92.06% 46,307 95.87%

North Somerset 990 89.60% 11,147 93.24%

Bath & NE Somerset 780 92.18% 8204 93.65%

Bristol 2,287 95.02% 27,429 97.05%

South Gloucestershire 1,117 93.64% 11,774 94.51%

Gloucestershire 2,599 89.00% 29,838 91.39%

Wiltshire 1,947 86.59% 21,873 88.63%

Swindon 1,007 93.64% 11,522 96.92%

TRUST 24,420 90.52% 29,6500 93.68%


Page 20 of 64

Urgent Care Service Line

QR12: Urgent and Less Urgent Base Site and Home Visit Consultations Performance Exception Status: Improvement Expected: The Trust is expecting both standards to be achieved going forward and move from partial to full compliance on all three OOH contracts.

Reason(s) for the performance exception category assigned in the reporting period:

• Urgent Consultations at Base Sites (Treatment centres) were compliant against the NQR in the reporting period in the county of Somerset (98%, 49 of 50 appointments), partially compliant in Dorset (91.62%, 91 of 99 appointments) and non-compliant in Gloucestershire (83.33%).

• In Gloucestershire the Trust met the two hour performance target on 10 of the 12 treatment centre appointments, and for the year to date still remains fully complaint at 95.89% performance.

• For Less Urgent Consultations at Base Sites the Trust was fully compliant in all three counties, Dorset (97.24%), Somerset (96.88%) and Gloucestershire (96.52%) against the 6 hour performance target.

• Trust performance for Urgent Home Visit consultations started within 2 hours was partially compliant in all three counties:

• In Gloucestershire (90.91%) 190 of the 209 urgent consultations commencing within the 2 hour target.

• In Somerset (92.76%) 141 of the 152 urgent consultations commencing within the 2 hour target.

• In Dorset (92.24%) with 309 of the 335 urgent consultations commencing within the 2 hour target.

• Trust performance for Less Urgent Home Visit consultations started within 6 hours was fully compliant in the counties of Somerset (98.56%) and Dorset (95.29%) and partially compliant in the county of Gloucestershire (93.02%).

• Actions being taken, specifically in Somerset and Dorset are detailed in the exception report below.

Risk Assessment: • The expectation is that these standards will be delivered. The Trust continues to report exceptions on an

individual basis to commissioners.

February 2015 Performance Actual Performance Variance to National Quality

Requirement

Dorset Somerset Gloucester Dorset Somerset Gloucestershire

Urgent Base Consultations started within 2 Hours Month: Performance (95%)

91.62% 98.00% 83.33% (3.38)% 2.00% (16.67)%

Less Urgent Base Consultations started within 6 Hours Month: Performance (95%)

97.24% 96.88% 96.52% 2.24% 1.88% 1.52%

Urgent Home Visit Consultations started within 2 Hours Month: Performance (95%)

92.24% 92.76% 90.91% (2.76)% (2.24)% (4.09)%

Less Urgent Home Visit Consultations started within 6 Hours Month: Performance (95%)

95.29% 98.56% 93.02% 0.29% 3.56% (1.98)%

Urgent Base Consultations started within 2 Hours Year to Date Performance (95%)

92.63% 94.65% 95.89% (2.37)% (0.35)% 0.89%

Less Urgent Base Consultations started within 6 Hours Year to Date Performance (95%)

96.72% 97.10% 95.96% 1.72% 2.10% 0.96%

Urgent Home Visit Consultations started within 2 Hours Year to Date Performance (95%)

91.67% 91.15% 94.45% (3.33)% (3.85)% (0.55)%

Less Urgent Home Visit Consultations started within 6 Hours Year to Date Performance (95%)

95.20% 97.56% 97.15% 0.20% 2.56% 2.15%



PAGE 21 of 64

Urgent Consultations at Base Sites (Treatment Centres)


Page 22 of 64

Urgent Home Visits



PAGE 23 of 64

Planned Mitigating Action being

taken by the Trust

Timescales for

Action


Impact Expected

The Trust is reviewing the level of activity being

classified as Urgent:

The Trust is reviewing all Treatment Centre Appointments and Home Visits in February 2015. This review will look at:

Time and locations of incidents to identify trends in activity and the associated resource requirements;

Appropriateness of initial telephone triage when compared to clinical triage at scene;

Analysis of patient conditions to identify those groups of patients that are being identified at scene as Less Urgent but were initially triaged as Urgent through telephone assessment;

Analysis of reasons for missed performance targets to identify any recurrent issues to be addressed.

February 2015 Appropriate reduction of the proportion of incidents classified as Urgent will enable more effective resource deployment and improve the capacity of the service to deliver performance against the National Quality Requirement 12.

Improving staffing by targeting improvements

in clinical leadership, the level of clinical cover

and availability of clinicians:

Revised control processes with a view to increasing the availability of dedicated Urgent Care Service ECPs;

Reviewing the mix of mobile clinicians and the introduction of additional dedicated Urgent Care ECPs;

Development of Clinician Skill sets within the Out of Hours service;

Engagement with locum agencies to provide additional resources when required;

Recruitment to fill vacant ECP rota lines.

On-going engagement with locum agencies to increase resilience in clinical resources at peak periods.

Development of a revised 2014/15 workforce plan to focus recruitment on filling the vacant ECP rota lines (completed in Quarter 3 of 2014/15).

Improved access to and control of dedicated Urgent Care Service ECPs will increase the number of available clinical resources.

Change of skill mix within the Out of Hours service will enable GPs to concentrate on cases of greater clinical complexity.

Increased resilience in the service to reduce call back times for patients during peak periods of demand.

Performance Management of Teams and

Individuals:

Analysis of performance benchmarking information for Out of Hours Dispatchers and Clinicians;

Increased coaching and improvement plans will be introduced for individuals where appropriate;

Utilisation of ‘live’ performance management tools and operational staff with specific responsibilities for performance management and monitoring;

Assessment and training for Out of Hours Dispatchers.

Current reports provide information for individual and team performance assessment.

Dedicated Performance Managers within the Out of Hours service have been introduced to support the performance management process.

Identify coaching opportunities to support staff.

Performance managers to deliver an increased focus on performance of individuals and enable timely identification of any issues to be addressed on a daily basis.

New ‘live’ management reports introduced designed to capture recurrent issues and themes and identify any areas for service change or improvement.


Page 24 of 64

NHS 111 Service : 60 Second Call Answering and Call Abandonment Rates Performance Exception Status: Real Concerns: The trust did not deliver call answering or call abandonment targets in February 2015.

Reason(s) for the performance exception category assigned in the reporting period: • Call answering performance during February 2015 was significantly below KPI levels across all four counties.

• Call answering performance during weekends remains the most challenging and whilst resource plans were introduced to deliver sufficient resources to meet the required activity levels, the current level of vacancies for some rota lines and high levels of short notice abstractions (including sickness) impact detrimentally on the number of call advisors required to maintain performance at the 95% level against the 60 seconds call answering target.

• A revised Quality Development Plan (QDP) and associated performance trajectories have been produced.

• The Trust continues to compare well nationally on other contracted KPIs including the percentage of patients advised to attend an Emergency Department or transferring a call to the 999 service.

Risk Assessment: • The Trust is working with Commissioners to agree an improvement trajectory for the 60 second call answering

target without compromising good performance on the other metrics including transfers to 999 or advising patients to attend an ED.

Actual

Performance

Variance to Quality

Requirement Target

Percentage of Calls Answered Within 60 Seconds - KPI Target 95% Month: February 2015 Performance

Dorset 74.45% (20.55)%

Devon 66.08% (28.92)%

Cornwall 64.86% (30.14)%

Somerset 66.57% (28.43)%

Percentage of Telephone Calls Abandoned 30 seconds after the recorded message - KPI Target 5% Month: February 2015 Performance

Dorset 6.15% 1.15%

Devon 8.88% 3.88%

Cornwall 8.74% 3.74%

Somerset 9.28% 4.28%

Percentage of Calls Answered Within 60 Seconds - KPI Target 95% Year to Date Performance

Dorset 84.98% (10.02)%

Devon 81.55% (13.45)%

Cornwall 78.98% (16.02)%

Somerset 82.23% (12.77)%

Percentage of Telephone Calls Abandoned 30 seconds after the recorded message - KPI Target 5% Year to Date Performance

Dorset 3.75% (1.25)%

Devon 4.53% (0.47)%

Cornwall 5.48% 0.48%

Somerset 4.73% (0.27)%


Page 25 of 64

Planned Mitigating Action being taken

by the Trust Timescales for Action

Performance Improvement / Impact

Expected

Demand Management & Resource Planning

Review the Profile of Relief Allocation

within Current Rota Patterns for Call

Advisors and Clinicians

• Current rota pattern incorporates an element of ‘relief’ to provide additional resilience to manage abstractions including sickness, annual leave, training, etc.

• The profile of this relief is to be reviewed.

• Focus on weekend periods.

• Identify the required changes to the rota patterns to meet these pressures.

Review of the abstraction profiles within the NHS 111 service completed. Identification of changes to the current rota patterns to meet the identified profile also completed. Additional shifts introduced.

Further analysis of abstractions undertaken in February 2015. Information used to inform further revisions to rotas, specifically to increase call advisor resilience during the weekend periods for 2015/16.

Improved profile of the relief allocation within the rota patterns will increase the resilience within the service to manage the increased levels of abstractions seen during the weekend periods.

Ensure rotas remain fit for purpose.


Page 26 of 64




Expected

NHS 111 Activity Profile Review:

• Review of the available telephony data to identify trends in call volumes.

• Identify recurrent patterns in calls within each hour the service operates.

• Where ‘batches’ of call volumes are identified the Trust will assess the resourcing within those hours, including rest breaks and other abstractions such as training to ensure they are managed effectively.

Data is reviewed against a rolling 8 week activity profile.

A review of weekend activity profiles was completed in January 2015 and this information will be used to inform future resource rota reviews in 2015/16.

Improved profiling of resources, including the management of ‘in shift’ abstractions such as rest breaks and training time will deliver increased call answering resources at the peak periods.

Source of NHS 111 Calls:

• Review activity to identify the source of calls received by the NHS 111 service.

Proactive management of identified frequent callers and management of repeat calls while waiting for a clinician to call back.

Frequent caller management reviews are undertaken within the NHS 111 service on a monthly basis.

Ongoing work with the local health community to reduce activity to the NHS 111 service as a result of limited or lack of alternative services in the health community.

Increase the capacity of the current resources to answer calls, particularly during periods of peak demand.

Increased focus on resource planning

through bi-weekly Resource

Management Group meetings.

Bi-weekly RMG meetings introduced August 2014.

Identify pressure points.

The increased focus and improved flow of information will enable any issues to be identified and addressed at the earliest opportunity.

Staff Recruitment

Recruitment of additional Call

Advisors and Clinical Supervisors

and revise shift patterns:

• Extension of late shifts on Fridays, Saturdays and Sundays;

• Revised start times for early shifts;

• Recruit additional call advisors to meet peak demand periods across the week;

• Recruitment to a pool of call advisors on bank contracts.

On-going recruitment to fill vacancies.

The majority of vacancies relate to part-time evening and weekend positions.

The first group of bank staff commenced operational shifts with effect from September 2014.

Deliver improved call answering performance.

An additional pool of bank staff for call answering will provide greater resilience with a flexible workforce available to meet shortfalls in resourcing at short notice.

Recruitment Campaign for Part Time,

Evening and Weekend Call Advisors:

• Targeted recruitment campaign. Identification of key groups of individuals who would be interested in working evening and weekend periods only.

Recruitment programme developed and introduced.

Additional courses being run through January, February and March. Scheduled to come out of training during February, March and April 2015 to fill call advisor shifts.

Fill current vacancies and provide full rota cover through the winter period.

Target recruitment to deliver a sustainable supply of part-time Call Advisors.


Page 27 of 64




Expected

Operational Management

Performance Management of Teams

and Individuals:

• Benchmarking information.

• Productivity reviews completed weekly to assess call advisor performance.

• Increased call auditing and coaching.

• Introduction of Clinical Floorwalkers in the NHS 111 hub to ‘manage the room’.

• An enhanced focus on managing individual performance.

Two additional members of staff seconded to work on performance management reports and processes.

Weekly productivity and call answering performance reports available for individual call takers and teams.

Identify coaching opportunities to support staff and improve morale.

Deliver performance improvements including improved call answering performance.

Reduce variation.

Introduction of Duty Managers

New Duty Manager posts introduced September 2014.

Introduction 24/7 to improve workflow , provide support to staff, improve performance and assist management focus.

Introduction of Non-Pathways Call

Advisors (NPAs)

• Introduced for callers who do not require a full clinical triage.

• The Trust currently undertakes a full NHS Pathways triage on approximately 92% of all calls compared to a national average of 85%.

Introduced January 2015.

Further work is being undertaken to assist in the streaming of appropriate calls to Non Pathways trained advisors during Quarter 4 of 2014/15.

Reduce recruitment timescales for new call answering resources.

To provide an introduction into the NHS 111 service for new starters. If successful in this role there is an opportunity to be trained on the full requirements of NHS Pathways.

Reduce the percentage of patients who are triaged through NHS Pathways.

Abstraction Management

Management of Sickness Absence:

• Re-publication of the Trust Sickness Management Policy.

• Welfare calls to be completed by Operational Managers.

• Introduction of a new central Sickness Line.

• Review of the reasons recorded for short term and long term sickness.

Weekly review of all sickness absences undertaken between the operational team and HR department.

New central sickness line was introduced during Quarter 3 of 2014/15.

Minimise the number of operational hours lost to sickness absence.

Understand the causes of short term sickness.

Regular reviews with the HR department to ensure that all sickness cases are being managed and escalated (where appropriate) in line with the Trust Policy.

Annual Leave Abstraction

Management:

• Assessment of annual leave allocation profiles on a regular basis.

• Utilisation of the GRS rota system.

• Identification of the key operational activity periods where annual leave abstractions need to be restricted in order to deliver enhanced operational cover.

• Introduce a dedicated operational manager (November 2014) to oversee all elements of abstraction.

All shift and annual leave information was introduced into the GRS system during July 2014. Annual leave allocation rules have been established within the GRS system.

Identification of the key operational periods has been completed and specific rule sets implemented into GRS in October 2014.

Improved abstraction management, including annual leave allocations, in line with the available relief within the current rotas will deliver a more consistent level of operational resources within the service.


Page 28 of 64

Urgent Care Service Line

Tiverton Urgent Care Centre 4 Hour Waiting Time Target Performance Exception Status: No Concerns The Trust achieved 99.62%. Performance is consistently high and above target levels.

Reason(s) for the performance exception category assigned in the reporting period: • Following a successful tender process the Trust signed a 21 month contract to operate the Urgent Care

Centre in Tiverton. The Trust took over operational control of the Unit on 8 July 2014.

• The primary performance measure within the contract is the 4 hour waiting time standard (this is the same target for acute trust Emergency Departments).

• In February 2015 of the 1,042 cases 1,038 were completed within the 4 hour target giving performance of 99.62% against the 95% performance target.

• For the period 8 July 2014 to 28 February 2015 the Trust has completed 9,012 of the 9,068 cases within the 4 hour target, delivering a performance of 99.38%, 4.38% above the national target level.

Risk Assessment: • Performance against the 4 hour target continues to be monitored on a daily basis and is expected to be

maintained above the 95% target levels.


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7. Ambulance National Quality Indicators (AQI)

7.1. This section provides a summary of performance against each of the National Ambulance

Clinical Quality Indicators. The definition for each is provided in Appendix C.

7.2. There are no national targets for 2014/15 however all ambulance Trusts are required to use a

consistent set of national indicators to evidence improvements in the quality of service. The indicators reported in the ICPR fall into two groups as follows:

Nationally defined system and clinical indicators;

Locally determined service experience indicators to meet the national requirement to report on how the experience of users of the ambulance service is captured, to publicise the results and to show what has been done to improve the design and delivery of services in light of the results.

7.3. The Trust has agreed performance thresholds for each of the indicators within the Accident

and Emergency contract for 2014/15. These were last reviewed in October 2013 and will be reviewed again with NHS Commissioners during 2014/15. These thresholds are designed to monitor performance and highlight at an early stage any deterioration in performance.

7.4. The Trust has participated in national working groups to help develop revised guidance for

both the Clinical and System Indicators. The most recent guidance was published on 16 May 2013 and was designed to deliver improvements in data quality and in the consistency of the data being reported. It is hoped that greater consistency will increase the level of confidence when comparing and benchmarking Trust performance against other ambulance trusts.

7.5. The revised guidance delivered some changes in calculations for the Clinical Indicators with

effect from April 2013 (data submitted in August 2013). Due to the complexities in the definitions and collection processes for the Clinical Indicators further work is required nationally to deliver consistency in the metrics reported by all ambulance trusts in England.


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Table 4: AQI System Indicators

AQI Trust Performance Performance vs Local Thresholds

(where appropriate) Benchmark Exception Reporting

Calls abandoned

Call Abandonment Rate February 2015

1.42% YTD

0.89% Local Threshold

1.50%

National Average

Apr 2014 – Jan 2015

1.44%

No concerns in the reporting period: % abandoned is lower (better) than local threshold.

Time Taken to Answer calls

Time to Answer Call February 2015

50th

2 secs 95

th 8 secs

99th

38 secs Local Thresholds

50th

3 secs 95

th 15 secs

99th

60 secs

No national average figures

available for this metric


In the reporting period call answering times were within the local threshold for the 50

th percentile metric, but above the

local thresholds for the 95th

and 99th

percentile metrics.

The average (median) time for answering calls remained below the local threshold at 2 seconds.

Time from call categorisation to arrival at scene

February 2015 50

th 7.2 mins

95th

23.9 mins 99

th 39.6 mins

Local Thresholds (to be reviewed with NHS

Commissioners)

No national average figures

available for this metric


In the more rural areas of the Trust, the 95th

and 99th

percentile measures are in the lower quartile compared to other ambulance trusts due to greater distances to travel.

As expected, performance in January 2015 reflected an improvement on the December 2014 response times following the reduction in overall activity volumes.

Actions being undertaken to improve performance against this metric are included within the Red Performance Plan detailed earlier in this report.

Further work on local issues continues to identify barriers to delivering reduced time to treatment and any actions are added to the action plan under the supervision of the A&E Service Line Group.

In addition to the above, the Trust continues to review the treatment times for all patients on a daily basis to identify any specific and/or recurrent issues.


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Re contact with the Ambulance Service following telephone advice

February 2015 13.55%

YTD 13.61%

Local Threshold 11.00%

National Average

Apr 2014 – Jan 2015

7.77%


As part of the current review process within the Trust, a review of the reasons for re-contacts is undertaken monthly within the Clinical Hub.

A regular clinical review of the re-contacts is undertaken and is reported to the ACQI Sub Group (which meets on a bi-monthly basis) for overview to identify any other trends or areas to be addressed.

Nationally reported figures for ambulance trusts show considerable variance, between 3.44% and 14.85% in December 2014.

The large variance in national performance raises concerns over the comparability of data being reported against these metrics by ambulance services. The National Ambulance Informatics Group is leading on a review of the data and calculation processes for all ambulance trusts.

An initial assessment of the processes and data used by ambulance trusts for these metrics was completed in January 2015 and will be reviewed by the National Ambulance Informatics Group during Q4 of 2014/15 with a view to delivering greater reporting consistency.

Following the completion of the national review, SWASFT will undertake benchmarking reviews against the best performing ambulance trusts in England for the –re-contact metrics to identify any best practices which may be introduced to improve performance during 2015/16.

Re contact with the Ambulance Service following treatment at scene

February 2015 6.53% YTD


5.50%

National Average

Apr 2014 – Jan 2015

5.38%


In the reporting period re-contact rates following treatment at scene were higher than the local threshold.

As with the re-contacts following telephone advice, there are considerable variances in the figures reported nationally by ambulance trusts against this metric. In December 2014 the reported re-contact rates varied between 3.56% and 9.00% which again raises some concerns over the comparability of data being reported against these metrics nationally.

A similar review of the data quality and consistency is being undertaken through the National Ambulance Informatics Group.

Following the completion of the national review the Trust will undertake a similar benchmarking exercise with other ambulance services to identify any best practices and improvements that can be delivered through 2015/16.


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Patients Managed Appropriately– Calls Closed with Telephone Advice


YTD 7.95%


National Average

Apr 2014 – Jan 2015

7.96%

No Concerns

In the reporting period with percentage of managed calls resolved by telephone advice were higher (better) than the local threshold.

Patients Managed Appropriately– Calls Closed without the need for Transport to A&E (Emergency Departments)


YTD 52.35%


National Average

Apr 2014 – Jan 2015 37.10%

No Concerns

SWASFT remains the ambulance trust with the highest (best) non conveyance rate in England.

For 2014/15 the Trust is committed to the delivery of Right Care across all incidents and therefore performance against Trust trajectories for Right Care is provided within the Right Care section of this report.

Progress against the identified actions within the Right Care action plans will also be included within the Right Care section of this report.

Table 5: AQI Clinical Indicators

AQI Trust Performance in

reporting period

Performance vs Local Thresholds

(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Return of spontaneous circulation following cardiac arrest

Nov 2013 to Oct 2014 24.76%


National Average Apr – Oct

2014 27.39%

No concerns in the reporting period the Trust was above the local threshold.

The Research and Audit Department are undertaking a Quality Improvement Initiative which will raise the awareness of the new post ROSC care bundle, provide benchmark data on compliance with the care bundle and examine barriers to implementation.


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reporting period


(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Return of spontaneous circulation following cardiac arrest (Utstein)

Nov 2013 to Oct 2014


45.00%


2014 51.49%

Improvement Expected: All Divisions

In the reporting period: performance was below the local threshold.

Linked to the Research and Audit Department work identified above as the Utstein Group is a subset of the

patients within the overall ROSC metric calculation.

Outcome from acute STEMI - (PPCI)

Nov 2013 to Oct 2014 79.75 %



2014 87.68%

Improvement Expected: All Divisions

The Clinical Development Officers will work with the Research and Audit Department to understand areas where improvements can be realised and support local clinical staff who attend PPCI meetings.

A&E CQUINN work undertaken within East and West Divisions has now been replicated in North Division, work examining the reasons for breaches to this indicator.

Recommendations from this report in the North Division are to be reviewed at the ACQI Sub Group meeting to consider roll out across the Trust.

Outcome from Acute STEMI – Care Bundle



85.00%


2014 80.08%

No concerns in the reporting period: performance is higher (better) than local threshold


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reporting period


(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Outcomes from Stroke for Ambulance Patients – FAST (Face, Arms, Speech, Time to Call 999)

Nov 2013 to Oct 2014 57.17%



2014 58.92%

No concerns

Performance against this metric is challenging due to the very rural nature of the geographical area covered by SWASFT with longer distances to travel to Hyperacute Centres, particularly in the areas of Cornwall, East Somerset and North East Somerset.

However, at present performance for the rolling 12-month period the Trust is 0.17% above the local performance threshold of 57.00%.

The Trust reviews responses in all operational areas (including multiple responses, back up times and on scene times) and how the type of response impacts on the times to Hyperacute centres.

Outcome from Stroke for Ambulance Patients – Care Bundle

Nov 2013 to Oct 2014 97.59%



2014 97.22%


Outcome from Cardiac Arrest – Survival to Discharge



8.00%


2014 8.15%



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reporting period


(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Outcome from Cardiac Arrest – Survival to Discharge (Utstein)

Nov 2013 to Oct 2014 27.90%



2014 25.28%



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8. NHS Commissioner Local Standards and Thresholds

8.1. This section includes those standards and thresholds agreed with local NHS Commissioners as part of the 2014/5 contract negotiations. The definitions are set out in Appendix C.

Table 6: NHS Commissioner Standards and Targets for 2014/15

Measure Local

Target

February

2015

Quarter 4

Forecast

Year to

Date

Green 1 Calls 90% 74.35% 75.00% 80.70%

Green 2 Calls 90% 75.28% 76.00% 83.94%

Green 3 Calls 90% 93.36% 93.50% 95.99%

Green 4 Calls – North Division 90% 77.43% 79.00% 82.54%

Green 4 (999) Calls – East/West Division 90% 73.05% 74.00% 80.96%

Green 4 (HPC) Calls – East/West Division 70% 63.44% 65.00% 67.88%

Compliance with Infection Prevention and Control Standards at Ambulance Stations (Dec 2014 only due to delay in Jan 15 data)

75% 73.00%

Compliance with Infection Prevention and Control Standards for Double Crew Ambulances (Dec 2014 only due to delay in Jan 15 data)

75% 83.00%

Vehicle Deep Cleaning Compliance with Schedule 90% 90.27%

Green Incident Performance Performance Exception Status: Improvement Expected: Performance against the locally agreed targets for Green 1, Green 2 and Green 4 incidents was below local targets.

Reason(s) for the performance exception category assigned in the reporting period: • The Trust failed to deliver the Green 1, Green 2 and Green 4 local performance targets in February 2015.

• Performance improvements are expected for Green incidents arising from a number of actions identified within the overall Trust Red Performance Sustainability Plan, including the introduction of additional operational resources.

• Following the introduction of the Dispatch on Distribution Pilot the Trust will be reviewing all areas of resource dispatch and response times. This pilot will focus on delivering the most appropriate response to meet the clinical need of the patient for all incidents within the Trust which includes Green incidents.




Impact Expected

• Introduction of additional operational

resources as part of Red Performance

Sustainability Plan will increase

responding and conveying capacity

within the Trust.

New resources identified as part of the Red Performance Plan and within the A&E Operational Plan for 2014/15.

Additional operational resources will increase the Trust response and conveying capacity in 2014/15.


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Compliance With Infection Prevention & Control Standards at Ambulance Stations Performance Exception Status: Improvement Expected: Performance against the locally agreed target for Infection Control Standards at Ambulance Stations was below target in the month of February 2015.

Reason(s) for the performance exception category assigned in the reporting period: • Due to operational pressures in recent months, as a result of increased activity levels and the extended

period of the Trust operating at REAP level 4, a number of associated duties and tasks have been delayed, including the completion of the required paperwork supporting the Infection Prevention and Control Standards at Ambulance Stations.

• The Trust is working with Operational Managers to deliver the required improvements to recover performance against this metric.

• A review of station cleaning contracts is also being undertaken with a view to delivering consistent and robust station cleaning contracts across the service. Contracts for station cleaning will include the required elements to deliver compliance against the Trust Infection Control Standards.

Handover Delays at Acute Hospitals Performance Exception Status: Real Concerns: The number of delays has increased during the Winter period, with a number of acute hospitals experiencing operational pressures due to significant increases in the volume of patients attending Emergency Departments.

Reason(s) for the performance exception category assigned in the reporting period: • Individual incidents and extended delays at acute hospitals are managed on a day to day basis and subject

to locally agreed handover escalation procedures.

• Unprecedented activity levels have been seen across the local and national health communities including increased pressures at Emergency Departments during this winter period. Significant increases in the volume of patients attending the Emergency Departments has exceeded the available capacity within the system and resulted in a number of issues at acute hospitals including some hospitals, nationally declaring major incident status.

• Within the South West the pressures within the Emergency Department resulted in extended handover times for some patients with the total ambulance operational resource hours lost increasing to 1,834 hours in December 2014.

• In January 2015 the operational time lost to handover delays reduced but remained high at a total of 1,579 hours during the month which equates to an average 51 operational hours lost per day. In February 2015 the total operational hours lost increased to 1,639 hours for the month, which is an increase to an average of 58 operational hours lost per day across the Trust.

• There were a total of 1,783 handover delays in excess of 30 minutes in February 2015, of which 367 were over 60 minutes in length (compared to 1,617 delays in excess of 30 minutes in January 2015).

• During February 2015 of the 367 delays over 60 minutes in length, 51 of these delays were at the Bristol Royal Infirmary, 48 at Royal Bournemouth Hospital, 50 at Southmead Hospital, 46 at Weston General Hospital, 35 at Great Western Hospital, 33 at Dorset County Hospital and 31 at Royal Cornwall Hospital Treliske.

• Handover delays are subject to a fining regime for 2014/15.

• The Trust continues to work closely with NHS Commissioners in targeting hospitals with consistently long delays particularly during periods of high activity levels.

February 2015 Year to Date

Operational Time Lost to Handover Delays in Excess of 15 Minutes

1,639 hours 16,150 hours

Number of Handover Delays between 30 and 60 Minutes 1,416 incidents 13,252 incidents

Number of Handover Delays in Excess of 60 Minutes 367 incidents 3,226 incidents


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Planned Mitigating Action being taken by

the Trust Timescales for Action


Impact Expected

Local action plans to manage and reduce the volume of handover delays have been agreed with each of the acute hospitals.

• Internal escalation plans to manage handover delays including a stepped approach to handover delays in order to deal with severe delays promptly;

• Confirmed patient overflow areas for periods of high demand;

• Procedures to divert patients to neighboring acute trusts during times of excessive demand;

• Local meetings between the ambulance service, acute trust leads and NHS Commissioners to agree local actions.

Operational service managers have met and agreed handover action plans with each of the acute hospitals.

Monthly meetings between OLMs and acute hospitals.

Early identification of issues and/or concerns and identification of any actions required to resolve.

Management of handovers in line with the

Trust Standard Operating Procedure.

Revised November 2014. Maximise resources available to respond to 999 calls by reducing the level of operational time lost to delays at acute hospitals.

Outcome aimed at improving patient safety.


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9. Patient Transport Contract 2014/15 Key Performance Indicators

Table 7: PTS Service Line: Bristol, North Somerset and South Gloucestershire KPIs 2014/15

Measure YTD

Performance Measure

YTD

Performance 1a Patients living up to 10 miles away from the treatment centre (Band A) should not spend more than 60 minutes on the vehicle on either an outward or return journey (Green >90%, Amber 80-90%, Red <80%)

91.82%

9a Patient satisfaction with the level of service received from the provider = assessed through the annual patient satisfaction survey (Green >85%, Amber 75-85%, Red <75%)

97.80%

1b Patients living over 10 miles and up to 35 miles away from the treatment centre (Band B) should not spend more than 90 minutes on the vehicle on either an outward or return journey (Green >90%, Amber 80-90%, Red <80%)

92.77%

9b NHS Commissioners to be satisfied with the level of service (Green = no issues or minor concerns resolved within 1 month) (Amber = minor issues and not resolved within 1 month or major issues resolved within 1 month) (Red = major issues not resolved within 1 month)

100.00%

1c Patients living over 35 miles away from the treatment centre (Band C) should not spend more than 120 minutes on the vehicle on either an outward or return journey (Green >90%, Amber 80-90%, Red <80%)

97.50% 9f Telephone answering (Green >95%, Amber 85-95%, Red <85%)

94.97%

2a Patients should not arrive more than 45 minutes before their booked arrival time (Green >90%, Amber 80-90%, Red <80%)

87.37%

10a Agreed activity performance report received in correct format and on time within 10 working days of the start of the following month

100.00%

2b Patients should not arrive after their booked arrival time (Green >97%, Amber 87-97%, Red <87%)

89.64%

10b Activity and finance queries are acknowledged within 3 days of receipt and resolved within 28 days from the date of the query

100.00%

3a SWASFT is to arrive to collect patients from the agreed location within 45 minutes of the outwards journey time (Green >90%, Amber 80-90%, Red <80%)

87.61%

12h Nil Serious Untoward Incidents (SUIs). Any SUIs are to be reported and action plans put in place – in line with NHS Bristol standard and timeframes (reported immediately; investigated within 24 hours and lessons learnt shared, then closed within 60 working days of the incident) (Green - No SUIs, Amber – SUIs reported but resolved within timeframe, Red SUIs reported but not resolved within timeframe)

100.00%

3a SWASFT is to arrive to collect patients from the agreed location within 75 minutes of the outward journey time (Green >90%, Amber 80-90%, Red <80%)

94.91%

12d Compliance with the agreed SWASFT complaints procedure – full response made in a timely manner agreed with the complainant (assessed quarterly)

100.00%

8c Pick-up time to be confirmed by text, email or personal phone call to the patient within a week of the appointment (phone call being the preferred method (assessed quarterly)

100.00%

3b A summary of reasons and actions to be provided, for each month, for all cases where collection was outside (i.e. later) of the KPI limits. This may include case by case analysis as deemed necessary.

Compliant


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10. Right Care, Right Place, Right Time 2

10.1. The Trust is committed to delivering the Right Care to all patients, in the Right Place at the Right Time. Working closely with NHS Commissioners the Trust has introduced the Right Care, Right Place , Right Time 2 initiative to deliver the highest quality of clinical care to patients in the most appropriate treatment locations using the most appropriate treatment pathways.

10.2. Through the enhancement of triage processes including the introduction of the NHS

Pathways clinical triage system, the Clinical Support Desk, Single Point of Access and other local initiatives the Trust is working with NHS Commissioners to reduce the number of avoidable attendances at Emergency Departments.

10.3. As part of the extension of the Right Care initiative the Trust has committed to deliver a

0.32% improvement in the percentage of incidents managed without a conveyance to an Emergency Department. This commitment would see the non-conveyance rate increase from 54.05% for 2013/14 to 54.37% for 2014/15. The Trust already has the best non conveyance rate in the country and therefore this represents an additional improvement.

10.4. The Trust has agreed trajectories with NHS Commissioners for reductions in inappropriate

conveyances to Emergency Department for 2014/15 and for the period 1 April to 28 February 2015 the Trust was 0.88% ahead (better than) of the trajectory target of 54.30%.

10.5. A specific Right Care Action Plan has been developed and shared with NHS Commissioners. The plan identifies the key actions to be undertaken across the Trust to deliver the required


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improvements. Progress against this plan is overseen by a dedicated project team, reporting to the Right Care Group.

10.6. Roadshows with operational staff were completed during Quarters 1 and 2 of 2014/15 to

promote the Right Care initiative and provide operational staff with the opportunity to feedback on their experiences and best practices in relation to the provision of Right Care. The Right Care Roadshow events took place at each of the acute hospitals across the South West area to promote closer working relationships between the hospitals and ambulance staff and to help identify any specific local issues that can be addressed as part of the Right Care imitative. The events held at the hospitals proved to be extremely successful and there has been a high level of feedback and sharing of ideas across the stakeholders involved and these ideas will now be carried forward under the leadership of the Trust Right Care project team as part of the Right Care action plan.

10.7. In addition to the hospital events, the Trust has also completed internal Roadshows for the

Clinical Hub and Non Operational Staff during Quarter 2 of 2014/15 as part of the process of embedding the Right Care message throughout the whole organisation.

10.8. In addition to the roadshows specific events for local Right Care Champions were held in

October 2014 and February 2015 which provided the opportunity for the Champions to come together and learn more about the Trust Right Care Action Plan and to:

Share feedback on the Right Care progress to date within their local areas;

Develop ideas to support further improvements;

Share best practices that have been successful within their local areas;

Introduce appropriate social media routes to provide access to information regarding Right Care and to share best practices including email, twitter and internet pages for SWASFT staff to access.

10.9. Regular meetings with NHS Commissioners are being held to discuss the identified local

Right Care initiatives. These discussions include the review of any feedback provided by operational staff which may have identified local barriers to delivering the Right Care to the patient. By working together with NHS Commissioners the Trust will look to:

Remove any identified barriers to delivering the Right Care for the patient;

Ensure all appropriate services are available and accessible within the local Health Community;

Identify any additional projects or process changes which may assist in the most appropriate management of patients within the local area;

Develop links between the local Right Care Champions and the Clinical Development Team to co-ordinate all local activity to support the Right Care program;

Maintain a full and clear Directory of Services of available facilities within the local health community and information on how and when these facilities may be accessed by ambulance resources.

10.10. Other key actions currently being progressed within the action plan include:

Improved access to support for clinicians on-scene, including telephone support from hub based clinicians where appropriate;

Additional clinical support and advice in the Clinical Hub, including the addition of GPs in the hub from October 2014, continuing throughout the winter period. The impact of these additional clinicians in the Hub has been highlighted by the improvements in the percentage of calls resolved by telephone advice in November (9.11%), December (11.81%), January (10.12%) and February (12.21%);

Targeted deployment of Emergency Care Practitioners (ECPs) to key patient and symptom groups to utilise their enhanced skill set to increase the proportion of patients treated at scene where appropriate;


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Improving access to alternative treatment locations (e.g. Minor Injury Units). Working closely with the local health community to improve the flow of patients to locations other than the Emergency Department where appropriate;

Working with local NHS Commissioners and other key stakeholders to identify more appropriate pathways for Mental Health patients in relation to the Crisis Care Concordat;

Reviewing the current process for the handling of calls received from other Healthcare Professionals into the ambulance service to ensure all patients receive the most appropriate treatment pathway;

Comprehensive mapping of all available treatment facilities across the South West including Minor Injury Units (MIUs), Urgent Treatment Centres and Walk in Centres, providing a comprehensive database of appropriate alternative treatment pathways for ambulance clinicians;

Identification of all direct acute hospital referral pathways available to ambulance clinicians to enable the avoidance of Emergency Departments for appropriate patients;

Introduction of additional Paramedic assessment skills to assist in managing patients at home where appropriate, this will be supported by a new Right Care Award consisting of 10 master classes and the opportunity for staff to complete a CPD module in conjunction with the University of the West of England with effect from February 2015;

Introduction of a new internal Frailty Group with effect from January 2015 to focus on the identifying the most appropriate treatment pathways for this group of patients who often have more complex and longer term medical conditions.

10.11. The delivery of Right Care over the next two years will be supported by the rollout of the new Electronic Patient Clinical Record across the Trust. The new system will provide staff with access to additional information to support clinical decisions at scene and provide access to information on the alternative services available within the local area to best meet the clinical needs of the patient. The rollout programme of the system will be undertaken throughout 2014/15.


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11. Internal Trust Headline Performance Indicators for 2014/15

11.1. The performance metrics set out in the table below are included in the ICPR as the internal Trust headline measures for 2014/15.

Metric Internal

Target

February 2015

Year to Date

Forecast

Outturn

Staff Appraisal Completion 85% 61.33%

On-going Compliance with Care Quality Commission Regulations and Quality Risk Profile

Compliant Green Green

Information Governance Toolkit Level 2 Amber Green

Implementation of the Equality Delivery System (EDS)

On Plan Green Green

Environmental Strategy & Work Programme On Plan Green Green

Delivery and Assessment of Environmental Impact Pilots

On Plan Green Green

NHS Constitution and Staff Pledges On Plan Green Green

11.2. Trust performance against the internal 85% staff appraisals target has dropped to 61.33% in February 2015, predominantly due to operational pressures seen as a result of the Trust operating at REAP level 4 for extended periods during the current financial year.

Information Governance Toolkit Performance Exception Status: Early Warning: Rated as Amber for February 2015 as one requirement to achieve level 2 is outstanding.

Reason(s) for the performance exception category assigned in the reporting period: • Significant work is on-going to support toolkit completion for 2014/15 to ensure the Trust meets at least level

2 for all 35 requirements which is the minimum expected by NHS Commissioners.

• Internal Audit completed their annual audit of the Information Governance Toolkit in December 2014 and published the final report in January 2015.

• An audit in February 2015 has identified that:

• Ten requirements are now compliant with a level 2 rating;

• One requirement remains non-compliant with a level 0 rating.

• The non-compliant requirement failed to achieve a level 2 rating due to one Trust Policy relating to Clinical Records Management requiring an internal review. This action will be completed by 31 March 2015.


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12. Trust Resource Performance Measures

12.1. This section includes resource measures specified by the Trust as having a significant impact on performance and delivery:

The Resource Escalatory Action Plan (REAP) level;

Service line activity;

The Trusts financial position;

Capacity and Capability.

Resourcing Escalatory Action Plan (REAP) Level 12.2. The Trust weekly REAP assessment takes into account the following measures:

A&E actual activity levels compared to contracted activity levels;

Performance against national performance targets and local performance trajectories;

Clinical Hub call answering performance;

Frontline staff sickness levels;

Average turnaround times at acute hospitals (Handover and Wrap Up times);

Local weather forecasts;

Other issues impacting on operational delivery:

o Winter pressures;

o Local events;

o ICT/System upgrades;

o Other national/local risks to operational delivery.

12.3. The Trust remained at REAP level 4 through December 2014, January 2015 and February 2015 due to the significant levels of activity seen across the Trust. The Trust continues to review REAP levels on a weekly basis.

Service Line Activity 12.4. Activity is reported against three service lines - Accident and Emergency/999, Patient

Transport Services and Urgent Care Services. The activity currencies are as follows:

Accident and Emergency activity is measured for contracting and performance management purposes. For 2014/15 the Trust is contracted on the basis of

‘incidents’.

Incidents are defined as any unique call resulting in the ambulance service providing a service which could include telephone advice only or referral to another service where appropriate.

Incidents are split into three categories:

o Hear & Treat/Refer – those incidents that were resolved by providing clinical advice over the telephone (without an ambulance resource attending the scene) or where the caller was referred to a more appropriate service (e.g. to contact the NHS 111 service);

o See & Treat/Refer – where an ambulance resource arrives at the scene of an incident and the patient is treated without the need to convey the patient. This may include referring the patient to an alternative care pathway (e.g. to visit their GP) where appropriate to best meet the needs of the patient.

o See & Convey – where an ambulance resource arrives at the scene of an incident and following treatment by the ambulance service, at least one patient requires conveyance. This measure includes all conveyances, therefore the See & Convey figure is often split between Emergency Department (type 1 and type 2) and non-Emergency Department destinations.

The currency used to measure Patient Transport Services activity in the Bristol, North

Somerset and South Gloucestershire contract is patient journeys.


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Accident and Emergency Service Line Incidents by Month:

Actual Contracted Variance %

April 2014 67,410 66,138 1.92%

May 2014 72,029 69,648 3.42%

June 2014 71,074 68,348 3.99%

July 2014 74,295 71,273 4.24%

August 2014 72,064 70,443 2.30%

September 2014 68,822 68,285 0.79%

October 2014 72,138 71,422 1.00%

November 2014 71,694 68,277 5.00%

December 2014 81,079 77,012 5.28%

January 2015 74,240 71,466 3.88%

February 2015 68,378 65,628 4.19%

Year to Date 793,223 767,940 3.29%

Accident and Emergency Service Line Incidents by CCG:

Actual Contracted Variance % Actual Contracted Variance %

Kernow CCG 7,687 7,168 7.24% 87,734 86,737 1.15%

NEW Devon CCG 11,431 10,471 9.17% 133,006 123,837 7.40%

South Devon & Torbay CCG 4,227 3,863 9.42% 49,755 47,465 4.82%

Somerset CCG 6,549 6,529 0.31% 77,417 76,442 1.28%

Dorset CCG 11,022 10,829 1.78% 129,831 128,449 1.08%

Bath & North East Somerset CCG 1,959 1,828 7.17% 21,935 21,286 3.05%

Bristol CCG 5,610 5,613 -0.05% 66,931 65,476 2.22%

North Somerset CCG 2,466 2,516 -1.99% 28,332 28,564 -0.81%

South Gloucestershire CCG 2,630 2,278 15.45% 29,755 27,491 8.24%

Gloucestershire CCG 6,829 6,994 -2.36% 79,453 78,135 1.69%

Swindon CCG 2,383 2,358 1.06% 27,135 26,412 2.74%

Wiltshire CCG 4,769 5,181 -7.95% 56,725 57,646 -1.60%

Total 68,378 65,628 4.19% 793,223 767,940 3.29%

In Month Year to Date

RAG ratings: Green Less than 4% above contract, Amber 4% to 6% above contract, Red greater than 6% above contract.

Trust Financial Position

12.5. The Trusts financial position reported as at the end of February 2015 has been included within this report. Financial headlines for the period 1 April 2014 to 28 February 2015 are set out below. The full financial appendices are included at Appendix G.

12.6. The Trust delivered a Continuity of Services Risk Rating of 4.00 in line with plan at the end of February 2015.

Metric February 2015

Debt Service Cover 5.89

Liquidity Ratio 13.21

Continuity of Services Risk Rating 4.00


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12.7. The financial information is based on the eleventh month of the financial year and includes

the actual and year end forecast position for the Trust against the agreed budget for 2014/15.

12.8. The Trust has delivered a surplus of £550k at the end of month ten against a planned surplus of £550k and has a cash balance of £38,970k as at 28 February 2015. This position includes a current and forecast under-spend on pay relating to vacancies which is offset by the use of overtime, agency and third parties. This position is being reviewed in line with the Trust recruitment plans.

12.9. The annual Cost Improvement target for 2014/15 is £8,950k. A risk of £500k has been identified in relation to the A&E Service Line for 2014/15; this has been offset year to date with replacement schemes of £458k. Further schemes are being developed and the Trust is forecasting delivery of the full CIP plan based on identification of these schemes.

12.10. A year to date shortfall of £275k has also been identified in relation to UCS modernisation. This is related to the implementation of a revised service model following the increase in GP Pay rate and is reflected in the year to date position.

12.11. The Trust is forecasting delivery of the remaining CIP plans and continues to work to mitigate any slippage in delivery of the schemes identified above.

12.12. Capital expenditure is off-plan in February due to a slippage in the expenditure on Mobimeds to 2015/16, and a delay in the planned ICT capital expenditure on the technical refresh and telephony systems. The Trust will be reporting a revised plan of £13,758k against an updated plan of £14,662k due to a reduction in the Safer Hospital / Safer Ward expenditure and the delay in the implementation of the ECS project.

Capacity and Capability

Key Performance Indicator February

2015

YTD

2014/15

Staff Sickness % YTD (Target 4%) 5.74% 6.22%

Staff Turnover Rate 13.27%

Staff Turnover Rate (excluding redundancies) 13.06%

Trust Total Staffing (WTE) 3,851.01

Trust Total Funded Establishment (WTE) 4,029.09

Total Staffing vs Funded Establishment (WTE) (178.08)

Trust Total Vacancy Rate (%) 4.42%

Operational Qualified Establishment (WTE) 1,574.20

Operational Qualified Vacancy Rate (%) 7.49%

Operational Non-Qualified Establishment (WTE) 883.22

Operational Non-Qualified Vacancy Rate (%) (0.54)%

Staff Numbers and Turnover

12.13. As at 28 February 2015 the Trust reported an establishment of 3,850.01 Whole Time

Equivalents (WTE) against a funded establishment of 4,029.09 WTE. The Trust therefore has 178.08 WTE vacancies (4.42%) compared to the funded establishment.

12.14. On-going recruitment continues for additional frontline resources to address residual vacancies across the Trust. A review of actual available WTE for the month of December


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2014 demonstrated that 4% of additional frontline resource was deployed by way of bank, agency and overtime.

12.15. In the past 12 months the Trust has filled 119 Paramedic vacancies, 75 of these new

Paramedics have been recruited within the past 6 months. The Trust has a further 14 Paramedics confirmed starting in the next two months and the Trust is working with the remaining 12 candidates to confirm offers made.

12.16. A considerable program of work is underway to secure qualifying Paramedic graduates to the

Trust from the Summer of 2015. Early offers of employment have been made and a significant proportion of these have accepted roles with the Trust.

12.17. Additionally the Trust has a number of year four Open University (OU) students who will

qualify in the Autumn of 2015 plus we have 60 Emergency Care Assistants (ECAs) who are commencing a fast track Paramedic conversion course which will provide a further internal supply route of Qualified Paramedics with effect from January 2016.

Management of Sickness Absence

Performance Exception Status: Real Concerns: Performance in the reporting period is significantly above (worse than) plan.

Reason(s) for the performance exception category assigned in the reporting period: • Sickness absence levels are higher than planned in February 2015 at 5.74% compared to the 4% target.

Planned Mitigating Action being taken by the Trust Timescales for Action

The Sickness Absence Policy, which was launched in August 2014, has recently been revised and approved through PRAG and JNCC in December 2014. This has strengthened the identification of sickness ‘patterns’ as contributing to formal management under the policy, giving managers greater discretion to manage sickness absence cases whereby sustained improvements in attendance are not seen. The policy has also been revised to include greater clarity on short term secondments for those unfit for their substantive roles, ensuring that absence from the individual’s substantive role continues to be managed in line with the policy.

All long term sickness cases (28 days and over) are reviewed monthly, with the latest reviewing having taken place in December 2014. Across the Trust in December, there were 17 long term sickness cases over 6 months which are being managed in line with the revised Sickness Absence Policy.

Active reconsideration of all staff on long term sickness against temporary secondments and alternative duties is now undertaken on an on-going basis with a database to ensure staff are matched to suitable assignments where these exist throughout the Trust. This process ensures that all options are considered to assist rehabilitation of staff back to the workplace.

A piece of work is currently being undertaken to ascertain the

effectiveness of the Sickness Absence Policy, which has identified that the current reporting of target breaches for those being managed in line with the policy is inconsistent across the Trust. Therefore, work is currently on-going with the ROC to determine the feasibility of improving

Complete

Monthly review as well as actions under the Sickness Absence Policy to include a formal Stage 2 review at 4 months and formal Stage 3 review at 6 months for all long term sickness cases.

On-going

On-going


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identification and management of target breaches through the use of GRS. A paper has recently been approved to improve sickness reporting and monitoring through GRS. This is currently being set up and it is anticipated that this will go live in Autumn 2015.

Stress management procedures have been reviewed,

resulting in better signposting for staff and managers to available support services as well as the re-launch of an improved stress risk assessment tool which utilises HSE guidance to assist staff and managers to identify stress triggers and enable the development of action plans to support those who may be experiencing stress. All stress risk assessments are monitored by the Trust’s Equality, Health and Wellbeing Lead.

Occupational Health services are now being provided by

Optima due to Capita withdrawing from the contract. The new service commenced on 1 December 2014, and has been awarded for an initial 12 month period.

A Health and Wellbeing consultation was commenced in

September and has recently concluded. Health and Wellbeing forums are now been established across the Trust to discuss the response to this consultation. This feedback will inform the design and implementation of the Trust’s Health and Wellbeing Strategy.

A review of the Trust’s Employee Assistance Programmes

(EAP) is currently underway to assess the effectiveness of each service with a view to aligning services across the Trust.

A new project has been commissioned seeking to review

current practice in the management of sickness absence. A workshop was held on 09 March 2015 with all HoPs, HR and the Head of Resource Management and feedback is being collated which will inform a detailed action plan to address current sickness absence concerns.

Complete

Monthly KPI monitoring against contract

Health and Wellbeing Forums to take place throughout January, February and March 2015.

April 2015

Ongoing


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Appendix A: ICPR Mapping Matrix: Trust Performance Measures for 2014/15 and the five National Outcome Framework Domains

Three Part

Definition of

Quality

National Outcome

Framework Domain

Heading

Key Contributions sought by

NHS Commissioners

Ambulance National

Quality Measures

Ambulance National Clinical

Quality Indicators (ACQIs)

Local Standards

and Targets

Effectiveness Domain 1: Preventing people from dying prematurely

• Earlier diagnosis;

• Improving early management in community settings;

• Improving acute services and treatment;

• Preventing recurrence after an acute event

Red 1 Performance; Red 2 Performance; A19 Performance.

Time to Treatment for life-threatening calls; Re-contact rates following telephone advice/referral; Re-contact rates following treatment at scene; All ACQI Clinical Indicators.

Resourcing Escalatory Action Plan (REAP) levels; A&E service activity volumes.

Domain 2: Enhancing the quality of life for people with long term conditions

• Improvements in primary care

• Putting patients in charge and giving them ownership of their care

• Coordination and continuity of care

Urgent Care Service National Quality Requirements.

UCS CQUIN schemes as agreed with local NHS Commissioners.

Domain 3: Helping people to recover from periods of ill health or following injury

• Keep people out of hospital when better care can be delivered in other settings

• Ensures effective joined up working between primary and secondary care

• Delivers high quality and efficient care for people in hospital

• Coordinates care and support for people following discharge from hospital

Ambulance calls closed with telephone advice; Ambulance calls closed with telephone advice or managed without transport to an Emergency Department; Stroke patients receiving an appropriate care bundle; ST-Elevation Myocardial Infarction (STEMI) patients receiving an appropriate care bundle.

Right Care, Right Place, Right Time; A&E CQUIN schemes as agreed with local NHS Commissioners; PTS CQUIN schemes as agreed with local NHS Commissioners.

Patient Experience

Domain 4: Ensuring that people have a positive experience of care

• Rapid comparable feedback on the experience of patients and carers

Annual Quality Account;

Time to answer emergency calls; Emergency call abandonment

Patient Experience: Making Experience Count (MECS)


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Three Part

Definition of

Quality

National Outcome

Framework Domain

Heading


NHS Commissioners

Ambulance National

Quality Measures



Local Standards

and Targets

• Building a capacity and capability in both providers and commissioners to act on patient feedback

• Assessing the experience of people who receive care and treatment from a range of providers in a coordinated package

Urgent Care Service: Call abandonment rates; calls answered within 60 seconds of the introductory message; Definitive clinical assessments within time appropriate to their condition.

rates; Patient Experience;

reported, investigated and closed; Patient Advice and Liaison Service (PALS) incidents reported, investigated and closed; Compliments received; Patient satisfaction surveys in A&E, UCS and PTS service lines; A&E CQUIN schemes as agreed with local NHS Commissioners; PTS CQUIN schemes as agreed with local NHS Commissioners.

Patient Safety Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm

• Commissioners will use the National Quality Dashboard to identify any potential safety failures

Annual Quality Account; Compliance with Care Quality Commission Regulations and Quality Risk Profile; NHS Litigation Authority – Level 1.

Patient Experience; Re-contact rates following telephone advice; Re-contact rate following treatment at scene.

No. of incidents and time lost to Handover Delays at acute hospitals; No. of incidents and time lost to delays in Handover to Clear times for ambulance resources;


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Three Part

Definition of

Quality

National Outcome

Framework Domain

Heading


NHS Commissioners

Ambulance National

Quality Measures



Local Standards

and Targets

Central Alerts (CAS); Adverse Incidents (AI) reported, investigated and closed; Security Incidents (SIRS) reported, investigated and closed; Serious Incidents identified, investigated and closed; Never events.

Compliance with Medicines Management Audit Standards; Compliance with Infection Prevention and Control Standards; Vehicle Deep Clean Compliance with Schedule.


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Appendix B: Trust Approach to the Management of Performance Exceptions in 2014/15

Early Warning Performance in the reporting period could be on or above target but there is evidence that performance is deteriorating or moving off trajectory AND/OR a metric has been escalated by a Directorate as part of the Trusts Performance Management arrangements. This indicates to the Trust that there is a perceived risk to performance regardless of whether this is evident in the reporting period The focus of the ICPR is on providing the Board of Directors with information on trends, forecasting and mitigating actions being taken by the Trust.

No Concerns Performance in the reporting period is on or above target and there are currently no predicted risks to the Trusts quarterly or forecast year end performance

The focus of the ICPR is on providing the Board of Directors with ongoing assurance that performance can be maintained.

Real Concerns Performance in the reporting period is significantly off plan and there is currently no action plan in place OR there is insufficient evidence of improvement as a result of actions already agreed and being taken by the Trust in order to improve performance The focus of the ICPR is on agreeing remedial action which may be escalated to Board level. Remedial actions are therefore likely to have Trust wide consequences

Improvement Expected Performance in the reporting period is below target but there is evidence that performance is improving and/or there is confidence in the action(s) being taken by the Trust. The forecast outturn position is therefore expected to be on or above plan if a performance metric is reported in this category.

The focus of the ICPR is on providing the Board of Directors with sufficient detail in order to provide an appropriate level of assurance. This will include detail contained within individual action plans as necessary.


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Appendix C: National Measures Definitions and Glossary

National Ambulance Quality Measures

Performance

Measure

2014/15

Target Definition Aim of the Target

How the Target is

measured

Red 1 75% Quarterly

Calls that are identified as the most time critical response and cover cardiac arrest patients who are not breathing and do not have a pulse and other severe conditions such as airway obstruction

To deliver better outcomes for patients by achieving a faster response for those patients with immediately life-threatening conditions

The percentage of Red 1 calls receiving an emergency response at scene within 8 minutes

Red 2 75% Quarterly

Calls that may be life-threatening but less time critical then Red 1 calls.

To deliver better outcomes for patients by achieving a faster response for those patients with life- threatening conditions

The percentage of Red 2 calls receiving an emergency response at scene within 8 minutes

A19 95% Quarterly

Calls that may be life-threatening (Red 1 and Red 2 calls) receive a response at scene which is able to transport the patient in a clinically safe manner.

To deliver better outcomes for patients with life-threatening conditions by ensuring they receive a response at the scene which is able to transport the patient if required.

The percentage of life-threatening calls receiving an ambulance able to transport the patient within 19 minutes

Monitor Risk Assessment Framework

Published on 27 August 2012 the Risk Assessment Framework (RAF) sets out Monitor’s approach to overseeing the sector under new rules. The RAF explains how Monitor will assess individual NHS Foundation Trusts’ compliance with two specific aspects of their work:

The Governance Risk Rating;

The Continuity of Services Risk Rating.

The RAF replaced the Compliance Framework for NHS Foundation Trusts from 1 October 2013.

Monitor will regularly consider the planned and actual financial performance and will use a Continuity of Services Risk Rating to assess financial risk. The metric focuses on financial elements only and comprise of two financial metrics:

Liquidity – days of operating costs held in cash or cash-equivalent forms, including wholly committed lines of credit available for drawdown;

Capital Service Capacity – the degree to which the organisation’s generated income covers its financial obligations.

Monitor will use the thresholds set out in the diagram below to assign a rating of 1, 2, 3 or 4 to each of the two components once they have been calculated. The Continuity of Services Risk Rating is the average of the two figures, rounded up.


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Monitor will primarily use the Governance Rating, incorporating information across a number of areas, to describe their views of the governance of the Trust. They will generate this rating by considering the following information regarding the Trust and whether it is indicative of a potential breach of the governance condition:

Category Metrics Governance concern triggered by

CQC Information

CQC judgments CQC warning notice issued

Civil and/or criminal action initiated

Access and Outcomes Metrics

For ambulance trusts, Category A response times (Red 1, Red 2 and A19 performance)

Three consecutive quarters’ breaches of a single metric or a service performance score of 4 or greater

Third Party Reports

Ad hoc reports from GMC, the Ombudsman, commissioners, Healthwatch England, auditors reports, Health & Safety Executive, patient groups, complaints, whistle-blowers, medical Royal Colleges etc.

Judgment based on the severity and frequency of the reports.

Financial Risk

Continuity of Services Risk Rating.

Breaching any continuity of service license condition as a result of governance

Inadequate planning processes.

Quality Governance Indicators

Patient Metrics

o Patient satisfaction

Staff metrics

o High executive team turnover

o Satisfaction

o Sickness/absence rate

o Proportion temporary staff

o Staff turnover

Aggressive cost reduction plans

Material reductions in satisfaction, or increase in sickness or turnover rates

Material increases in proportion of temporary staff

Cost reductions in excess of 5% in any given year.

Monitor uses performance against a limited set of national measures of access and outcome objectives as indicators or governance and as a trigger to detect potential governance issues.

For ambulance trusts each will be monitored quarterly and include:

Targets and Indicators Threshold Weighting

Category A call – emergency response within 8 minutes, comprising Red 1 calls Red 2 calls

75% 75%

1.0 1.0

Category A call – ambulance vehicle arrives within 19 minutes 95% 1.0

Certification against compliance with requirements regarding access to health care for people with a learning disability1

N/A 1.0

1 Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All


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Where the Trust breaches a target(s), Monitor will use the sum of each metric’s weighting to calculate a Service performance Score. Where this score is 4.0 or greater, this will represent a governance concern. Where the Trust breaches a target systematically (i.e. a performance breach for three consecutive quarters) this will also represent a governance concern. The Governance Rating could represent one of three broad views:

Monitor will assign a Green rating if no governance concern is evident;

Where Monitor identifies potential material causes for concern with the Trust’s governance in one or more of the categories (requiring further information or formal investigation), Monitor will replace the Trust’s Green rating with a description of the issues and the steeps (formal or informal) Monitor is taking to address;

Monitor will assign a Red rating if they take regulatory action.

In assigning an appropriate governance risk rating, Monitor will be informed by the seriousness of the issue, information they already have concerning the situation, the effectiveness of the Trust’s initial response to the situation and the time-critical nature of the situation:

(DH, 2008)


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Ambulance Clinical Quality Indicators

Ambulance Quality

Indicator

What is the Indicator Measuring & Why

is it Measured? Measure

Local

Performance

Threshold

2014/15

Call Abandonment Rate

The call abandoned rate is a marker of patient experience. A high call abandoned rate is not safe and may reflect a high level of clinical risk for patients

% of calls received that abandoned before being answered. 1.50%

Time to Answer Calls

The time until a call is answered represents a period of clinical risk to the patients prior to assessment from trained ambulance service personnel. Many adverse events are related to initial delays in care and many emergency conditions are time-sensitive therefore the time before a patient begins treatment represents a clinical risk.

Average time (in seconds) to answer 999 calls presented to the Trust switchboard. Measured at the 50

th,

95th and 99

th

percentiles

50th 3 secs

95th 15 secs

99th 60 secs

Time from Call Categorisation to Arrival at Scene

The period before being seen by a health professional represents a period of clinical risk and anxiety for the patient. By encouraging earlier definitive care and reducing delays in treatment this indicator seeks to improve health outcomes and patient experience for all patients with life threatening conditions.

Time for the first emergency response vehicle to arrive at scene for A category Incidents measured to 50

th, 95

th and 99

th

percentiles

To be confirmed

Re-Contact with the Ambulance Service following Telephone Advice

Patients may re-contact the ambulance service because their condition has worsened. However in some cases there may be further contact due to an incorrect initial telephone diagnosis or poor explanation by clinical staff. Unplanned re-contact is a marker of the accuracy of initial telephone assessment in identifying those patients requiring an escalation of care or likely to experience deterioration.

% of unplanned re-contact within 24 hours following initial telephone advice.

11.00%

Re-Contact with the Ambulance Service following Treatment at Scene

Ambulance staff will always use the most appropriate treatment pathways based on their clinical assessment of the patient on scene. However patients may re-contact the ambulance service because their condition has worsened or they have received a poor explanation. Unplanned re-contact is a marker of the accuracy of initial treatment at scene in identifying those patients requiring an escalation of care or likely to experience deterioration.

% of unplanned re-contact within 24 hours following treatment at scene

5.50%

Patients Managed Appropriately (Right Care, Right Place, Right Time) – Calls Closed with Telephone Advice

Providing clinically appropriate pre-hospital care through clinical telephone advice may result in better outcomes for patients and a more efficient use of ambulance resources. This can include advice from Nurses within our Clinical Hubs and advice about other NHS facilities the patient could attend themselves (Minot Injury Units, etc.)

% of calls that are managed through telephone advice without the need for an ambulance resource arriving on scene

6.50%


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Ambulance Quality

Indicator



Local

Performance

Threshold

2014/15

Patients Managed Appropriately (Right Care, Right Place, Right Time) – Calls Closed without the need for Transport to A&E (Emergency Departments)

Providing effective pre-hospital care allows for better care for the patient; such as care being delivered closet to home. A reduction in avoidable emergency patient journeys and admissions to hospitals whilst responding to and conveying those patients who would not be suitable for treatment at the scene or through clinical telephone advice.

% of calls that are managed through without the need for an ambulance resource arriving on scene, or onward transport to major Emergency Department

51.00%

Return of spontaneous circulation following cardiac arrest

The aim of this indicator is to reduce the proportion of patients who die from out of hospital cardiac arrest. It reviews patients who were in cardiac arrest but, following resuscitation, have a pulse on arrival at hospital. Improvement in ROSC rates informs the effectiveness of pre-hospital response and intervention. The ROSC is calculated for two patient groups:

The overall rate measures the overall effectiveness of the pre-hospital response and intervention for all out of hospital cardiac arrest patients;

The rate for the Utstein comparator group applies to a sub-set of all cardiac arrest patients and provides a more comparable measure of management of cardiac arrest for patients where timely and effective clinical care can particularly improve survival.

% of resuscitated cardiac arrest patients that had a Return of Spontaneous Circulation (ROSC) at the point of handover of clinical care of the patient to the hospital

24.00%

Return of spontaneous circulation following cardiac arrest (Utstein)

% of resuscitated cardiac arrest patients that had a Return of Spontaneous Circulation (ROSC) at the point of handover of clinical care of the patient to the hospital – where the arrest was witnessed and the initial rhythm was VF or VT.

45.00%

Outcome from acute STEMI - (PPCI)

Early access to reperfusion and other assessment for care interventions are associated with reductions in mortality and morbidity for inpatients suffering an ST elevation myocardial infarction (STEMI) mortality and morbidity. This is evidenced in both NSF and CHD and National Infarct Angioplasty Project Gateway 9116 (2008) and Mending Hearts and Brains (2006).

% of patients suffering a STEMI receiving Primary Percutaneous Coronary Intervention (PPCI), also known as primary angioplasty, within 150 mins of call.

84.00%

Outcome from Acute STEMI – Care Bundle

% of patients suffering a STEMI who receive an appropriate care bundle.

85.00%

Outcomes from Stroke for Ambulance Patients - FAST

Patients should be arriving at the hyper-acute stroke centre as soon as possible so that they can be rapidly assessed for thrombolysis, with this being delivered following a CT scan in a short but safe time frame. This has been demonstrated to reduce mortality and improve recovery. Eligibility criteria, particularly in relation to the therapeutic time window, will vary between local services, depending on the availability of local expertise e.g. intra-arterial clot lysis. This indicator supports the NICE national

% of patients assessed face to face and provided a FAST (Face, Arms, Speech, Time to Call 999) positive response and were potentially eligible for thrombolysis that arrive at hospitals with a Hyper Acute Stroke Centre within 60 mins of the call.

57.00%


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Ambulance Quality

Indicator



Local

Performance

Threshold

2014/15

Outcome from Stroke for Ambulance Patients – Care Bundle

quality standard that indicates this is an effective measure of the ambulance service’s contribution to the stroke pathway.

% of suspected stroke patients assessed face to face who receive an appropriate care bundle

95.00%

Outcome from Cardiac Arrest – Survival to Discharge

Survival to discharge is where a patient is able to be discharged from hospital and continue recovery after a cardiac arrest. The indicator measures the effectiveness of the whole urgent and emergency care system in managing out of hospital cardiac arrest. Survival to discharge is calculated for two patient groups:

The overall survival rate measures the overall effectiveness of the urgent and emergency care system in managing care for all out of hospital cardiac arrest patients;

The Utstein survival rate applies to a sub-let of all cardiac arrest patients and provides a more comparable measure of management of cardiac arrest for patients where timely and effective clinical care can particularly improve survival.

% of patients who had resuscitation (Advanced or Basic Life Support) commenced/continued by the ambulance service following an out-of-hospital cardiac arrest.

8.00%

Outcome from Cardiac Arrest – Survival to Discharge (Utstein)

% of patients who had resuscitation (Advanced or Basic Life Support) commenced or continued by the ambulance service following an out-of-hospital cardiac arrest of presumed cardiac origin, where the arrest was bystander or emergency medical service witnessed and the initial rhythm was VF or VT.

20.00%


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NHS 111 Service Quality Requirements

Quality

Requirement What is the Indicator Measuring? Measure

National Quality

Requirement

Standard

QR1 National Quality Requirement performance reporting

Providers must report regularly to NHS Commissioners on their compliance with the national Quality Requirements

Trust compliance with reporting requirements against the national Quality Requirements

Compliance

QR2 NHS 111 Consultations to GP surgeries by 08:00 next working day

Providers must send details of all out of hours consultations to the practice where the patient is registered by 08:00 the next working day

Percentage of NHS 111 consultations where details are provided to GPs by 08:00 next working day

Greater than 95%

QR3 Systems for exchange of information on patients with predefined needs

Providers must have systems in place to support and encourage the regular exchange of information between all those who may be providing care to patients with predefined needs (including e.g. patients with terminal illness)

Trust compliance with system requirements and exchange of information

Compliance

QR4 Audit of patient contacts to review clinical performance of individuals working in the service

Providers must regularly audit a random sample of patient contacts. This sample must be defined in such a way that it will provide sufficient data to review the clinical performance of each individual working within the service

Trust compliance with audit requirements for to review clinical performance

Compliance

QR5 Regular Audit of Patient Experience

Providers must regularly audit a random sample of patients’ experiences of the service

Compliance with patient experience audits on a regular basis

Compliance

QR6 Compliance with NHS Complaints procedure principles

Providers must operate a complaints procedure that is consistent with the principles of the NHS complaints procedure

Compliance with NHS complaints procedure principles

Compliance

QR7 Ability to match capacity to demand

Providers must demonstrate their ability to match their capacity to meet predictable fluctuations in demand for their contracted service, especially at periods of peak demand, such as Saturday and Sunday mornings, and the third day of a Bank Holiday weekend. They must also have robust contingency policies for those circumstances in which they may be unable to meet unexpected demand.

Compliance

QR8 call answering performance

Initial Telephone Call into the NHS 111 service should be handled promptly.

Percentage of abandoned telephone calls. Time taken for the call to be answered by a person within 60 seconds of the end of the introductory message.

Less than 5% of calls abandoned.

More than 95% of calls answered

within 60 seconds


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Quality


National Quality

Requirement

Standard

QR9 telephone triage performance

Providers must have a robust system for identifying all immediate life threatening conditions and, once identified, those calls must be passed to the ambulance service within 3 minutes.

Providers that can demonstrate that they have a clinically safe and effective system for prioritising calls must meet the required standards for clinical assessment.

Compliance with system requirements for passing calls to the ambulance service. Where required patient call backs are commenced within 10 minutes

Compliance

Greater than 95%

QR13 provision of interpretation services when required

Patients unable to communicate effectively in English will be provided with an interpretation service within 15 minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or impaired sight.

Compliance with service provision within 15 minutes of initial contact.

Compliance

QR14 compliance with Information Governance Toolkit

Providers must demonstrate the online completion of the annual assessment of the Information Governance Toolkit at level 2 (satisfactory) or above and that this is audited on an annual basis by Internal Auditors using the national framework.

Compliance with IG Toolkit Requirements at level 2.

Compliance

QR15 compliance with Department of Health Information Governance SUI Guidance

Providers must demonstrate that they are complying with the Department of Health Information Governance SUI Guidance on reporting Information Governance incidents appropriately.

Compliance with Department of Health guidance on the reporting of Information Governance incidents appropriately.

Compliance


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Urgent Care Services Quality Requirements

Quality


National Quality

Requirement

Standard

QR1 National Quality Requirement performance reporting

Providers must report regularly to NHS Commissioners on their compliance with the national Quality Requirements

Trust compliance with reporting requirements against the national Quality Requirements

Compliance

QR2 Out of Hours Consultations to GP surgeries by 08:00 next working day

Providers must send details of all out of hours consultations to the practice where the patient is registered by 08:00 the next working day

Percentage of out of hours consultations where details are provided to GPs by 08:00 next working day

Greater than 95%

QR3 Systems for exchange of information on patients with predefined needs

Providers must have systems in place to support and encourage the regular exchange of information between all those who may be providing care to patients with predefined needs (including e.g. patients with terminal illness)

Trust compliance with system requirements and exchange of information

Compliance

QR4 Audit of patient contacts to review clinical performance of individuals working in the service

Providers must regularly audit a random sample of patient contacts. This sample must be defined in such a way that it will provide sufficient data to review the clinical performance of each individual working within the service

Trust compliance with audit requirements for to review clinical performance

Compliance

QR5 Regular Audit of Patient Experience

Providers must regularly audit a random sample of patients’ experiences of the service

Compliance with patient experience audits on a regular basis

Compliance

QR6 Compliance with NHS Complaints procedure principles

Providers must operate a complaints procedure that is consistent with the principles of the NHS complaints procedure

Compliance with NHS complaints procedure principles

Compliance

QR7 Ability to match capacity to demand

Providers must demonstrate their ability to match their capacity to meet predictable fluctuations in demand for their contracted service, especially at periods of peak demand, such as Saturday and Sunday mornings, and the third day of a Bank Holiday weekend. They must also have robust contingency policies for those circumstances in which they may be unable to meet unexpected demand.

Compliance

QR10 face to face triage performance

Face to Face Clinical Assessment: Providers must have a robust system for identifying all immediate life threatening conditions and, once identified, those calls must be passed to the ambulance service within 3 minutes.

Providers that can demonstrate that

Compliance with system requirements for passing calls to the ambulance service. Start definitive clinical

Compliance


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Quality


National Quality

Requirement

Standard

they have a clinically safe and effective system for prioritising calls must meet the required standards for clinical assessment.

At the end of the assessment, the patient must be clear of the outcome, including (where appropriate) the timescale within which further action will be taken and the location of any face-to-face consultation.

assessment for urgent calls within 20 minutes of the patient arriving at the centre Start definitive clinical assessment for all other calls within 60 minutes of the patient arriving at the centre Compliance with assessment requirements.

Greater than 95%

Greater than 95%

Compliance

QR11 patient treatment requirements

Providers must ensure that patients are treated by the clinician best equipped to meet their needs in the most appropriate location. Where it is clinically appropriate, patients must be able to have a face-to-face consultation with a GP, including where necessary, at the patient's place of residence.

Compliance with patient treatment requirements.

Compliance

QR12 face to face consultation within agreed timescales

Face-to-Face Consultations (assessed for both patient home visits and patients visiting a treatment centre) must be started within the appropriate timescales, after the definitive clinical assessment has been completed.

Emergency calls within 1 hour Urgent calls within 2 hours Less Urgent calls within 6 hours

Greater than 95%

Greater than 95%

Greater than 95%

QR13 provision of interpretation services when required

Patients unable to communicate effectively in English will be provided with an interpretation service within 15 minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or impaired sight.

Compliance with service provision within 15 minutes of initial contact.

Compliance

Note: Following the introduction of the NHS 111 service with effect from February 2013, the Out of Hours service are no longer required to report on QR 8 (call answering performance) and QR9 (definitive clinical assessment by telephone) as these areas are now under the remit of the NHS 111 service provider contracts.


Page 63 of 64

Appendix D: Local Measures Definitions and Glossary

A&E Local Key Performance Indicators

Measure 2014/15

Local Target Definition

How the Target is

measured

Green 1 90%

These are calls where presenting conditions are serious but not life threatening, and there is a less serious clinical need. These calls should receive an emergency response within 20 minutes.

Monthly performance vs KPI monitoring

Green 2 90%

These are calls where presenting conditions are serious but not life threatening, and there is a less serious clinical need. These calls should receive an emergency response within 30 minutes


Green 3 90%

These are calls which are assessed as lower acuity calls requiring a response at normal road speeds within 60 minutes or a phone assessment within 30 minutes (a clinician calling back for a secondary telephone triage to establish the most appropriate care pathway for the patient).


Green 4 North Division

90%

These are calls where presenting conditions are not serious and therefore not life threatening and do not require an emergency response. These calls should receive a clinical response within 90 minutes or a clinician call back within 60 minutes.


Green 4 (999) East/West

Division 90%

These are calls where presenting conditions are not serious and therefore not life threatening and do not require an emergency response. These calls should receive a clinical response within 60 minutes


Green 4 (HPC) East/West

Division 70%

The Green 4 category includes all responses made by the Trust to requests from Healthcare Professionals to undertake urgent transfers of patients within a 1, 2 or 4 hour time window


Non Conveyance Rate

n/a Incidents that are completed without the need to convey a patient to an Emergency Department at an acute hospital.

Monthly performance vs local trajectory and KPI

targets


Page 64 of 64

Appendix E: Board Assurance

Board Assurance

Framework (BAF)

Integrated

Performance

Report

Annual Cycles and

Records

Committee

Assurance

Medicines

ManagementEnd of Life

Research

and AuditSepsis CQUIN

Clinical audit plan CE CE All

PS PE PS

CQC registration

compliance

PS PS All

CE PE All

CE PS All

Safeguarding PS PE

PS

PECritical Assurance

RolesCritical assurance roles appointed to include: Caldicott Guardian, Senior Information Risk Owner, Accountable

Officer for Controlled Drugs, and Board Champions

Where and how the Board has received assurance at key forums against key performance indicators and objectives

plus documenting external assurance and an assurance evaluation tool

NHSLA compliance

Codes of conduct

Risk RegistersCorporate Risk Register reviewed at each Board meeting; all risk registers, including directorate, reviewed annually

(cross referenced on BAF)

Code of governance

Quality

Governance

Reviews

Quality reviews of Trust arrangements against negative assurance about other trusts: eg Mid Staffs. Action plans

developed and monitored

Board DevelopmentBoard development and training register is maintained for all Board members. Regular annual training includes: risk

management; health and safety; and information governance

Clinical and governance policy and strategy

Governance checklist initiative designed to provide a quick assessment of the governance requirements for any new

function or initiative

Quality Board Assurance

Governance Reporting

Each Board commitee is chaired by a Non Executive Director (NED); an action point register and minutes from each

committee are reviewed by the Board of Directors at each meeting

Governance

Checklists

The new Integrated Corporate Performance Report, from February 2013, provides the Board with assurance

against a set of contractual and statutory metrics on a monthly basis. The report focuses on peformance exceptions

and provides the Board with an early warning of metrics that are of concern across the Trust.

Regulatory

Framework

The Regulatory Framework contains details of all statutory and regulatory targets with details of which forum they

should be presented to.

Board, and each of its committees, has an annual cycle of business, reviewed and revised at the start of each

year;and a record of all business conducted detailing review, approval or referral of key documents

The following working groups provide assurance to the Quality and Governance Committee:

Health and Safety

Accident statistics, risk assessments, health,

safety and security indicators

Aggregated review of serious and other incidents,

safeguarding, MECs, claims; and identification of trends

and lessons learned; as well as review of compliance

with key targets such as CQC outcomes

Clinical

Effectiveness

The Board of Directors uses a variety of mechanisms to seek assurance that the Trust is meeting its corporate objectives;

identifies and manages any risks; and remains compliant with its statutory and regulatory targets

Assurance Mechanisms

Quality and Governance

Committee

Develop and implement effective

quality and governance assurance

systems and processes

Audit Committee

Review and seek assurance on the effectiveness of

processes in place for the management of

arrangements for Governance, Risk Management,

Clinical Assurance, Internal Control, and Financial

Reporting; and to ensure the Trust and its auditor

remain compliant with Monitor's Audit Code for NHS

Foundation Trusts (terms of authorisation)

Finance and Investment

Committee

Review financial planning,

cost improvements,

investments and financial

performance

Information governance

Learning from

Experience

Patient experience

Infection

Prevention and

Control

Resuscitation

PS

Clinical guidelines

HR key indicators

Infection prevention and

control

Infection Prevention and Control policies, procedures and guidelines; clinical efficiency and best practice. The work of the

Group is supported by a set of sub groups:

Air

Ambulance

Clinical

Vehicle

Equipment &

Uniform Working

Corporate and Directors' risk registers

Identification of risk

The Quality Strategy and Quality Account are each structured around five priorities: patient safety (PS); patient experience

(PE); clinical effectiveness (CE); access; and value for money

Ambulance Clinical Quality indicators Assurance framework

Quality account

Identification of legislation

Health and safety KPIsMedicines management plan

The following quality reports and action plans are received at each Quality and Governance committee meeting and used as mechanisms of

quality assurance. Highlighted boxes show which quality priority they meet:

Appendix Fi - Clinical Dashboard 2014/15 Month: Feb-15 Year: 2014/15

National

TargetTrend YTD Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Q1 Q2 Q3 Q4

Red 1 Category A - Red 1 Performance 75.00% 74.45% 76.18% 75.31% 75.02% 73.74% 75.20% 77.56% 75.13% 74.67% 69.63% 73.39% 74.80% 75.50% 75.44% 72.91%

Red 1Category A - Red 1 Time to Treatment - 95th percentile of time from call connect to an emergency response

arriving at the scene of the incidentn/a 14:42 14:48 14:32 14:20 14:15 14:00 14:00 14:52 15:24 16:00 15:12 14:24

Red 2 Category A - Red 2 Performance 75.00% 72.05% 76.78% 75.47% 75.65% 74.05% 76.53% 76.86% 73.56% 70.79% 63.33% 67.95% 61.59% 75.95% 75.78% 69.00%

A19 A19 Performance 95.00% 93.68% 95.40% 95.25% 95.00% 94.57% 95.31% 95.25% 93.87% 93.34% 89.71% 92.50% 90.52% 95.21% 95.04% 92.20%

Performance

Threshold

2014/15

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

CO1.1 Call Abandonment Rate (% of calls abandoned before answering) 1.50% 0.89% 0.59% 0.98% 0.64% 1.15% 0.70% 0.88% 0.62% 0.84% 1.27% 0.64% 1.42%

CO1.2Re-Contact Rate Following Discharge of Care (unplanned re-contact with the ambulance service

within 24 hours of discharge of care by clinical telephone advice)11.00% 13.61% 13.32% 14.02% 13.59% 13.70% 13.56% 13.98% 13.20% 13.84% 14.00% 12.98% 13.55%

CO1.2Re-Contact Rate Following Discharge of Care (unplanned re-contact with the ambulance service

within 24 hours of discharge of care following treatment at scene)5.50% 5.98% 5.49% 5.82% 5.85% 5.69% 5.96% 5.86% 5.85% 5.88% 6.49% 6.32% 6.53%

CO1.8Time to Answer Emergency Calls - Median time spent between call connect and call answer

(seconds)3 2 2 2 2 2 2 2 2 2 2 2 2

CO1.8Time to Answer Emergency Calls - 95th percentile of times from call connect and call answer

(seconds)15 19 16 20 16 23 17 22 16 15 23 15 26

CO1.8Time to Answer Emergency Calls - 99th percentile of times from call connect and call answer

(seconds)60 58 47 56 52 66 54 65 54 55 69 51 66

CO1.9Time to Treatment (time to arrival of ambulance dispatched health professional for immediate life

threatening (cat A) calls - Median time spent to arrival of a qualified health professional (mins)n/a 6.1 5.7 5.8 5.6 5.8 5.6 5.5 6.0 6.2 6.9 6.5 7.2

CO1.9Time to Treatment (time to arrival of ambulance dispatched health professional for cat A calls - 95th

percentile of times to arrival of a qualified health professional (mins)n/a 21.6 18.9 19.2 19.5 19.9 19.0 18.6 20.0 21.2 24.1 22.4 23.9

CO1.9Time to Treatment (time to arrival of ambulance dispatched health professional for cat A calls - 99th

percentile of times to arrival of a qualified health professional (mins)n/a 33.8 30.4 32.0 32.4 33.2 32.1 30.8 31.1 34.9 38.4 37.3 39.6

CO1.10Ambulance calls closed with telephone advice or managed without transport to A&E departments

(where clinically appropriate) - calls closed with telephone advice6.50% 7.95% 6.62% 6.34% 7.03% 6.61% 6.54% 6.78% 7.61% 8.04% 10.72% 9.85% 11.35%

CO1.10Ambulance calls closed with telephone advice or managed without transport to A&E departments

(where clinically appropriate) - incidents managed without the need for transport to A&E51.00% 52.35% 50.64% 51.47% 52.42% 52.13% 52.44% 51.92% 52.33% 52.53% 54.06% 53.23% 52.35%

CO1.11 Number of Emergency Patient Journeys n/a - 398,036 35,501 37,205 36,137 37,941 36,472 35,377 36,293 35,505 38,043 36,495 33,067

Performance

Threshold

2014/15

TrendRolling 12

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

CO1.3Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital

(overall)24.00% 24.76% 25.78% 22.63% 26.70% 25.41% 26.07% 18.65% 25.69% 25.00% 24.71% 28.62% 26.91% 21.31%

CO1.3Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital

(Utstein Comparator Group)45.00% 44.59% 39.58% 32.08% 45.10% 59.09% 52.54% 33.33% 52.83% 42.22% 48.15% 38.00% 54.90% 35.56%

CO1.5

Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - % of patients suffering a STEMI

and who, following a direct transfer to a PPCI centre, primary angioplasty commences within 150

minutes of call

84.00% 79.75% 86.61% 78.68% 78.71% 78.91% 78.62% 78.45% 79.13% 88.07% 80.00% 77.93% 76.64% 77.50%

CO1.5Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - % of patients suffering a STEMI

and who receive an appropriate care bundle85.00% 89.57% 93.96% 88.24% 89.09% 89.41% 89.74% 89.02% 93.89% 85.14% 89.94% 85.96% 90.53% 89.70%

CO1.6

Outcome from Stroke for Ambulance Patients - % of Face Arm Speech Test (FAST) positive stroke

patients (assessed face to face) potentially eligible for stroke thrombolysis, who arrive at a

hyperacute stroke centre within 60 minutes of call

57.00% 57.17% 55.14% 55.59% 59.52% 57.25% 55.93% 55.63% 59.66% 57.81% 63.11% 58.12% 55.31% 53.23%

CO1.6Outcome from Stroke for Ambulance Patients - % of suspected stroke patients (assessed face to

face) who receive an appropriate care bundle95.00% 97.59% 98.13% 96.74% 98.02% 96.93% 98.14% 97.30% 98.65% 96.56% 97.96% 97.33% 98.10% 97.10%

CO1.7 Outcome from Cardiac Arrest - Survival to Discharge - overall survival rate 8.00% 10.15% 10.59% 9.48% 8.31% 14.24% 12.15% 7.44% 12.15% 10.18% 10.59% 8.58% 10.74% 7.59%

CO1.7 Outcome from Cardiac Arrest - Survival to Discharge - Utstein Comparator Group survival rate 20.00% 27.90% 22.92% 20.75% 27.45% 43.18% 36.84% 22.92% 33.96% 25.00% 30.77% 20.00% 36.00% 13.33%

Improving Trend

No Change

Reducing Trend

Performance for the Clinical Indiciators is monitored against a rolling 12 month performance for the Trust

Ambulance Performance Targets

Ambulance Clinical Quality Indicators - Clinical Indicators

Ambulance Clinical Quality Indicators - System Indicators

Performance Thresholds detailed above have been agreed locally with Commissioners and performance against these thresholds will be monitored within this report throughout 2014/15.

Appendix Fii - A&E Local Performance Targets Month: Feb-15 Year: 2014/15

KPI Trend YTD Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Q1 Q2 Q3 Q4

Green 1Percentage of calls that are serious, but not life threatening, receiving an emergency response within 20

minutes90.00% 80.70% 85.26% 82.58% 81.70% 81.99% 83.90% 82.24% 79.71% 81.62% 75.13% 78.86% 74.35% 83.18% 82.72% 78.73%

Green 2Percentage of calls where presenting conditions are serious, but there is a less clinical need, receiving

and emergency response within 30 minutes90.00% 83.94% 90.12% 88.25% 87.87% 86.21% 87.46% 87.54% 85.78% 82.66% 73.43% 80.30% 75.28% 88.72% 87.05% 80.37%

Green 3Percentage of lower acuity calls which receiving a response within 60 minutes or a telephone assessment

within 30 minutes90.00% 95.99% 97.71% 97.18% 97.87% 97.37% 97.19% 96.78% 96.14% 95.56% 92.42% 94.82% 93.36% 97.57% 97.12% 94.64%

Green 4Low acuity calls receiving a response within 90 minutes or a clinician call back within 60 minutes (North

Division Only)90.00% 82.54% 86.40% 81.82% 85.74% 84.88% 88.45% 84.45% 81.63% 81.34% 78.80% 81.98% 77.43% 84.05% 85.88% 80.61%

Green 4 (999)Low acuity calls received from the public receiving a response at normal road speed within 1 hour

(East/West Division Only)90.00% 80.96% 86.13% 85.37% 85.27% 81.72% 83.49% 84.84% 81.60% 76.64% 71.50% 75.21% 73.05% 85.77% 83.28% 76.28%

Green 4 (HPC)Low acuity calls received from Healthcare Professionals that receive a response at normal road speeds

within a agreed time window (1, 2 or 4 hours in length depending on acuity) (East/West Division Only)70.00% 67.88% 70.46% 68.21% 70.55% 63.34% 67.08% 70.37% 66.38% 66.71% 66.47% 69.98% 63.44% 69.30% 66.83% 66.16%


Activity Percentage of Incidents through Hear & Treat Pathway - 8.71% 7.29% 7.77% 7.97% 8.31% 7.88% 7.80% 8.53% 9.11% 11.81% 10.12% 12.21% 7.68% 8.00% 9.90%

Activity Percentage of Incidents through See & Treat Pathway - 38.36% 37.86% 37.87% 38.78% 38.21% 39.31% 38.28% 38.66% 38.51% 38.23% 37.85% 36.33% 38.17% 38.60% 38.45%

Activity Percentage of Incidents through See & Convey to Non Emergency Department Locations - 8.11% 8.33% 8.28% 8.31% 8.27% 7.60% 8.28% 7.79% 8.12% 7.97% 8.20% 8.30% 8.41% 8.05% 7.96%

Activity Percentage of Incidents through See & Convey to Emergency Departments - 44.82% 46.52% 46.08% 44.94% 45.22% 45.20% 45.64% 45.02% 44.27% 41.99% 43.83% 43.16% 45.74% 45.35% 43.69%

Non

ConveyancePercentage of Incidents Closed without Conveyance to Emergency Departments 54.30% 55.18% 53.48% 53.92% 55.06% 54.78% 54.80% 54.36% 54.98% 55.74% 58.01% 56.17% 56.84% 54.26% 54.65% 56.31%


Handover

DelaysTime lost to Chargeable Handover Delays in excess of 15 minutes (hrs) 0 16,150 1,220 1,423 1,355 1,420 1,507 1,451 1,449 1,273 1,834 1,579 1,639 3,997 4,378 4,556 3,218

Handover

DelaysNumber of Chargeable Handover Delays between 30 minutes and 60 minutes 0 13,252 915 1,096 1,070 1,262 1,264 1,180 1,300 944 1,512 1,293 1,416 3,081 3,706 3,756 2,709

Handover

DelaysNumber of Chargeable Handover Delays in excess of 60 minutes 0 3,226 224 295 279 247 307 279 240 243 421 324 367 798 833 904 691


A&E Contract A&E Actual Incidents vs Contracted Incidents 100.00% 103.29% 101.92% 103.42% 103.99% 104.24% 102.30% 100.79% 101.00% 105.00% 105.28% 103.88% 104.19% 103.11% 102.47% 103.78%

Contract Activity

Ambulance Performance Targets

Right Care, Right Place, Right Time 2

A&E Service Line Key Performance Indicators

Appendix Fiii - PTS KPIs and Local Performance Targets Month: Feb-15 Year: 2014/15

KPI Trend YTD Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

1aPatients living up to 10 miles away from the treatment centre (Band A) should not spend more than

60 minutes on the vehicle on either an outward or return journey90.00% 91.82% 93.41% 92.57% 92.50% 91.81% 90.57% 90.58% 91.00% 90.70% 92.43% 91.39% 93.16%

1bPatients living over 10 miles and up to 35 miles away from the treatment centre (Band B) should not

spend more than 90 minutes on the vehicle on either an outward or return journey90.00% 92.77% 94.12% 92.47% 93.96% 92.07% 90.14% 92.83% 91.70% 89.20% 93.32% 93.72% 96.40%

1cPatients living over 35 miles away from the treatment centre (Band C) should not spend more than

120 minutes on the vehicle on either an outward or return journey90.00% 97.50% 94.74% 94.44% 100.00% 94.44% 100.00% 94.74% 94.12% 100.00% 100.00% 100.00% 100.00%

2a Patients should not arrive more than 45 minutes before their booked arrival time 90.00% 87.37% 80.06% 82.56% 84.36% 85.88% 88.50% 90.64% 90.26% 90.26% 90.54% 88.44% 89.39%

2b Patients should not arrive after their booked arrival time 97.00% 89.64% 88.93% 88.11% 88.22% 89.78% 89.05% 89.55% 90.08% 90.07% 91.03% 90.65% 90.42%

3aSWASFT is to arrive to collect patients from the agreed location within 45 minutes of the outward

journey time90.00% 87.61% 84.84% 86.08% 84.75% 87.38% 86.17% 88.83% 89.68% 89.82% 88.48% 88.20% 88.68%

3aSWAS is to arrive to collect patients from the agreed location within 75 minutes of the outward

journey time90.00% 94.91% 92.85% 93.90% 94.38% 95.41% 94.30% 95.82% 95.96% 96.22% 94.88% 95.10% 94.78%

8cPick up time to be confirmed by text, email or phone call to the patient within a week of the

appointment (phone call being the preferred method (assessed quarterly)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

9aPatient satisfaction with the level of service received from the provider - assessed through the

annual patient satisfaction survey85.00% 97.80% 97.80% 97.80% 97.80% 97.80% 97.80% 97.80% 97.80% 97.80% 97.80% 97.80% 97.80%

9b NHS Commissioners to be satisfied with the level of service 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

9f Call answering performance 95.00% 94.97% 92.43% 95.02% 95.17% 96.67% 95.79% 94.14% 94.51% 95.77% 95.10% 95.11%Not yet

available

10aAgreed activity performance report received in correct format and on time within 10 working days of

the start of the following month100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

10bActivity and finance queries are acknowledged within 3 days of receipt and resolved within 28 days

from the date of the query100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

12h

Nil Serious Untoward Incidents (SUIs) - Any SUIs to be reported and action plans put in place - in

line with NHS Bristol standard and timeframes (reported immediately, investigated within 24 hours

and lessons learnt shared, then closed within 60 working days of the incident)

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

12dCompliance with the agreed SWASFT complaints procedure - full response made in a timely

manner agreed with the complainant (assessed quarterly)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

3b

A summary of reasons and actions to be provided, for each month, for all cases where collection

was outside of the KPI limits (i.e. later than agreed timeframes). This may include case by case

analysis as deemed necessary

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Patient Transport Services - Bristol, North Somerset and South Gloucestershire - 2014/15

Contract KPIs

Due to the timing of the report for February 2015 the information relating to Call Answering Performance is not yet available. This information will be updated and included in the March 2015 report.

Appendix Fiv - Urgent Care Services Quality Requirements Month: Feb-15 Year: 2014/15

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

QR1 Providers must report regularly to NHS Commissioners on their compliance with the Quality Requirements Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant

QR2Providers must send details of all consultations (including appropriate clinical information) to the practice where

the patient is registered by 8.00 a.m. the next working day. 95.00% 88.49% 74.38% 74.73% 75.40% 87.86% 98.14% 98.52% 98.60% 97.11% 92.33% 91.02% 90.60%

QR3Providers must have systems in place to support and encourage the regular exchange of information between

all those who may be providing care to patients with predefined needsCompliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant

QR4Providers must regularly audit a random sample of patient contacts (audit should provide sufficient data to

review the clinical performance of each individual working within the service)Compliance 0.81% 0.72% 0.57% 0.61% 1.01% 0.76% 1.02% 0.69% 0.70% 0.46% 0.76% 0.92%

QR5 Providers must regularly audit a random sample of patients' experiences of the service 1.00% 0.30% 0.53% 0.92% 0.24% 0.22% 0.22% 0.24% 0.35% 0.20% 0.10% 0.26%Not Yet

Available

QR6Providers must operate a complaints procedure that is consistent with the principles of the NHS complaints

procedureCompliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant

QR7Providers must demonstrate their ability to match their capacity to meet predictable fluctuations in demand for

their contracted serviceCompliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant

QR8a No more than 5% of calls abandoned before being answered 5.00% 3.75% 1.47% 2.94% 1.02% 0.88% 1.05% 0.64% 1.05% 1.53% 13.96% 6.38% 6.15%

QR8b Calls to be answered within 60 seconds of the end of the introductory message 95.00% 84.98% 88.66% 80.98% 90.55% 91.93% 91.35% 95.79% 95.28% 85.90% 68.30% 76.35% 74.45%

QR9a All immediately life threatening conditions to be passed to the ambulance service within 3 minutes 100.00% 93.79% 100.00% 100.00% 100.00% 95.45% 100.00% 94.44% 100.00% 88.89% 93.33% 73.33% 93.75%

QR9b Patient callbacks must be achieved within 10 minutes 100.00% 25.48% 36.99% 34.31% 30.52% 26.76% 25.96% 29.15% 27.47% 17.17% 21.39% 21.31% 15.71%

QR13Patients unable to communicate effectively in English will be provided with an interpretation service within 15

minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or

impaired sight

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

QR14Providers must demonstrate the online completion of the annual assessment of the Information Governance

Toolkit at level 2 or above and that this is audited on an annual basis by Internal Auditors using the national

framework

Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant

QR15Providers must demonstrate that they are complying with the Department of Health Information Governance

SUI Guidance on reporting of Information Governance incidents appropriately.Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant










Available











impaired sight

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%



framework




Due to the timing of the February 2015 report the information relating to the audit of patient experinces (QR5) is not available, however this information will be updated and included in the March 2015 report.

Urgent Care Services - NHS 111 Dorset


Urgent Care Services - NHS 111 Devon










Available











impaired sight

100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%



framework













Available











impaired sight

100.00% 100.00% Compliant Compliant Compliant Compliant Compliant Compliant 100.00% 100.00% 100.00% 100.00% 100.00%



framework




Urgent Care Services - NHS 111 Somerset



Urgent Care Services - NHS 111 Cornwall



QR2Percentage of Out of Hours consultation details sent to the practice where the patient is registered by 08:00 the

next working day95.00% 99.51% 99.22% 99.77% 99.68% 99.71% 99.70% 99.67% 99.65% 98.30% 99.67% 99.50% 99.75%




review the clinical performance of each individual working within the service)Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant

QR5 Providers must regularly audit a random sample of patients' experiences of the service Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant





QR10aAll immediately life threatening conditions (walk in patients) to be passed to the ambulance service within 3

minutes of face to face presentation95.00% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

QR10bDefinitive Clinical Assessment for Urgent cases presenting at treatment location to start within 20 minutes - not

applicable to this service as a separate clinical assessment is not carried out between presentation and clinical

consultation at walk-in-centres

95.00% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

QR10bDefinitive Clinical Assessment for Less Urgent cases presenting at treatment location to start within 60 minutes -

not applicable to this service as a separate clinical assessment is not carried out between presentation and

clinical consultation at walk-in-centres


QR10d At the end of an assessment, the patient must be clear of the outcome Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant

QR11Providers must ensure that patients are treated by the clinician best equipped to meet their needs in the most

appropriate locationCompliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant

QR12 Emergency Consultations (presenting at base) started within 1 hour 95.00% 50.00%100%

(1 case)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

0%

(1 case)

n/a

(0 cases)

n/a

(0 cases)

QR12 Urgent Consultations (presenting at base) started within 2 hours 95.00% 92.63% 91.71% 93.65% 93.80% 89.84% 88.15% 91.94% 95.38% 92.65% 93.86% 95.74% 91.92%

QR12 Less Urgent Consultations (presenting at base) started within 6 hours 95.00% 96.72% 95.90% 97.23% 97.83% 96.63% 97.11% 96.94% 97.34% 98.09% 93.08% 97.31% 97.24%

QR12 Emergency Consultations (home visits) started within 1 hour 95.00% 66.67%50.00%

(2 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

100%

(1 case)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

QR12 Urgent Consultations (home visits) started within 2 hours 95.00% 91.67% 93.08% 91.54% 93.58% 91.30% 89.54% 92.46% 93.02% 93.81% 89.05% 89.32% 92.24%

QR12 Less Urgent Consultations (home visits) started within 6 hours 95.00% 95.20% 95.43% 96.79% 97.58% 93.11% 96.32% 98.60% 97.71% 95.46% 90.47% 91.51% 95.29%



impaired sight


Urgent Care Services - Dorset Out of Hours

Following the introduction of the NHS 111 Service in the counties of Dorset and Somerset on 19 February 2013 all calls for urgent services (including out of hours services) in these areas are now processed through NHS 111 telephony systems.

Any appropriate incidents are then transferred to the Urgent Care Services in Dorset and Somerset for action. As a result QR8 and QR9 are no longer applicable to the Urgent Care Services in Dorset and Somerset with effect from March 2013.




next working day95.00% 99.75% 99.42% 99.91% 99.92% 99.93% 99.89% 99.89% 99.89% 98.85% 99.84% 99.73% 99.97%























QR12 Emergency Consultations (presenting at base) started within 1 hour 95.00%n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)



QR12 Emergency Consultations (home visits) started within 1 hour 95.00% 100.00%n/a

(0 cases)100.00%

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)





impaired sight


Following the introduction of the NHS 111 Service in the counties of Dorset and Somerset on 19 February 2013 all calls for urgent services (including out of hours services) in these areas are now processed through NHS 111 telephony systems.


Urgent Care Services - Somerset Out of Hours




next working day95.00% Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant























QR12 Emergency Consultations (presenting at base) started within 1 hour 95.00% 100.00%n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

100%

(1 case)

n/a

(0 cases)

100%

(1 case)

n/a

(0 cases)

n/a

(0 cases)



QR12 Emergency Consultations (home visits) started within 1 hour 95.00% 100.00%100%

(2 cases)

n/a

(0 cases)

100%

(3 cases)

100%

(1 cases)

n/a

(0 cases)

100%

(1 cases)

100%

(2 cases)

100%

(3 cases)

100%

(3 cases)

100%

(2 cases)

100%

(3 cases)





impaired sight



Percentages of Cases completed within 4 Hours 95.00% 99.38% 98.68% 99.50% 99.36% 99.12% 99.62% 99.49% 99.64% 99.62%

Urgent Care Services - Tiverton Minor Injuries Unit

Conract commenced on 8 July 2014, therefore performance reports are only available from July 2014 onwards.


Urgent Care Services - Gloucester Out of Hours

Following the introduction of the NHS 111 Service in the counties of Gloucestershire on 19 February 2013 all calls for urgent services (including out of hours services) in these areas are now processed through NHS 111 telephony systems.

Appendix Fv - A&E Local Performance Targets Month: Feb-15 Year: 2014/15

National

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

Sickness Staff Sickness Level 4.00% 6.22% 5.78% 5.92% 6.05% 6.16% 5.98% 6.16% 6.21% 6.26% 7.24% 7.02% 5.74%

Appraisals Staff Appraisals Completed within 12 month period 85.00% 61.33% 48.68% 44.76% 73.83% 89.20% 86.38% 84.43% 82.15% 78.46% 74.86% 67.49% 61.33%

Medicines

ManagementCompliance with Medicines Management Audit Standards 95.00%

Not Yet

Available

Not Yet

Available

Not Yet

Available

Not Yet

Available

Not Yet

Available

Not Yet

Available

Not Yet

Available

Not Yet

Available

Not Yet

Available

Not Yet

Available

Not Yet

Available

Not Yet

Available

Infection

ControlCompliance with Infection Prevention and Control Standards at Ambulance Stations 75.00% 73.00% 75.00% 75.00% 74.00% 74.00% 76.00% 74.00% 75.00% 68.00% 73.00% 70.00% 73.00%

Infection

ControlCompliance with Infection Prevention and Control Standards for Double Crew Ambulances 75.00% 83.00% 82.00% 82.00% 80.00% 81.00% 82.00% 81.00% 84.00% 80.00% 83.00% 83.00% 82.00%

Vehicle Deep

CleanVehicle deep cleaning compliance with schedule 90.00% 90.27% 95.20% 95.70% 96.82% 95.50% 94.10% 94.95% 96.90% 96.70% 93.13% 92.50% 90.27%

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

Patient Safety Adverse Incidents reported relating to medication administration, prescription and supply errors 568 54 59 65 46 52 36 44 63 58 41 50

Patient Safety Central Alert System (CAS) received 147 9 8 17 19 13 9 16 11 21 15 9

Patient Safety Central Alert System warnings (outside deadline) 7 2 2 0 2 0 0 0 0 1 0 0

Safety

MeasuresNumber of Moderate Incidents Reported 9 5 0 14 1 6 3 3 7 1 1

Safety

MeasuresNumber of Moderate Incidents Currently Under Investigation 9 5 0 13 15 8 9 11 10 8 7

Safety

MeasuresNumber of Adverse Incidents Reported 8,139 802 798 767 811 659 649 773 692 812 703 673

Safety

MeasuresNumber of Adverse Incidents Closed 7,670 570 1,057 754 742 469 561 913 648 533 889 534

Safety

MeasuresNumber of Adverse Incidents Currently Under Investigation 1,893 1,655 1,757 1,762 2,030 1,904 1,735 1,750 2,013 2,061 1,957

Safety

MeasuresNumber of Security Incident Reported (SIRS) 60 82 69 71 67 82 72 80 61 49 55

Safety

MeasuresNumber of Security Incidents Closed 48 90 61 83 61 59 86 93 74 70 60

Safety

MeasuresNumber of Security Incidents Currently Under Investigation 112 98 113 109 113 138 123 114 98 79 70

Safety

MeasuresSerious Incidents Identified in Month 53 3 6 8 7 6 4 4 7 4 4 0

Safety

MeasuresSerious Incidents Investigated and Presented to Panel 62 6 5 10 5 9 3 8 3 5 6 2

Safety

MeasuresSerious Incidents Currently Under Investigation 10 12 5 14 11 12 8 12 11 12 10

Safety

MeasuresNever Events' Identified in Month (included in Serious Incidents figure above) 0 0 0 0 0 0 0 0 0 0 0 0

Patient

ExperienceNumber of MECS Reported 1,169 94 103 95 103 85 101 122 106 130 120 110

Patient

ExperienceNumber of MECS Closed (resolved with the Complainant and all investigations completed) 975 61 79 86 97 79 76 113 94 71 125 94

Patient

ExperienceNumber of MECS Resolved (with the Complainant but internal investigation ongoing) 3 7 8 9 8 4 10 7 8 13 12

Patient

ExperienceNumber of MECS Open (not resolved with the complainant and currently under investigation) 87 82 76 81 75 100 107 113 129 124 130

Patient

ExperienceTotal PALS Reported 748 55 65 66 78 51 72 70 69 76 71 75

Patient

ExperienceTotal PALS Closed 706 52 59 68 75 52 63 61 74 75 70 57

Patient

ExperienceTotal PALS Currently ongoing 15 19 14 9 11 11 21 14 21 37 32

Patient

ExperienceCompliments Received 1,851 144 158 155 176 168 194 176 155 168 186 171

Local Indicators

Following a revision to the process for collecting data in respect of Medicines Management Audit Standards the Trust is currently updating its reporting tools and as a result this information is not currently available. The new process will collect data online for the Trust.

Patient Experience

South Western Ambulance Service NHS Foundation Trust - Financial Summary Dashboard Appendix G

Better Payment Practice Code KPI YTD Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Better Payment Practice Code NHS (Value) % 95% 96.59% 99.06% 98.79% 88.57% 93.72% 96.94% 99.24% 91.34% 93.29% 100.00% 99.80% 99.29% 97.90% 98.15% 95.06% >95% <95%

Better Payment Practice Code NHS (Volume)

%95% 96.81% 97.00% 98.00% 98.00% 98.00% 93.00% 96.00% 98.00% 94.00% 98.00% 97.00% 95.00% 98.17% 96.46% 96.75% >95% <95%

Better Payment Practice Code Non NHS

(Value) %95% 95.15% 96.67% 94.39% 93.40% 91.19% 82.77% 97.59% 99.34% 95.56% 97.09% 97.35% 95.37% 94.87% 90.64% 97.46% >95% <95%

Better Payment Practice Code Non NHS

(Volume) %95% 96.41% 96.41% 97.04% 98.14% 96.50% 97.83% 97.65% 96.79% 94.54% 96.13% 94.12% 95.06% 97.19% 97.26% 95.90% >95% <95%

Other Key Financial Metrics KPI YTD Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Debtors >90 Days Past Due as a % of Total

Debtor Balances5.00% 2.77% 9.05% 14.49% 15.62% 5.53% 10.45% 8.62% 5.45% 11.07% 1.76% 2.66% 2.77% 15.62% 8.62% 1.76% <5% >5%

Creditors >90 Days Past Due as a % of Total

Creditor Balances5.00% 0.68% 0.65% 0.08% 0.71% 8.31% 1.86% 1.44% 0.11% 0.61% 1.00% 0.49% 0.68% 0.71% 1.44% 1.00% <5% >5%

Capital Expenditure as a % of Plan (Min) 85.00% 84.96% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 125.36% 90.30% 72.33% 72.50% 84.94% 100.00% 100.00% 86.87% >85% <85%

Capital Expenditure as a % of Plan (Max) 115.00% 84.96% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 125.36% 90.30% 72.33% 72.50% 84.94% 100.00% 19.75% 86.87% <115% >115%

Continunity of Services Risk Rating KPI YTD Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Debt Service Cover 5.89 7.37 6.81 6.77 6.46 6.49 5.26 5.40 5.41 5.48 5.69 5.89 6.77 5.26 5.48 >2.501.25 to

2.50<1.25

Debt Service Metric Score 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00

Liquidity 13.21 14.82 16.03 16.95 18.55 20.83 21.36 20.84 21.70 18.46 15.72 13.21 16.95 21.36 18.46 >0.00 -7.00 to

14.00<-14.00

Liquidity Metric Score 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00

Continuity of Services Risk Rating 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00 4.00

Comments:

The Trust has revised the Capital Expenditure plan for 2014/15 and an updated scheduled has been submitted to Monitor. Performance against the updated schedule is included within the above table.

South Western Ambulance Service NHS Foundation Trust Appendix Gi

2013/14

Outturn

Statement of Comprehensive Income Actual Budget Variance Actual Budget Variance Actual

Period Ending 28/02/2015

Month 11

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Income:

A&E Income (163,265) (163,026) (239) (178,040) (177,847) (193) (175,893)

UCS Income (22,225) (23,097) 872 (24,359) (25,201) 842 (17,878)

PTS Income (3,547) (3,413) (134) (3,869) (3,723) (146) (10,337)

HART Income (6,026) (6,025) (1) (6,574) (6,573) (1) (6,434)

VACS Income (17) - (17) (18) - (18) (1,137)

Other Income (11,251) (5,199) (6,052) 1,3,5 (16,209) (5,644) (10,565) 3,5 (13,938)

Total Income (206,330) (200,760) (5,570) (229,068) (218,987) (10,081) (225,617)

Expenditure:

Employee Benefits (Pay) 148,590 150,612 (2,022) 1 , 2 163,129 164,260 (1,131) 2,3 158,924

Drugs 788 777 11 909 848 61 596

Medical 4,913 3,895 1,018 5,876 4,250 1,626 6,094

ICT 7,851 4,387 3,464 5 8,748 4,786 3,962 5 5,817

Estates 5,784 5,766 17 6,870 6,298 572 6,443

Fleet Expenses 4,827 4,300 528 4,953 4,695 257 4,613

Fuel 5,918 6,197 (279) 6,414 6,760 (346) 6,893

Vehicle Insurance 1,398 1,540 (142) 1,540 1,680 (140) 2,005

Vehicle Leasing 637 595 43 699 649 50 716

Education & Training 1,799 1,203 596 1 2,061 1,299 762

Other 12,244 8,653 3,590 2,3 13,670 9,434 4,236 2,3 15,645

Total Operating Expenses 194,748 187,925 6,824 214,870 204,959 9,911 207,747

EBITDA (11,581) (12,836) 1,254 (14,199) (14,028) (170) (17,870)

Profit/Loss on Asset Disposal 77 - 77 77 - 77 54

Depreciation 9,327 10,179 (852) 1 10,150 11,130 (981) 1 12,094

Impairments - - - 1,642 - 1,642 3,505

Total Operating (Surplus)/Deficit (2,178) (2,656) 478 (2,331) (2,898) 567 (2,217)

Total Interest Receivable (86) (77) (9) (91) (84) (7) (89)

Total Interest Payable 114 147 (33) 124 160 (36) 146

PDC Dividend 1,601 2,037 (436) 4 1,698 2,222 (524) 4 1,827

Net (Surplus)/Deficit (550) (550) - (600) (600) - (333)

Comments:1 Delay in implementation of business plans

2 Use of third parties to offset vacancies

3 Additional income and expenditure in relation includes Tiverton MIU and Operational Resilience and Capacity funding

4 PDC variance due to increased cash above plan as plan based on 2013/14 Month 11 forecast cash position

5 Additional income and expenditure relating to the payment for the ECS project funded Centrally

Year to Date Forecast

South Western Ambulance Service NHS Foundation Trust Appendix Gii

31-Mar-14

Statement of Financial Position Actual Actual Budget Variance Actual Budget Variance

Period Ending 28/02/2015

Month 11

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Non-Current Assets

Property, Plant & Equipment & Intangible Assets, Net 81,974 83,215 84,590 (1,375) 7 82,732 84,539 (1,807)

Trade & Other Receivables Non-Current - 508 - 508 48 48 -

Total Non-Current Assets 81,974 83,723 84,590 (867) 82,780 84,539 (1,759)

Current Assets -

Inventories 2,036 2,002 1,965 37 2,075 1,942 133

NHS Trade Receivables, Current 1,924 1,456 2,652 (1,196) 5 1,939 2,150 (211)

Non NHS Trade Receivables, Current 426 434 600 (166) 5 434 434 -

Other Receivables, Current 370 46 77 (31) 370 6 364

Prepayments, Current, Non-PFI related 3,533 1,505 1,027 478 4 2,016 2,158 (142)

Other Financial Assets, Current 114 1,276 567 709 6 69 313 (244)

Cash and Cash Equivalents 30,449 38,970 24,880 14,090 2,6,7 35,085 24,505 10,580 -

Current Assets 38,852 45,689 31,768 13,921 41,988 31,508 10,480

Non Current Assets Held for Sale - - - -

Total Current Assets 38,852 45,689 31,768 13,921 41,988 31,508 10,480

TOTAL ASSETS 120,826 129,412 116,358 13,054 124,768 116,047 8,721

Current Liabilities -

Deferred Income (141) (5,406) (1,219) (4,187) 3 (56) (150) 94

NHS Trade Payables (655) (316) (375) 59 2 (400) (310) (90)

Non-NHS Trade Payables (3,724) (2,159) (2,158) (1) 2 (3,500) (2,750) (750)

Capital Accruals (2,967) (3,691) (1,158) (2,533) (2,896) (1,296) (1,600)

Other Liabilities (4,480) (4,536) (4,930) 394 (4,585) (4,950) 365

Borrowings (518) (510) (494) (16) (510) (494) (16)

Other Financial Liabilities (8,461) (11,913) (6,844) (5,069) 2 (11,042) (7,712) (3,330)

PDC Dividend Payable, Current - (643) (810) 167 - - -

Provisions for Liabilities and Charges (7,875) (6,716) (6,428) (288) (7,106) (6,428) (678)-

Total Current Liabilities (28,821) (35,890) (24,416) (11,474) (30,095) (24,090) (6,005)

Net Current Assets/(Liabilities) 10,031 9,799 7,352 2,447 11,893 7,418 4,475

TOTAL ASSETS LESS CURRENT LIABILITIES 92,005 93,522 91,942 1,580 94,673 91,957 2,716

Non-Current Liabilities -

Finance Leases, Non-Current (599) (604) (599) (5) (604) (599) (5)

Long Term Borrowings (2,609) (2,448) (2,490) 42 (2,202) (2,245) 43

Other Financial Liabilities, Non-Current - (267) - (267) (221) - (221)

Provisions, Non-Current (3,952) (4,238) (4,050) (188) (4,303) (4,115) (188)

Trade and Other Payables, Non-Current - - - - - - - -

Total Non-Current Liabilities (7,160) (7,557) (7,139) (418) (7,330) (6,959) (371)

TOTAL ASSETS EMPLOYED 84,845 85,965 84,803 1,162 87,343 84,998 2,345

Represented By

Public Dividend Capital 42,455 43,025 43,030 (5) 43,025 43,175 (150)

Income & Expenditure Account 35,275 36,134 36,251 (117) 36,214 36,341 (127)

Revaluation Reserve 7,115 6,806 5,522 1,284 1 8,104 5,482 2,622

TOTAL TAXPAYERS EQUITY 84,845 85,965 84,803 1,162 87,343 84,998 2,345

Comments:

1 Plan based on Month 11 forecast for March 2014 SOFP.

2 PO Receipts, OO accrual, Third party transport, overtime accrual, Med & Surg and estimated impairment for buildings from DV valuation. Outstanding invoices being accrued this contra with Trade Payables.

3 Profiling variance and deferral of income to match expenditure, DH ECS funding, HART training and £500k instalment for Bristol.

4 Vehicle insurance, computer prepayment and responder contract with DH.

5 Improved management of debtors.

6 Accrued income CQUIN and Handover delays.

7 Delay in original budget capital plan Bristol, vehicles and improved management of debtors.

Year to Date Forecast

Appendix Giii

Month End 28/02/2015 Period 11

2014/15

Annual CIP Target 8,950

Total CIP Identified 8,950

Total Savings Delivered YTD 8,204 8.33%

CIP Target YTD 8,204

Ref CIP Description

Identified

Annual

Saving

Savings

Delivered

YTD

Target

Savings

YTD

YTD

Variance

Forecast

Outturn

Annual

Target

Forecast

Variance

RAG

RatingComments

1 A&E Modernisation 3,600 3,300 3,300 0 3,600 3,600 0 GREEN

2 UCS Modernisation 669 338 613 -275 369 669 -300 AMBER Implementation of scheme still delayed

3 A&E Resource Review 1,260 697 1,155 -458 760 1,260 -500 AMBER £500k risk at present

4 Fuel Cost Reduction Action Plan 750 688 688 0 750 750 0 GREEN

5 Fleet Strategy 138 127 127 0 138 138 0 GREEN

7 Non Pay Expenditure Review 719 659 659 0 719 719 0 GREEN

8 111 Conribution 190 174 174 0 190 190 0 GREEN

9 Staff Turnover 1,624 1,489 1,489 0 1,624 1,624 0 GREEN

10 Replacement schemes 0 733 0 733 800 0 800 AMBER Non recurrent replacment schemes

Total 8,950 8,204 8,204 0 8,950 8,950 0

South Western Ambulance Service NHS Foundation Trust

Overall CIP 2014/15 Summary Dashboard

Board of Directors Meeting 26 March 2015

Page 1 of 2


Title: Draft Regulatory Framework 2015/16

Prepared by: Helen Braid, Interim Compliance Manager

Presented by: Jennifer Winslade, Executive Director of Nursing & Governance

Main aim: To provide the Board of Directors with the draft Regulatory Framework for 2015/16

Recommendations: The Board of Directors is requested to: 1. Consider and approve the attached draft

Regulatory Framework 2015/16; and 2. Advise of any additional regulatory or statutory

requirements which also should be included.

Previous Forum: None



BAF References Directorate

Business Plans Nursing & Governance

Implications



Page 2 of 2

Draft Regulatory Framework 2015/16

1. Background 1.1. The Trust is regulated by a number of external bodies which assess it against

statutory and other targets and requirements.

1.2. To ensure compliance with meeting these targets and requirements, a Regulatory Framework is developed on an annual basis which maps out the reporting route and timeframe for each regulatory requirement to enable monitoring throughout the year.

2. Purpose

2.1. The purpose of this paper is to provide the Board of Directors with a draft Regulatory Framework for 2015/16.

3. 2015/16 Regulatory Framework 3.1. The attached Framework has been drafted based on all identified requirements, and

sets out the reviews and submissions required for 2015/16. Reports and ratings from external bodies such as Monitor and the Care Quality Commission have also been included to identify when these will be reported to the Board of Directors.

3.2. The Framework has been considered in conjunction with the schedule of meetings of the Board of Directors, its committees and the Council of Governors, to ensure that meeting dates align and that the annual cycles for each can be developed.

3.3. The Framework will be managed by the Governance Team and reports on compliance will be presented to the Quality and Governance Committee.

3.4. Some dates are yet to be confirmed, as the appropriate guidance has not been published, these dates will be updated as soon as they are available.

4. Recommendation 4.1. The Board of Directors is requested to:

4.1.1 Consider and approve the attached draft Regulatory Framework 2015/16;

and 4.1.2 Advise of any additional regulatory or statutory requirements which also

should be included. Jenny Winslade Executive Director of Nursing & Governance

Key

Statutory Regulatory

Working GroupConsultation

(with whom)Directors

Charitable

Funds

Committee

Finance and

Investment

Committee

Quality and

Governance

Committee

Audit

CommitteeBoard Council of Governors

Monitor

(Draft)

Parliamentary

Clerk

Available to the

public

Monitor

Final

Other

(Specify)

Area Components Guidance or source DetailResponsibility

(Author)Date of Meeting Date of Meeting Date of Meeting Date of Meeting Date of Meeting Date of Meeting Date of Meeting Date Date Date Date Date

Annual AccountsAnnual Accounts and

FTCs 2014/15

Monitor Annual

Reporting Manual

(Updated Annually)

Approved, audited

accounts, and

Foundation Trust

Consolidations

Deputy Chief

Executive /

Executive Director

of Finance

21 May 2015 28 May 2015

23 April 2015 at

noon (DRAFT)

29 May 2015 at

noon (FINAL)

25 June 2015July/

August10 July 2015

Annual Members

Meeting/Annual

General Meting

Annual Meeting

Members 2015 &

Annual General

Meeting

Trust ConstitutionAnnual meeting for

members of the TrustTrust Secretary 17 September 2015

Annual PlanOperating Plan

2015/16

Monitor Guidance on the

2015/16 Annual

Planning Review

Forward plan for the

Trust for 2015/16

covering how the 5 Year

Strategy has been

updated in light of

2014/15 performance

and environmental

changes. How quality,

operational and financial

requirements will be

met.

Business Planning

Manager

Draft - March

2015

Final - tbc

Draft - 19 March

2015

Final - tbc

Draft - 26 March 2015

Final - tbc

9 July 2015 (Final) April 2015 - tbc May 2015 - tbc

Annual Plan Strategic Plan 2014/19

Montor Annual Plan

Advice for FTs (Updated

Annually)

Forward plan for the

Trust covering five years

Monitor version &

Public Version

Including: declaration of

sustainability; market

analysis and context;

risks to sustainability;

strategic options and

strategic plans

Business Planning

Manager

Annual PlanCorporate Governance

Statement 2014/15

Monitor Risk

Assessment Framework

Annual Corporate

Governance Statement

Head of

Governance09 April 2015

Draft - 26 March 2015

Final - 28 May 2015

Annual Report

Annual Governance

Statement

2014/15

Monitor Annual

Reporting Manual

(Updated Annually)

Assurance statement

that the Trust has

sufficiently robust

internal controls in place

to manage its risk

Head of Patient

Safety & Risk09 April 2015 28 May 2015

29 May 2015 at

noon

Annual Reports Annual Report 2014/15

Monitor Annual

Reporting Manual

(Updated Annually)

Annual report on

business of the Trust in

the previous financial

year inc statements on:

public engagement

patient experience

information security

serious incidents -

Quality Account

narrative

Trust Secretary14 May 2015 (for

comment)28/05/2015 (draft)

Comms &

Engagement Sub

Group to Proof Read

29 May 2015 at

noon (draft)25 June 2015 September 10 July 2015

Annual ReportsQuality Report 2013/14

Audit

Detailed Guidance for

External Assurance on

Quality Reports

(Updated anunally)

External Audit to review

mandated indicators and

local indicators and

provide a report to the

CoG

Medical Director

(Compliance

Manager)

21 May 2015

19 February 2015

(select indicators for

audit)

17 September 2015

(receipt of audit

opinion)

29 May 2015 at

17:00

Annual ReportsQuality Report

2013/14Monitor

Annual Report on the

quality of care aimed at

improving accountability

Medical Director

(Compliance

Manager)

14 May 2015 (for

comment)21 May 2015 28 May 2015

29 May 2015 at

09:0025 June 2015

July/

August10 July 2015

Date to be confirmed

Board Regulatory Framework 2015/16

Target metReports/Ratings Received

No requirement to submit update during 2015/16

M:\Board of Directors\Board Papers\2014-15\26 March 2015\Public\3. Draft Regulatory Framework\Regulatory Framework 2015-16_DRAFT as at 20.02.2015 1



Charitable

Funds

Committee

Finance and

Investment

Committee

Quality and

Governance

Committee

Audit


Monitor

(Draft)

Parliamentary

Clerk

Available to the

public

Monitor

Final

Other

(Specify)



Annual ReportsQuality Account

2014/15 (Indicators)

National Health Service

(Quality Accounts)

Regulations 2010

Setting of indicators for

the Quality Account

Medical Director

(Compliance

Manager)

Commissioners;

Council of

Governors

Consultation with

Governors and Trust

Members - not in

formal meeting

setting.

Annual ReportsQuality Account

2014/15

National Health Service

(Quality Accounts)

Regulations 2010

Annual review of quality

of care provided for all

three core services

Medical Director

(Compliance

Manager)

Commissioners

and Council of

Governors

14 May 2015 (for

comment)28 May 2015

Annual ReportsRegister of Interests

of DirectorsTrust Constitution Trust Secretary 31 March 2016

Available to the

Public

Annual Reports

Non Executive

Director Declaration of

Independence

Trust Constitution Trust Secretary 31 March 2016Available to the

Public

Annual ReportsRegister of Interests

of GovernorsTrust Constitution

Register of members

and interests of all

governors

Trust SecretaryAvailable to the

Public

AssuranceBoard Assurance

Framework 2015/16

Department of Health

Building the Assurance

Framework: A Practical

Guide for NHS Boards

Board Assurance

Framework in place at

start of financial year

Head of

Governance26 March 2015

Annual Internal

Audit Annual

Review

AuditorsAuditor's Report

2014/15ISA260

Auditor's verification of

accounts and Audit

Letter

External Audit 21 May 2015 28 May 201529 May 2015 at

noon25 June 2015

July/

August

AuditorsAppointment of

AuditorsTrust Constitution

Approve appointment of

Auditor or consider

tender for new

arrangement

Deputy Chief

Executive /

Executive Director

of Finance

CoG Audit Sub

Group & Audit

Committee

(If Required)

Breach of

Authorisation

Notice of Intervention

by MonitorSection 52, 2006 Act

Notice of the exercise of

intervention powers by

Monitor in the event of

breach of authorisation

Monitor

Monthly Light

Touch and

Quarterly

Compliance

Meetings

As required. As required.Available to the

Public

CapitalWorking Capital

Facility exceptions

Board approved working

capital facility

Reports on use of and/or

changes to working

capital facility

arrangements

Deputy Chief

Executive /

Executive Director

of Finance

Monthly Light

Touch and

Quarterly

Compliance

Meetings

As required. As required.

CapitalWorking Capital

Facility

Board approved working

capital facility

Expansion and renewal

of working capital facility

arrangement

Deputy Chief

Executive /

Executive Director

of Finance

14 January 2016 28 January 2016 1 February 2016 tbc

Care Quality

Commission

Hygiene Code

Compliance and

Infection Control

Annual Report 2013/14

Health & Social Care

Act 2008: Code of

Practice for health and

adult social care on the

prevention and control of

infections and related

guidance

Annual Infection

Prevention & Control

Report

(to support

CQC outcome 8)

Deputy Clinical

Director

Infection

Prevention and

Control Group

14 May 2015

Care Quality

Commission

Care Quality

Commission

Regulations

Health & Social Care

Act 2008 (Regulated

Activities) Regulations

2010

Reports on ongoing

registration without

compliance conditions

Compliance

ManagerMonthly

Each Meeting as

part of Governance

Assurance Report

Included in the ICPR

Care Quality

Commission

Intelligent Monitoring

Report - when

reporting commences

Care Quality

Commission

Update on monthly

report from CQC against

indicators from multiple

sources

Compliance

ManagerMonthly

Each Meeting by

exception

Each Meeting by

exception

Appointment process will not take place until 2016/17. The CoG Audit Sub Group will undertake preparatory work during 2015/16.

Secretary of State

(and published on

NHS Choices)

30 June 2015




Charitable

Funds

Committee

Finance and

Investment

Committee

Quality and

Governance

Committee

Audit


Monitor

(Draft)

Parliamentary

Clerk

Available to the

public

Monitor

Final

Other

(Specify)



Charitable Funds

Annual Accounts

2014/15 for Trust

Charitable Funds

Charities Commission

Annual approved

accounts for the Trust

Charitable Funds

Committee, and Letter of

Representation

Deputy Chief

Executive /

Executive Director

of Finance

July 2015 - tbc24 September 2015

(Final)

Clinical AuditsMandatory Clinical

Audits for 2014/15

Trust Audit Plan -

Department of Health,

CQC

AQI, MINAP, CQC

Audits

Research and Audit

Manager

Research and

Audit Group

Clinical

Effectiveness

Each meeting as

required.

Code of Conduct Code of Conduct

Board approved codes

of conduct for directors

and governors

Exception reports on any

breach of compliance

with codes of conduct for

board of directors and/or

council of governors

Trust Secretary 06 August 2015Each meeting as

required.

Each meeting as

required.

Code of Conduct Code of ConductApproved code of

conduct for staff



with codes of conduct for

staff

Director of HR &

Organisational

Development (Head

of Governance)

Each Meeting 14 May 2015Each meeting as

required.

Code of GovernanceCode of Governance

(Incl Disclosure)

Monitor Code of

Governance

Report on compliance

with code of governance

and its required

disclosure in the Annual

Report

Head of

Governance14 May 2015 28 May 2015

Declarations of

InterestsRegister of Interests

Good Governance and

Anti-Bribery Act

All Senior Managers and

personnel with

purchasing authority to

make a declaration of

interests

Compliance

Manager

April 2015

(Report) - tbc

ConstitutionConstitution and

Standing Orders

Approved Trust

constitution

Report on changes to

constitution and standing

orders

Trust Secretary As required As requiredCoG approval as

required

Available to the

public

ConstitutionConstitution and

Standing Orders

Approved Trust

constitution



with constitution and

standing orders

Trust Secretary

Monthly Light

Touch and

Quarterly

Compliance

Meetings

Each Meeting by

exception

Each Meeting by

exception

Each Meeting by

exception

Available to the

public

ConstitutionNHS Constitution

Action Plan 2014/15Health Act 2012

Reports on

implementation of duties

set out in the NHS

Constitution

Trust SecretaryEach meeting by

exception28 May 2015

Commissioner

approval

Council of

GovernorsGovernor elections Trust Constitution

Election of new or re-

election of existing

governors as required

Trust SecretaryEach Meeting as

applicable

Each outcome when

available

EnvironmentCarbon Reduction

Risk Assessment

Climate Change Act and

Adaption ReportingEstates Manager

Environmental

Management

Group

14 May 2015

Equality DutyPublic Sector Equality

Duty

Equality Act 2010 and

Public Sector Equaltiy

Duty

Publication of required

data, engagement with

stakeholders, objective

setting and work

programme to meet

objectives

Executive Director

of HR and

Organisational

Development

Each Meeting as

applicable

Head of Internal

Audit Opinion

Head of Internal Audit

Opinion 2014/15Audit Code

Official opinion on and

referenced in the Annual

Governance Statement

Head of Internal

Audit09 April 2015 28 May 2015

Information

Governance

Information

Governance Toolkit

Level 2 Compliance

2015/16

Information Governance

Toolkit

Annual self assessment

against IG Toolkit

requirements

Information

Governance

Manager

Information

Governance

Steering Group

31 March 2016

Information

Commissioner

31 March 2016




Charitable

Funds

Committee

Finance and

Investment

Committee

Quality and

Governance

Committee

Audit


Monitor

(Draft)

Parliamentary

Clerk

Available to the

public

Monitor

Final

Other

(Specify)



Lead Governor

Appointment of Lead

and Deputy Lead

Governor

Trust Constitution

Appointment of new lead

and deputy lead

governor for council of

governors (from elected

public constituency)

Trust Secretary 17 September 2015 September 2015

Local Counter Fraud

Annual Plan

Local Counter Fraud

Annual Plan 2015/16

Secretary of State

Directions 2004

Local Counter Fraud

Specialist to attend Audit

Committee and present

an annual plan

Local Counter Fraud

Specialist09 April 2015

MembershipReview of

Membership StrategyTrust Constitution

Annual review of

membership strategy by

Council of Governors

Trust Secretary

CoG

Membership and

Comms Sub

Group

30 July 2015 17 September 2015

Performance KO41 Department of HealthData on written health

service complaints

Patient Experience

ManagerApril/May 2015 6 May 2014

Regulatory

Framework

Regulatory

Framework

2015/16

Good Governance and

Trust requirements

Maintain the regulatory

framework for 2014/15

Compliance

Manager

Each Meeting as

part of Governance

Assurance Report

Remuneration and

Recommendations

Panel

Appointment of

Chairman and Non

Executive Directors

Trust Constitution

Reappointment of

existing Chairman and

Non Executive Directors

if they wish to be

reappointed or

recruitment of new

Board members if

necessary

Executive Director

of HR and

Organisational

Development

CoG

Remuneration

and

Recommendatio

n Panel

As Required As Required

Remuneration and

Recommendations

Panel

Appointment of Chief

ExecutiveTrust Constitution

Appointment of new

Chief Executive if

required

ChairmanRemuneration

CommitteeAs Required Approval as required

Remuneration

Committee

Terms of office for

Directors Trust Constitution

Agree existing terms of

office for Directors

Executive Director

of HR and

Organisational

Development

Remuneration

Committee

Resilience

Major Incident Plan

(and Mass Casualties

Plan)

Civil Contingencies ActPlan for management of

any major incidentHead of EPRR 31 March 2016

Safeguarding Adults

Section 11 Audit tool

adapted for Adults

2013/14

Section 11, Children Act

2004

Adapted audit (from

Section 11) tool

reviewing the

safeguarding of adults

Head of

Safeguarding

Safeguarding

Operational

Group

14 May 2015

Safeguarding

Children

Section 11 Audit for

Safeguarding of

Children 2013/14

Section 11, Children Act

2004

Audit to confirm that

Trust functions are

functions are 'discharged

taking into consideration

the duty to safeguard

and promote the

wellbeing of children’

Head of

Safeguarding

Safeguarding

Operational

Group

14 May 2015

Senior Independent

Director

Senior Independent

Director

Monitor and Terms of

Authorisation

Appointment of new

Senior Independent

Director (if required)

Trust Secretary As Required




Charitable

Funds

Committee

Finance and

Investment

Committee

Quality and

Governance

Committee

Audit


Monitor

(Draft)

Parliamentary

Clerk

Available to the

public

Monitor

Final

Other

(Specify)



Standing Financial

Instructions

Standing Financial

Instructions

Board approved Trust

standing orders and

financial instructions


breach in compliance

and/or changes to the

standing orders and

financial instructions and

scheme of delegation

Deputy Chief

Executive /

Executive Director

of Finance

Audit Committee As required

Standing Financial

Instructions

Standing Financial

Instructions

Board approved Trust

standing orders and

financial instructions

Annual confirmation that

all Senior

Managers/Budget

Holders have read the

SFI

Financial Controller

As required -

following any

update of SFIs

NHS Provider

Licence

Board Memorandum

on Quality

Governance

Monitor Risk


Head of

Governance11 February 2016 31 March 2016

NHS Provider

LicenceNHS Provider Licence Provider Licence

Compliance against

Provider Licence as an

FT made available to the

public

Deputy Chief

Executive /

Executive Director

of Finance

Monthly Light

Touch and

Quarterly

Compliance

Meetings

Available to the

public

Monthly 'Light-

Touch' or Quarterly

Return Meetings

NHS Provider

LicenceNHS Provider Licence Governance Review

3 yearly Governance

Review by an exeternal

organisation

Deputy Chief

Executive /

Executive Director

of Finance

Monthly Light

Touch and

Quarterly

Compliance

Meetings

Work to commence

in Quarter 2 -

2015/16.

3 yearly review

required, timeframe

determined by

Board of Directors

NHS Provider

Licence

Quarter 1 Monitoring

Report

Monitor Risk


Including: latest quarter

financials

YTD financials

Financial commentary

Governance (inc self

certs)

Business Planning

Manager

Monthly Light

Touch and

Quarterly

Compliance

Meetings

30 July 2015 31 July 2015

NHS Provider

Licence


Report

Monitor Risk



financials

YTD financials



certs)

Business Planning

Manager

Monthly Light

Touch and

Quarterly

Compliance

Meetings

26 November 2015 31 October 2015

NHS Provider

Licence


Report

Monitor Risk



financials

YTD financials



certs)

Business Planning

Manager

Monthly Light

Touch and

Quarterly

Compliance

Meetings

28 January 2016 30 January 2016

NHS Provider

Licence


Report

Monitor Risk



financials

YTD financials



certs)

Business Planning

Manager

Monthly Light

Touch and

Quarterly

Compliance

Meetings

tbc April 2016 30 April 2016

NHS Provider

Licence

Monitor Published

Quarter 1 Risk Rating

Monitor Risk


Risk (finance and

governance) rating

assigned by Monitor

Monitor 24 September 2015 17 September 2015

NHS Provider

Licence

Monitor Published


Monitor Risk


Risk (finance and

governance) rating

assigned by Monitor

Monitor 26 November 2015 10 December 2015

NHS Provider

Licence

Monitor Published


Monitor Risk


Risk (finance and

governance) rating

assigned by Monitor

Monitor 31 March 2016 tbc April 2016

NHS Provider

Licence

Monitor Published


Monitor Risk


Risk (finance and

governance) rating

assigned by Monitor

Monitor tbc June 2016 tbc July 2016



Page 1 of 3


Title: Declaration of Interests, Declaration of Independence and Salary Disclosure

Prepared by: Marty McAuley, Trust Secretary

Presented by: Marty McAuley, Trust Secretary

Main aim: The paper is intended for approval prior to inclusion within the Trust Annual Report 2014-15

Recommendations: Each Board Member confirms the accuracy of the Declaration of Interests, and sign the documentation at Appendix A; Each Board Member agrees for their salary details to be included in the Trust annual report 2014/1 Non-Executive Directors confirm that they meet the test of independence.

Previous Forum: No other forum



BAF03-13 Directorate Business Plans

Implications


None


Page 2 of 3

Declaration of Interests, Declaration of Independence and Salary Disclosure

1. Background

1.1 It is an annual requirement for the Directors of the Trust Board to declare any conflicts of interest that they may have in the course of their business

2. Declaration of Interests

2.1 ‘It is a requirement that chairmen and all board members should declare any conflict of interest that arises in the course of conducting NHS business. That requirement continues in force. Chairmen and board members should declare on appointment any business interests, position of authority in a charity or voluntary body in the field of health and social services care and any connection with a voluntary or other body contracting for NHS services. These should be formally recorded in the minutes of the board, and entered into a register which is available to the public. Directorships and other significant interests held by NHS board members should be declared on appointment, kept up to date and set out in the annual report.’

NHS Trust ~ Model Corporate Governance Documents - (March 2006) 23

2.2 The register at Appendix A represents the interests held by directors throughout

2014/15.

3. Disclosure of Salary Information 3.1 Board members are required to confirm that they give permission for details of their

remuneration to be published in the Trust’s annual report and accounts as, under the Data Protection Act 1998, they are entitled to request that these details are not disclosed.

4. Declaration of Independence

4.1 The Chairman and each Non-Executive Director should confirm that they meet the test of independence in that none of the criteria below is applicable to them.

The Board of Directors is required to determine whether the Non-Executive director is independent in character and judgement and whether there are relationships or circumstances which are likely to affect, or could appear to affect, the Non-Executive Director’s judgement. The Board of Directors should state its reasons (within the annual report) if it determines that a Non-Executive Director is


Page 3 of 3

independent, notwithstanding the existence of relationships or circumstances which may appear relevant to its determination, including if the Non-Executive Director:

has been an employee of the NHS Foundation Trust within the last five years;

has, or has had within the last three years, a material business relationship with the NHS Foundation Trust either directly, or as a partner, shareholder, director or senior employee of a body that has such a relationship with the NHS Foundation Trust;

has received or receives additional remuneration from the NHS Foundation Trust apart from a Director’s fee, participates in the NHS Foundation Trust’s performance related pay scheme, or is a member of the NHS Foundation Trust’s pension scheme;

has close family ties with any of the NHS Foundation Trust’s advisers, directors or senior employees;

holds cross-directorships or has significant links with other directors through involvement in other companies or bodies;

has served on the Board of the NHS Foundation Trust for more than nine years from the date of their first appointment; or

is an appointed representative of the NHS Foundation Trust’s university medical or dental school.

Recommendation

3.1 Each Board Member confirms the accuracy of the Declaration of Interests, and sign the documentation at Appendix A;

3.2 Each Board Member agrees for their salary details to be included in the Trust

annual report 2014/15 3.3 Non-Executive Directors confirm that they meet the test of independence.

Marty McAuley Trust Secretary

Director Interests Disclosed Where a change occurred during 2014/15 please provide date of change

Heather Strawbridge (Chairman)

Director, Ambulance Services Association (Dormant) Trustee, NHS Confederation; Non Executive Director, Somerset Care Ltd.

Vice Chair, HFMA, Chair, NED and Lay Member Faculty Chair, HFMA, Chair, NED and Lay Member Faculty Chair of the Urgent and Emergency Care Steering Group, NHS Confederation(current); Trustee, Bridgwater College Academy Trust

Ceased January 2014 Commenced January 2014

I confirm that the above register of interests is an accurate reflection of my interests throughout 2014/15 and includes any changes in year. I confirm that I am/am not* happy for my salary to be disclosed within the Trust Annual Report. *delete as applicable

I declare that, with effect from the date of the Trust’s authorisation as an NHS foundation trust none of the above will be applicable to my circumstances and I therefore confirm my independence as a Non-Executive Director.

Name

Role

Date

Page 2 of 13


Ken Wenman (Chief Executive)

Chairman, Ambulance Services Association (Dormant); Director of the Association of Ambulance Chief Executives (non remunerated) Member of the South West Peninsula Education and Training Board


Name

Role

Date

Page 3 of 13


Jennie Kingston (Deputy Chief Executive/ Executive Director of Finance)

Director of the Association of Ambulance Chief Executives (non remunerated)


Name

Role

Date

Page 4 of 13


Dr Andy Smith (Executive Medical Director)

GP, College Surgery, Cullompton; GP Partners at College Surgery include: Dr David Jenner, Chair, Eastern Locality NEW Devon CCG and Dr Michael Dixon, chair, NHS Alliance Sessional OOH GP service work for Devon Doctors Ltd Partner, Culm Health Plus Sessional work for SWASFT Urgent Car service (including Out of Hours GP work and 999 GP work)


Name

Role

Date

Page 5 of 13


Francis Gillen (Executive Director of IM&T)

None


Name

Role

Date

Page 6 of 13


Jennifer Winslade (Executive Director of Nursing and Governance)

Chief Nursing Officer, NEW Devon Clinical Commissioning Group Member of the Department of Health Public Health Nursing and Midwifery Model Group Member of the Senate Council

Joined the Trust in January 2014 Ceased June 2014


Name

Role

Date

Page 7 of 13


Emma Wood (Executive Director of HR & OD)

None


Name

Role

Date

Page 8 of 13


Mary Watkins (Non-Executive Director)

Trustee, Hamoaze House, Plymouth Emeritus Professor (Health Care Leadership) - Plymouth University; Member, BUPA Foundation Board; BUPA Medical Advisory Panel; BUPA Communications Panel; Member, HEFCE UK Healthcare Education Advisory Committee. Chair, Aster Living Chair of PenCLAHRC Management Board Chair, Peninsula Medical Foundation

Appointed July 2013 Appointed 28/01/2014 Appointed January 2014



Name

Role

Date

Page 9 of 13


Robert Davies (Non-Executive Director)

Director, Copland Davies Associates Limited; Chairman of the Trustees Friends of Holy Cross Church, Newton Ferrers, Devon Chairman, Institute of Chartered Accountants in England and Wales (ICAEW) Support Members’ Scheme Member, Institute of Chartered Accountants in England and Wales (ICAEW) Ethics Advisory Committee

Ceased April 2014 Ceased June 2014 Ceased June 2014



Name

Role

Date

Page 10 of 13


Tony Fox (Non-Executive Director)

Director of Operations Royal Mail Group plc Board member for Opportunity Now (BITC).



Name

Role

Date

Page 11 of 13


Hugh Hood (Non-Executive Director)

Director of Organisation Development, BT plc Director & Chair of Remuneration Committee One Connect Ltd (A joint venture service between Lancashire County Council and BT)



Name

Role

Date

Page 12 of 13


Christopher Kinsella (Non-Executive Director)

Chief Financial Officer The British Council Board Member, Industrial Development Advisory Board, Dept of Business Innovation & Skills (HMG) Board Member, Member of Audit Committee, Sheffield Hallam University Teaching Fellow, Lancaster University Management School Director, Christopher Kinsella Ltd



Name

Role

Date

Page 13 of 13


Venessa James (Non-Executive Director)

None



Name

Role

Date


Page 1 of 1

Trust Board of Directors’ Meeting 26 March 2015

Title: Final Board Assurance Framework 2014/15 Update

Prepared by: Nicole Casey, Head of Governance

Presented by: Ken Wenman, Chief Executive

Main aim: To provide the Board of Directors with a final update to the Board Assurance Framework for 2014/15

Recommendations: The Board of Directors is requested to take assurance from this update

Previous Forum: This paper has not been presented to a previous forum



BAF05-14 Directorate

Business Plans Nursing and Governance

Implications


Department of Health Guidance

Strategy

Key Performance Indicators

Action Plan

Integrated Corporate Performance Report (monitoring)

No gaps in controls have been identified

QAS of 6-8

mechanisms of assurance provided are sound

Ref

Ty

pe

Objective

Risk Register

(Corporate)

Qu

ali

ty G

ov

ern

an

ce

Fra

me

wo

rk

CQC

RefSuitable Controls or Areas of Assurance

Positive Controls / Assurance Received

(by the Board of Directors or a Board delegated committee or group)

Gaps in Controls

(including those

identified as Medium

risk during Internal

Audit Reviews) Ac

tio

n P

lan

s

De

ad

lin

e

Ex

ec

uti

ve

Se

nio

r M

an

ag

er

Mo

nit

ori

ng

Fo

rum

Assurance

Mechanism

pale text indicates QAV not

in place

Qu

ali

ty A

ss

ura

nc

e

Sc

ore

(Q

AS

)

External

Assurance

(eg audits/

inspections)

QAS of 4-5

additional mechanisms of

assurance may be required

Specific gaps have been identified but may be outside the

Trust's control

QAS of 1-3

mechanisms of assurance are inadequate and should be

reviewed urgently

The Quality Assurance Score column is RAG rated -

this relates to the value of assurance provided:

Please note that it is possible that an objective could have a high scoring QAS because it has sound assurance mechanisms but still be off plan because of a gap in its controls; similarly, an objective could be on plan but have a low scoring QAS because the mechanisms for assurance need to be strengthened

The Gaps in Controls column is RAG rated - this

relates to risk to achievement of the objective

*Deputy Directors attend one meeting a month

Gaps in controls have been

identified and addressed as

detailed

Associate/Deputy Directors' Group, Directors' Group*: individual meetings not listed but business items included where assurance is provided against key objectives (last meeting noted - 26th August 2014)

Background

Any gaps in controls and/or assurance will remain identified in the relevant column for the year and a report will be provided at the end of the year regarding any which have not been addressed/controlled.

Management

Audit Committee: 3rd April; 22nd May; 17th July; 2nd Oct; 15th Jan

The Framework will be document controlled by means of a date reference at the bottom of each page. No items will be removed without the approval of the Board of Directors. Changes to the core document since the previous meeting will be shown in blue.

Finance and Investment Committee: 13th Mar; 22nd May; 17th July; 2nd Oct; 15th Jan

Quality and Governance Committee: 15th May; 10th July; 18th Sept; 13th Nov; 8th Jan; 12th Mar

Board of Directors' Meetings: 27th Mar; 24th April; 22nd May (extra), 29th May; 31st July; 25th Sept; 30th Oct; 27th Nov; 18th Dec; 29th Jan; 26 Mar

Council of Governors: 2nd April; 3rd July; 11th Sept (AMM); 9th Oct; 11th Dec; 5th Mar

All Board and committee papers will identify links to the BAF with clear references. These will then be updated on the Framework itself each month. The BAF is considered alongside changes to risk ratings reviewed at each Quality Risk Watch. Risk references are then updated accordingly.

Version Control

Board of Directors, Committee, Group Meetings through which the Board has received assurance throughout the year

South Western Ambulance Service NHS Foundation Trust Board Assurance Framework 2014/15

All NHS Trusts, including Foundation Trusts, are required to provide a Board Assurance Framework (BAF) as a mechanism for the Board of Directors to ensure the effective and focused management of principal risks to the achievement of key objectives. This SWASFT framework has been developed for 2014/15 as an iteration of the framework followed throughout 2013/14. NB: any

reference to the Board of Directors will also refer to any one of the committees of the Board of Directors to which it has delegated specific responsibility and authority

The BAF will be managed by the Head of Governance and will be reported to the Board of Directors at each meeting by the Chief Executive Officer. Following the end of each financial year (ie at the March Board) the BAF will be 'closed' for the year, summarising the assurance provided. A new document will be drafted for approval at each March Board of Directors' meeting.

The BAF is presented to each meeting of the Board of Directors with updates highlighted in blue. Updates are provided using only information which has already been presented as assurance at an appropriate forum.

Board or Committee (monitoring)

Non Executive Director Chair (of monitoring forum)

Clinical Lead (where applicable)

External Review or Assessment (eg Internal Audit review, CQC etc)

QAV is Board level monitoring more than annually

QAV is non-executive scrutiny

QAV is clinical leadership (if required)

QAV is impartial scrutiny

QAV is having a strategy in place to set direction

QAV is having a set of targets against which the function can be measured

QAV is a programme of work to monitor achievement against targets (this could be an annual cycle of business)

QAV is high profile reporting and review at each Board meeting

In 2011/12 a Quality Assurance Score (QAS) was included to indicate the robustness of the assurance measurements used. This highlights those areas where additional assurance measures may be required. The Quality Assurance Value (QAV)is set out below which explains the value of and rationale behind the assurance measure. The scoring is derived from the sum of points

allocated according to the number of the following mechanisms in place, with 1 point added for each. The maximum score is therefore 8; a score of 5 or less may indicate that further assurance is required:

Content

The Trust annually reviews its strategic goals, from which it then develops its corporate objectives. Both the strategic goals and corporate objectives are derived from the annual plan. The BAF cross references the relevant risk register associated with achievement of the objectives and details controls and assurances which are already in place. It also identifies any gaps in those

controls and assurances and responsibility for managing those gaps, or for providing positive assurance, is allocated to individuals, committees and action plans. The BAF is intended to be a dynamic document which is not fixed in time, although timescales are included and progress against them will be incorporated and reported upon. An additional column has been added to

demonstrate where external assurance has been provided, eg and Internal Audit review or regulatory inspection. In 2011/12 a Quality Assurance Score (QAS) was included to indicate the robustness of the assurance measurements used. This highlights those areas where additional assurance measures may be required. The Quality Assurance Value (QAV)is set out below which

explains the value of and rationale behind the assurance measure. The scoring is derived from the sum of points allocated according to the number of the following mechanisms in place, with 1 point added for each. The maximum score is therefore 8; a score of 5 or less may indicate that further assurance is required:

Reporting

Review

This BAF has been designed to provide Board members with the assurance they require that any risk to achievement of Trust objectives is managed, highlighting any gaps in controls, any mitigating action, and providing an ongoing record of assurance work undertaken by the Board, its committees, and the Directors' Group. An Annual Board Cycle will set the programme for information

to be presented to the Board of Directors at each meeting throughout the year and will help to support this process by ensuring that Board members receive the most appropriate information to enable them to fulfil their role. The same cycle is prepared for each committee of the Board of Directors.

M:\Board of Directors\Board Papers\2014-15\26 March 2015\Public\5. Final Board Assurance Framework 201415\Board Assurance Framework 2014 15 10 March 2015 1

Ref

Ty

pe

Objective

Risk Register

(Corporate)

Qu

ali

ty G

ov

ern

an

ce

Fra

me

wo

rk

CQC




Gaps in Controls

(including those



Audit Reviews) Ac

tio

n P

lan

s

De

ad

lin

e

Ex

ec

uti

ve

Se

nio

r M

an

ag

er

Mo

nit

ori

ng

Fo

rum

Assurance

Mechanism


in place

Qu

ali

ty A

ss

ura

nc

e

Sc

ore

(Q

AS

)

External

Assurance

(eg audits/

inspections)

BAF01-

14

Pati

en

t S

afe

ty a

nd

Exp

eri

en

ce5

APatient Experience

Patient Experience

Patient Engagement

Corporate 20

(Handover Delays)

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

; M

ea

su

rem

en

t

O6,

O16,

O17

Patient Experience Strategy and Policy

Patient Experience Reports

Patient Experience CQUIN and Plan

Patient Stories

Complaint Action Plan

Patient Engagement Programme (including Learning

Disability)

Focused Reviews

Deep Dives

Stakeholder Engagement

Plaudits

Patient ExperiencePatient Experience Deep Dive Executive Summary received at Board

Patient Experience Annual Report to Board in May

Parliamentary Health Service Ombudsman Referrals Reports to Q&G

Patient Experience and Engagement Strategy approved

Complaint management review by Directors' Group; updated Complaints Policy approved at Q&G; and new process

implemented from 1st October

Patient EngagementIncrease in plaudits received for staff in 2014/15 to date

National CQUIN for 2014/15 (Friends and Family Test for Patients) on target at end Q4

Patient stories to each meeting of the Board of Directors and Council of Governors

Accessibility (including Learning Disability) Programme approved at Q&G

Deep dive by Q&G in March - Learning Disability

Urgent Care Service patient surveys centralised to Patient Engagement team in March

No gaps identified

Pa

tie

nt

Ex

pe

rie

nc

e a

nd

En

ga

ge

me

nt

Str

ate

gy

Pla

n

Ac

ce

ss

ibil

ity

(in

clu

din

g L

ea

rnin

g D

isa

bil

ity

Pla

n)

31

/03

/20

15

Ex

ec

uti

ve

Dir

ec

tor

of

Nu

rsin

g a

nd

Go

ve

rna

nc

e

He

ad

of

Pa

tie

nt

Sa

fety

an

d R

isk

Qu

ali

ty a

nd

Go

ve

rna

nc

e C

om

mit

tee

Q&G Committee

NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Reports

8Green/Low Internal

Audit Report on

Complaints

BAF02-

14

Pati

en

t S

afe

ty a

nd

Exp

eri

en

ce4

Clinical Development

Medicines Management

Clinical Guidelines

Infection Prevention and

Control

N/A

Ca

pa

bil

itie

s a

nd

Cu

ltu

re;

Pro

ce

ss

an

d

Str

uc

ture

; M

ea

su

rem

en

t

O8, O9

& O16

Infection Control and Stroke Care Strategies

Medicines Management Strategy

Clinical Effectiveness Strategy

NICE Guidelines Compliance

Clinical Guidelines and Instructions

Clinical Effectiveness Group and Sub Groups

Clinical GuidelinesDeep dive by Q&G in May - Clinical Guidelines

New Clinical Development Manager post

Medicines ManagementMedicines Management Policy updated

Asset Management Solution - Medicines Management - module agreed

Deep Dive by Q&G in November - Medicines Management

Infection Prevention and ControlEbola Assurance Programme (led by Infection Control Lead)

Infection Prevention and Control Hand Decontamination Assurance to Q&G

Deep dive to Q&G in July - Infection Prevention and Control

PoliciesClinical Supervision; Appropriate Care Pathway; NICE, Resuscitation and Confirmation of Death policies approved at

Q&G

No gaps identified

Cli

nic

al

De

ve

lop

me

nt

Pro

gra

mm

e

Me

dic

ine

s M

an

ag

em

en

t P

lan

31

/03

/20

15

Ex

ec

uti

ve

Me

dic

al

Dir

ec

tor

De

pu

ty C

lin

ica

l D

ire

cto

r

Qu

ali

ty a

nd

Go

ve

rna

nc

e C

om

mit

tee

Q&G Committee

NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Reports

8

BAF03-

14

Pati

en

t S

afe

ty a

nd

Exp

eri

en

ce3

Clinical Audit and Research

National Research Metrics

Clinical Audits

Clinical Performance

Indicators

N/A

Ca

pa

bil

itie

s a

nd

Cu

ltu

re;

Pro

ce

ss

an

d

Str

uc

ture

; M

ea

su

rem

en

t

O4,

O16,

O21

Clinical Audit Strategy and Plans

National Research Metrics

National Benchmarking

Clinical Performance Indicators

Research and Audit Group

Audit Committee Review

Clinical Audit

Clinical Audit plan for 2014/15

Deep Dive to Q&G in July - Clinical Audit and Research

Pen CHORD research into ambulance demand presented to Directors

Annual Assurance Report to Audit Committee July 2014

No gaps identified

Cli

nic

al

Au

dit

An

nu

al

Pla

n

31

/03

/20

15

De

pu

ty C

lin

ica

l D

ire

cto

r

Re

se

arc

h a

nd

Au

dit

Ma

na

ge

r

Qu

ali

ty a

nd

Go

ve

rna

nc

e C

om

mit

tee

Q&G Committee

NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Reports

8

BAF04-

14

Pati

en

t S

afe

ty a

nd

Exp

eri

en

ce2

Patient Safety (including

Risk and Litigation)

Risk Management

Health, Safety and Security

Serious, Moderate, Adverse

Incidents

Claims

Safeguarding

N/A

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

; M

ea

su

rem

en

t

O7, O16

Risk Management Process

Risk Strategy and Policies

Risk Registers

Health, Safety and Security KPIs

Investigation Framework

Serious and Moderate Incident Action Plan

Adverse Incident Process

Duty of Candour and Being Open

Claims Process

Deep Dives

Audit Committee Review

Experiential Learning Forum

Safeguarding Policy

Safeguarding Operational Group

SafeguardingSafeguarding CQC Statement of Compliance March 2014; Peer Review; Annual Report to Q&G in May; updated

Safeguarding Policy approved at Q&G; Deep Dive to Q&G in September - Safeguarding; and bi-monthly Safeguarding

Operational Group; Safety Referral SOP; Safeguarding Training Strategy

Patient SafetySerious and Moderate Incident decision making process updated; Action Plan reviewed at Directors' Group;

Workshop in May 2014

LearningNew learning forum (Experiential Learning Forum) approved at Q&G in July - 4 meetings to date in 2014/15 reviewing:

non-conveyance; mental health and capacity; and health and wellbeing

Risk ManagementRisk Management Strategy update ratified at Board in July; Risk Process reviewed by Audit Committee in January;

deep dive to Q&G in March - Risk

Duty of CandourDuty of Candour update to Board July 2014; Duty of Candour Implementation Plan approved at Q&G; Venessa James

is Duty of Candour NED Lead; and new definition approved by Directors (based on final guidance);

Health, Safety and SecurityDeep Dive to Q&G in November - Physical Assaults (with additional review of staff struck by weapons - to January

meeting)

Deep dive to Q&G in March - Health, Safety and Security

ClaimsClaims process reviewed by Audit Committee in January (referred by Q&G); Legal Services Review undertaken

Medium/Amber

Internal Audit Report

on Station Visits

Ris

k a

nd

Lit

iga

tio

n W

ork

Pro

gra

mm

e

He

alt

h,

Sa

fety

an

d S

ec

uri

ty W

ork

Pro

gra

mm

es

Sa

feg

ua

rdin

g W

ork

Pro

gra

mm

e

31

/03

/20

15

Ex

ec

uti

ve

Dir

ec

tor

of

Nu

rsin

g a

nd

Go

ve

rna

nc

e

He

ad

of

Pa

tie

nt

Sa

fety

an

d R

isk

Sa

feg

ua

rdin

g M

an

ag

er

Qu

ali

ty a

nd

Go

ve

rna

nc

e C

om

mit

tee

Board of Directors

NED Chair

Clinical Lead

External Review

Strategy

KPIs

Action Plan

ICPR Reports

8Green/Low Internal

Audit Report on

Risk


Ref

Ty

pe

Objective

Risk Register

(Corporate)

Qu

ali

ty G

ov

ern

an

ce

Fra

me

wo

rk

CQC




Gaps in Controls

(including those



Audit Reviews) Ac

tio

n P

lan

s

De

ad

lin

e

Ex

ec

uti

ve

Se

nio

r M

an

ag

er

Mo

nit

ori

ng

Fo

rum

Assurance

Mechanism


in place

Qu

ali

ty A

ss

ura

nc

e

Sc

ore

(Q

AS

)

External

Assurance

(eg audits/

inspections)

BAF05-

14

Pati

en

t S

afe

ty a

nd

Exp

eri

en

ce1

Quality Governance

Monitor's Quality Governance

Framework

Monitor's Code of Governance

N/A

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

; M

ea

su

rem

en

t

O16

Board Memorandum on Quality Governance and

Implementation Plan

Quality, Governance and Risk Strategies

Risks to Quality

Board Leadership Skills and Knowledge

Cultural Review

Quality Roles and Accountabilities

Quality Performance Escalation

Board Engagement with Staff, Patients, Stakeholders

Quality Information Analysis

Policy and StrategyGovernance and Risk Management strategy updates ratified at Board in July

Quality Strategy reviewed by Executive Medical Director to incorporate requirements of Clinical Effectiveness Strategy

Anti-Bribery Policy updated

Assurance/ComplianceBoard Assurance Framework for 2014/15

Regulatory Framework for 2014/15

Board Memorandum on Quality Governance March 2014

Code of Governance Compliance Plan, and Third Party Schedule approved by Q&G; Code of Governance Plan update

and Annual Report Disclosure Statement to Q&G in March

Green/Low Internal Audit Report on Data Quality

Deep dive by Q&G in January - Governance Framework (re-presented in March)

Corporate Governance Statement and Quality Governance Statement to March Board

Board EngagementPaid staff meetings attended by Board

No gaps identified

Qu

ali

ty G

ov

ern

an

ce

Pla

n

31

/03

/20

15

Ex

ec

uti

ve

Dir

ec

tor

of

Nu

rsin

g a

nd

Go

ve

rna

nc

e

He

ad

of

Go

ve

rna

nc

e

Bo

ard

of

Dir

ec

tors Q&G Committee

NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

Not in ICPR

7

Green/Low Internal

Audit Report on

Data Quality

Green/Low Internal

Audit Report on

BAF

BAF06-

14

OC

orp

ora

te O

bje

cti

ves

Strategic Goal 1

Safe, Clinically Appropriate

Responses

Delivering high quality and

compassionate care to patients in

the most clinically appropriate,

safe and effective way

Corporate 20

(111 call answering)

Str

ate

gy

; P

roc

es

s a

nd

Str

uc

ture

O4, O8,

O9, O16

ACQIs

CPIs

CQUINs

Operational Performance (Red 1, 2 and A19)

OOH and 111 National Quality KPIs

PTS KPIs

Deep Dives

External Reviews

Winter Pressures

Quality Account Priorities

Infection Prevention and Control Standards

Medicines Management Standards

NICE Guidelines

JRCALC Guidelines

PTS KPIs

A&EAchievement of Red targets and A19 for Q1, Q2 2014/15. Not achieved for Q3 2014/15

Consolidated Action Plan and service improvement initiatives for 2014/15 to sustain Red performance. New Red 1

Plan in March 2015

OLM/CCG trajectory updates to Directors

CQUIN Programme agreed for 2014/15, to be monitored by commissioners - milestones met for Q1, Q2, Q3

North Division performance deep dive and roll out of My Performance tool for staff

Operational Resilience and Capacity Planning for 2014/15 from NHS England

UCSNHS 111 Performance Sustainability Plan for 2014/15, including new management structure and rota changes

Trust management of Tiverton MIU commenced 8th July 2014

Update by Health Education SW on National GP Recruitment to Directors

NHS 111 Quality Development Plan to Q&G in March

Weekly UCS Project Board

GeneralNHS 111, OOH, A&E, Right Care 2 Performance Updates to each Directors' Group

ACQIDeep Dive to Q&G in July - ACQI

NHS 111 Quality

Development Plan to

Q&G in January

Red and A19

performance met for

Q1, Q2 but not met

for Q3

(unprecedented

demand over

Christmas and New

Year periods - led to

Major Incident

Standby REAP5 -

level 2 SI)

Q4 performance

c/fwd to new BAF

Re

d 1

Ac

tio

n P

lan

Q4

NH

S 1

11

Qu

ali

ty D

ev

elo

pm

en

t P

lan

Le

ve

l 2

Ma

jor

Inc

ide

nt

Se

rio

us

In

cid

en

t

31

/03

/20

15

Dir

ec

tor

of

De

liv

ery

(s

ys

tem

s i

nd

ica

tors

)

Ex

ec

uti

ve

Me

dic

al

Dir

ec

tor

(cli

nic

al

ind

ica

tors

)

Dir

ec

tor

of

Op

era

tio

ns

De

pu

ty C

lin

ica

l D

ire

cto

r

Bo

ard

of

Dir

ec

tors Board of Directors

NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Reports

8

BAF07-

14

OC

orp

ora

te O

bje

cti

ves

Strategic Goal 2

Right People, Right Skills,

Right Values

Supporting and enabling greater

local responsibility and

accountability for decision making;

building a workforce of

competent, capable staff who are

flexible and responsive to change

and innovation

Corporate 20

(SME)

Corporate 20

(Operational Resources)

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

O12,

O13,

O14

HR and Organisational Development Reports:

Sickness, Induction, Appraisals Reports

Staff Survey Actions

Turnover

Cultural Engagement

Health & Wellbeing Strategy

Statutory, Mandatory, Essential Training

Establishment

Leadership/Management

Learning and Assessment

Continuing Professional Development

Deep Dives

EngagementOperational Strategic Away Day, April; Management Strategic Away Day, September; and Paid Staff Meetings held

across the Trust in November

DevelopmentDevelopment Pathway Workstream; CPD Website; Talent and Clinical Workforce Development Strategy - strategic

principles agreed at Directors' and Deputies Group; Our People Awards Policy approved

Sickness ReviewSickness Absence and Working Hours policies approved by Directors

Long Term Sickness/Accident Review to Q&G in January

TOIL Policy approved by Directors

Health and WellbeingHealth and Wellbeing information on intranet; and Health and Wellbeing forums launched across the Trust in January

Deep dive to Q&G in March - Public Sector Equality Duty

TrainingDeep Dive to Q&G in November - Training

GeneralThrice weekly Recruitment 'Gold Group' established

Amber/Medium


on Sickness

Management - report

to be revisited at the

request of the Audit

Committee

Operational

Resources

Corporate Risk

Register

25

SME Training

Corporate Risk

Register

20

(risks c/fwd to new

BAF)

HR

an

d W

ork

forc

e P

lan

s

31

/03

/20

15

Ex

ec

uti

ve

Dir

ec

tor

of

HR

an

d O

rga

nis

ati

on

al

De

ve

lop

me

nt

De

pu

ty D

ire

cto

r o

f H

R a

nd

Org

an

isa

tio

na

l D

ev

elo

pm

en

t

Bo

ard

of

Dir

ec


NED Chair

Clinical Lead Not Required

Strategy

External Review

KPIs

Action Plan

ICPR Reports

8

Amber/Medium

Internal Audit

Reports on

Recruitment

(actions

completed); and on

Sickness

Management -

report to be

revisited

Green/Low Internal

Audit Reports on

TUPE; and on

Public Sector

Equality duty

BAF08-

14

OC

orp

ora

te O

bje

cti

ves

Strategic Goal 3

24/7 Emergency and Urgent

Care

Influencing local health and social

care systems in managing

demand pressures and developing

new care models. Leading

emergency and urgent care

systems, providing high quality

services 24 hours a day, seven

days a week

Corporate 20

(Handover Delays)

Str

ate

gy

; P

roc

es

s a

nd

Str

uc

ture

; M

ea

su

rem

en

t

O6,

O10,

O16

A&E Business Plan

PTS Business Plan

UCS Business Plan

111 Minimum Data Set Requirements

Handover Delays

Crew Clear Delays

OOH Quality Requirements

Green Call Local KPIs

Right Care Two

Fleet (VOSA standards)

Deep Dives

Business Continuity and Resilience Plans

A&ESMT engagement with, and attendance at bi monthly commissioner Integrated Quality and Performance Management

Group meetings from May 2014; Quality and Performance Reports bi monthly; Demand Management Plan reviewed

at Directors' Group; and regular Right Care 2 Bulletin reports

Dispatch on Disposition pilot awarded to Trust

UCSSir Bruce Keogh visit to St Leonards; 111 Rota changes agreed for May 2014; SMT engagement with, and

attendance at UCS /111 commissioner Contract Review meetings from May 2014; Clinical Governance Reports

quarterly; Tiverton MIU under Trust management from 8 July 2014; Gloucester OOH Contract awarded to SWASFT

and mobilisation group established; and MoU with BASICs approved; UCS deep dive leading to development plan

New BusinessTendering Activity updates to Directors' Group

UCS Project Board (weekly), and mobilisation groups for each new contract

Amber/Medium


on UCS and 111

Implementation -

recommendations

being implemented

Handover Delays

Corporate Risk

Register

20

Call Answering

Performance

Corporate Risk

Register

20

UCS Contracts

Corporate Risk

Register

20

Re

d 1

Ac

tio

n P

lan

NH

S1

11

De

ve

lop

me

nt

Pla

n

31

/03

/20

15

Ch

ief

Ex

ec

uti

ve

Ex

ec

uti

ve

Dir

ec

tor

of

Nu

rsin

g a

nd

Go

ve

rna

nc

e

Dir

ec

tor

of

De

liv

ery

Dir

ec

tors

' G

rou

p

Board of Directors

NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Reports

8

Amber/Medium

Internal Audit

Report on Fleet

Management

Amber/Medium

Internal Audit

Report on UCS and

111

Implementation


Ref

Ty

pe

Objective

Risk Register

(Corporate)

Qu

ali

ty G

ov

ern

an

ce

Fra

me

wo

rk

CQC




Gaps in Controls

(including those



Audit Reviews) Ac

tio

n P

lan

s

De

ad

lin

e

Ex

ec

uti

ve

Se

nio

r M

an

ag

er

Mo

nit

ori

ng

Fo

rum

Assurance

Mechanism


in place

Qu

ali

ty A

ss

ura

nc

e

Sc

ore

(Q

AS

)

External

Assurance

(eg audits/

inspections)

BAF09-

14

OC

orp

ora

te O

bje

cti

ves

Strategic Goal 4

Creating Organisational

Strength

Continue to ensure the Trust is

sustainable, maintaining and

enhancing financial stability. In

this way the Trust will be capable

of continuous development and

transformational change by

strengthening resilience, capacity

and capability

Corporate 20

(Operational Resources)

Corporate 20

(UCS Contracts)

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

; M

ea

su

rem

en

t

O16,

O21

Environmental Work Programme

Carbon Emissions Reduction Strategy

CQC Registration Compliance

NHS Constitution Compliance (see BAF06-14)

COSRR (Monitor RAF) (see BAF04-14)

GRR (Monitor RAF) (see BAF04-14)

IG Toolkit Compliance

Succession Planning

Leadership and Management (see BAF13-14)

Board Skills and Leadership (see BAF11-14)

Strategic Workforce Planning

Business Continuity

IM&T Service Delivery for Support Functions

Delivery of Trust Programmes

Service Development

Information Flows - Internal/External

Deep Dives

EnvironmentDeep Dive by Q&G in May - Environmental Work Programme and Trust Carbon Footprint

Service Development/ConsolidationSMT attendance at bi monthly A&E/PTS commissioner Integrated Quality and Performance Management Group

meetings from May 2014; SMT attendance at UCS /111 commissioner Contract Review meetings from May 2014;

Clinical Hub and North Consolidation Plan approved at Directors; Business Development Team enhanced

PlanningPESTLE analysis undertaken at May Board

IM&T Service DeliveryCorporate Records Management Policy revised and approved; IM&T A&E and Admin Telephony Project Proposal

approved at Directors

GeneralIndustrial Action Resilience Plan in place for October and November

No gaps identified

En

vir

on

me

nta

l P

lan

NH

S C

on

sti

tuti

on

Pla

n

31

/03

/20

15

Ex

ec

uti

ve

Dir

ec

tor

of

Nu

rsin

g a

nd

Go

ve

rna

nc

e

All

Dir

ec

tors

' G

rou

p

Board of Directors

NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Reports

8

BAF10-

14

Le

ad

ers

hip

Board Capacity and

CapabilityN/A

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

O16

Board Development

Board Register of Interests (no material conflict)

Code of Conduct for Directors

Executive and Non-Executive Appointments

Non-Executive Appraisals

Scrutiny of Council of Governors

Declarations/Codes of ConductDirectors' Interests and Non-Executive Directors' declarations of independence confirmed, end 2013/14; Codes of

Conduct for Governors and Directors

Board CommitteesAudit Committee terms of reference updated; Charitable Funds Committee terms of reference updated; Q&G

Committee self assessment May 2014, and review of working in July; Directors', and Directors' and Deputies group

cycle of business agreed 2014/15

ExecutivesExecutive Directors of HR and Organisational Development, and Nursing and Governance joined the Board

Non-ExecutivesNon-Executive Director, Venessa James, joined the Board; NEDs attending SI Reviews

Board DevelopmentPresentation to Board from HealthWatch Gloucestershire

Policy and ProcessEmergency Powers - Use of Seal

No gaps identified

Bo

ard

De

ve

lop

me

nt

Pla

n

31

/03

/20

15

Ch

ief

Ex

ec

uti

ve

Tru

st

Se

cre

tary

Bo

ard

of

Dir

ec


NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

Not in ICPR

7

BAF11-

14

Le

ad

ers

hip

National Engagement

Board National Engagement

Responses to Consultations

N/A

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

O16,

O17

Keogh Report and any Action Plan

Francis Report Action Plan

Review of National Reports

Staff Engagement

Patient Engagement

Cultural Development Plans

Patient Safety and Experience Reports

Leadership Training

Consultation Responses

National VisitorsSir Bruce Keogh visit to St Leonards; visit to Trust HQ by Una O'Brien, Permanent Secretary, DoH in November; visit

to St Leonards by Professor Keith Willett

National ConsultationsTrust responses submitted to consultation on Duty of Candour, and Fit and Proper Persons Test; and consultation on

National Audit Office - Code of Audit Practice

National InputAACE submissions to DoH on ambulance trust implementation of Friends and Family Test for Patients; Liaison with

CQC and input to the development of the 111 Provider Handbook; Board attendance at the Ambulance Leadership

Forum annually

Staff EngagementImplementation of Friends and Family Test for Staff, and for Patients

Paid Staff Meetings, November

Patient EngagementPatient stories at each Board, and Council of Governors' meeting; Patient Safety and Experience reports to each

Q&G and Board

No gaps identified

Fra

nc

is A

cti

on

Pla

n

31

/03

/20

15

Ch

ief

Ex

ec

uti

ve

Tru

st

Se

cre

tary

He

ad

of

Go

ve

rna

nc

e

Bo

ard

of

Dir

ec


NED Chair


Strategy

External Review

KPIs

Action Plan

Not in ICPR

7

BAF12-

14

Le

ad

ers

hip

Management Capacity and

CapabilityN/A

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

O16

Strategic Away Days

Associate/Deputy Directors' Group

Performance Management Framework

Manager Development

Quality and Governance Committee Highlight Reports

Code of Conduct for Staff

DevelopmentOperational Strategic Away Day, April; Management Strategic Away Day in September; Development Pathway

Workstream; CPD Website; Performance Management Framework reviewed and updated by Directors; Talent and

Clinical Workforce Strategy

Code of ConductCode of Conduct for Staff updated

Organisational StructureUCS management structure reviewed and enhanced

HR structure review

No gaps identified

Ta

len

t a

nd

Cli

nic

al

Wo

rkfo

rce

Str

ate

gy

31

/03

/20

15

Ex

ec

uti

ve

Dir

ec

tor

of

HR

an

d O

rga

nis

ati

on

al

De

ve

lop

me

nt

De

pu

ty D

ire

cto

r o

f H

R

Qu

ali

ty a

nd

Go

ve

rna

nc

e C

om

mit

tee

Q&G Committee

NED Chair


Strategy

External Review

KPIs

Action Plan

Not in ICPR

7


Ref

Ty

pe

Objective

Risk Register

(Corporate)

Qu

ali

ty G

ov

ern

an

ce

Fra

me

wo

rk

CQC




Gaps in Controls

(including those



Audit Reviews) Ac

tio

n P

lan

s

De

ad

lin

e

Ex

ec

uti

ve

Se

nio

r M

an

ag

er

Mo

nit

ori

ng

Fo

rum

Assurance

Mechanism


in place

Qu

ali

ty A

ss

ura

nc

e

Sc

ore

(Q

AS

)

External

Assurance

(eg audits/

inspections)

BAF13-

14

Le

ad

ers

hip

Audit Committee

Role and Duties

N/A

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

; M

ea

su

rem

en

t

O16

HR and Organisational Development Reports:

Sickness, Induction, Appraisals Reports

Staff Survey Actions

Turnover

Cultural Engagement

Health & Wellbeing Strategy

Statutory, Mandatory, Essential Training

Establishment

Leadership/Management

Learning and Asse

Local Counter FraudLCFS Plan for 2014/15

Committee GovernanceCommittee Terms of Reference revised

NED Chris Kinsella appointed as Audit Committee Chair

Presentation to CoG on work of Committee, December

Internal AuditInternal Audit Plan for 2014/15 and Annual Report for 2013/14

External AuditAudit Unqualified Opinion on Annual Accounts; Going Concern status confirmed at Board; Annual Accounts and

Letter of Representation; Annual Governance Statement; Quality Report and Account and Letter of Representation

signed off; Feedback provided by Council of Governors on appointment of External Auditors

Process ReviewBoard Assurance Framework for 2014/15 amended; Clinical Audit Annual Assurance Report received July 2014;

NHS Protect Annual Fraud Self Review and Organisational Crime Profile; Risk Process Review, January; Claims

Process Review, January

Assurance ReviewAudit Committee request for Internal Audit Report on Sickness Management to be revisited; Mid Year Review of

Internal Plan changes approved; Changes to Management of Internal Audit Recommendations approved;

Recommendation of CQC Outcomes for Review approved

No gaps identified

Au

dit

Co

mm

itte

e A

nn

ua

l C

yc

le

31

/03

/20

15

De

pu

ty C

hie

f E

xe

cu

tiv

e/

Ex

ec

uti

ve

Dir

ec

tor

of

Fin

an

ce

All

Bo

ard

of

Dir

ec


NED Chair


Strategy (Audit Code)

External Review

KPIs (ToRs)

Action Plan

Not in ICPR

7

BAF14-

14

Le

ad

ers

hip Quality and Governance

Committee

Role and Duties

N/A

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

; M

ea

su

rem

en

t

All

Deep Dives:

ACQIs; Training and Education; Infection Prevention &

Control; Information Governance; Medicines

Management; Responders; Safeguarding; HR and

Organisational Development; Governance; Risk

Management; Compliance; Patient Experience; Health,

Safety & Security; Equality and Diversity

Quality and Governance Annual Reports

Quality and Governance Highlight Reports

Self Assessment

Deep DivesMay - Environmental Work Programme and Trust Carbon Footprint; Clinical Guidelines

July - ACQI; Clinical Audit and Research; Infection Prevention and Control

September - Safeguarding; HR and Wellbeing

November - Medicines Management; Training; Physical Assaults

January - CQC Compliance, Governance Framework, Community Responders

March - Health, Safety and Security, Governance, Learning Disability, Risk and Claims, Public Sector Equality Duty

ComplianceInformation Governance Level 2 Compliance, 2013/14; Safeguarding CQC Statement of Compliance March 2014

Annual ReportsMay - Safeguarding; Patient Experience

Committee GovernanceCommittee self assessment May 2014; Work of Committee presented to Council of Governors May 2014; Revised

working of Q&G implemented from July Committee

Strategy and PolicyInformation Governance Strategy updated; Updates to Governance and Risk Management strategies approved;

Updates to Corporate Records Management, and Serious Incident policies approved

Work PlansNew Learning Disability/Accessibility Work Plan approved; Duty of Candour Implementation Plan approved

No gaps identified

Qu

ali

ty a

nd

Go

ve

rna

nc

e C

om

mit

tee

An

nu

al

Cy

cle

31

/03

/20

15

Ex

ec

uti

ve

Dir

ec

tor

of

Nu

rsin

g

an

d G

ov

ern

an

ce

All

Bo

ard

of

Dir

ec

tors

Board of Directors

NED Chair

Clinical Lead

Strategy

External Review Not

Required

KPIs (ToRs)

Action Plan

Not in ICPR

7

Internal Audit

Review March

2014 -

Medium/Low

pending completion

of actions

(confirmed

completed, May

2014)

BAF15-

14

Le

ad

ers

hip

Council of Governors

Role and Duties

N/A

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

;

Pro

ce

ss

an

d S

tru

ctu

re;

Me

as

ure

me

nt

O16

Trust Constitution and Standing Orders

Code of Conduct for Governors

Annual Cycle of Business for Council of Governors

Fulfilment of Statutory Duties

Governor Development

Annual Members' Meeting

Governor Statutory DutiesQuality Report Indicator chosen for audit by CoG - dignity, privacy and respect [later amended to ROSC at the

auditors' request]; Non-Executive Director appointed by Governors in May 2014; CoG consulted on Quality Account

priorities for 2014/15; Lead and Deputy Lead Governors appointed April and September 2014; Remuneration and

Recommendations Panel appointed; Council of Governors'/Members' views on the Trust Annual Plan to May Board;

Non-Executive Director appraisal process reviewed

Feedback provided to Audit Committee on appointment of External Auditors

Board ReportsNon-Executive Director reports to each Council meeting from April 2014; CEO Trust Performance Report to each

Council meeting from April 2014; Work of Q&G Committee presented to Council April 2014; Work of Audit

Committee and FIC presented to Council in December; Patient Experience Overview presentation to Council

No gaps identified

Sta

tuto

ry D

uti

es

Fra

me

wo

rk

Co

un

cil

of

Go

ve

rno

rs' A

nn

ua

l C

yc

le

31

/03

/20

15

Ch

ief

Ex

ec

uti

ve

He

ad

of

Co

mm

un

ica

tio

ns

Tru

st

Se

cre

tary

Bo

ard

of

Dir

ec


NED Chair

Clinical Lead

Strategy

External Review

KPIs (statutory duties)

Action Plan

Not in ICPR

8

BAF16-

14

Le

ad

ers

hip Finance and Investment

Committee

Role and Duties

N/A

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

; M

ea

su

rem

en

t

O16

Business Cases

Tenders

Financial Plans

MAVIS

Financial Plans and ContractsA&E Contract position and Financial Plan for 2014/15; Draft Commercial Principles; Revised Capital Budgets

approved; Draft 5 year plan reviewed at FIC; Capital Expenditure Reprofile 2014/15 and Reference Cost Submission

for Q1 approved

Mitigating PlansMAVIS reviews

Strategy and PolicyEstates and Facility Strategy approved

Committee GovernanceBusiness Development Steering Group established; Draft FIC Annual Work Programme approved; FIC Terms of

Reference reviewed July 2014; FIC Annual Review of Effectiveness noted July 2014; Presentation on work of

Committee to CoG

GeneralContinuity of Services Asset Register annual review

Business CasesNorth Clinical Hub Business Case options agreed at FIC and approved at Directors'; Telephony Business Case

options agreed at FIC and approved at Directors'; Implementing NHS Pathways Trustwide business case approved by

Directors; Vital Signs Monitoring (North) Business Case approved; Procurement of Croyden Street Business Case

approved; Clinical Hub HS Pathways Business Case approved; Clinical Hub Programme - Implementing Trustwide

CAD in A&E Business Case approved

No gaps identified

Fin

an

ce

an

d I

nv

es

tme

nt

Co

mm

itte

e A

nn

ua

l C

yc

le

31

/03

/20

15

De

pu

ty C

hie

f E

xe

cu

tiv

e/

Ex

ec

uti

ve

Dir

ec

tor

of

Fin

an

ce

De

pu

ty D

ire

cto

r o

f F

ina

nc

e

Bo

ard

of

Dir

ec

tors

Board of Directors

NED Chair


Strategy

External Review Not

Required

KPIs (ToRs)

Action Plan

Not in ICPR

7


Ref

Ty

pe

Objective

Risk Register

(Corporate)

Qu

ali

ty G

ov

ern

an

ce

Fra

me

wo

rk

CQC




Gaps in Controls

(including those



Audit Reviews) Ac

tio

n P

lan

s

De

ad

lin

e

Ex

ec

uti

ve

Se

nio

r M

an

ag

er

Mo

nit

ori

ng

Fo

rum

Assurance

Mechanism


in place

Qu

ali

ty A

ss

ura

nc

e

Sc

ore

(Q

AS

)

External

Assurance

(eg audits/

inspections)

BAF17-

14

Co

mp

lia

nc

e

Monitor Provider Licence

Risk Assessment Framework

Corporate 20

(Performance)

Corporate 20 (Operational

Resource)

All O16

Quarterly Submissions to Monitor on Continuity of

Services and Governance Risk Ratings (Risk

Assessment Framework)

Monitor Published Risk Ratings

Corporate Governance Statement

Code of Governance Compliance

Board Memorandum on Quality Governance

Third Party Body Schedule

Council of Governors' Statutory Duties

Access Targets and Outcomes (Category A)

Learning Disability Compliance

CQC compliance

Third Party Reports

Executive Turnover

Staff Satisfaction

Submissions to MonitorQ1, Q2, Q3 2014/15 confirmed by Monitor as Governance Green Risk Rating and Continuity of Service Rating of 4

Annual Self-Certifications including Corporate Governance Statement approved and submitted to Monitor

Access and Outcome Targets and Indicator Compliance and AssuranceAchievement of Red targets and A19 for Q1, Q2 but not for Q3 2014/15; Learning Disability Indicator monitored by

Q&G; Consolidated Action Plan and service improvement initiatives for 2014/15 to sustain Red performance; CQC

Inspection Report - no recommendations (March 2014); No Executive or Non-Executive vacancies; Third Party Body

Schedule to Q&G in September; Code of Governance Action Plan to Q&G in September; New Learning

Disability/Accessibility Work Plan approved by Q&G; Corporate Governance and Quality Governance statements to

Board in March; Code of Governance Disclosure Statement to Q&G in March

See BAF06-14 above

Re

d 1

Ac

tio

n P

lan

Le

arn

ing

Dis

ab

ilit

y P

lan

Qu

ali

ty G

ov

ern

an

ce

Fra

me

wo

rk P

lan

31

/03

/20

15

Ex

ec

uti

ve

Dir

ec

tor

of

Nu

rsin

g a

nd

Go

ve

rna

nc

e

He

ad

of

Go

ve

rna

nc

e

Bo

ard

of

Dir

ec


NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Report

8

BAF18-

14

Co

mp

lia

nc

e Care Quality Commission

Registration

Ongoing Compliance, No

Compliance Conditions

N/A All All

Compliance with Individual Outcomes

Registered for 3 Regulated Activities

Outcome of any inspections

Inspections and ReviewsCQC Inspection in February 2014 - no compliance issues

OOH inspection preparedness undertaken in July

CQC relationship meetings with Trust Compliance Team

RegistrationStatement of Purpose amended to include minor injury units

AssurancePositive view of SWASFT in national CQC Hear and Treat survey

Deep dive by Q&G in January - CQC Compliance

Briefings and GuidanceCQC New Regulation Report to Q&G in September; Recommendation of CQC Outcomes for Review by Internal

Audit approved; Duty of Candour implemented by Patient Safety team; Fit and Proper Persons Test to be added to

Code of Conduct for Directors; Trust meeting with SCAS inspection team to understand the new inspection process

No gaps identified

Co

mp

lia

nc

e W

ork

Pro

gra

mm

e

31

/03

/20

15

Ex

ec

uti

ve

Dir

ec

tor

of

Nu

rsin

g a

nd

Go

ve

rna

nc

e

Co

mp

lia

nc

e M

an

ag

er

Qu

ali

ty a

nd

Go

ve

rna

nc

e C

om

mit

tee

Q&G Committee

NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Reports

8

Positive CQC

Inspection in

February 2014 - no

compliance

conditions

BAF19-

14

Co

mp

lia

nc

e

NHS Constitution Corporate 20

(SME)

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

All

NHS Constitution Action Plan

Friends and Family Test

Staff Engagement

Patient Engagement

NHS Staff Survey

Code of Conduct for Staff

Health and WellbeingCentralised return to work process for 2014/15; back pain audit in May 2014; Health and Wellbeing area on intranet;

Health and Wellbeing Forums launched across Trust;

Patient ExperienceFriends and Family Test Patient CQUIN implemented in 2014/15 by Patient Engagement team;

Patient Experience Annual Report in May 2014

Staff ExperienceFriends and Family Test Staff introduced in 2014/15 by HR; Code of Conduct for Staff updated; NHS Staff Survey

Management Report to Directors; Car parking review and improved system at Trust HQ; NHS Staff Survey

presentation to Council of Governors in July; Appraisal performance monitored by Q&G; Our People Awards Policy

approved

No gaps identified

Sta

ff S

urv

ey

Lo

ca

l A

cti

on

Pla

n

31

/03

/20

15

Ex

ec

uti

ve

Dir

ec

tor

of

HR

an

d O

rga

nis

ati

on

al

De

ve

lop

me

nt

Tru

st

Se

cre

tary

Qu

ali

ty a

nd

Go

ve

rna

nc

e C

om

mit

tee

Q&G Committee

NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Report

8

BAF20-

14

An

nu

al

Pla

nn

ing

an

d R

ep

ort

ing

Annual PlanningN/A

Pro

ce

ss

an

d S

tru

ctu

re;

Me

as

ure

me

nt

O16

Forward Plan

Financial Plan

Service Developments

Quality Impact Assessments

Service Line Business Plans

Enabling Strategies

Budget Setting

MAVIS

Capital Programme

Cost Improvement Plan

IBP2

Quality Account

Internal Audit Reviews

Council of Governor Feedback

Monitor Published Risk Ratings

Corporate Objectives


Planning and Performance Meetings

Strategic Goals and Corporate ObjectivesCorporate Objectives approved for 2014/15

Forward PlanningForward Plan 2014/15 and 2015/16

Cost Improvement ProgrammeGreen/Low Internal Audit Report on Cost Improvement Plans

Capital Expenditure ReforecastingCapital Expenditure Reforecasts to Monitor in Q1, Q2, and Q3

No gaps identified

Co

st

Imp

rov

em

en

t P

lan

Re

d 1

Ac

tio

n P

lan

An

nu

al

Ac

co

un

tab

ilit

y A

gre

em

en

ts

31

/03

/20

15

De

pu

ty C

hie

f E

xe

cu

tiv

e/

Ex

ec

uti

ve

Dir

ec

tor

of

Fin

an

ce

Bu

sin

es

s P

lan

nin

g M

an

ag

er

Fin

an

ce

& I

nv

es

tme

nt

Co

mm

itte

e

F&I Committee

NED Chair

No Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Reports

7

Green/Low Internal

Audit Report on

Cost Improvement

Plans


Ref

Ty

pe

Objective

Risk Register

(Corporate)

Qu

ali

ty G

ov

ern

an

ce

Fra

me

wo

rk

CQC




Gaps in Controls

(including those



Audit Reviews) Ac

tio

n P

lan

s

De

ad

lin

e

Ex

ec

uti

ve

Se

nio

r M

an

ag

er

Mo

nit

ori

ng

Fo

rum

Assurance

Mechanism


in place

Qu

ali

ty A

ss

ura

nc

e

Sc

ore

(Q

AS

)

External

Assurance

(eg audits/

inspections)

BAF21-

14

An

nu

al

Pla

nn

ing

an

d R

ep

ort

ing

Annual Report and

Accounts

Annual Report

approved by the Board of

Directors and submitted to

Monitor

N/A

N/A O16

Annual Governance Statement (and Head of Internal

Audit Opinion)

Audit Committee Sign Off

Quality Account

Auditors' Annual Governance Report

Going Concern

Annual Accounts

Charitable Funds Accounts

Code of Governance Disclosures

Annual Report and Accounts

Code of Governance Disclosure Statement to Q&G in March

Annual Accounts and Letter of Representation; Annual Governance Statement; Quality Report and Account and

Letter of Representation approved at May Board

No gaps identified

An

nu

al

Re

po

rt P

lan

30

/06

/20

14

Ch

ief

Ex

ec

uti

ve

He

ad

of

Co

mm

un

ica

tio

ns

Tru

st

Se

cre

tary

Dir

ec

tors

' G

rou

p

Directors' Group

No NED Chair


Strategy

External Review

KPIs

Action Plan

ICPR Reports

7

Internal Audit

Review of Financial

Systems

Green/Low

BAF22-

14

An

nu

al

Pla

nn

ing

an

d R

ep

ort

ing

Quality Account

Quality Account and Report

approved by Board of Directors

and submitted within Annual

Report

N/A

Str

ate

gy

; C

ap

ab

ilit

ies

an

d C

ult

ure

; P

roc

es

s a

nd

Str

uc

ture

; M

ea

su

rem

en

t

O16

Quality Account

Quality Report

External Audit Opinion

Stakeholder Consultation

CQUIN Programme

Quality Highlight Reports

Quality Account for 2014/15 approved and submitted to Monitor

Quality Highlight and Exception Reports to each Q&G

CQUIN programme for 2014/15 approved

CQUIN milestones met for Q1, Q2, Q3 and confirmed by A&E commissioners

CQUINs for 2015/16 drafted with commissioners

UCS CQUIN delays at

end of Q3

CQ

UIN

s

30

/06

/20

14

De

pu

ty C

lin

ica

l D

ire

cto

r

Co

mp

lia

nc

e M

an

ag

er

Qu

ali

ty a

nd

Go

ve

rna

nc

e C

om

mit

tee

Q&G Committee

NED Chair

Clinical Lead

Strategy

External Review

KPIs

Action Plan

ICPR Reports

8External Audit

Review of Quality

Report

BAF23-

14

An

nu

al

Pla

nn

ing

an

d R

ep

ort

ing

Performance Management

Framework

Corporate 20

(Performance)

Corporate 20

(Activity)

Ca

pa

bil

itie

s a

nd

Cu

ltu

re;

Pro

ce

ss

an

d S

tru

ctu

re;

Me

as

ure

me

nt

O16

Performance Management Framework

Deputy Director Working Groups

Planning and Performance Reviews

Annual Accountability Agreements

Personal Appraisal Development Reviews


Performance Management Framework reviewed and updated by Directors

Restriction of Practice Policy revised and approved

Planning and Performance Reviews undertaken with individual Directors

ICPR presented to each Board meeting

No gaps identified

An

nu

al

Ac

co

un

tab

ilit

y A

gre

em

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Page 1 of 4


Title: Data Quality Report – Quarter 3

Prepared by: Phil Jones, Information Manager

Presented by: Francis Gillen, Executive Director of IM&T

Main aim: The purpose of this report is to update the Board on Data Quality Activities internal to and external to the Trust in support of the services we provide

Recommendations: The Trust Board of Directors is asked to note the content of this paper and take assurance from the on-going Trust activities in respect to Data Quality

Previous Forum: N/A



BAF04-14 BAF05-14 BAF06-14 BAF08-14 BAF14-14 BAF21-14 BAF23-14

Directorate Business Plans

Implications



Page 2 of 4

Data Quality Report

1. Introduction

1.1 This paper is provided for information and assurance, reporting position against Data Quality (DQ) returns and the general progress of key Data Quality activities within the Trust.

2. Governance

2.1 Information Assurance Steering Group The Information Assurance Steering Group (IASG) provides a forum to focus on

the implementation and management of effective Information Assurance within the Trust.

This covers not only processes within the Trust but configuration and

maintenance of its critical business systems. There has been a successful major project this year to improve the efficacy of

the IASG driven by IM&T. The meetings are a forum where people across the trust can raise DQ issues in a positive environment where the actions can be tracked. The meeting is becoming a focal point to improve data quality across the trust and provide a voice to people with DQ concerns so they can be safely dealt with in a structured and corporate way.

The Information Assurance Steering Group (chaired by the Executive Director

for IM&T) is scheduled to meet quarterly. The last meeting was held on the 15th of January 2015 and the next meeting is scheduled for the 25th of March 2015.

3. Service Line Reporting

3.1 The table and narrative below outlines the maturity of our internal Trust data Quality framework as of February 2015. This reflects reporting validations against all major data-sets incorporated within the Trust Integrated Corporate Performance Report excluding finance which is subject to governance and audit

2014-15

Service Line/Function

Status Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

A&E Ongoing

111 Ongoing

UCS Ongoing

PTS Ongoing

Nursing & Governance

Ongoing

HR & Organisational Development

Ongoing

Fleet & Logistics

Ongoing


Page 3 of 4

Procedures are in place to ensure appropriate escalation within Service lines to Director Level upon incident or issue. As a result of the IASG project this year engagement across the 7 service lines/functions has been improving and we are now in receipt fo regular monthly returns from the 111 service. Engagement from the UCS service remains a challenge as does engagement from PTS. This is largely down to operational pressures and management/admin capacity. Through the period from May-14 to Sep-14 Data Quality reporting was deferred due to the AACE commissioned national standards review and audit an exercise the trust were instrumental in delivering. A draft report of the national findings is now available within the Trust and will inform the ongoing Data Quality audit which is currently underway and due to be completed by early April. In summary the national reflected positively on the governance associated with the A&E returns.

4. Key Activities and Events

4.1 Trust Wide Reporting

Work continues to improve the Trust’s online reporting systems to provide a unified online reporting system with new ways to view the data. A review of all A&E service line reporting is integral to the CAD replacement project which is ongoing and due to complete in the September timeframe. All commissioner reports for service lines were provided within agreed timescales over the last quarter. A status table will be provided in future reports.

4.2 ACQI – 2014/2015 SWASFT has submitted all monthly Returns by the required date. 4.2.1 ACQI System Indicators Sub Group This group had an exceptional meeting on the 4th of February 2015 to cover in

detail the technical elements of the data provision for next year’s A&E contract and address residual inconsistencies between divisional following the acquisition.

This item was first aired in the IASG meeting and the detail is being dealt with in the ACQI Sub Group.

4.3 111 and GP OOH Reporting


Page 4 of 4

Recently a unified 111 report has become available. Reporting preparations for Gloucestershire OOH are progressing well and will result in further online management reporting for key OOH KPIs.

4.4 Audit South West Audit An audit of the trust’s data is in currently in progress with an anticipated

completion date of early April in support of wider year end activities. The draft terms of reference for the audit have been produced and are being assessed. Given the large number of audits on A&E data in the last year the focus is likely to be UCS.

5. Recommendations

Members are requested to note the content of this paper and take assurance from the on-going Trust activities in respect to Data Quality.

Trust Public Board of Directors Meeting, 26 March 2015

Page 1 of 4

Trust Public Board of Directors Meeting Date 26 March 2015

Title: Information Governance Toolkit - Level 2 Compliance 2014/15

Prepared by: Debbie Bridge, Information Governance Manager

Presented by: Francis Gillen, Executive Director of IM&T

Main aim: To provide an update on the information governance agenda

Recommendations: That the report be noted.




BAF01-14 BAF04-14 BAF06-14 BAF07-14 BAF08-14 BAF14-14 BAF21-14 BAF22-14 BAF23-14


IM&T

Implications


- Information Governance Toolkit - Data Protection Act 1998 - Freedom of Information Act 2000 - Public Records Act 1958 and 1967 - Protection of Freedoms Act 2012. - Records Management: NHS Code of Practice


Page 2 of 4

Information Governance Report

1. Information Governance Toolkit – Level 2

1.1 Activities continue in the final quarter in support of the Trust IG Toolkit return. We remain on target to meet at minimum the level 2 standard for all 35 requirements. The associated work programme monitored centrally by the IG Team covers the work required by the information governance team and other functions across the Trust. The Toolkit covers a very broad range of issues including the general management and governance of the Trust held information, patient record management, staff record management, confidentiality, information security, data quality, training and business continuity.

1.2 Work to support the toolkit includes:

The review and approval of policies and procedures

Completion of information risk assessments on information assets

Completion of data flows of personal and sensitive information

Corporate records audits

Confidentiality audits

IG Training

1.3 The Information Governance team are now at full establishment with the appointment of an Assistant Information Governance Manager who started on the 1st March 2015. Interim contract resource will remain in place for a further 4 month period to support handover.

2. Freedom of Information (FoI) Act Requests

2.1 The volume of FoI requests received has shown a decrease on comparative YTD figures for the previous year. Cumulatively we have had 203 requests for 2014/2015 Year to Date (YTD) to the end of February, compared to 252 for 2013/2014 for the same period, a reduction of approximately 20%. Of the requests completed since the 1st April 2014, 97.4% of requests have been replied to within the 20 day legislative time limit against a target of 95%. In the lead up to the general election we are anticipating an increase in requests.

2.2 Analysis of the type of requests YTD show a broad range of topics, with small

groups of requests around some issues e.g. handover times, use of agency staff, private ambulances, but nothing that significantly dominates. The FOI Act ‘celebrated’ 10 years on 01 January 2015. Despite continuing concerns over the cost to the public sector, the perceived misuse of the Act by commercial organisations and private sector organisations who provide public services not


Page 3 of 4

being subject to the FOIA it is set to continue in its current form for the foreseeable future.

2.3 To reduce the impact of FOI requests we are looking to streamline the process of

dealing with requests. The Risk department is currently putting together a business case for the introduction of enhanced incident management software. It is proposed that FOI requests and Data Protection disclosures will be logged on the same system as Risk information to increase efficiency and tracking across the Trust.

3. Data Protection Act (Subject Access Request) Disclosures

3.1 Demand for requests to the end of February is slightly down on the previous year. For April 2013-February 2014 there have been 1773 requests against 1835 for the same period. Of note is an increase in subject access requests from members of staff. The internal target is to respond to 95% of requests for records within 40 days (this excludes providing police statements which invariably require scheduled interviews). For April 2014 to February 2015, the team achieved 98.9% against the 95% target.

3.2 As mentioned above the introduction of enhanced management software would

assist in streamlining the processes. Some requests will continue to take longer to deal with, as due to the acquisition and changes to technology and services, multiple data sources need to be accessed to formulate a response.

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

Trust 12/13 11 18 14 14 9 22 11 23 11 21 26 19

Trust 13/14 27 13 18 29 29 19 24 31 16 21 25 14

Trust 14/15 19 22 13 24 10 12 19 25 14 23 22

0

5

10

15

20

25

30

35

Monthly Totals of FoI Requests received


Page 4 of 4

4. Recommendation

4.1 That the report be noted.

Debbie Bridge Information Governance Manager

0

25

50

75

100

125

150

175

200

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

Monthly Totals of Subject Access Requests received

E&W 2010/11

E&W 2011/12

E&W 2012/13

Trust 2013/14

Trust 2014/15

Board of Directors Meeting, 26 March 2015

Page 1 of 20


Title: Board Assurance - Monitor Corporate Governance Statement and Update on Quality Governance Requirements in the Annual Report


Presented by: Jenny Winslade, Executive Director of Nursing and Governance

Main aim: To provide assurance and to support the signing of the Corporate Governance Statement for inclusion in the Trust Annual Report

Recommendations: Board members are requested to consider the appended statements and associated assurance and confirm their approval for the Corporate Governance Statement to be signed and included in the Trust Annual Report for 2014/15; and subsequently to be submitted as a self- certification to Monitor. They are also required to consider and approve the statement on governance of quality for inclusion in summary within the Trust’s Annual Governance Statement

Previous Forum: This paper has not been presented to any other forum


Board Assurance Framework BAF05-14 BAF17-14


Nursing and Governance

Implications Monitor’s licensing regime

Monitor’s Annual Reporting Manual 2014/15


Page 2 of 20

Corporate Governance Statement, and Statement on Governance of Quality 1.1. Corporate Governance Statement

1.1.1 To comply with the governance conditions of their licence, NHS foundation trusts are

required to provide a statement (the corporate governance statement) setting out:

any risks to compliance with the governance condition; and

actions taken or being taken to maintain future compliance.

1.1.2 Where facts come to light that could call into question information in the corporate governance statement, or indicate that an NHS foundation trust may not have carried out planned actions, Monitor is likely to seek additional information from the NHS foundation trust to understand the underlying situation. Depending on the trust’s response, they may decide to investigate further to establish whether there is a material governance concern that merits further action.

1.1.3 A draft Corporate Governance Statement for SWASFT is attached to this report at

Appendix A. Board members are requested to consider this assurance, and confirm that the identified statements can be signed on behalf of the organisation.

1.1.4 The statements must be signed on behalf of the board of directors, and having regard to

the views of the governors, noting that reports on Trust performance, including quality dashboards, have been presented to each meeting of the Board of Directors and the Council of Governors, together with presentations on the work of each Board committee.

1.2. Quality Governance Framework 1.2.1 NHS foundation trusts are required to include in the annual report, a section which gives

a brief overview of the arrangements in place to govern service quality and which signposts the reader to where quality governance and quality are discussed in more detail in the annual report (ie, within the annual governance statement, quality report or strategic report). The section should summarise briefly:

How the foundation trust has had regard to Monitor's quality governance framework in arriving at its overall evaluation of the organisation’s performance, internal control and board assurance framework and a summary of action plans to improve the governance of quality.

1.2.2 Foundation trusts are no longer required to produce the Board Memorandum on Quality

Governance which is a requirement of aspirant FTs and it is proposed that an account of SWASFT’s governance of quality in line with Monitor’s Quality Governance Framework is included within the Trust’s Annual Governance Statement. The draft text is attached to this report at Appendix B.


Page 3 of 20

1.3 Recommendation 1.3.1 Board members are requested to consider the appended statements and associated

assurance and confirm their approval for the Corporate Governance Statement to be signed and included in the Trust Annual Report for 2014/15; and subsequently to be submitted as a self- certification to Monitor. They are also required to consider and approve the statement on governance of quality for inclusion in summary within the Trust’s Annual Governance Statement.

Nicole Casey Head of Governance


Page 4 of 20

Appendix A

Corporate Governance Statement Corporate Governance Question Confirmed or

Not Confirmed Board Assurance with any risks and mitigating action

1.

The Board is satisfied that the Trust applies those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of health care services to the NHS.

Confirmed

The Trust is fully and legally constituted; is compliant with (or has provided explanation for non-compliance with) the new Monitor Code of Governance (issued in 2014); is compliant with Monitor’s Audit Code; and has a plan in place to undertake a full Board Governance and Leadership review in 2015/16. The Trust has retained a Green Governance Risk Rating, and a Continuity of Services Risk Rating of 4 throughout 2014/15 (confirmed by Monitor up to and including Quarter 3). SWASFT employs a Trust Secretary to ensure that both the Board, and the Council of Governors is aware of and compliant with corporate governance standards. No risks or mitigating action required

2. The Board has regard to such guidance on good corporate governance as may be issued by Monitor from time to time

Confirmed

The Trust has consistently applied the guidance principles within Monitor’s Code of Governance, with a plan of compliance monitored by the Quality and Governance Committee. An updated plan was presented to the Committee in March 2015. All relevant Code of Governance disclosures will be included within the Trust annual report for 2014/15, together with a comprehensive statement of all disclosures and their location as required by the new Code, issued in July 2014. That statement was presented to the Quality and Governance Committee for approval in March 2015 and agreed for inclusion within the Annual Report. No risks or mitigating action required

3. The Board is satisfied that South Western Ambulance Service NHS Foundation Trust implements: (a) effective board and committee structures; (b) clear responsibilities for its Board, for committees

reporting to the Board and for staff reporting to the

Confirmed

(a) The Board robustly reviewed and agreed its Board and Committee reporting and responsibilities during acquisition of Great Western Ambulance Service in early 2013 and continually considers the fitness for purpose of its governance structure. The membership and focus of the Quality and Governance Committee was reviewed and revised in 2014. The Audit Committee acquired a new Chair in September 2014 and a review of the Committee’s working practice and focus will be undertaken in


Page 5 of 20

Corporate Governance Question Confirmed or Not Confirmed

Board Assurance with any risks and mitigating action

Board and those committees; and (c) clear reporting lines and accountabilities throughout

its organisation.

2015/16. (b) A Non-Executive Director appointment and reappointment process is in place and

implemented with the Trust Council of Governors. New Executive Directors for Nursing and Governance, and HR and Organisational Development took up posts in 2014. The former acquired responsibility for the Urgent Care Service, as well as Governance and Safeguarding; and the latter has undertaken a structural review of the HR team and developed a whole-Trust Talent and Workforce Strategy to take forward in 2015/16. There are currently (at March 2015) no vacancies on the Board of Directors.

(c) The Trust governance structure is clear in terms of lines and accountabilities throughout the organisation with: a fully constituted Board of Directors; a Council of Governors; a cadre of Associate and Deputy Directors who review business in detail prior to review at Directors’ Group for sign off; each directorate has a clear structure and line of accountability (although both HR and UCS structures are under review at March 2015); and a Performance Management Framework, including Annual Accountability Agreements for each individual Director. Both the Board of Directors and Council of Governors operate in accordance with written Standing Orders (appended to the Trust Constitution), and each of the Board committees has terms of reference which are reviewed regularly and cross-checked against one another.

No risks or mitigating action required

4. The Board is satisfied that the Trust effectively implements systems and/or processes: (a) To ensure compliance with the Licensee’s duty to operate efficiently, economically and effectively; (b) For timely and effective scrutiny and oversight by the Board of the Licensee’s operations; (c) To ensure compliance with health care standards binding on the Licensee including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions;

Confirmed

(a) The Trust’s Annual Governance Statement for 2013/14 was supported by a Head of Internal Audit Opinion of significant assurance. The Annual Governance Statement for 2014/15 will include full details of the process put in place by the Board of Directors for recovery and sustainability of performance against the Category A targets, and 111 performance during 2014/15. The Trust has maintained regular and proactive contact with Monitor during the year, particularly where performance was off plan (none of the three Category A targets were achieved for Quarter 3 and…text to be added after year end). Performance Targets are one of the top three risks on the Corporate Risk Register, with mitigating actions monitored at meetings of the Board, Quality and Governance Committee, and Directors’ Group. However, missing three targets in one quarter has not affected the Trust Risk Ratings to date, and Monitor has confirmed that SWASFT retained a Governance Risk Rating of


Page 6 of 20



(d) For effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licensee’s ability to continue as a going concern); (e) To obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making; (f) To identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the Conditions of its Licence; (g) To generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and (h) To ensure compliance with all applicable legal requirements.

Green, and a Continuity of Services score of 4 for Quarter 3. text to be added after year end

(b) An annual cycle of business is managed by the Board of Directors, with the Board meeting each month other than August. Each Board Committee is chaired by one of the Non-Executive Directors. The Board receives the Integrated Corporate Performance Report at each meeting; the Audit Committee scrutinizes the work of Internal and External Audit, and reviews the process of assurance for key areas such as risk – the review of the work of the Committee will consider whether it should extend that scrutiny to other functions; the Finance and Investment Committee receives business cases and considers all aspects of financial governance; the Quality and Governance Committee has a large remit and takes annual deep dives into areas of clinical and quality governance as well as receiving highlight and exception reports against annual plans of work.

© The Board receives assurance from the Quality and Governance Committee, chaired by the Trust’s Vice Chairman, that it reviews compliance with all statutory and regulatory healthcare requirements, as well as commissioning specific deep dives into areas which may not be subject to regulation but could impact upon patient safety and experience, eg community responders. It also receives minutes from the Experiential Learning Forum which undertakes focused reviews into areas of risk or trends identified which might impact upon patient safety. This learning is then shared. The Board reviews the Patient Safety and Experience report at most meetings.

(d) The Trust financial controls are monitored by a Finance and Investment Committee, chaired by a Non-Executive Director and the Trust undertakes an annual assessment by the Audit Committee to ensure it remains a going concern

(e) Papers for Board and Committees are drawn from individual annual cycles which are fed by the Trust Regulatory Framework (recording all statutory and regulatory targets). These then support the development of agendas for each meeting and help managers to prepare for the reporting requirements for the year ahead.

(f) A monthly Light Touch monitoring meeting is chaired by the Deputy Chief Executive/ Executive Director of Finance to identify any risk to compliance with the Monitor governance conditions. All Trust meeting agendas include an item to identify any New Risks or Exception Reporting Triggers. Where performance concerns are


Page 7 of 20



raised (eg breach of Category A or NHS 111 performance during 2014/15) recovery plans are developed and achievement monitored by Directors’ Group with an agreed escalation process to the Trust Board of Directors. In addition, Project Boards and Mobilisation Groups are established for each new contract prior to and immediately following these being awarded. The Board of Directors receives an assurance report to support the signing off of each quarterly submission. This report includes assurance that: the Trust is compliant with its Access and Outcome Targets and Indicators; there are no exceptions in relation to CQC compliance; the Trust remains compliant with Monitor’s Quality Governance Framework; and that there are no exceptions to the Risk Assessment Framework Diagram 6, or any governance concerns.

(g) The Board engages in the development of the Trust Annual Plan with input from the Council of Governors. Planning and bidding for new contracts is undertaken with executive sponsorship and ownership to support the Planning team in ensuring bids are robust and successful.

(h) A Trust Secretary was appointed in 2013 with responsibility for ensuring the Board of Directors, and the Council of Governors, is appropriately constituted.

See risk and mitigation at a) above

5. The Board is satisfied that the systems and/or processes referred to in paragraph 5 should include but not be restricted to systems and/or processes to ensure: (a) That there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided; (b) That the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations; (c) The collection of accurate, comprehensive, timely and up to date information on quality of care; (d) That the Board receives and takes into account accurate, comprehensive, timely and up to date

Confirmed

(a) Board capacity and capability was reviewed during the acquisition and at each reappointment or new Non-Executive Director appointment, in conjunction with the Council of Governors

(b) The Trust’s Quality Strategy is reviewed and updated annually and the Board lead on Quality is the Executive Medical Director. He also reviewed the Strategy in 2014 against the Clinical Effectiveness Strategy and was satisfied that the Quality Strategy met the requirements of both. This view was endorsed by the Quality and Governance Committee.

© The agenda and membership of the Quality and Governance Committee were reviewed in May 2014. The Committee will continue to receive annual deep dives for all clinical and quality governance functions, supported by exception reports.

(d) As well as reports and assurance received from the Quality and Governance Committee, the Board reviews the Integrated Corporate Performance Report and an Executive Summary of the Patient Safety and Experience Report at each meeting


Page 8 of 20



information on quality of care; (e) That the Trust, including its Board, actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and (f) That there is clear accountability for quality of care throughout the Trust including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate.

(e) The Board receives a patient story at each meeting. The Board has also supported subscription to Patient Opinion and closer working with the Patient Association. Board members each have responsibility for engagement with a Health Watch organization in their area, and regularly attend station meetings with Trust staff. The Board engages with the Council of Governors, and chairs of the Board committees provide an annual presentation on the work of those committees to the Council. Comments are invited annually on the Trust Quality Account from Clinical Commissioning Groups, Health Watch, and the Health and Wellbeing Boards and these are included verbatim. In addition, the Trust has a membership of over 18,000 (at March 2015).

(f) The Trust quality focus is led by the Quality and Governance Committee to which those responsible for key areas of quality provide regular reports. The Committee also has an agenda item to allow for escalation of issues and referred a number of issues to the Directors’ Group during 2014/15. The Committee also asks report authors for additional assurance where it is required. The Trust has a robust incident reporting system and an Experiential Learning Forum which takes a focused approach to a specific subject at each meeting, based upon trends or themes identified from the review of patient safety incidents, complaints, HR cases etc. This Forum reports into the Quality and Governance Committee. Non-Executive Directors are invited to each Serious Incident Review.

No risks or mitigating action required

6. The Board is satisfied that there are systems to ensure that the Trust has in place personnel on the Board, reporting to the Board and within the rest of the organisation who are sufficient in number and appropriately qualified to ensure compliance with the conditions of its NHS provider licence.

Confirmed

The Board has approved a robust process for recruitment of its Executives and Non-Executives and this includes review of skills and experience where a vacancy occurs. The Board has also consulted with Monitor where a vacancy, such as lack of a Nurse Director for a period during 2013, might breach licence conditions, and agreed on corrective action. Operational Resources and Delivery of Statutory and Mandatory Education are (at March 2015) two of the three highest risks on the Corporate Risk Register. Actions to mitigate these risks are monitored at meetings of the Board, Quality and Governance Committee, and Directors’ Group.


Page 9 of 20

Appendix B Statement on Governance of Quality The statement has been prepared using as guidance Monitor’s Quality Governance Framework whereby quality governance is defined as the combination of structures and processes at and below board level to lead on Trust wide quality performance. It follows the 10 questions set out in the Framework below: Monitor’s Quality Governance Framework

Strategy Capabilities and culture Process and Structure Measurement

1A Does quality drive the trust’s strategy?

2A Does the Board have the necessary leadership, skills and knowledge to ensure delivery of the quality agenda?

3A Are there clear roles and accountabilities in relation to quality governance?

4A Is appropriate quality information being analysed and challenged?

1B Is the Board sufficiently aware of potential risks to quality?

2B Does the Board promote a quality focused culture throughout the trust?

3B Are there clearly defined processes for escalating and resolving issues and managing quality performance?

4B Is the Board assured of the robustness of the quality information?

3C Does the Board actively engage patients, staff and other key stakeholders on quality?

4C Is quality information used effectively?

Aspirant foundation trusts are required to produce a highly detailed Board Memorandum on Quality Governance and SWASFT provided an updated Board Memorandum to support its forward plan as a newly enlarged trust in accordance with Monitor’s (then) Compliance Framework in relation to significant transactions. A further update was approved in March 2014 at the end of the first year post-acquisition. Foundation trusts are not required to continue to produce a Board Memorandum but are required to provide ongoing assurance of the Trust quality governance arrangements, as well as providing assurance of those arrangements going forwards and also taking account of requirements within:


Page 10 of 20

Monitor, Annual Planning Review guidance 2014/15, quality plans

Monitor, Quality Governance: How does a board know that its organisation is working effectively to improve patient care?

Monitor, Risk Assessment Framework 2013, evidence of best practice SWASFT therefore provides the following Statement on the Governance of Quality to meet these requirements. It follows the ten questions within Monitor’s Quality Governance Framework (see above) and offers a detailed summary of SWASFT’s arrangements, for approval by the Board of Directors at the end of 2014/15. For the purposes of the Trust Annual Report, the statement will be summarised within the Annual Governance Statement for 2014/15.

1A Does quality drive the Trust’s strategy?

Governance Arrangements

Quality Strategy Reviewed annually (encompasses Clinical Effectiveness) and sets out roles and responsibilities for quality governance at all levels Governance and Risk strategies Reviewed annually and set out roles and responsibilities for governance and risk at all levels Quality Governance Plan Monitored by Quality and Governance Committee Strategic Goals Reviewed annually by the Board of Directors with input from senior managers and governors, and influenced by national guidance and direction as well as local quality requirements Quality Journey Poster charting the Trust’s quality progress Mandatory Workbook Articulates the Trust approach to quality training – all staff are required to complete within 6 months of issue Quality Account Developed annually with quality indicators set under three priorities: patient safety, patient experience, and clinical effectiveness; and with progress monitored by the Quality and Governance Committee CQUIN

1

Programme of quality initiatives developed annually with clinical quality priorities and monitored by commissioners Performance Framework

1 CQUIN – Commissioning for Quality and Innovation


Page 11 of 20

Governance Arrangements

Includes: Board of Directors; Directors’ Group; Associate and Deputies’ Group; Annual Accountability Agreements; annual Personal Appraisal Development Reviews; Integrated Corporate Performance reports including off plan risks and mitigation Trust Website Publishes information on quality aims and objectives, and performance Trust Intranet Publishes information for staff on performance and policy, staff Bulletins, CEO chat forum Newsletters Clinical Notices, Bulletins, Reflect newsletter issued to staff Station Meetings Attended by Board members to address questions and concerns raised by staff Appraisals Personal Appraisal Development Reviews include a quality dimension and should be completed annually by all staff Stakeholder Engagement Undertaken with commissioners at quality and performance contract meetings; Health Watch and OSC input to Quality Account; public events Council of Governors Hold meetings and workshops throughout the year to support fulfilment of their statutory duties Quality and Governance Committee Takes assurance against work programmes for : ambulance clinical quality indicators; patient safety, experience, and engagement; infection prevention and control; clinical audit and effectiveness; medicines management; safeguarding; human resources and training; quality governance; risk management; compliance; health, safety and security; and learning from experience, through deep dives and highlight reports against action plans

1B Is the Board sufficiently aware of the potential risks to quality? Assurance

Board Assurance Framework Developed annually and consistently rated as low risk by Internal Audit. Highlights performance against core objectives and risks to their achievement Monitor Governance Statements Signed and submitted by the Board each quarter to Monitor, confirming ongoing compliance with targets set by Monitor’s Risk Assessment Framework, and that there are no governance exceptions. Signing of the statements is supported by a Board Assurance Report Monitor Self-Certifications Signed and submitted annually supported by assurance reports to the Board Annual Governance Statement


Page 12 of 20

Assurance

Developed annually to provide evidence of the robustness of the Trust’s internal controls. Supported consistently by a Head of Internal Opinion of Significant Assurance Internal Audit Reviews Scheduled in an annual Internal Audit Plan based on risks to the organisation and reported to the Audit Committee Risk Registers Reviewed by the Board, Quality and Governance Committee, and Directors’ Group, as well as a bi weekly Risk Watch Board Committees Chaired by a Non-Executive Director who provides an assurance report to each Board meeting Key Board Roles Include: Senior Information Risk Owner; Senior Independent Director; Caldicott Guardian CQC Inspections No recommendations from last inspection in February 2014 Patient Safety and Experience Presented to each Quality and Governance Committee and Board meeting, and include data and trends relating to patient safety, experience, and engagement Benchmarking SWASFT performance is benchmarked against other ambulance trusts in terms of clinical performance indicators, patient safety incidents and complaints, and peer reviews are undertaken where appropriate (eg safeguarding and a proposed review by SCAS following their pilot CQC inspection) Cost Improvement Schemes Cost Improvement strategic issues and cost improvement plans are discussed and reviewed by the Finance and Investment Committee Workforce Panels Approve all requests for new staff posts to ensure they are appropriate and funded Staff Concerns Raised through incident reports, whistleblowing, or via the CEO chat room sessions, or station meetings Incident Reporting and Complaints Managed centrally and cover adverse, moderate, serious incidents, and comments, concerns and complaints. They are investigated by a Quality Lead or local manager. Details, including learning and action plans, are reported through the Patient Safety and Experience Report to Board and to commissioners


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2A Does the Board have the necessary leadership skills and knowledge to ensure delivery of the quality agenda? Assurance

Board of Directors Continually reviews its membership and any skills gaps, particularly where vacancies arise Clinical Direction Provided by an Executive Medical Director (GP); two Associate Medical Directors; an Executive Director of Nursing and Governance (Nurse); Accountable Officer for Controlled Drugs (Pharmacist) Board Leads Each Non-Executive Director is champion for a quality area Working Groups Report quality issues into Quality and Governance Committee including: Clinical Effectiveness; Infection Prevention and Control; Health and Safety; Safeguarding; Experiential Learning Forum Board Challenge Recorded in minutes of meetings. Committee chairs can, and do, refer items to the Directors’ Group or Board of Directors Board Review of Performance Undertaken through consideration of the ICPR at each meeting and agreement on metrics at the start of each year. Board committees set their annual cycles of business to achieve corporate objectives. They also seek assurance on any performance recovery plans and the implementation of new contracts Independent Assurance Commissioned by the Board as required including presentations from Trust lawyers on new legislation or regulation, and review of operational resources. The CEO is a member of the Association of Ambulance Chief Executives’ Group which considers an influences the national position for ambulance trusts Succession Planning Each Executive has a deputy or associate director to provide resilience within their team. When vacancies on the Board occur, the Board considers the skills required to fill the gap and advertises the vacancy accordingly Board Development Undertaken during Board Seminars at which presentations are given and time is spent on strategic discussion Development needs are identified during the appraisal process and Board self-assessment


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2B Does the Board promote a quality-focused culture throughout the Trust? Assurance

National Profile Maintained by individual Board members including the Association of Ambulance Chief Executives and the Quality Governance and Risk Directors’ Group Clinical Direction Provided by an Executive Medical Director (GP); two Associate Medical Directors; an Executive Director of Nursing and Governance (Nurse); Accountable Officer for Controlled Drugs (Pharmacist) Cultural Review The Board has previously undertaken a cultural review following release of the Francis Report and in 2014 held a series of staff meetings including questions to test the culture of the organisation Clinical Leadership Provided, as stated previously, by Executive clinicians. Each Serious Incident Review is also chaired by a Director clinician and the operational structure is comprised of clinical managers. Each service line has a regular project board or meeting to consider operational performance and risks Clinical Developments Led by the Deputy Clinical Director with a team of clinicians who develop clinical guidelines and protocols Non-Clinical Leadership Provides a different perspective on quality governance, ensuring processes are in place to meet statutory and regulatory requirements and improve quality Training and Development Managed by a well-established team setting training needs analysis for the whole Trust implemented through a training plan, and enhanced by a Talent and Workforce Strategy developed during 2014 Learning and Quality Opportunity Promoted through the weekly Bulletin and via email Internal Communication Email announcements; the staff Bulletin and Special Bulletins; and Clinical Notices and Reflect. The Chief Executive also hosts a chat forum which he answers personally


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3A Are there clear roles and accountabilities in relation to quality governance? Assurance

Organisational Structure Published on the intranet and sets out levels of responsibility within each directorate Organisational Statements Printed in policy forewords and including: health and safety; risk; equality and diversity; and Code of Conduct Quality and Governance Strategies Set out individual responsibilities within the organisation for quality governance Board Meetings Feature quality as an integral part of the agenda. At the end of each meeting the Board considers and records any new risks or legislation identified; and any exception triggers. Committee Effectiveness Tested annually but this was not completed during 2014/15, pending preparation for the Monitor Governance Review

3B Are there clearly defined well understood processes for escalating and resolving issues and managing performance? Assurance

Incident Reporting and Escalation Well-established Datix incident reporting system which is accessible to all staff and generates over 9,000 incidents per year from staff and other healthcare professionals. A review of all adverse incidents is undertaken to identify any where moderate or serious harm was caused. These are investigated and actions identified. Contact is made with the patient where possible and appropriate Complaints Managed by a well-established team, with a new process introduced in 2014 to give greater local accountability. Serious complaints follow the serious incident process Focused Reviews Undertaken by the Experiential Learning Forum which chooses a theme for each bi-monthly meeting and looks at incidents, complaints, claims, HR cases etc to identify issues and whether any further work, or new guidelines etc are required. Outcomes are published in the staff Reflect newsletter Internal Audit Plan Generates a series of reviews each year which all receive a risk rating and if necessary remedial action. These are monitored by the Audit Committee. A mid-year review is undertaken to identify any new risks


Page 16 of 20

Assurance

Clinical Audit Plan Generates a series of clinical audits, including national mandatory audits. Progress is monitored by the Quality and Governance Committee and also by the Audit Committee Action Plans Generated for each key work area and these are monitored by the Board and its committees with essential plans monitored through Annual Accountability Agreements with individual directors. Actions arising from Serious Incidents and Complaints are monitored by Directors’ Group Annual Governance Statement Produced annually to report on the robustness of the Trust’s systems of internal control Board Assurance Framework Reports on achievement of the Trust’s corporate objectives, also highlighting gaps in controls and is cross-referenced to the Corporate and Directors’ Risk Registers Learning from Experience Disseminated through a number of routes: Clinical News; Patient Safety and Experience Reports; commissioner quality reports; and the Reflect newsletter Clinical Notices, Operational Instructions and Training Scenarios Cascaded through clinical teams and via the Experiential Learning Forum Whistleblowing Reported through the Speak Up, Speak Out process, however staff make greater use of the Datix reporting system Performance Management Operates through a framework with four levels from frontline staff to the Board with director performance managed via Annual Accountability Agreements which set objectives which are then cascaded down through their teams

3C Does the Board actively engage patients staff and other key stakeholders on quality? Assurance

Patient Feedback and Engagement (proactive) Managed by a Patient Engagement team which monitors the Patient Opinion website and proactively encourages feedback. A Have Your Say leaflet is available to the public and a Friends and Family Test card is given to See and Treat patients. A patient story is also presented at each Board meeting. A programme of work is also underway to support patients with learning disabilities Patient Feedback and Engagement (reactive) Managed by the Complaint team, with positive feedback received on responses and Ombudsman referrals being rarely upheld. The Patient Engagement team also manages the plaudit system and provides feedback to staff on positive reports


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Assurance

Membership Service users and their family and friends are courage to become members of SWASFT which makes them eligible to become a governor. Governors also contribute comments on the Quality Account and on the Trust Annual Plan Staff Engagement Encouraged through an annual staff survey, with local questions added where appropriate. At staff meetings in 2014, staff were asked to vote on a series of questions with the results compared across the organisation. A wealth of information is also available for staff on the Trust intranet. Board members regularly attend station meetings to talk to staff Stakeholder Engagement Supported by the Trust website which offers many useful publications including patient leaflets and healthcare campaign information. Public events are attended through the summer with the Trust PR vehicle offering feedback clinics and often Know Your Blood Pressure. Commissioners and other public bodies are also invited to comment on the Trust Quality Account

4A Is appropriate quality information being analysed and challenged?

Assurance

Performance Dashboard Included within the ICPR reviewed by the Board at each meeting. It contains all key national and local metrics which are RAG rated and supported by exception reports produced where targets are off plan Quality Account Indicators Developed by a small team, led by the Deputy Clinical Director. They focus on the three priorities: patient safety, clinical effectiveness, and patient experience. Each year a Quality Report is produced on progress against each indicator at year end. Risk to Performance Coded in the ICPR as either: Early Warning; No Concerns; Real Concerns; or Improvement Expected. They are also identified at Board and Committee meetings and reported to Risk Watch for assessment Monitoring Patient Safety Issues Undertaken by the Quality and Governance Committee and Board through the Patient Safety and Experience report which focuses on adverse, moderate and serious incidents; complaints and PALS; claims; and qualitative information on learning and review of trends and themes. The Board also reviews a quarterly report on serious incident investigations and outcomes. The Experience Learning Forum undertakes focused reviews of individual issues.


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4B Is the Board assured of the quality of information? Assurance

Information Assurance Taken from a number of sources: national groups (National Information Assurance; National Director of Operations; Ambulance Association of Chief Executives) provide benchmarking and influence on future direction; Trust Information Assurance Group as the central forum for governance of data quality with regular reports to Directors’ Group. Progress against the IG Toolkit is reported to Quality and Governance Committee. Clinical Governance – Clinical Audit Clinical Audit and Research team develops an annual Clinical Audit and Research schedule, encompassing national requirements and local requirements and risks. Audits are reported into the Clinical Effectiveness Group. The team also provides governance around research projects and the Research and Audit Manager chairs the National CPI Sub Group Clinical Governance – Risk The Trust’s risk management process is subject to annual Internal Audit review and consistently presented as Low Risk. The Audit Committee also undertakes a twice yearly review of the fitness for purpose of the risk process. The Risk team manages the Risk Registers (including those for individual directorates) and quality checks investigation of adverse incidents (reported on Datix), with the Patient Safety team quality assuring investigation of serious and moderate harm incidents. Clinical Governance - Education and Training Reported to the Quality and Governance Committee, including a deep dive annually. The team works closely with Heads of Operations to deliver training across the Trust. When training is affected by operational pressures, strategies are put in place to mitigate this managed by Directors’ Group. Staff training records are stored on the Electronic Staff Record Clinical Governance – Evidence Based Care and Effectiveness Managed by the Clinical Development Team, providing assurance of continual review of evidence based practice and monitoring and reviewing compliance with national guidelines (NICE and JRCALC). They maintain a register of guidelines, each is then reviewed by the Deputy Clinical Director and if relevant referred to the Clinical Effectiveness Group for discussion, with an action plan resulting if appropriate. The team also review incidents reported on Datix for any relating to non-compliance with guidelines Clinical Governance – Patient and Carer Experience and Involvement Patient comments, concerns and complaints are recorded on Datix. Complaint data is recorded within the Patient Safety and Experience Reports and shared with commissioners. A deep dive is also reported to Quality and Governance Committee annually. The Patient Engagement team supported patient experience CQUINs and the Learning Disability programme. They also manage plaudits and surveys including: UCS, and the Friends and Family Test for Patients Clinical Governance – Staffing and Staff Management


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Assurance

Staffing reports are included within the bi monthly updates to Quality and Governance Committee and a deep dive was presented to the Committee in November 2013. The deep dive focused on sickness absence and workforce establishment Audit Concerns Raised through Internal Audit reviews and any recommendations made for individual functions. The Annual Governance Statement provides assurance on the system of internal control and has consistently received a Head of Internal Audit Opinion of Significant Assurance Coding Accuracy Data owners are assigned in accordance with IG principles and recorded on the Information Asset Register. They are responsible for the accuracy of their data – reported to the IASG. Coding in the clinical hubs is reviewed through individual audits. Coding on individual patient records is reviewed at station level in line with the Clinical Records Management Policy. A PCR audit tool is used where required to assess an individual’s performance. All issues monitored through the ICPR have appropriate links to data quality checks

4C Is quality information being used effectively?

Assurance

Integrated Corporate Performance Report Consistently uses RAG rating and comparative historical data in the production of its performance reports, e.g. operational performance is reported daily to managers, indicating daily, month to date, quarter to date, and year to date, performance against the Category A8 (Red 1s and Red 2s) and A19 targets both by CCG area and also Trust-wide (this information is also published on the Trust intranet). The ICPR has evolved over time so that the information has become clearer, more consistent and relevant, and enables both historical review and external benchmarking. Exception reports and mitigation action provide assurance that off plan performance is being addressed Quality and Governance Committee Reports Received in relation to: patient safety and experience; HR and workforce; training and education; safeguarding; infection prevention and control; medicines management etc. All provide an annual deep dive including qualitative/quantitative data, identification of trends/risks, and future plans Incident Reporting Uses high level categories which are broken down into sub categories in order that trends can be identified. These form part of focused reviews by the Experiential Learning Forum and the Patient Safety and Experience Report which lead directly to service improvements Service Line Quality Indicators Managed through individual service line groups (A&E and UCS). For A&E, system indicators only report to the service line group, with clinical indicators reporting to the Clinical Effectiveness Group. Daily bronze conference calls are held for A&E and for UCS to discuss performance Financial Review Undertaken by the Finance and Investment Committee which receives financial performance information in relation to current and forecast financials. This include: implementation of the Finance and Investment Strategy; Business Development Pipeline; review of the Protected Asset Register; finance reports including the budget position. The Committee reviews these reports in detail, seeking assurance as required.


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Page 1 of 3


Title: Dementia Report update – Impact of SME Training

Prepared by: Jim Petter, Head of Education and Professional Development

Presented by: Emma Wood, Executive Director of Human Resources and Organisational Development

Main aim: The purpose of this report is to inform the Trust Public Board meeting

Recommendations: To discuss the contents and be assured by the report that the Trust is meeting it’s obligations.

Previous Forum: Quality and Governance meeting, 8 January 2015



BAF14-14


HR

Implications



Page 2 of 3

1. Dementia Training 1.1 The Department of Health’s (DH) mandate to Health Education England (HEE),

published in April 2013, set out a work programme for HEE and their regional Local Training and Development Boards (LETBs) to create and develop a national plan for rapid role out of Level 1 Dementia Training for all NHS staff. Level 1 (Essential) training is to be considered as mandatory training for all

patient-facing staff.

1.2 HEE, and subsequently Health Education South West (HESW) and Health Education Wessex (HE Wessex) have requested that all NHS staff receive Tier 1 Dementia Training by March 2015.

1.3 In addition, HEE is working with the bodies that set curricula, such as the College of Paramedics (CoP) and the Nursing and Midwifery Council (NMC) to ensure that all undergraduate curricula include Tier 2 (Enhanced) and 3 level (Specialist and Intensive) training in dementia by September 2015. Consequently in future, newly registered paramedics and nurses will have received training before they come to the Trust from 2016.

1.4 HESW has asked the Trust to provide cumulative figures for Tier 1 training

completion on a quarterly basis. These figures are then submitted to the two regional LETBs and then to the National Dementia Team. This team will submit a national report to the Department of Health to enable a measurement of achievement against target for the HEE mandate for Dementia training. 100.000 NHS staff have already achieved this requirement, with a further 250,000 required to complete the training by March 2015.

1.5 The ambulance trusts have been asked to provide figures for qualified staff only and to date the Trust has trained 1801 qualified staff (registered staff and ambulance technicians as per DH definition) in the Tier 1 training. However the total number of staff receiving the training including non qualified staff (ECAs and ACAs) was 2325/2539 or 91.57%.

1.6 Tier 1 training aims to familiarise staff with recognising and understanding Dementia, interacting with those with Dementia and being able to signpost patients and carers to appropriate support.

The training learning outcomes include:

Staff awareness and confidence to support patients affected by dementia;


Page 3 of 3

Better diagnosis, treatment and care of those with dementia;

Staff awareness of the needs of patients affected by dementia, their families and carers to enable them to provide safe, dignified and compassionate care;

Staff signposted to the most appropriate care;

Staff awareness of the increased likelihood of mental health problems presenting in those with Long Term Conditions.

1.7 The Trust’s Mandatory Workbook was redesigned during 2014 and includes a section on the Mental Capacity Act (2005) to support clinical practice around dementia as well as mental health problems. This section discusses:

Capacity and lack of capacity

The basic principles set out in the Act

How capacity can be assessed using a diagnostic tool

What to do in the event of a refusal to be assessed

What is meant by autonomy and beneficence. The section also covers: other Acts, including mental health legislation, connected with mental capacity assessment; advanced decision to refuse treatment; Lasting Powers of Attorney; decisions by the Court of Protection and Court appointed deputies; the role of the Public Guardian and Independent Mental Capacity Advocates.

1.8 In order to ensure that all new staff receive Tier 1 training it has been built into the Trust’s Clinical Induction programme as part of the mandatory training. In addition, all Emergency Care Assistants (ECAs) that undertake the QCF Diploma in Healthcare Support Worker (Emergency Care Assistant) Level 3 award will study additional units including: Understanding the process and experience of dementia and Understanding mental health problems. These units are a requirement of the Apprenticeship Framework which supports training of staff up to and including band 4.

1.9 Further details on requirements around Tier 2 training are due from HESW and HE Wessex. The Learning and Development team will act on this guidance as appropriate.

2.0 Recommendation 2.1 To discuss the contents and be assured by the report that the Trust is meeting

it’s obligations.

Emma Wood Executive Director of HR & OD


Page 1 of 6

Trust Public Board of Directors Meeting 26 March 2015

Title: Learning and Development Report

Prepared by: Jim Petter, Head of Education

Lizzie Ryan, Education Business Manager and Clinical Training Manager East

Presented by: Emma Wood, Executive Director of Human Resources and Organisational Development

Main aim: This paper is to provide assurance

Recommendations: Members of the Trust Board of Directors are requested to take assurance from the highlights and exceptions included within this




BAF02-13, BAF04-13, BAF 07-13, BAF09-13, BAF11-13, BAF16-13BAF20-13, BAF23-13, BAF24-13, BAF25-13, BAF26-13


Implications


The statutory and mandatory requirements of the NHSLA, and HSE.

NHSLA Standard 2, 3, 4 and 5

CQC - Outcome 4, 6, 7, 8, 9,10, 11, 12, 14, 15, 20, 21, 25

Good Governance Practice


Page 2 of 6

Quality and Governance Report: Training Department

1. Introduction

1.1 This Report provides an update on the training delivery for the Trust from the 1st April 2014 to 28th February 2015, against projected training compliance and the 2013/14 and 2014/15 Training Plans.

2. Main Report 2.1 The following sections include a brief summary of key pieces of work completed

since April 2014.

2.1.1 The Mandatory Workbook

All Divisions The Trust published the new Mandatory Workbook 2014 – 2016 in October 2015 and disseminated them the following month. All 5,871 staff in employment with the Trust have been provided with the Workbook, to be completed by 1st May, 2015. All newly employed staff have received a Workbook pre-employment and employed staff have received one via their relevant OM or manager, with books signed for on allocation; Completion rates to date have been poor to date: West/East Division = 65/3882 (2%) North Division = 56/1456 (4%) We are aware that this may be for a variety of reasons, such as for example: completion certificates not forwarded, lack of line manager scrutiny. Lack of staff understanding of the timescales and/or significance of the workbooks.

To mitigate non completion:

All operational staff and managers have received a letter at the start of the period detailing the completion timeframe and their responsibility within this process;

Regular Bulletin articles have been use to remind staff on the requirement to complete the workbook in the 6 month period.

Operational managers at the A&E Service Line meeting have been reminded of the need to encourage completion.


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2.1.2 SME Training 2013/14 in North Division

In North Division 71% of the staff have completed this training. This leaves a shortfall of 19% of staff (n223) to achieve the target of 90% completion, bearing in mind that the overall workforce in North Division has grown since 2013/14 and that the completion number is based on the 2013/14 headcount (n770) The delivery shortfall is due to the lack of capacity for staff extraction and low attendance on SME days following the cancellation of SME due to operational constraints.

2.1.3 SME Training 2014/15 in all Divisions

West Division and East Division Compliance has reached the required trajectory of 90% to be completed by year end.

The Learning and Development Department continues to ensure that staff on maternity leave and long term sick are provided with the required training on their return to work, and is working with the operational mangers to ensue that all active bank staff are trained to ensure their compliance. Table 1 and 2 provides the statistical detail. The figures presented do not include Bank Staff.

SME 14/15 (all clinical staff)

North Devon

East Devon

South Devon

West Devon

East

Cornwall West

Cornwall TOTAL

Completed and Booked (headcount 111 178 148 118 162 176 893 Percentage Completion 88% 100% 88% 91% 100% 93% 94%

Total Staff Numbers (headcount) 126 178 168 130 162 189 953

Table 1: West Division SME Progress to date 2014/15

SME 14/15 (all clinical staff)

East Somerset

West Somerset

North Somerset

East Dorset

West Dorset

TOTAL

Completed and Booked (headcount 123 124 123 165 142 677 Percentage Completion 100% 95% 79% 100% 100% 95%

Total Staff Numbers (headcount) 123 130 155 165 142 715

Table 2: East Division SME Progress to date 2014/15


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North Division Compliance is under trajectory due to operational constraints. There remains n169 staff to complete SME to achieve the 90% target required within the division.

. SME 14/15 (All Clinical Staff) North

Gloucs North Wilts Bristol

South Gloucs

Bath and

South Wilts

North Bristol

Other Total

Completed and Booked (headcount) 103 138 124 96 171 84

38 754

Percentage Completion 62% 91% 78% 86% 96% 76%

79% 82%

Total Staff Numbers (headcount) 165 151 159 111 179 110

48 923

Table 3: North Division SME Progress to date 2014/15

2.1.4 Ambulance Care Assistant and Emergency Care Assistant Courses ECA courses continue to be provided in this financial year trust-wide against heightened recruitment demands The ECA courses continue to be delivered using the QCF Diploma in Healthcare Support Worker Level 3 (Emergency Care Assistant) to ensure that all newly employed support staff receive an award that is aligned or equivalent to the Skills for Health Care Award. The award is now part of the Apprenticeship Framework and learners are eligible for apprenticeship funding. The Trust is able to run Functional Skills testing for its staff using an OFQUAL programme, so that the Trust can provide training to staff needing English and Maths qualifications for future development

2.1.5 Integration Training (North Division Paramedics only)

786 of the relevant clinical staff have completed the Integration Training which was provided on overtime in order to achieve projected targets. Due to operational constraints training was cancelled in Quarter 4.


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2.1.6 ECS Training This table shows the completion rates for ECS day 1 and ECS/SME day 2

Training OM Area Staff Trained Total Staff

Day 1: ECS only

Pilot (West Somerset) 62 65 95%

West Devon 139 145 96%

West Somerset 86 97 89%

East Devon and HART 139 201 69%

East Somerset 96 119 81%

East Cornwall 155 164 94.5%

West Cornwall 139 196 71%

West Dorset 61 156 39%

Day 2: ECS and SME

Pilot (West Somerset) 49 49 100%

West Devon 104 104 100%

West Somerset 67 76 88%

East Devon and HART 58 179 32%

East Somerset 58 87 66%

East Cornwall 131 142 92%

West Cornwall 33 174 19%

West Dorset 37 106 35%

Table 4: ECS progress to date Due to operational constraints, training was cancelled over the winter pressures period in Devon, Somerset and Dorset.


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3 Learning and Development Review (LDR)

3.1 Learning and Development reviews allow 1-1 coaching and mentoring within the

workplace. The intention is 90% of staff will receive a Learning and Development Review shift by October 15. Given operational pressures this target is unlikely to be met. In the North Learning and Development Officers have been managing volume ECA courses or deployed operationally, hence the low percentage recorded.

Staff Assessed Total Staff exc. Bank

East Division – includes North Somerset

November 298 602 December 313 602 February 391 715 (55%) West Division

November 560 1047

December 609 1047

February 764 1047 (73%)

North Division

February 36 923 (1%)

Table 5: LDR success rates

4 Recommendation

Members of the Committee are requested to take assurance from the highlights and exceptions included within this.

Jim Petter Head of Education and Professional Development


Page 1 of 23


Title: Patient Safety and Experience Report 2014/15 – February 2015

Prepared by: Governance and Patient Experience Team

Presented by: Jennifer Winslade, Executive Director of Nursing and Governance

Main aim: The purpose of this paper is to provide the Board of Directors with a copy of the full Patient Safety and Experience Report for information.

Recommendations: The Board of Directors is asked to note the Patient Safety and Experience Report for information.






Implications



Page 2 of 23

Patient Safety and Experience Report – 2014/15 February 2015

1. Introduction

1.1. The Trust is committed to delivering high quality services designed around the needs of patients, carers and the public, staff, local communities and all relevant stakeholders.

1.2. We continually seek to improve what we do, but must also consider where our services fall short of what our patients and service users expect and deserve. This involves investigating and learning from patient safety incidents and from comments, concerns and complaints. It also involves being open about incidents where harm has been caused to a patient.

2. Purpose

2.1. The purpose of this report is to provide an update on activity within the Patient Safety and Experience functions during February 2015.

2.2. The report contains statistics on the number of incidents and complaints received. The Board is asked to be aware that the statistics contained within this report are correct at the time that the report is prepared, but that there may be some changes over time – e.g. changes in the level of investigation assigned to complaints; serious incidents subsequently being downgraded; or the coding of adverse incidents being amended.


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3. Table 1: Overall Summary of Activity April 2014 – February 2015

Feedback received from: Apr May June July Aug Sept Oct Nov Dec Jan Feb 2014/15

YTD Apr-Feb 2013/14

Total 2013/14

Compliments 145 158 155 176 168 194 176 155 168 186 171 1852 1,309 1,454

Patient Opinion Stories 14 23 17 25 45 34 32 17 19 10 16 252 Not Available

PALS (General Enquiries) 59 66 67 78 53 74 74 71 78 74 78 772 643 711

Comments, Concerns & Complaints1

93 103 94 103 83 99 120 105 127 117 107 1151 925 1020

No investigation required 5 10 5 9 9 7 23 15 14 21 18 136 Not Available

Low level investigations 48 62 55 65 43 70 65 66 75 66 65 680 Not Available

Moderate level investigations 39 31 30 28 28 21 32 23 24 29 23 308 Not Available

Ombudsman Referrals Upheld 0 0 0 1 (in part)

0 1 0 0 0 0 0 0 0 1 (in part)

Never Events 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Serious Incidents Confirmed2 4 (1) 7 (0) 8 (4) 9 (1) 6 (3) 3 (1) 4(0) 7(1) 5(14)3 4(1)4 0(1) 57 (27) 71 78

Downgrades 1 1 0 2 1 1 0 0 1 0 1(1) 7 Not Available

Moderate Incidents5 9 3 0 14 1 6 4 3 6 2 1 49 13 18

Adverse Incidents (excl SIs/MIs) 812 799 774 820 671 653 775 698 814 706 678 8,200 6,124 6,781

Injury/Accidents 78 61 75 66 64 63 60 74 83 69 58 751 865 935

Security Management Incidents 58 85 69 72 68 83 72 79 61 47 52 746 654 726

Claims 2 10 5 8 5 4 7 5 7 2 3 58 56 64

1 Serious Incidents from complaints included in Serious Incident numbers.

2 Includes those from complaints. All subject to the Duty of Candour in relation to contacting the patient or their next of kin 3 Complaints which are informing the Major Incident Standby SI 4 Complaints which are informing the Major Incident Standby SI 5 Subject to the Duty of Candour in relation to contacting the patient or their next of kin


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3.1 The number of complaints received year to date is approximately 25% higher than

during the same period last year. However, there has been a 41% increase in compliments in that time. 61% of the complaints received have been or are being managed through a low level investigation; 17% have been closed with the complainant on receipt by the Patient Experience Team; and 22% of complaints received have been or are being managed by through a moderate level investigation.

3.2 Serious Incidents 3.2.1 There were no serious incidents confirmed in February 2015. There were five that

were considered at a serious incident review meeting and closed. (It should be noted that the figures reported in the Tables within this report may slightly differ when compared to earlier reports due to serious incidents being subsequently downgraded.)

3.2.2 On analysis there is an emerging trend in relation to spinal immobilisation. A data

search of the last six months identifies that three cases relating to lack of spinal immobilisation have been investigated at serious incident level. Of these three cases one patient became paraplegic as a result of their injuries and has since passed away. The spinal guideline, CG 31, was reviewed and re-published in October 2014 replacing previous versions. Further changes have been highlighted to the Deputy Clinical Director, as the guideline has been rolled out, for consideration as part of a future review.

3.2.3 The Trust confirmed a serious incident review following the declaration of a major

incident standby over the Christmas period. Due to the extensive media coverage and following communication with South West Commissioning Support Unit the incident was declared as a Level 2 incident.

3.2.4 The number of serious incidents confirmed to date is equivalent to 1% of the total

number of adverse incidents reported. 3.3 Moderate Harm Incidents 3.3.1 The Trust’s definition of what constitutes moderate harm has been revised in light of

the definition provided within the statutory Duty of Candour regulation, along with a new decision making template. The number of moderate harm incidents confirmed has reduced as a result of the new definition.

3.3.2 There was one moderate harm incident confirmed during February 2015 making a

year to date total of 49. This incident related to the 111 triage of a patient with central chest pain. The patient’s symptoms should have elicited a blue light ambulance response, however the patient was advised to attend the out of hours GP. The patient was admitted to coronary care with a myocardial infarction.

3.3.3 The number of moderate harm incidents confirmed to date is equivalent to 0.5% of

the total number of adverse incidents reported.


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3.4 Adverse Incidents 3.4.1 There has been a 34% increase in reporting of adverse incidents year to date

compared with the same period of 2013/14. This overall figure is due in the most part to a 125% increase in reported adverse incidents from the Urgent Care Service.

3.4.2 The Trust received 673 incident reports during February 2015 and investigated 535

incidents. As of 5 March 2015 there were 1,951 adverse incidents being investigated, with this figure excluding health and safety incidents. Training continues throughout all areas of the Trust as required to ensure the increasing level of incident reporting can be investigated.

3.4.3 Table 2 shows the adverse incidents broken down by reporting category. 3.4.4 Urgent Care Services Teams (NHS111 and Out of Hours) have the highest number

of open incidents at 1,327 and the Incidents Team continues to work closely with them on stream lining processes for reporting incidents; developing a new process for investigation management; and helping to clear the backlog of investigations. The highest number of incidents reported relate to Infrastructure (Table 2) and for the most part these relate to NHS111 services.

3.5 Proactive Apologies 3.5.1 The “proactive apology” process was introduced in July 2014 for incidents reports

where no harm was caused to the patient, but where it is felt that we did not provide them with a good experience of our service. Since that time letters have been sent to 74 patients (including five letters sent as a result of the Christmas period serious incident). Themes identified through this process include issues with manual handling; delays that have not caused harm; and stretchers coming loose from their fixings. To date there have been four positive responses to the process from patients and no complaints. In February two plaudits were received for the care the Trust had provided following receipt of the proactive apology letter.


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Table 2: Adverse Incidents by Reporting Category - April 2014 to February 2015

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb 2014/15

YTD April-Feb 2013/14

Total for 2013/14

Access, Appointment, Admission, Transfer, Discharge

46 90 48 71 50 37 44 25 35 48 66 560 410 448

Clinical assessment (investigations, images and lab tests)

2 0 0 2 4 1 1 2 4 0 2 18 8 8

Consent, Confidentiality or Communication

209 128 109 118 104 94 121 104 61 57 61 1,166 1,224 1,427

Conveyance 218 187 189 238 161 157 148 150 203 150 122 1,923 1,700 1,828

Patient Information (records, documents, test results, scans)

22 35 23 18 10 24 29 19 15 18 20 233 138 145

Infrastructure or resources (staffing, facilities, environment)

50 152 235 224 192 162 209 179 273 218 190 2,084 635 687

Medical device/equipment 21 5 23 11 19 41 91 81 57 65 60 474 368 385

Medication 54 60 65 46 52 36 44 64 58 41 51 571 593 630

Other 2 11 6 2 1 0 1 1 1 0 0 25 25 30

Treatment and intervention 188 131 76 90 78 101 87 73 107 109 106 1,146 1,015 1,185

Totals: 812 799 774 820 671 653 775 698 814 706 678 8,200 6,116 6,773


Page 7 of 23

4. Table 3: Analysis for the Accident and Emergency Service Line – April 2014 to February 2015

Feedback Received from Apr May June July Aug Sept Oct Nov Dec Jan Feb 2014/15

YTD Apr-Feb 2013/14

Total for 2013/14

Compliments 125 138 135 151 148 176 150 131 145 159 147 1605 Not Available

Comments, Concerns and Complaints6

63 73 63 69 53 68 83 80 79 80 68 779 633 697



Moderate level investigations

34 27 27 21 26 17 26 17 19 20 18 252 Not Available

Serious Incidents (including from Complaints)7 3 (0) 4 (0) 6 (2) 6(4) 6 (3) 4 (0) 2(0) 6(1) 3(2)8 4(1)9 0 (1) 44 67 71

Downgrades 1 1 0 0 1 1 0 1 1 0 0 6 Not Available

Moderate Incidents 5 1 0 10 1 4 4 3 6 2 0 36 12 17

Adverse Incidents 502 554 509 549 474 496 544 499 550 462 419 5,558 4,636 5039


Security Management Incidents

57 81 68 69 66 83 72 79 59 45 48 727 601 669

Claims 2 10 4 7 5 4 5 5 6 2 3 53 47 54

Number of patient contacts

73,501 79,126 78,246 82,749 79,155 76,033 80,087 79,608 91,617 81,827 76,689 878,638 702,830 869,907

6 Serious Incidents from complaints included in Serious Incident numbers below

7 These figures may be different to previous reports due to Serious Incidents subsequently being downgraded. 8 Complaints which are informing the Major Incident Standby SI 9 Complaints which are informing the Major Incident Standby SI


Page 8 of 23

4.1 From 1 April 2014 28 February 2015, the A&E service line managed 878,638 patient contacts. (Source: Information Cell). Based on this, the A&E service line had:

1,83 compliments per 1000 patient contacts

0.89 complaints per 1000 patient contacts

6.33 adverse incidents per 1000 patient contacts

0.05 serious incidents per 1000 patient contacts 4.2 Operations – All Divisions 4.2.1 Nine of the complaints received related to standards of ambulance driving and

parking. Staff concerned were identified where possible and feedback passed to their line managers to take forward.

4.2.2 Two complaints were in relation to the volume of ambulance vehicle sirens.

Apologies were offered to both complainants for any distress caused.

4.2.3 Several complaints were received in respect of missed fractures in patients, with injuries including a fractured pelvis, broken ribs, a broken toe, and an elbow fracture. In each case, a thorough investigation into the assessment and care afforded to each patient is being undertaken by local management.

4.2.4 Two complainants raised concerns in respect of the Patient Clinical Records (PCRs) completed by the attending ambulance crew. One complainant was concerned that a copy of the PCR was not left at home with the patient. An appointed Investigating Officer is currently collating documentation and evidence in respect of this matter to ensure that appropriate Trust standards are being followed.

4.2.5 In the other PCR-related case, a complainant raised concerns that her condition, including her pain score, was not recorded accurately. An analysis of the patient’s documentation is being completed by an appointed Investigating Officer.

4.2.6 Two operational complaints related to bariatric patients and perceived delays in providing their care. In a harbour incident, the Investigating Officer has identified that a local coastguard facility should have been utilised in the efforts to extricate the patient. It has also been recommended that duty Bronze Officers should be appointed to such incidents to ensure efficient coordination between all parties. Local management is raising awareness of these learning points where required.

4.2.7 Two complaints were in respect of patients suffering from seizures, with one complainant believing that her non-epileptic seizure was not taken seriously by the attending ambulance crew. The second patient was concerned that her seizure was not believed to be epileptic in nature, with the ambulance crew assuming that she had imbibed alcohol or drugs. It was subsequently confirmed to the patient that she is epileptic. An apology has been provided to both patients concerned for any distress or anxiety caused and clinical investigations are currently being undertaken.


Page 9 of 23

4.2.8 One patient believed that they were not assessed appropriately as they swore at

the attending ambulance crew during their attendance. This complaint has not been upheld as the patient’s PCR clearly details that an appropriate and thorough clinical assessment took place, and that the patient was conveyed to hospital for further assessment and treatment.

4.3 Clinical Hub – North 4.3.1 Three of the complaints received related to the length of time it took for an

ambulance to attend to patients who had fallen. 4.3.2 In one case, a complainant’s concerns were exacerbated by the non-functioning of

an emergency vehicle’s siren. The local operations manager has since confirmed that this fault was promptly reported and rectified.

4.3.3 Two complainants were unhappy at the number of questions asked during their

contact with the Clinical Hub. In one complaint, a non-compliant 999 call was identified by the Clinical Hub. The Emergency Medical Dispatcher (EMD) in question incorrectly coded a patient’s hip injury as being to a “non-dangerous” part of the body rather than “possibly dangerous”. As the patient was outside at the time of the injury, the ultimate coding of the call was not affected. Nonetheless, the outcome of the audit has been reviewed with the EMD concerned to minimise the risk of future reoccurrence.

4.4 Clinical Hub East and West 4.4.1 Six complaints received related to ambulance response times to patients that had

fallen. Three of the incidents have been confirmed as occurring at times of extremely high demand on the service, with ambulance resources being prioritised to life-threatening emergencies.

4.4.2 One complainant felt concerned that the questions asked by the Clinical Hub

delayed the emergency response to the patient. The complaint was not upheld as it was ascertained that a resource was allocated to the patient within one minute and 14 seconds, which arrived on scene in eight minutes and 21 seconds.

4.4.3 Another complainant was unhappy with the handling of his contact with the Clinical

Hub in respect of his son, a frequent caller. All three calls, including two calls undertaken by a Clinical Supervisor, were reviewed and deemed compliant and to have been handled safely.


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5. Table 4: Analysis for Patient Transport and Voluntary Ambulance Car Services – April 2014 to February 2015

Type of Feedback Apr May June July Aug Sept Oct Nov Dec Jan Feb 2014/15

YTD Apr-Feb 2013/14

Total for 2013/14

Compliments 1 1 0 1 1 2 2 1 1 2 1 13 Not Available

Percentage of patients who would to recommend the service to friend or family

(number of responses)

-

89%

(83)

Survey

- - - - 100%

(10)*

96%

(94)

Survey

100%

(3)*

100%

(1)*

50%

(4)*

92.5% Average

(177) Survey

87.5%

(18)

Not Available

Comments, Concerns & Complaints10

4 5 2 3 5 7 8 6 0 4 7 51 95 102



Moderate level investigations 0 0 0 0 0 0 1 0 0 1 0 2 Not Available

Serious Incidents (incl from

Complaints) 0 0 0 0 0 0 0 0 0 0 0 0 0 0



Adverse Incidents 3 4 4 5 1 1 1 0 1 1 0 21 105 107


Security Management Incidents 0 1 0 0 1 0 0 0 0 1 0 3 11 11

Claims 0 0 1 1 0 0 2 0 0 0 0 4 8 8

Number of patient contacts 8,041 7,736 8,226 8,960 7,643 8,619 8,911 8,053 7,912 8,427 8,338 90,868 315,064 323,303

*Friends and Family Test

10 Serious Incidents from complaints included in Serious Incident numbers


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5.1 The Patient Transport Service (PTS) managed 90,868 patient contacts during the

period 1 April 2014 to 28 February 2015. (Source: Information Cell). Based on this, the PTS service line had:

0.14 compliments per 1000 patient contacts



0 serious incidents per 1000 patient contacts

5.2 Patient Transport Services 5.2.1 Two of the seven complaints received during February raised concerns that PTS

transport did not arrive for either the complainant or a relative. In one of these cases, the PTS management team confirmed that an error had been made in the expected collection date. Transport was rearranged for the patient that day and they were conveyed to their hospital appointment as required.

5.2.2 Five complaints related to the timeliness of PTS when picking up or collecting patients, and are currently being investigated by the PTS management team to ascertain the root cause of these. In the interim, an apology has been provided to each complainant.


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6. Table 5: Analysis for the Urgent Care Service (GP Out of Hours, NHS111 and Tiverton MIU) – April 2014

to February 2015


YTD Apr-Feb 2013/14

Total for 2013/14

Compliments 12 13 14 18 13 14 20 10 20 14 15 163 Not available

Comments, Concerns and Complaints11

25 24 25 31 22 23 28 18 43 31 31 301 197 221

No investigation require 0 0 0 1 1 0 9 3 2 1 6 36 Not Available


Moderate level investigations

5 4 3 7 2 4 5 6 5 8 5 53 Not Available

Serious Incidents (incl from Complaints)

1 (0) 2 (0) 0 3 (0) 0 0 1(0) 1(0) 1(12)12 0 0 9 3 5



Adverse Incidents 272 208 222 227 181 145 192 145 249 230 204 2,275 1,008 1,235



0 2 1 3 0 0 0 0 2 1 2 11 16 16

Claims 0 0 0 0 0 0 0 0 0 0 0 0 1 2

Number of patient contacts (OoH, 111 &

MIU) 82,027 85,561 76,624 78,923 84,981 68,853 73,826 81,309 94,619 89,391 76,538 892,378 450,207 521,194

11

Serious Incidents from complaints included in Serious Incident numbers below. 12

Complaints which are informing the Major Incident Standby SI


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6.1 The Urgent Care Service (including GP Out of Hours, NHS 111 and Tiverton MIU) managed 892.378 patient contacts in the period 1 April to 28 February 2015. Based on this, the UCS service line had:

0.18 compliments per 1000 patient contacts



0.01 serious incidents per 1000 patient contacts 6.2 Urgent Care Services - NHS111

Access and Waiting 6.2.1 The majority of the complaints received were in respect of the delay in receiving a

call back from the 111 Service. Delays increase during periods of high demand, such as weekends or evenings. This can result in the call back taking place in the early hours of the morning, when the complainant/patient is in bed asleep. In addition, on occasion callers have requested that they are not contacted after a certain time at night and unfortunately this has not been relayed to the clinician making the call.

6.2.2 Call Advisors have been reminded of the importance to note any special requests made so that the caller does not feel ignored or get upset when they are called at an unsociable hour. Call Advisors are asked at the start of every shift to communicate the current delay to each caller. This enables the caller to make an informed decision as to whether they wish to remain in the queue for a call back or cancel the planned call back.

Clinical Care

6.2.3 Some of the complaints received have been in respect of whether clinical care may have been delayed due to the call handler sending the patient to an inappropriate health organisation. For example at Minor Injury Units the clinical staff are not as equipped as other major hospitals to treat certain illnesses or conditions.

6.2.4 Call Advisors have received further training on the use of the Directory of Services

(which provides details of available local health provision) and have also been encouraged to challenge the results produced by the Directory when they are unsure of the relevance of the information to be provided to callers. Call Advisors have been asked to judge each situation individually and if there is any doubt to check with a senior member of staff. It is anticipated that this will reduce the amount of incorrect information provided and enable callers to know what to do in the event that they visit a health establishment which cannot help them.

Communication

6.2.5 A small number of the complaints received were around the perception of the number of ‘non-relevant’ questions asked by the Call Advisor and also the way in which the Call Advisors themselves are perceived by callers.


Page 14 of 23

6.2.6 When a caller contacts the 111 Service, they may be distressed or in pain. This can

result in the caller perceiving that the questions being asked are frustrating and a waste of time. However, in most cases, Call Advisors are doing their utmost to keep calm and in control of the conversation in order to provide the most appropriate care.

6.2.7 In cases where a Call Advisor has not kept an acceptable level of composure, the call has been reviewed and feedback has been provided to the Call Advisor to ensure future calls are handled more appropriately.

6.2.8 Call Advisors are also encouraged to be as transparent as possible so that they can manage a caller’s expectations. If the caller does not know what the Trust is aiming to do to help them and in what timeframe, they may well assume that no help is being provided, their request for help has been ignored, or their call has not been prioritised appropriately.

6.3 UCS CQUIN (Commissioning for Quality and Innovation) 6.3.1 As part of the CQUIN program the Patient Engagement Team has worked with

commissioners to ensure that the CQUIN plan for Patient Experience is fit for purpose and offers good value for all concerned.

6.3.2 The CQUIN sets out plans to improve the quality and reporting of the patient experience surveys sent out every month for patients of the GP Out of Hours service, and fortnightly for NHS 111, in line with the contracts for those services.

6.3.3 The Trust has worked with an external supplier to review and re-design the Trust’s patient experience surveys. This work has now been completed and the new surveys will be used from March 2015. Future reports will reflect the content of the new survey and thus will not be comparable to previous reports.

6.3.4 As of March 2015 the responsibility for managing the patient experience surveys will lie with the Patient Engagement Team; any outstanding activities relating to surveys from before this date will be undertaken by the team at the St Leonard’s Clinical Hub.


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6 Table 6: Analysis for Other Activity – April to 2014 to February 2015

7.1 Some comments, concerns and complaints, adverse incidents and claims do not relate to a specific, or any, service line. For reporting purposes these have been categorised as ‘other’.


YTD Apr-Feb 2013/14

Total for 2013/14

Compliments 7 6 6 6 6 6 4 13 2 11 8 75 38 45

Comments, Concerns and Complaints

0 1 0 0 0 0 1 0 0 2 0 4 0 0

Low level investigations

0 1 0 0 0 0 1 0 0 2 0 4 0 0

Serious incidents 0 1 2 0 0 0 1 0 1 0 0 5 Not Available


Adverse Incidents 20 29 28 31 5 7 27 47 35 34 36 299 367 400



1 1 0 0 1 0 0 0 0 0 2 5 6 6


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8. Compliments and Cloud Tags 8.1 Many patients, or their families, contact the Trust to compliment staff on the care

that they provided. 8.2 Since 1 August 2014 all compliments received have been coded according to the

‘6Cs’ (see Table 7) of the Compassion in Practice model. Each one may be coded against more than one of the ‘6Cs’ as set out in the table below. Examples of the compliments received are at Annex 1 to this report.

Table 7: Compliments Received Since 1 August 2014

Code Aug Sept Oct Nov Dec Jan Feb

Care 158 191 169 140 166 175 161

Compassion 93 103 33 60 107 150 132

Competence 108 176 172 147 166 182 167

Communication 52 48 39 41 67 136 134

Courage 5 2 0 1 0 0 1

Commitment 38 38 27 33 44 35 36

8.3 When the compliment is processed, the member of staff to whom it refers, receives a

letter from the Chief Executive. In addition to conveying the thanks of the patient, these letters also make reference to the 6Cs which staff can use as as evidence for their annual Personal Appraisal and Development Review.

8.4 161 people proactively contacted the Trust during February to pass on their thanks

to our staff. The kind words used to describe the care patients, and their families, have received have been translated into ‘cloud tags’. The cloud tag below shows how often words were used by patients to express their gratitude – the more times the word was used the larger the word appears.


Page 17 of 23

9. Duty of Candour 9.1 As of 27 November 2014 the statutory Duty of Candour, Regulation 20 of the Health

and Social Care Act 2008 (Regulated Activities) Regulations 2014 became a statutory requirement for NHS Trusts.

9.2 The duty requires that the patient (or legally appointed person acting on behalf of

the patient) is notified of a potential or actual patient safety incident that has or may have caused moderate harm, severe harm or death. It is a requirement of Regulation 20 that the notified party receives:

a. all factual information known to date at the point of notification; b. an apology; c. an explanation of what enquiries any investigation may make; d. written follow up including all points raised in a-c above; e. reasonable support (provision of friends, family, advocate, access to needed

treatment to facilitate recovery); and f. the outcome of the investigation (including a step by step explanation and a

copy of the report) is fed back in person (unless they specifically say that they do not want a meeting) and in writing.

9.3 There are stipulated timescales and notification requirements set out by NHS England

in relation to completion of the investigation and communication with patients or their next of kin which have been reaffirmed by the recently published Care Quality Commission guidelines. Any breaches in the timescales or failure in identifying a Duty of Candour incident could result in penalties (financial or otherwise) against the Trust or against a specific Manager. The Duty is also regulated by the Care Quality Commission and therefore subject to inspection and enforcement.

9.4 The Trust has been working to the principles of the contractual Duty of Candour

since 1 April 2013 and a significant amount of background work has been completed in order to achieve compliance. The Patient Safety Team maintains a “Being Open” log which enables the tracking and monitoring of all contacts relating to serious and moderate harm incidents. Every effort is made, where possible and appropriate, to make contact with a patient or their next of kin where the Trust believes it has caused serious or moderate harm. In certain circumstances, where it is felt to potentially be more damaging to make contact, a risk assessment is undertaken and the rationale for not making contact is recorded. This process is reviewed by our commissioners. However, contact has been made in all but 4 of 49 incidents to date in 2014/15.

9.5 According to the standard NHS contract, contact (if appropriate under the Duty of

Candour) should be made with the patient or next of kin within 10 working days. Because of the nature of an emergency service, this is not always possible and we are working with our commissioners to look at our processes and decision making to help improve our compliance with this target.


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Serious Incidents 9.6 In the reporting period, there were two serious incidents reported. One of these

incidents was reported via a complaint. Contact has not yet been made in respect of the other incident as the investigating officer is liaising with the hospital concerned as to the patient’s identity and next of kin.

9.7 Four serious incidents were closed in February 2015. In all four cases, successful

contact was made with the patient or their next of kin in to advise them of the investigation and the subsequent outcome of the Serious Incident Review.

Moderate Harm Incidents

9.8 One modern harm incident was confirmed in February 2015. The patient has been contacted in accordance with the Duty of Candour requirement. No Moderate Harm incidents were closed in February 2015.

10. Friends and Family Test for Patients

10.1 In July 2014 NHS England published guidance detailing how all NHS Trusts must implement the Friends and Family Test (FFT). The FFT is a single question survey which asks patients whether they would recommend the NHS service they have received to friends and family who need similar treatment or care. The Trust is offering patients the opportunity to answer the FFT by three means - text, telephone or via an online survey. Patients not conveyed (999) or patients travelling with PTS have been invited to answer the FFT, with crews providing patients with a postcard which details the three response mechanisms.

10.2 The FFT implementation plan involved a staged roll out starting from 1 October

2014. The Trust has now rolled this out across all relevant service lines and geographical areas. The results are being collated on a monthly basis and the results from February 2015 can be seen at Table 8. Table 8: Friends and Family Test Responses

Via FFT measures

February

Score

Tota

l

%

Rec

om

men

d

% Not

reco

mm

end

EL L NLU U EU DK

999

North 7 0 0 0 0 0 7 100 0

East 3 0 0 0 0 0 3 100 0

West 7 0 0 0 0 0 7 100 0

PTS BNSSG 2 0 0 0 2 0 4 50 50

GP OOH and MIU

2 0 0 0 2 0 4 50 50

Total 21 0 0 0 4 0 25 84 16


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*scoring is recorded as EL – Extremely Likely L – Likely NLU – Neither Likely or Unlikely U – Unlikely EU – Extremely Unlikely DK – Don’t Know

10.3 Feedback from patients has been overwhelmingly positive. As the feedback left is

completely anonymous, comments have not being translated into compliments. Below are a some verbatim comments left by patients on the automated phone line:

999: ‘The operator who answered my call and the paramedic who attended thank

you very much to both of them.’ 999 ‘Thank the team for the help. I live on my own and my first thoughts a stroke

but I seem to be fine. Just thanks to our team.’ PTS ‘The two people involved were a lady and a gentleman, I know their names I

think were Karen and Craig, they both began with a K, anyway it was an ambulance and they were absolutely fantastic. It was on the 24th February and they picked us up round about 2 o'clock for a quarter to 3 appointment and I can't praise them enough. Thank you very much indeed.’

10.4 Trust Managers are being provided with the detail of all feedback relevant to their

areas of work and have been asked to disseminate this to their staff. 10.5 In December 2015 the Trust introduced the FFT into the Community Health setting.

For the Trust this means the GP Out of Hours and Urgent Care Centre (formally known as the MIU) in Tiverton. In February 2015 the Trust began reporting details of the FFT responses from patients receiving care from the Trust’s Community Health services to NHS England. In turn, NHS England makes this data publicly available.

10.6 Planning is currently underway to ensure readiness for when the FFT becomes

mandatory for the 999 and PTS services in April 2015.

11. Friends and Family Test for Staff 11.1. As of April 2014, NHS England introduced the Staff Friends and Family Test (Staff

FFT) in all NHS trusts providing acute, community, ambulance and mental health services in England.

11.2. NHS England’s vision for the Staff FFT is that all staff should have the opportunity to

feedback their views on their organisation at least once per year. It is hoped that Staff FFT will help to promote a big cultural shift in the NHS, where staff have further opportunity and confidence to speak up, and where the views of staff are increasingly heard and are acted upon.

11.3. Staff FFT is a feedback tool for staff, predominantly for local improvement work;


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consisting of two questions (with options to give free text feedback for each) through which organisations can take a temperature check of how staff are feeling. It is a quicker feedback mechanism than the existing NHS annual staff survey, and at its best will enable staff to voice their concerns (on a regular basis if they wish to) and for organisations to respond. The more engaged staff members are, the better the outcomes for patients and the organisation generally. It is therefore important that the Trust strengthens the staff voice, as well as the patient voice. Table 9 sets out the responses received to date.

Table 9: Staff Friends & Family Test

Responses % of Headcount

Q1. % would recommend the Trust to friends and family if they needed care or treatment

Q2. % would recommend the Trust as a place to work

Yes No Yes No

Q1 162 3.5% 86% 4% 59% 28%

Q2 72 1.7% 83% 11% 56% 32%

11.4. The Trust uses Picker to carry out the survey. When comparing our average scores to all other ‘Picker’ Trusts, including Ambulance, Acute, Community and Mental Health Trusts, Trust staff scored us higher than average by 4% on question 1 and above average by 14% for question 2 in Quarter 2. Overall, Trust staff rated it as the best performing Trust across all other ‘Picker’ Trusts including Ambulance, Acute, Community and Mental Health Trusts for both questions.

11.5. The annual staff survey replaced the Quarter 3 staff FFT.

11.6. Quarter 4 opened on 5 January 2015 and will close on 31 March 2015.

12. Learning Disability Programme 12.1 The Accessibility and Learning Disability Programme is monitored by the Trust’s

Quality and Governance Committee. 12.2 The approach taken by the Trust, due to the inherent difficulties in identifying

patients with LD at the ‘front door’, ie when a call is received, is on engagement with groups which support those patients to find out what they want and need from us, and what causes them anxiety when they interact with us. We will then be better able to educate and train our staff to ensure that their interaction with LD patients is as positive and support as it can be.


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12.3 In this period, the Patient Engagement Manager attended a third meeting with the

group of service users in Plymouth. The meeting was well attended by patients and those who support them. The aim of the meeting was to desensitize patients to the Trust uniform and vehicles, and to reassure the client group how to recognise an ambulance clinician as a ‘safe stranger’.

12.4 At this meeting, the Trust was very fortunate to have in attendance Jo Stonehouse,

Clinical Development Officer and nine Student Paramedics from the University of Plymouth. This was particularly beneficial as it meant that the patients could ‘buddy up’ with a student/clinician who could then take the time to show them around the ambulance and offer support and reassurance.

12.5 The event was very well received by the patient group, their supporters and the

students who have since expressed an interest with working with the Patient Engagement Team in future.

12.6 The Patient Engagement Manager has received training on how to produce complex

document in an Easy Read format. Since this training, work has commenced with the Frequent Caller Lead at the Clinical Hub to prepare documentation used to communicate with patients contacting the service frequently in an Easy Read format.

13. Recommendation 13.1 The Board of Directors is asked to note for assurance the Patient Safety and

Experience Report. Governance and Patient Experience Team


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Annex A Compliments Received – Coded Against the 6Cs of the Compassion in Practice Model

Code Example Plaudit/Compliment

Care

Hello. My name is [name]. Last Friday I had need to call the ambulance and the fast response and two paramedics come. They was with me for an hour and all 3 of them was absolutely fantastic. They couldn't have given me better service if I was paying them a million pounds an hour. I don't know their names because I was out of it, I only thought they was with me for 10 minutes, but my daughter said no it was nearly an hour, and then the NHS doctor, they sent for him to come see me as well. They came to [ ] last Friday about 1ish I think it was. But they were, well, absolutely fantastic and if I could reward them I certainly would. Ok? Thank you very much and thank them if you can track them down. Thank them from me.

Compassion

This morning we called the ambulance service to attend an elderly friend of ours who was unwell. She is 82 and had been unwell for the last 48 hours. She deteriorated significantly this morning and we were obviously worried. When the ambulance team arrived, they were really friendly and immediately put us, and Rosemary, at ease. The paramedic, MJ, and the ECA Joe were really attentive, kind and reassuring. They were very thorough in asking questions and checking her and listened carefully to what she had to say. Throughout their time with us, they treated her with genuine care and respect for which we are so grateful.

At a time when we know what a strain the ambulance service is under, it is so reassuring to know that we have such dedicated, caring and knowledgeable medical professionals, delivering such an outstanding level of service to our community.

Please pass on our praise and thanks to MJ and Joe.

Competence

I would like to say a big thank you for a great service. My Mum has had numerous 'encounters' which ambulance staff since 2008, and she has had nothing but very prompt and professional attention. Twice this year, 2nd January with an MI. Thanks to ??Ron the Paramedic and yesterday thanks to the crew who took her to hospital in the evening. Although they introduced themselves I can't remember their names but it was a male/female crew. As a carer of an elderly parent I also thank every professional that has attended her for the support it as given me by their swift responses.


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Communication

Just a quick note to say thank you to the rapid response paramedic (& call handlers) that attended my house today when my friend cut his hand with a chainsaw.

The Paramedic was very professional & reassuring keeping every one calm and even made the patient laugh by making light of the situation, he was a true professional and I don't know what we would do without people like him, he is a credit to our brilliant NHS.

Commitment

I should like to thank the ambulance crew who on Christmas Day picked me up together with my hand bag and locked my front door.

I was alone and when the pain came I had just enough time to unlock the front door, dial 999 and give details to the operator. I heard the ambulance siren but was gone before it arrived. The crew, I understand, took me and my handbag to hospital where I was transferred to a specialist hospital but knew nothing about it. The first thing I remember was on the 12th day when a doctor explained a procedure to be carried out on me.

After 2 weeks I was sent back to the original hospital where my brain and limbs improved. I have been home 3 weeks and am slowly getting back to normal after my brain hemorrhage. I live alone having lost my husband last year so my son has helped me. My son, as a full-time fire fighter for 28 years, has great admiration for paramedics etc.

Thank you so much for what you did. But for you my granddaughters would have found me dead on Boxing Day. Sorry I ignored you when you arrived.

Wishing you a healthy, happy life.

Courage

Back in January this year, Paramedic [name] attended a nasty assault upon a female patient suspected of suffering domestic violence.

Whilst at the scene dealing, the patient personally disclosed to [name] that she had been beaten up by her boyfriend.

That victim remained unwilling to support a prosecution, however with the evidence of [name] and then that of my colleagues, we were today able to convict the offender at Court and ultimately get him recalled to Prison as a result.

[name] was most helpful in coming forward, and even ended up sacrificing her day off work today in order to attend Court in the expectation of giving evidence.

She played a pivotal role in support a vulnerable victim in society, who regardless of not wishing to engage with Police, will now be safeguarded from a horrific individual with a propensity towards extreme violence.

Please cascade my thanks to her superiors and raise this with the relevant persons.


Page 1 of 3


Title: Use of Emergency powers

Prepared by: Marty McAuley, Trust Secretary

Presented by: Marty McAuley, Trust Secretary

Main aim: To provide the Board of Directors with information about the use of emergency powers.

Recommendations: The Board is asked to ratify the use of the emergency powers.




BAF22-13 Directorate Business Plans

Implications


Requirement of the Trust Constitution.


Page 2 of 3

Use of Emergency powers

1. Introduction

1.1 Within annex seven of the constitution (the Board standing orders) there is the ability to exercise the powers of the Board of Directors, by the Chief Executive and the Chairman after having consulted at least two Non-Executive Directors. This is known as the use of emergency powers.

1.2 The use of the powers is overseen by the Trust Secretary. Whenever they are used,

it will be reported at the next Board meeting. This report details the use of the emergency powers since the last meeting of the Board of Directors.

2.0 Use of Emergency Powers – Dinan garage 2.1 The emergency powers were used on 26 February 2015 to waive the standing

orders for waiver number 427/01/2014/15. The waiver was for £24,000.00 for vehicle maintenance.

2.2 The use of emergency powers was approved by the Chief Executive and Chairman.

It was supported by Mary Watkins, Hugh Hood and Tony Fox.

3.0 Use of Emergency Powers – Capita 3.1 The emergency powers were used on 26 February 2015 to waive the standing orders

– waiver number 432/02/2014/15. The waiver was for £69,055.74 and relates to expenditure on upgrading the telephony system to enable a virtual integrated telephony system.




Page 3 of 3

4.0 Use of Emergency Powers – Advanced Health & Care Ltd 4.1 The emergency powers were used on 26 February 2015 to waive the standing orders

– waiver number 432/02/2014/15. The waiver was for £28,465.63 and relates to incremental expenditure on Adastra (AHC) to support the delivery of Gloucestershire OOH.



5.0 Use of Emergency Powers – Use of the seal 5.1 The emergency powers were used on 26 February 2015 to authorise the Trust

Secretary to apply the seal and execute a deed. The deed was for construction works to be undertaken at Trust HQ.



6. Recommendation

6.1 The Board is asked to ratify the use of the emergency powers.

Marty McAuley Trust Secretary


Page 1 of 3

Trust Board of Directors 26 March 2015

Title: Corporate Risk Register

Prepared by: Vanessa Williams, Head of Patient Safety and Risk

Presented by: Ken Wenman, Chief Executive

Main aim: To provide the Board of Directors with an update on significant risks contained within the Corporate Risk Register.

Recommendations: This paper has been produced for information and assurance

Previous Forum: This paper has previously been presented to the Quality and Governance Committee



BAF04-14, BAF14-14 Directorate Business Plans

Nursing & Governance Directorate

Implications


The implications of each risk are set out within the title of the risk. This report relates to BS 31000:2009, Corporate Manslaughter Act, Health and Safety legislation.


Page 2 of 3

Corporate Risk Register 1. Introduction

1.1 The Trust’s Risk Management Strategy sets out the process for the management of the

risk registers.

1.2 The Quality Risk Watch Group is responsible for reviewing the content of the risk registers, quality assuring and proposing changes to risks. This group last met on 4th February 2015, paragraph 2 summarises the updates and any proposals which were agreed at the Directors Group on 18 February 2015 and presented to Quality and Governance Committee on 12 March 2015.

1.3 Copies of the current version of the Corporate Risk Register is attached for information

and assurance.

2. Corporate Risk Register

2.1 New Risks 2.1.1 The following new risk was been placed on the Corporate Risk Register for

consideration by the Directors Group.

New Risk

Clinical Hub Rationalisation This new risk was placed on the Directors Risk Register on 5th December 2014 and transferred to the Corporate Risk Register by the Quality Risk Watch Group.

2.2 Risk Movements and Updates 2.2.1 The table below summarises the movement of risks on the Corporate Risk Register

Risk Movement

Industrial Action Likelihood score reduced to 4.

Delivery of Statutory and Mandatory Education

Likelihood score increased to 5.

Urgent Care Services Contract Likelihood score increased to 5.

Handover delays (Impact on Resources)

Risk merged with newly titled Operational Resources Risk (previously titled Workforce Establishment).


Page 3 of 3

2.2.3 The table below summarises updates made to risks on the Corporate Risk Register

Risk Update

Workforce Establishment Levels Title of risk changed to ‘Operational Resources’ as the group believe that the risk is a reduction in the number of resources due to a number of reasons including establishment.

Call Answering Performance 111

Actions transferred to Controls.

Corporate Financials Additional Actions

Delivery of Statutory and Mandatory Education

Additional Action

3. Recommendation

3.3.1 Members of the Board of Directors are requested to note the contents of this paper.

Vanessa Williams Head of Patient Safety and Risk

Confidential

Proximity Risk

L = Long term (3 years - 5 years)

M = Medium term (1 year - 3 years)

S = Short term (less than 1 year)

O = Ongoing risks

Ris

k T

itle

Qu

ali

ty R

isk

Perf

orm

an

ce

Ris

k

Fin

an

cia

ls R

isk

Risk DescriptionA

cc

ou

nta

ble

Dir

ec

tor

Ori

gin

al

Co

nse

qu

en

ce

Sco

re

Ori

gin

al

Lik

eli

ho

od

Sco

re

Ori

gin

al

Ris

k R

ati

ng

Controls in Place

Cu

rren

t C

on

se

qu

en

ce

Sco

re

Cu

rren

t L

ikeli

ho

od

Sco

re

Cu

rren

t R

isk R

ati

ng

Action Summary

Acti

on

Dea

dlin

e

Fo

rec

as

t C

on

se

qu

en

ce

(po

st

acti

on

s)

Fo

rec

as

t L

ikeli

ho

od

(po

st

acti

on

s)

Fo

rec

as

t ri

sk r

ati

ng

(po

st

acti

on

s)

Pro

xim

ity R

isk

Co

rpo

rate

Ob

jecti

ves

Ris

k S

ou

rce

Date

ad

ded

to

reg

iste

r

Ref

Ris

k R

ati

ng

Mo

ve

men

t (s

ince

la

st

up

date

)

Op

era

tio

nal

Reso

urc

es

X X X

Potential reduced resource levels at times of peak

demand as a result of a significant number

vacancies, handover delays at hospitals, national

shortage of paramedics, abstractions (including

sickness absence), changes to rules regarding

qualifications, implementation of new projects and

availability of 3rd party providers affecting safety,

performance, morale and reputation.

Risk score increased by Directors Group.

Executive D

irecto

r of H

R a

nd O

rganis

ational develo

pm

ent

SERIOUS

(4)

LIKELY

(4)

16 ●Resource Operations Centre (ROC) established;

●Annual Accountability Agreement for all directorates;

●Implementation of REAP;

●Workforce plan;

●Weekly Resource Management Group (RMG) conference calls;

●Workforce Planning Establishment Group (WPEG) in place to review

workforce forecasting, plans and actions;

●Provision of staff by third parties, agencies, bank and overtime;

●Recruitment tracker in place for 111 staff which is meeting the trajectory;

●Deployment of clinically qualified managers to frontline duties,as required;

•Management reports provided to CPR, Directors Group and Quality and

Governance Committee;

•Absence Management Training being delivered as part of Leadership and

Management development programme;

•Global Rostering System (GRS) implemented across Trust;

●Revised Sickness Policy to manage regular short term sickness absentees;

●Ongoing recruitment programme;

●University Liaison Officer appointed to actively recruit students;

●National recruitment marketing campaign;

●Revised handover delay reporting procedure agreed with Commissioners;

●Revised handover delay SOP implemented across Trust.

V.SERIOUS

(5)

ALMOST

CERTAIN

(5)

25 ●Ongoing achievement of core cover;

●National review of unsocial hours payments;

●Trust to overestablish;

●Consideration of recruitment incentives;

●Working Group on management of annual leave to be led

by ROC Manager;

●Review of workforce recruitment plan underway (AH);

●Additional bank staff being appointed;

•Employee Assistance Programme under review (EW);

•Implement actions contained within Staff Survey Action

Plan (EW);

•Health and Wellbeing Group to be established as sub-group

of Health & Safety Group (EW);

●Review of Occupational Health and welfare services

launched, encouraging partication by Trust staff;

●Staff engagement expert undertaking review of attritution

rates;

●Exercise being undertaken to forecast workforce numbers

over future years to take account of changes to rules

regarding paramedic qualifications;

●Additional 60 ECAs in training;

●Proposal agreed for additional conversion from ECA to

Paramedic;

●Paramedic conversion course (April 2015);

●Qualifying Open University students being appointed;

●Review of handover penalty arrangements with

Commissioners;

Apr-15 SERIOUS

(4)

POSS (3) 12 S CO1,

CO2,

CO3, CO4

Executive D

irecto

r of H

R a

nd G

overn

ance

20/0

9/2

013

HR

815

↑

Perf

orm

an

ce T

arg

ets

X X X

The potential for not achieving and sustaining Red

1, Red 2 and A19 targets in 2014/15 which could

impact on patient safety, staff experience,

financials, Monitor's Risk Assessment Framework

and the Quality Premium Payment.

Chie

f E

xecutive

V.SERIOUS

(5)

POSS (3) 15 •Robust business plan and corporate objectives monitored by Directors Group;

•Effective and fully staffed Clinical Hub with rolling recruitment programme;

•Implementation of Regional and Trust wide REAP levels;

•National agreement on Red 1 definition alignment;

●Implementation of Early Exit procedure within Clinical Hubs;

●Standard Operational Procedure regarding deployment of Responding

Officers in place since January 2014;

●Clinical Floor walkers within 111 to prevent inappropriate Red 1 dispositions;

●Individual OM trajectories developed, disseminated and monitored;

●Implementation of Enhanced Pre Hospital Care within Clinical Hubs;

●Roll out of Public Automatic Defibrillators;

•Development of divisional Operational Implementation Plans;

●Roll out of Airwave Responder Pagers;

●Developments identified within MAVIS implemented;

●Trust achieved Red 1 performance for Q1 and Q2;

●Winter Pressures funding;

●Operational Resilience Capacity Plan (ORCP) being implemented with

dedicated lead;

●Red 1 performance trajectory agreed with each CCG;

●Revised enhanced Trust wide hospital handover SOP agreed with

Commissioners;

●Revised 999 Mitigation Plan agreed by Directors Group;

●Use of agency paramedics to address establishment levels.

V. SERIOUS

(5)

LIKELY

(4) 20 • Ongoing internal monitoring and improvement;

•Implementation of A&E Business Programme;

●Ongoing contract negotiations;

●Implementation of divisional Operational Implementation

Plans;

●National review of performance targets by research

organisation;

●Implementation of ORCP;

●ORCP reporting to Commissioners;

●Assess impact of Dispatch on Disposition trial taking place

from 10 February 2015 - 9 March 2015;

●National review of REAP.

Mar-15 SERIOUS

(4)

LIKELY (4) 16 M CO1,

CO2,

CO3, CO4

Directo

rs G

roup

27/1

1/2

012

D788

↔

Confidential

Corporate Strategic Risk Register equal to or greater than 15

18 February 2015 (20 significant risks )Key: Text highlighted blue indicates the changes that

have been made to the Risk Register since it was last

presented to the Board of Directors.

MEAP = Mitigation Escalatory Action Plan

Page 1 of 6 M:\Board of Directors\Board Papers\2014-15\26 March 2015\Public\13. Corporate Risk Register\Corporate Risk Register 18.02.2015 Confidential

http://hqweb/metatraffic2/track.asp?mtr=../../images/swastftlogo_new.jpg

ConfidentialR

isk

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an

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cia

ls R

isk

Risk Description

Acc

ou

nta

ble

Dir

ec

tor

Ori

gin

al

Co

nse

qu

en

ce

Sco

re

Ori

gin

al

Lik

eli

ho

od

Sco

re

Ori

gin

al

Ris

k R

ati

ng

Controls in Place

Cu

rren

t C

on

se

qu

en

ce

Sco

re

Cu

rren

t L

ikeli

ho

od

Sco

re

Cu

rren

t R

isk R

ati

ng

Action Summary

Acti

on

Dea

dlin

e

Fo

rec

as

t C

on

se

qu

en

ce

(po

st

acti

on

s)

Fo

rec

as

t L

ikeli

ho

od

(po

st

acti

on

s)

Fo

rec

as

t ri

sk r

ati

ng

(po

st

acti

on

s)

Pro

xim

ity R

isk

Co

rpo

rate

Ob

jecti

ves

Ris

k S

ou

rce

Date

ad

ded

to

reg

iste

r

Ref

Ris

k R

ati

ng

Mo

ve

men

t (s

ince

la

st

up

date

)

Call

An

sw

eri

ng

Perf

orm

an

ce (

111)

X X X

Potential failure to meet performance against

national benchmarking for call answering (95%

within 60 seconds) could result in call

abandonment, affecting service quality, patient

safety and experience, reputation, contractual non-

compliance and have financial implications.

Executive D

irecto

r of N

urs

ing a

nd G

overn

ance

SERIOUS (4) POSS (3) 12 •Daily telephony performance reports;

•Ongoing recruitment and training of Call Taking staff and Clinical Supervisors;

•Weekly Call Taker performance reports;

●Quality Development Plan, trajectory and weekly meetings;

●New wall boards in 111 Hub to display performance information;

●Automated Caller Dispatch Queues (ACDQ) implemented in both 111 hubs;

●External independent review of rotas identified that establishment levels are

correct;

●Additional part time staff appointed;

●Development of Performance Management Framework for call answering;

●Executive and management leadership strengthened;

●Implementation of rota review;

●Clinical Floor walkers within 111 Hub;

●Improvement trajectory agreed with Commissioners;

●External review of OOH and 111 service complete;

●Review of staff profiling complete;

●Introduction of Duty Managers within 111 Hubs;

●Recruitment campaign targetted at specific demographics;

●Review and analysis of data to inform modelling and activity profiles;

●Winter pressures funding;

●Introduction of Integrated Voice Response (IVR);

●Introduction of Non-Pathways Agents (NPA).

SERIOUS

(4)

ALMOST

CERTAIN

(5)

20 •Ongoing monitoring of performance;

●Review of core cover and staff absence;

●Implement actions within Performance Recovery Plan;

●Review of audit process underway including structure,

frequency and performance management;

●Review of Automated Caller Distribution (ACD) Queue and

patient call flows with CCG;

●Review source of activity, specifically inappropriate

callbacks and abandonments;

●Ongoing work with key stakeholders, specifically looking at

patient pathways;

●Undertake detailed analysis of all shift patterns;

●Additional resources to meet anticipated uplifts in demand;

●Review of clinical delivery model;


rates;

●Data review being undertaken;

●Ongoing recruitment.

Mar-15 SERIOUS

(4)

LIKELY (4) 16 S CO1,

CO2,

CO3, CO4

Executive D

irecto

r of IM

&T

30/0

4/2

013

D806

↔

Nati

on

al

Po

sit

ion

On

Para

med

ic

Ban

din

gs

X

The potential national increase in bandings for

Paramedics from 5 to 6 could create a significant

financial cost to the Trust.

Executive D

irecto

r of

HR

and

Org

anis

ational

develo

pm

ent

V.SERIOUS

(5)

LIKELY (4) 20 The Trust's Chief Executive is working on this nationally with the Association of

Ambulance Chief Executives.

V.SERIOUS

(5)

LIKELY

(4) 20 Awaiting outcome of national discussions. Residual risk

scoring remains the same until further clarification is

received.

Mar-15 V.

SERIOUS

(5)


CO2,

CO3, CO4

Deputy

Directo

r of

Fin

ance

05/1

2/2

014

HR

873

↔

Deli

very

of

Sta

tuto

ry a

nd

Man

dato

ry E

du

cati

on

X

Potential failure to deliver in year and outstanding

Statutory and Mandatory Education to all relevant

staff as a result of REAP levels, activities and

vacancies.

Executive D

irecto

r of H

R a

nd

Org

anis

ational D

evelo

pm

ent

SERIOUS

(4)

LIKELY

(4)

16 ●Integration training plan approved;

●Extended training day;

●Trajectory in place with monthly reporting to the Directors Group;

●Included within Annual Accountability Agreement and monthly progress

reported through Performance Management Framework;

●Divisional REAP levels;

●Weekly monitoring by the Resource Management Group (RMG);

●Training exception reports presented to Quality and Governance Committee;

●Overtime provided to assist in completion of training;

●Training plan for 2014/15 approved by Directors Group and triangulated with

finance and operations;

●Mandatory training workbook issued to all staff for completion within 6

months;

●New Learning Development Officer structure implemented.

SERIOUS

(4)

ALMOST

CERTAIN

(5)

20 ●Integration training underway;

●Evaluation of virtual station implementation (NLC 2014);

●Revised training plan for SME training to take place in

North division during Q4;

●Divisional wide training day to take place during Q4 for staff

who have not completed integration training;

●Director of Operations to develop plan to deliver historical

gaps in training.

Mar-15 SERIOUS

(4)

POSS (3) 12 S CO1,

CO2,

CO3, CO4

Executive D

irecto

r of H

R a

nd G

overn

ance

20/0

9/2

013

HR

816

↑

Han

do

ver

Dela

ys a

t H

osp

ital

- Im

pact

on

Pati

en

t S

afe

ty

an

d R

eso

urc

es

X X

Increasing number of handover delays in acute

hospital trusts potentially resulting in delays in

attending patients who require emergency and

urgent assessment, treatment and/or conveyance

affecting clinical care and patient safety. In

addition the handover delays impact on the ability

to provide a timely conveying resource to patients

assessed by a clinician as requiring conveyance to

hospital affecting patient safety and experience

and staff morale.

Executive M

edic

al D

irecto

r

V.SERIOUS

(5)

ALMOST

CERTAIN

(5)

25 •NHS Pathways initial triage (East and West Divisions);

•Provision of Bronze Commander to ED;

•Joint working between Trust and acute trusts to resolve issue through local

action plans between OLMs and Commissioners;

• Clinical Notice issued to ensure that observations and continuity of clinical

care continues whilst patients are waiting in handover area;

•Clinical Supervisor call-back to manage risk of delayed responses;

•Implementation of delayed handover SOP to introduce 30 minute handover

(incorporated within Contracts) when there is a risk to patient safety;

•Renewed focus by DH on emergency and urgent care being led nationally by

the Chief Medical Officer;

•REAP in place with recent review (Dec 2014);

•24/7 Logistics Cell in place to escalate handover delays as appropriate;

●Strategically deployed trolleys placed in acute hospitals to improve

turnaround times;

●Triggers for implementation of delayed handover SOP reviewed;

●Issue highlighted to CSU by Director of Operations;

●Revised enhanced Trust wide hospital handover SOP agreed with

Commissioners;

●Review of procedures for receiving patients at new hospital site;

●Monitoring sub-hub of North Logistics desk providing feedback to North

division Commissioners;

●Automatic implementation of handover SOP when Trust is at REAP 4.

V. SERIOUS

(5)

LIKELY

(4) 20 ●Continue to monitor situation and submit adverse incident

reports for each handover delay of more than 90 minutes;

•Review of handover procedure with Commissioners;

•Ongoing dialogue with acute hospital trusts;

●Contract discussions;

●Mid-review of handover delays in accordance with contract

clause;

●Commissioners to agree handover delay reporting

procedure (January 2015);

●Review impact of Trial of Dispatch on Disposition taking

place Feb - March 2015.

Mar-15 V.

SERIOUS

(5)

UNLIKELY

(2)10 M CO1,

CO2, CO4

Ris

k A

ssessm

ent

11 A

pril 2013

D805

↔


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ou

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ble

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ec

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gin

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al

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od

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Cu

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Acti

on

Dea

dlin

e

Fo

rec

as

t C

on

se

qu

en

ce

(po

st

acti

on

s)

Fo

rec

as

t L

ikeli

ho

od

(po

st

acti

on

s)

Fo

rec

as

t ri

sk r

ati

ng

(po

st

acti

on

s)

Pro

xim

ity R

isk

Co

rpo

rate

Ob

jecti

ves

Ris

k S

ou

rce

Date

ad

ded

to

reg

iste

r

Ref

Ris

k R

ati

ng

Mo

ve

men

t (s

ince

la

st

up

date

)

Urg

ent

Car

e Se

rvic

es C

on

trac

t

X

Potential loss of contracts for UCS may result in:

• Loss of synergy between service lines and

patient pathways;

• Strengthened position of competitors;

• Opens the Trust to competition for other service

lines;

• Poor staff morale;

●Additional financial pressure.

Deputy

Chie

f E

xecutive/E

xecutive D

irecto

r of F

inance a

nd

Executive D

irecto

r of N

urs

ing a

nd G

overn

ance

V.SERIOUS

(5)

POSS (3) 15 • Contracts in place for Urgent Care delivery with Dorset extended to 2017;

• Effective performance management system in place;

• Regular performance meetings with Commissioners;

●Commercial principles in place;

• TUPE applicable for directly employed staff;

• Local performance targets have been negotiated with Commissioners;

• Trust awarded NHS 111 contract for Dorset, Devon and Cornwall;

•Gloucester contract awarded;

•Urgent Care MEAP developed;

•FIC review tender financials for any service line;

●Trust attends Urgent Care Review Boards;

●Business Development Manager appointed and tender lead identified;

●Dedicated Tender lead identified;

●Business Development Steering Group established to oversee tendering

activity;

●Director of Urgent Care and senior leadership team fully engaged;

SERIOUS

(4)

ALMOST

CERTAIN

(5)

20 •Action Plan in place to deliver performance targets;

• Contract discussions ongoing between UCS Service Line,

Finance and Commissioners;

•Develop model of care for tenders;

•Implementation of revised performance management

system;

●Review of ECP Strategy;

●Responses to tenders being prepared;

●Urgent Care Workforce Strategy being developed.

Dec-14 MOD (3) LIKELY (4) 12 M CO3, CO4

A021

Fin

ance T

eam

16/1

0/2

009

F544

↑

Co

rpo

rate

F

inan

cia

ls

X

Adverse financial variances within Urgent Care

Service line impacting on the overall financial

position of the Trust. Variance due to a mixture of

non-recurrent issues relating to the re-profiling of

resources to activity and the slippage in the

delivery of cost improvement schemes.

Executive D

irecto

r of N

urs

ing a

nd

Govern

ance

SERIOUS (4) LIKELY (4) 16 ●Stabilisation of 111 performance;

●Robust management of abstractions;

●New UCS leadership structure;

●Ongoing budget monitoring;

●UCC contract signed;

●Quality Development Plan.

SERIOUS

(4)

LIKELY

(4) 16 ●Implementation of rota changes;


rates;

●Review of services provided by SPoA;

●Improve financial controls;

●Further work to be conducted on OOH rotas;

●Review of penalty arrangements;

●Review of cost per call;

●Implement actions arising from UCS deep dive;

●Deliver revised Performance Recovery action plan.

Mar-15 SERIOUS

(4)

POSS (3) 12 S CO1,

CO2,

CO3, CO4

Directo

rs G

roup

18 J

uly

2014

N850

↔

Ind

ustr

ial

Acti

on

X X X

Increased potential for industrial action within all

service lines (including A&E and UCS) as a result

of a national decision regarding renumeration

which could affect safety, performance and morale.

Executive D

irecto

r of H

R a

nd O

rganis

ational

develo

pm

ent

SERIOUS (4) POSS (3) 12 • Resilience and mitigation plan in place for loss of key staff across the Trust;

• Information available on TU membership and hot spots;

• Mutual aid arrangements with external partners;

• REAP levels as appropriate;

• Media and external Comms plan to establish protocols during industrial

action;

• Guidance developed for managers on rules for managing during industrial

action;

• Positive industrial relations culture within the Trust;

• Workforce Establishment and Planning Group (WEPG) in place;

• Agreement with staff side not to ballot during negotiations;

●Industrial Action Contingency Plan in place and circulated;

●Trust successfully managed response to Industrial action which took place in

October and November 2014;

●Establishment of Incident Coordination Centre (ICC) as required.

SERIOUS

(4)

LIKELY

(4) 16 • Executive Director of HR and Organisational Development

monitoring Department of Health and staff side;

communications to gather intelligence of any future

developments;

• Reissue guidance for managers on rules for managing

during industrial action;

• Ongoing liaison with staff side representatives;

●Implementation of Industrial Action Contingency Plan;

●Implementation of actions arising from debrief following

industrial action in October and November 2014;

●Implementation of Dispatch on Disposition;

●Revised process for Green 4 calls during times of industrial

action;

●National discussions underway.

Feb-15 MOD (3) ALMOST

CERTAIN

(5)

15 S CO1,

CO2,

CO3, CO4

HR

Ris

k R

egis

ter

3 M

arc

h 2

011

HR

685

↓

Majo

r IT

Serv

ice F

ail

ure

X X

Major ICT service failure of clinical hub and/or

radio and mobile data may lead to potential

business continuity risk in A&E, UCS or PTS.

Executive D

irecto

r of IM

&T

SERIOUS

(4)

POSS (3) 12 ●ICT Strategy action plans in place to deliver agreed business continuity

arrangements;

●Card System and manual practices defined and in place to support loss of

computer systems;

●Uninterrupted Power Systems and Generators in situ covering critical ICT

Services within clinical hubs;

• Fallback plans cover Minor, Major and Critical faults;

● BCM Strategy and outline plan agreed;

• Virtual CAD implemented and tested (East and West Hubs);

• Test of East Hub fall back arrangement;

●Production and implementation of timely ICT business continuity plans;

•Clinical Hub business continuity lead;

•IT on call rota;

●Generator 'load test' took place within West Hub;

• IG Toolkit plan for 2013/14 implemented;

• IT work programme for 2013/14 implemented;

●North Clinical Hub Duty Managers trained in new Fall Back arrangements;

●North Hub exercise took place in March 2014 - no issues raised;

●New C3 contract signed;

●PTS Fall back tested.

SERIOUS

(4)

LIKELY

(4) 16 ● Staff to be trained and plans tested (March 2015, FG);

• Deliver IG Toolkit plan for 2014/15 (March 2015, FG);

• Deliver IT work programme for 2014/15 (March 2015, FG);

•Review of core network underway in HQ including links to

Acuma House (April 2015, FG);

•Service Managers reviewing process to strengthen contract

management;

●Support Estates development and employee IT

infrastructure within the North division, in particular within the

Clinical Hub;

●CAD Implementation (September 2015);

●Clinical Hub review with dedicated project manager;

●Implementation of actions arising from serious incident

investigation relating to IT failures;

●Hub rationalisation;

●Clinical Hub fallback Business Continuity Plan in final

development before approval;

●East and West Hub Duty Managers to receive training on

fallback arrangements;

●Programme management investment.

March

2015

SERIOUS

(4)

POSS (3) 12 L CO1,

CO2,

CO3, CO4

Executive D

irecto

r of IM

&T

12/0

2/2

007

ICT

199

↔


ConfidentialR

isk

Tit

le

Qu

ali

ty R

isk

Perf

orm

an

ce

Ris

k

Fin

an

cia

ls R

isk

Risk Description

Acc

ou

nta

ble

Dir

ec

tor

Ori

gin

al

Co

nse

qu

en

ce

Sco

re

Ori

gin

al

Lik

eli

ho

od

Sco

re

Ori

gin

al

Ris

k R

ati

ng

Controls in Place

Cu

rren

t C

on

se

qu

en

ce

Sco

re

Cu

rren

t L

ikeli

ho

od

Sco

re

Cu

rren

t R

isk R

ati

ng

Action Summary

Acti

on

Dea

dlin

e

Fo

rec

as

t C

on

se

qu

en

ce

(po

st

acti

on

s)

Fo

rec

as

t L

ikeli

ho

od

(po

st

acti

on

s)

Fo

rec

as

t ri

sk r

ati

ng

(po

st

acti

on

s)

Pro

xim

ity R

isk

Co

rpo

rate

Ob

jecti

ves

Ris

k S

ou

rce

Date

ad

ded

to

reg

iste

r

Ref

Ris

k R

ati

ng

Mo

ve

men

t (s

ince

la

st

up

date

)

Incre

ase i

n A

cti

vit

y

X X X

Changes in daily and hourly spread of demand

within all service lines impacting on ability to

respond, funding, patient care and experience,

performance and staff experience.

Chie

f E

xecutive

SERIOUS (4) POSS (3) 12 •Use of rolling average for activity commissioning;

•Activity reports sent to Commissioners on a monthly basis;

•Daily monitoring of activity growth and impact of NHS 111 on A&E;

•Signed contracts which have activity growth embedded within the terms;

●Implementation of handover SOP.

•Revised Demand Management Plan for Clinical Hub implemented;

•Escalatory Management Plan reviewed and updated;

•Independent review of performance activity;

●Provision of staff by third parties, agencies, bank and overtime;

●Red 1 Sustainability Plan developed and monitored;

●Development of Operational Implementation Plans 2014/15;

●111 Recovery Plan;

●Ongoing work with stakeholders;

●Revised Interhospital Transfer Procedure implemented;

●Demand Management Group established to identify areas for focus;

●Annual demand review within contract;

●Right Care 2;

●'Choose well' campaign;

●Clinical floor walkers within 111 hubs managed by Trust;

●Introduction of additional Clinical Supervisors within Hubs;

●Demand management trial in Gloucestershire in liaison with CCG.

SERIOUS

(4)

LIKELY

(4) 16 •Performance to be monitored through contract meetings;

•Evaluation of implementation of virtual stations;

●Review of performance activity against demand;

●Review activity profiles;

●Review source of activity, specifically inappropriate

callbacks and abandonments;

●Review of data to inform modelling;

●Additional resources to meet anticipated uplifts in demand;

●Pilot collaborative working with CCG to reduce demand;

●GP to be based in North Hub to review demand

management and liaise with GP practices;

●Trust position on activity for 2015/16 to be provided to

Commissioners;

●Workstream to be established to consider demand

management and growth;

●Commissioner negotiations commenced for 2015/16;

●National review of REAP;

●Monitor Dispatch on Disposition Trial taking place from 10

February 2015 - 9 March 2015.

Mar-15 SERIOUS

(4)

POSS (3) 12 M CO1,

CO2,

CO3, CO4

Str

ate

gic

Forw

ard

Pla

nnin

g R

isk R

egis

ter

24 S

ept 2012

F786

↔

Em

plo

ym

en

t L

eg

isla

tio

n

Lit

igati

on

X

Litigation claims of unfair dismissal, discrimination

or breach of contract as a result of dismissal or

redeployment could :

● have financial implications;

• affect organisational reputation;

• have significant resource implications for senior

management and HR resources to respond to

litigation claims, grievances and staff complaints.

Risk transferred to Corporate Risk Register by

Directors Group Executive D

irecto

r of H

R a

nd

Org

anis

ational develo

pm

ent MOD (3) LIKELY (4) 12 • Organisational change policy;

• Compliant with employment law and good practice;

• Ongoing and regular review of employment policies to ensure employment

law changes are reflected;

• Grievance process is transparent and appropriate to seniority of

management in Trust structure to board level;

• ET training delivered to senior managers and ongoing change management

support and advice from HR.

• Deputy Director of HR overseeing all employment litigation cases;

• Legal advice and TUPE training provided to senior managers;

●Following an ET case, lessons learned are strengthened via feedback

through the management structure.

SERIOUS

(4)

LIKELY

(4) 16 • Priority of resources reviewed quarterly (Ongoing, AH);

• Escalate risks as appropriate (Ongoing, AH);

• Management of change programme/development of career

support processes;

●Legal services review underway.

Mar-15 SERIOUS

(4)

LIKELY (4) 16 M CO3, CO4

HR

Ris

k R

egis

ter

H542

↑

Dela

y i

n A

rriv

al

of

Back U

p R

eso

urc

e

X X

Delays in the arrival of conveying resources to

back up RRVs and Community Responders could

affect-

Patient care - delayed treatment by other

providers;

Patient experience;

Reputation;

Financial implications;

Availability of resources;

Staff morale.

Chie

f E

xecutive

SERIOUS (4) POSS (3) 12 •Effective performance monitoring arrangements in place through A&E

Service Line meetings;

•C3 Pathways Front End Screen developed and implemented within Hubs

(East and West);

•Back up SOP circulated;

•Return of Resources to Cornwall SOP published;

•Contract negotiations;

•New monthly report on back up delays developed;

●Red Performance Recovery Plan;

•Revised CAD to improve reporting on back up priority levels;

●Interim status plan in North division prior to delivery of new CAD;

●Revised Back Up report accepted by Directors Group;

●Live Back Up responder reporting;

●New back up SOP D045 section 6 issued, amended regarding priority 1 back

up requests and general broadcasts;

●Dual response SOP in place;

●Use of agency paramedics to address establishment levels.

SERIOUS

(4)

LIKELY

(4) 16 •A&E Service line and Information Cell to review status plan

and utilisation reports (ongoing, NLC);

•Implementation of ELAN3 which will allow better utilisation

of resources (April 2015, NLC/FG);

•Implementation of A&E Business Plan;

●National review of performance targets by external

organisation;

●Dispatch on disposition trial.

Mar-15 SERIOUS

(4)

UNLIKELY

(2)8 S CO1,

CO2,

CO3, CO4

Executive D

irecto

r of D

eliv

ery

02/0

2/2

012

D716

↔

Au

dit

Co

mp

lian

ce

X

Failure to meet call taking audit compliance could

have the potential to compromise patient safety

and the requirements of software licences.

Executive D

irecto

r of N

urs

ing

and G

overn

ance

SERIOUS (4) LIKELY (4) 16 ●Executive leadership and management strengthened;

●Board approved Quality Development Plan;

●Interim additional CQI team in place (on temporary basis).

SERIOUS

(4)

LIKELY

(4) 16 ●Review of Audit process underway including structure,

frequency and performance management;

●Review of UCS structure underway;

●Review of Clinical Hub structure;

●Review outcome of NHS Pathways review;

●Business case submitted;

●Review of CQI model.

March

2015

SERIOUS

(4)


CO2,

CO3, CO4

Ris

k W

atc

h

04/0

6/2

014

N851

↔

Imp

act

of

RE

AP

Levels

, an

d S

um

mer,

Win

ter

an

d P

eak p

ressu

res

X X X

Increased REAP levels as a result of a threat to

national performance indicators leading to:-

•over activity against contract ;

•slippage to training programme deliveries and

other workstreams, including cancellation of

priority meetings dependent on REAP levels,

winter pressures and weather;

•increased demand on three core services;

•impact on delivery of business plans;

•impact on resilience within the Trust.

Trust currently at REAP 4

Directors Group agreed to update risk score as a

result of REAP level movement

Chie

f E

xecutive

SERIOUS

(4)

LIKELY (4) 16 • Effective escalatory process with clear command and control process in

place;

• Performance management arrangements in place to monitor achievement of

objectives;

• Business Continuity arrangements and processes in place;

• Weekly review of performance including assessment of REAP level by

Deputy Director of Delivery;

•Demand Management Plan for Clinical Hub;

•Updated escalatory management plan;

•Tactical response plans issued weekly by Head of Resilience;

•Red 1 Performance Action Plan meetings and conference calls;

•New REAP monitoring introduced for NHS 111 service provided by the Trust;

•Revised REAP escalation plan implemented with divisional REAP levels;

•Divert hospital procedure agreed;

●Operational Resilience Capacity Plan and dedicated lead in place for winter

pressures;

●Review of REAP undertaken (Dec 2014).

SERIOUS

(4)

LIKELY

(4) 16 • Ongoing discussions with Commissioners at C&P

meetings to review activity and demand profile in each CCG

area and agree actions to mitigate increase in demand

including the review of alternative pathways;

• Executive Gold meetings convened as required (Ongoing,

KW);

●Emergency Planning Recovery Resilience Group reviewing

REAP levels;

●Implementation of Winter Pressures Capacity Plan;

●Dispatch on disposition trial;

●National review of REAP.

Mar-15 SERIOUS

(4)

UNLIKELY

(2)8 L CO1,

CO2,

CO3, CO4

Ris

k R

egis

ter

Revie

w D

ay 2

007

22/0

2/2

007

EP

218

↔


ConfidentialR

isk

Tit

le

Qu

ali

ty R

isk

Perf

orm

an

ce

Ris

k

Fin

an

cia

ls R

isk

Risk Description

Acc

ou

nta

ble

Dir

ec

tor

Ori

gin

al

Co

nse

qu

en

ce

Sco

re

Ori

gin

al

Lik

eli

ho

od

Sco

re

Ori

gin

al

Ris

k R

ati

ng

Controls in Place

Cu

rren

t C

on

se

qu

en

ce

Sco

re

Cu

rren

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Action Summary

Acti

on

Dea

dlin

e

Fo

rec

as

t C

on

se

qu

en

ce

(po

st

acti

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s)

Fo

rec

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od

(po

st

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on

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Fo

rec

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sk r

ati

ng

(po

st

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s)

Pro

xim

ity R

isk

Co

rpo

rate

Ob

jecti

ves

Ris

k S

ou

rce

Date

ad

ded

to

reg

iste

r

Ref

Ris

k R

ati

ng

Mo

ve

men

t (s

ince

la

st

up

date

)

Cli

nic

al

Hu

b R

ati

on

ali

sati

on

X X

Implementation of new CAD and triage system and

estates project with changes to each element

could impact on short term quality and

performance.

Executive D

irecto

r of IM

&T

SERIOUS (4) POSS (3) 12 ●Project Group

●Programme Board includes attendance from Estates Programme Manager;

●Weekly meetings with Clinical Hub managers;

●Programme workbook monitored by Programme Board;

●Dedicated project team in place;

●Trust has previous experienced of transferring to new triage systems.

V.SERIOUS

(5)

POSS (3) 15 ●Ongoing monitoring by Project team;

●Ongoing positive liaison with CAD supplier

●Escalate issues through the Programe Board;

●Testing to take place locally to enable quick installation and

reduce testing at new estate;

●Communications Strategy to be developed for each project;

●Clinical Hub layout to be agreed;

●Information on handover and arrival screens being

disseminated internally and externally;

●Implementation of MIS training;

●Implementation of Telephony Platform;

●Terms of Reference for St James A to be agreed;

●Roll out of NHS Pathways in North division.

Sep-15 V.

SERIOUS

(5)

UNLIKELY

(2)10 S C01, C02,

C04

Deputy

Directo

r of F

inance

5 D

ecem

ber

2014

D875

↑

Wo

rkfo

rce

Inte

gra

tio

n

Issu

es

X

Outstanding A4C Appeals

Executive D

irecto

r of

HR

and

Org

anis

ational

Develo

pm

ent

V.SERIOUS

(5)

LIKELY (4) 20 •Appropriate legal representation in place. V. SERIOUS

(5)

POSS (3) 15 •On-going liability review by solicitors and Trust. Mar-15 V.

SERIOUS

(5)

RARE (1) 5 M

CO4

Sta

ff G

rievances

24.1

2.1

0

HR

47

↔

NH

S 1

11 I

mp

act

X X X

Impact of NHS 111 on A&E delivery as a result of

working with a variety of providers and interfacing

services, both in terms of growth in activity

(anticipated to be between 10% - 20% increase)

and also the ability of 111 providers to dispatch

Trust resources which could impact on patient and

staff experience.

Chie

f E

xecutive

V.SERIOUS

(5)

POSS (3) 15 •Robust Performance Framework for monitoring trends

•Early escalation process to Commissioners and Providers;

• 111/999 Liaison Group in place considering modelling arrangements;

• Commissioning arrangements in place;

•Daily Gold Meetings as required;

•REAP escalatory arrangements in place;

•Log of 111 calls not requiring conveyance being maintained;

•Dedicated 111 Liaison team in place;

•Ongoing discussions with Commissioners;

•Review of Demand Management Plan to allow for re-triage of 111 calls at

higher levels of demand;

●GPs temporarily utilised within Clinical Hubs to manage 111 demand;

●Mental Health nurse within Clinical Hubs;

●Clinical Floor walkers within 111 Hub;

●Regular dialogue with 111 Providers regarding demand management;

●Winter Pressures funding;

●Trial of demand management scheme in Gloucestershire in liaison with CCG.

V. SERIOUS

(5)

POSS (3) 15 •Ongoing negotiations with Commissioners as part of

contracts for 2014/15;

•Implementation of REAP as required;

•Continue to work with 111 providers;

•Review of Demand Management Plan to allow for re-triage

of 111 calls at higher levels of demand;

●Demand Activity Assessment in North Division;

●ORCP Plan to manage impact of 111 on 999 in part of

North Division during winter period;

●Trial of Dispatch on disposition.

Mar-15 V.

SERIOUS

(5)

POSS (3) 15 M CO1, CO2

Directo

rs G

roup

26/0

9/2

012

D789

↔

Co

st

Imp

rovem

en

t S

trate

gy

X X

Non achievement of the 5 year cost improvement

strategy targets could result in:-

• lack of investment in service infrastructure;

• a trigger of downside scenarios;

• compromised delivery of national targets;

● non delivery of Financial Plan.

Deputy

Chie

f E

xecutive/E

xecutive D

irecto

r of F

inance

V.SERIOUS

(5)

POSS (3) 15 ● Programme for 2014/15 implemented in budget setting;

•Strict controls on costs and monitoring of budgets;

• Downside scenario planning identified in IBP;

• 5 year strategy robustly detailed;

• Established Governance framework in place;

• Finance and Investment Committee monitor CIS at each meeting;

• Operating Business Plan being lead by Deputy Director of Delivery;

• Implementation plans developed with clear accountability identified and

implemented;

• Recognition Agreement in place and ongoing dialogue with staffside;

• Ongoing programme of station visits by Board members;

• Trust Strategy Days;

• Senior Management sub-group established to review additional CIP

schemes;

•Workforce Planning aligned to CIS programmes;

●IPB updated and disseminated.

V. SERIOUS

(5)

POSS (3) 15 • In the event of downside instigate MEAP or CEAP;

•Monitoring of implementation plans;

•Undertake review of operational remodelling;

•Review of Strategic Business Plan;

• Review local OLM budget savings (ongoing, NLC);

•Ongoing approach to stakeholder engagement and

reputational management;

●Update 2 year and 5 year Annual Plans;

●Reconciliation of 5 year Annual Plan with CCGs;

●Delivery of enabling strategies;

●Quality Impact Assessments to be signed off for each CIP;

●Implementation of updated IBP.

Mar-15 SERIOUS

(4)

POSS (3) 12 M CO1,

CO2,

CO3, CO4

Chie

f E

xecutive

9 D

ecem

ber

2010

F677

↔


ConfidentialR

isk

Tit

le

Qu

ali

ty R

isk

Perf

orm

an

ce

Ris

k

Fin

an

cia

ls R

isk

Risk Description

Acc

ou

nta

ble

Dir

ec

tor

Ori

gin

al

Co

nse

qu

en

ce

Sco

re

Ori

gin

al

Lik

eli

ho

od

Sco

re

Ori

gin

al

Ris

k R

ati

ng

Controls in Place

Cu

rren

t C

on

se

qu

en

ce

Sco

re

Cu

rren

t L

ikeli

ho

od

Sco

re

Cu

rren

t R

isk R

ati

ng

Action Summary

Acti

on

Dea

dlin

e

Fo

rec

as

t C

on

se

qu

en

ce

(po

st

acti

on

s)

Fo

rec

as

t L

ikeli

ho

od

(po

st

acti

on

s)

Fo

rec

as

t ri

sk r

ati

ng

(po

st

acti

on

s)

Pro

xim

ity R

isk

Co

rpo

rate

Ob

jecti

ves

Ris

k S

ou

rce

Date

ad

ded

to

reg

iste

r

Ref

Ris

k R

ati

ng

Mo

ve

men

t (s

ince

la

st

up

date

)

Terr

ori

st

Acti

vit

y

X X X

Terrorist activity could affect delivery of Trust

services and impact on its business continuity.

Potential for Trust resources to be utilised for

terrorist activities

Current National Terrorist Threat Level is at

SEVERE (an attack is highly likely)

Chie

f E

xecutive

V.SERIOUS

(5)

POSS (3) 15 ●Major Incident Plan in place and reviewed annually;

●Staff training in CBRNE;

●Special Operations Response Teams (SORT) teams formed and trained;

• Trust has a strong track record and experience of dealing with major

incidents and events;

• AACE national agreement on mutual aid;

• Annual training exercise in programme;

• Trust HART teams have received extensive training;

• Trust Commander training for Bronze, Silver and Gold officers;

•Members of Enhanced Ambulance Intervention Team Cadre have received

training;

•Casualty Clearing Station;

• Implementation of National Ambulance Service Command and Control

guidance;

•REAP escalation process;

•Dedicated on call tactical advisors within Resilience team;

•On call Communications rota;

•Implementation of Trust wide National Interagency Liaison Officers (Technical

Advisors);

●Engagement with other agencies through Local Resilience Forums;

●PREVENT training delivered to trainers for roll out;

●Introduction of Joint Emergency Services Interoperability Programme

(JESIP);

●Revision of Maraudering Terrorist Firearms Incidents training completed.

V. SERIOUS

(5)

POSS (3) 15 • Implement recommendations arising from exercises and

incidents (lessons learned) (ongoing, NLC);

●Delivery of JESIP training programme (currently 80%

complete) (NLC );

●Trust to review compliance with PREVENT requirements

(JW);

●Commander training to take place for newly appointed

Directors and Managers;

●Recruitment of additional SORT and Ambulance

Intervention Team (AIT) (NLC );

●PREVENT workplan and training strategy to be developed

by Safeguarding Lead;

●Roll out of PREVENT training (March 2015 and ongoing);

●Trust Resilience team leading on 2 National Counter

Terrorism Exercises;

●Development of new Commander package following

review of Commander Policy (NLC Sept 2014);

●Initial Operations Response (IOR) - training of all

operational staff in dry decontamination to take place

between Sept 2014 and March 2015.

Mar-15 V.

SERIOUS

(5)

POSS (3) 15 O CO1,

CO2,

CO3, CO4

Assura

nce F

ram

ew

ork

29/0

5/2

009

EP

004

↔

M = Medical Directorate

NG = Nursing and Governance Directorate

HR = Human Resources Directorate

D = Delivery Directorate

MC = Marketing and Communications

Directorate

FP = Finance and Performance Directorate

CE = Chief Executive

R = Resilience

T = Training

F = Finance

O = Operations


Board of Directors’ Meeting, 26 March 2015 (M:\Board of Directors\Board Papers\2014-15\26 March 2015\Public\PDF's\14. Quality and Governance Committee Board Assurance Report 26 March 2015.docx)

Page 1 of 4

Trust Board of Directors’ Meeting 26 March 2015

Title: Board Assurance Paper – Quality and Governance Committee

Prepared by: Jennifer Winslade, Executive Director of Nursing and Governance

Presented by: Mary Watkins, Non-Executive Director

Main aim: The paper is to share with the Trust Board of Directors the business of the Quality and Governance Committee on 12 March 2015

Recommendations: Members of the Board of Directors are requested to take assurance regarding the business conducted at the committee meeting




BA05-14 Directorate Business Plans

Nursing & Governance Directorate

Implications


Good governance practice


Page 2 of 4

Board Committee Assurance Report 1. Introduction

The Trust Board of Directors has three committees to which it delegates responsibility for essential business - Quality and Governance; Finance and Investment; and Audit. Each of these committees is chaired by a Non-Executive Director and operates an annual cycle of business to ensure statutory, regulatory, strategic, and operational objectives are achieved.

In order to provide assurance that this work is undertaken, and that Board committees operate effectively, a report is prepared following each committee meeting and presented to the Board of Directors.

2. Assurance Report

2.1 Presentations No presentations received.

1.2.2 Assurance

Document (includes deep dives)

Further assurance requested by Committee

Health, Safety and Security Deep Dive

The Committee requested assurance that more codes could be added to Datix reporting in order to increase the level of detail and enhance reporting. Vanessa Williams and Anne Payne confirmed that they would take this forward.

Corporate Governance Deep Dive

Committee assured and no further assurance requested.

Risk and claims Deep Dive Committee assured and no further assurance requested.

Learning Disability Deep Dive The Committee sought assurance that the issues highlighted by the CQC ahead of the new inspection regime would be picked up by SWASFT. Sara Coburn gave assurance that SWASFT was not expecting any planned CQC inspections before April 2015 and the Trust therefore had time to formulate actions in response to these issues.

Public Sectors Equalities Duty Committee requested further assurance and support from the Council of Governors. Marty McAuley and Jenny Winslade to follow up.

Code of Governance Disclosure The Committee sought assurance regarding the one area which the Trust was not compliant against. MM to explore further and agree Trust position.


Page 3 of 4

1.2.3 Documents for approval

Document Approved or approved subject to amendment

Any challenge or change requested

Managing Recommendations from External Bodies Policy

Approved. No further assurance was requested.

Domestic Abuse Policy Approved. No further assurance was requested.

Safeguarding Referral Process Standard Operating Procedure

Approved. No further assurance was requested.

Safeguarding Training Strategy

Approved subject to amendment.

Addition of Complaints Team Team Leaders to the list for Level 2 training and removal of PALS team leaders.

1.2.4 Highlight Reports

Document Further assurance requested by Committee

Clinical Effectiveness (including End Tidal CO² Utilisation)

No further assurance requested.

Quality Highlight Report No further assurance requested.

Information Governance Quarter 3 Report

No further assurance requested.

HR and Wellbeing (including Review of Appraisals)

The Committee sought assurance that staff would be aware of the positive benefits of moving to one provider of Occupational Health. The Executive Director of HR and OD gave assurance that the benefits would be published to staff via the weekly bulletin.

Safeguarding No further assurance requested.

Training The Committee sought assurance that the Trust would not be liable if an adverse incident took place involving a staff member who had not completed SME training in the last two years. JW gave assurance that those who had not received training were not unsafe to practice but advised that there was a risk should an adverse incident occur.

Patient Safety and Experience No further assurance requested.


Page 4 of 4

1.2.5 Documents for information 1.2.5.1 The following documents were presented to the Committee for information:

Clinical Effectiveness Group Minutes 27 January 2015.

Quality Risk Watch Register.

Safeguarding Group Minutes 28 January 2015.

Information Governance Group Minutes 12 December 2014.

Health and Safety Group Minutes 03 December 2014.

Mental Health Group Minutes 16 December 2014.

Patient Safety and Experience Report.

1.2.6 Issues referred to Executive Directors Group 1.2.6.1 No issues were referred to the Executive Directors Group.

1.1. Recommendations

1.3.1 Members of the Board of Directors are requested to take assurance regarding the business conducted at the committee meeting.

Mary Watkins Chair of Quality and Governance Committee

Trust Public Board of Directors Meeting Monday 2 February 2015

Minutes Trust Public Board of Directors Meeting Monday 2 February 2015, 10:00hrs Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Exeter EX2 7HY Chair Mrs H Strawbridge- Chairman Administration Mrs J Smalley – Executive Assistant & Business Manager to Chairman and Chief Executive

Members in attendance: Mrs H Strawbridge HS Chairman Mr K Wenman KW Chief Executive Mr R Davies RD Non-Executive Director Mr T Fox TF Non-Executive Director Mr H Hood HH Non-Executive Director Mrs V James VJ Non-Executive Director Mr C Kinsella CK Non-Executive Director Mr F Gillen FG Executive Director of IM&T Mrs J Kingston JK Deputy Chief Executive/Executive Director of

Finance Mrs J Winslade JW Interim Executive Director of Nursing Mrs E Wood EW Executive Director of HR & OD Non Members in attendance: Mr N Le Chevalier NLC Director of Operations Mr M McAuley MM Trust Secretary Mrs C Warner CW Interim Head of Communications and Engagement Observer: Mr Sean Hegarty SH Student Paramedic Circulation: All of above and in addition: Council of Governors Mr D Young Member of Events and Media Committee, Torbay Healthwatch Mr C Nelson Joint Branch-Secretary, Unison Ms J Fowles Joint Branch-Secretary, Unison


No Agenda Item Action


1.1 1.2

HS welcomed everyone to the meeting and thanked them for attending. Sean Hegarty, Student Paramedic was welcomed and Craig Holmes, Governor. Julie Smalley was welcomed as Administrator. Apologies were received from Professor Mary Watkins and Dr Andy Smith.

2.0 Declarations of Conflict of Interest

2.1 There were no declarations of conflict of interest.

3.0 Patient Story

3.1 3.2 3.2.1

VJ read a patient story regarding a patient with dementia attending hospital without an escort from the nursing home where they resided. The ambulance crew had advised the nursing home that no escort was required as due to the severity of the injury to the patient they felt it likely that the patient would be admitted for observation. Learning was taken from this incident and discussed with the crew members concerned. FG read a patient story regarding a patient transferred to Newcastle for a transplant. Thanks were given to the crew. JW advised that when there are commendations to staff they are personally written to by Ken Wenman, CEO. In terms of publishing the plaudit depends on the patient themselves as plaudits are never shared without patient consent. They are available on the intranet for staff to see and Patient Opinion is available to all.

4.0 Report from the Chairman and Non-Executive Directors

4.1 4.2

HS gave thanks to all staff. There have been increased demands on crews over the Christmas period and either side of this and their efforts have been tremendous. The Trust Board appreciates all that they have done to keep the service working effectively. HS gave thanks to Gloucestershire Rotary Clubs who have been fundraising to put defibrillators into schools as part of their Saving Lives


Campaign. HS has been joining them alongside Kev Linney who has been proactive in bringing this together in partnership with SWASFT, the Schools and the Rotary Clubs.

5.0 Report from the Chief Executive

5.1 5.2 5.2.1 5.3

Strike Action KW informed the meeting that all industrial action has been deferred. This will be discussed in more detail during the Confidential Meeting. The Trust plans to deal with the strike had been robust and comprehensive, however, with the nature of the strike it would have been difficult for the Trust to provide the Secretary of State with assurance that a safe service could have been provided. Trust plans have been kept in case the strike plans reignite on 24 February 2015. Dispatch and Disposition The Trust proposal has been accepted and the Dispatch and Disposition pilot will commence on 10 February 2015. There has been media attention from GMB who are concerned that the pilot will cost lives. The Trust is pushing back with the press to overturn comments such as these in the media. This will be discussed further in the Confidential Meeting. NHS England has confirmed that the pilot will involve the whole Trust. This will involve major work that will change the way that performance standards are measured and how the service deals with patients. Investment The Trust is to receive investment from Health Education South West to assist with the Emergency Care Assistant (ECA) to Paramedic training.

6.0 Questions from the Public, Council of Governors and Staff

6.1 6.1.1 6.1.1.1

Craig Holmes, Gloucestershire Representative, FT Council of Governors raised the following question: Question: ‘There has been a very big achievement in setting up static defibrillator sites across the South West and I am sure this will greatly benefit our communities. However, I am concerned with how these locations may be dealt with by the EOCs. Please will you clarify what effect these static defibrillator locations have on resource allocation and performance measures, especially in the non-Cardiac Arrest situations?’ Response: NLC stated that static defibrillator sites do not replace


6.1.1.2 6.1.1.3 6.1.1.4

Community Responders, most static sites have trained first aiders. Basic Life Support and Unconscious Patient training is provided. The crews can dual respond and this message has gone to the Control Room. The National Ambulance Quality Indicator (AQI) can only count for that site. If it is a registered site the clock can stop if a red call is undertaken at that site. CH was concerned that the clock stops immediately if there is a red call whether it is for a cardiac arrest or not. CH suggested this may give the wrong impression. NLC confirmed that there is a nationally agreed defined criteria that the clock can stop if the patient is seen by a Responder or Health Care Practitioner for a Red 1 or Red 2 call. NLC stated that this does not replace the Community Responder. HS advised that having a community defibrillator in use does not stop a response being dispatched. CW advised that this is made clear in all Trust press releases. TF attended the presentation of a defibrillator recently and agreed that training was offered to those in the local community and it is made clear that this would not stop the response coming. On behalf of the Trust Board of Directors HS thanked CH for the question. CH accepted the response.

7.0 Action Point Register

7.1 7.2 7.3 7.4 7.5

The Action Point Register was reviewed and the following updates noted by the Trust Board of Directors: 29 May 2014 10.2.2 Corporate Risk Register – it was noted that the Risk Session had been deferred from the December 2014 Board Seminar Agenda. 31 July 2014 10.5.2 Duty of Candour – it was noted that Duty of Candour would be added to a future Board Seminar Agenda. 25 September 2014 10.5.3 Patient Safety and Experience Report – it was noted that this was not on the Agenda today as the report is prepared every quarter. This would be presented to the March 2015 Trust Board of Directors. All actions would be picked up by JW. 27 November 2014 6.3 Questions from the Public, Council of Governors and Staff – it was noted that Brian Jarvis has made contact with Craig Holmes. Completed.


7.6 7.7 7.8 7.9

27 November 2014 10.2.3 Corporate Risk Register regarding mitigating actions – it was noted that JW and MM are regenerating the Risk Register and Board Assurance alongside the Head of Governance and Risk and Litigation Manager. Risk Watch is scheduled monthly but this had been cancelled and December 2014. HS asked that JW check to ensure that there is full understanding. 27 November 2014 10.4.5 Patient Safety and Experience Report – it was noted that NLC has picked up stop the clock on staff responders. Responders sent to green calls are followed up with an ambulance. KW advised that the question was where there are longer back-ups could responders go and wait for back up. NLC advised that he is picking up the governance issues. It was agreed that KW and NLC should discuss this outside the meeting. 27 November 2014 10.6.2 Committee Assurance Reports regarding CK, MW, EW, MM and HS meeting to review papers which go to committees on sickness to identify any gaps in reporting – it was noted that this meeting had not yet taken place but would be scheduled in due course. The Action Point Register would be updated and circulated with the Minutes of the Meeting.

8.0 Strategic

8.1 Communications and Engagement Strategy

8.1.1 8.1.2 8.1.3

CW presented the Communications and Engagement Strategy for approval. CW confirmed the Strategy has been through a process of review by the Deputy Directors has had input from key teams such as Patient Experience. Feedback from the Directors was that there are strong links to patient experience. CW highlighted that there are a couple of gaps in the team. These include; the marketing function linking to business development and new business. A skill set for market analysis and market positioning is not held within the team. The role may involve a Director of Marketing and this will be picked up. The Strategy focuses on raising the profile of the trust, with various campaigns tied into the Business Plan and new business opportunities. Another gap is with stakeholder management and relationship management. The team is working with colleagues in


8.1.4 8.1.5 8.1.6 8.1.7 8.1.8 8.1.9

IM&T to pull together a bespoke database which will be an improvement on the existing database to capture more information for sharing. For reassurance to the Trust Board of Directors there is a comprehensive programme of monitoring and assurance shared with both the Chief Executive and Executive Directors. HS commented that is was good to see the assurance given and requested that the Strategy is presented to the Quality and Governance Committee. ACTION: CW to submit the Communications and Engagement Strategy to the next Quality and Governance Committee in March 2015. RD asked what happens when more integrated national ambulance campaigns need to take place. KW advised that the Ambulance Service Chief Executives Group commissions a Communications Lead to link with all ambulance services regarding comms issues. VJ observed that this is a neat strategy and there is nothing unfamiliar within it. VJ liked the branding and emphasis on marketing and relationship management. Now that the Strategy has been developed the task will be in the delivery of it with plans being worked up. VJ was interested to understand what the gaps would be in the development of leads who are charged with relationship management with commissioners and how the members of the team will be developed. KW stated that it is less to do with skills of the staff but more to do with capacity. Heads of Operations and Operational Managers are more outward facing and have responsibilities with commissioners. The Heads of Operations are now much more engaged in Clinical Commissioning Group (CCG) regular meetings and escalation meetings where there is a need to have a presence and for softer work within local plans and support within SWASFT. The Executive Director of HR and OD has produced a paper on the marketing role but funding is yet to be sourced. KW will be meeting with NLC to discuss operational engagement. CK would advocate increased marketing and offered assistance with scoping for the marketing role. The Communications and Engagement Strategy has been approved by the Executive Directors and was ratified by Trust Board of Directors.

CW

8.2 Talent and Clinical Workforce Development Strategy


8.2.1 8.2.2 8.2.3 8.2.3.1 8.2.4 8.2.5 8.2.6 8.2.7

EW presented the Talent and Clinical Workforce Development Strategy which was previously approved at the Confidential Trust Board of Directors on 27 November 2014. EW advised that the Strategy sets out three areas; clinical development pathways encouraging staff to participate, harnessing of talent locally and corporately and succession planning. EW provided the following updates as a consequence of the thinking around the strategy:

- The ECA to Paramedic Course has commenced. - Advert has commenced for Specialist Paramedics. - Next month top up degrees - Scheduling distance learning - Level 3 ECA qualifications have commenced for 30 existing staff

members. - Apprenticeship funding has been received.

Nursing careers and plans will be taken forwards by the Head of Nursing in the Urgent Care Service and an integrated workshop is planned for later in February 2015. EW advised there is a toolkit being developed for local managers to use and there will be amendments to the appraisal framework. EW will present this to the Directors Group prior to roll out. EW gave thanks to HH for advice and support provided. Corporate planning has been set within the new financial year. CK commented that this has a divisive nature in terms of people being left out. EW advised that the idea of talent piece of strategy is so that everyone can identify themselves as talent. Talent toolkits are discussed with Operational Managers and Heads of Service and how they can integrate non clinical members of their teams. KW attended the Operational Officers meeting in North Division on 30 January 2015 and noted that this has raised the level of morale. The Trust Board of Directors noted the Talent and Clinical Workforce Development Strategy.

9.0 Performance

9.1 Integrated Corporate Performance Report (ICPR) – Appendices F&G Tabled

9.1.1 JK presented the Integrated Corporate Performance Report and


9.1.2 9.1.3 9.1.4 9.1.5 9.1.6 9.1.7

advised that in terms of reflecting on Christmas and New Year the metric used was to take the mid December 2014 position through to 5 January 2015, a three week period. The Trust was 25% busier on 999 compared to the same three weeks 12 months previously. Handover delays had doubled with almost 2,000 hours delay compared to 1,000 hours during the same period the previous year. During Quarter 3 the Trust failed to meet two of the three targets against the Monitor performance framework. JK would expect Monitor to award a rating of two rather than four for performance. January 2015 has seen an improving position on 999. It took the first two weeks for performance to settle down as hospitals started to regain control and social services galvanized. The Trust has seen a week on week improvement specifically in terms of Red 1. JK advised the Board that the Directors Group and the A&E Service Line Team have made the decision to ensure that performance of Red 1 receives focus. Dispatch on Disposition commences 10 February 2015 and the Trust would expect that to have a positive impact on both the Red 2 and A19 targets. JK stated that looking forward the view of the Directors is that in terms of Quarter 4 there will be a continuing strengthening of the Red 1 position both Year To Date (YTD) and Quarter To Date. The Trust could still recover the YTD position and deliver Red 1 in Quarter 4. Strengthening of Red 2 and A19 will continue but JK was not as confident in their recovery for Quarter 4. Handover delays and sickness were discussed. The Trust has zero tolerance on handover delays and these are improvement. Sickness saw the Trust peak at over 7% in December 2014. This has been more acute in the NHS 111 Service. The management team needs to focus staff on supporting them back into the workplace to improve this area. JK confirmed that the Red Recovery Plan is in place. KW reported that over Christmas decisions were made to try to preserve Red 1 and the staff were under considerable pressure. Due to the focus on Red 1 the Directors Group had agreed that the Trust may fail the Red 2 target without compromising patient safety. The Dispatch on Disposition Pilot was discussed and KW stated that the length of the pilot is four weeks. NHS England has identified the metrics. There are weekly calls planned with the NHS England Project Lead. .


9.1.8 9.1.9 9.1.10 9.1.11 9.1.12 9.1.13 9.1.14 9.1.15

VJ requested clarification on the expectations achieving the Red 2 target. JK advised that the Trust is not expecting to deliver Red 2 by the end of Quarter 4 and the Commissioners and Monitor are aware of this. VJ asked whether the Commissioners are supportive of the approach. JK commented that they appreciate the quality premium associated with the delivery of Red 1. Monitor understands the pressures and they have been very well briefed on issues around workforce vacancies, particularly around paramedics and they are supportive of the Dispatch on Disposition trial. FG advised that 20 to 30 measures will be captured for the pilot, over the same 4 weeks as last year and the same 12 weeks leading up to the period of the pilot. NLC noted that further assurances will be sought with a qualitative staff survey. NLC is leading on Dispatch and Disposition alongside Andy Perris, Head of Clinical Hubs and Sue Tuckett, Lead Clinical Supervisor who have been released from their current roles and are supported by a full time Project Manager for the duration and for writing the report at the end of the pilot. HH noted that staff turnover high at 13% and asked whether Dispatch on Disposition would impact on sickness and the causes of that turnover. KW would not expect to see a difference during the pilot but may improve in the future if the work pattern changes. Craig Holmes asked about re-triage of NHS 111 calls. KW advised that the Trust has never been allowed to re-triage when a resource arrives on scene but on the telephone the call can be moved to a different level if not life threatening and then re-triaged. HS noted that activity had increased and asked whether the calls come from Health Care Professionals (HCPs) or other members of the public. ACTION: JK would request this data for the next Integrated Corporate Performance Report produce detail for next time. Monitor compliance focuses on minor injuries and learning disabilities. HS on behalf of the Trust Board asked that the Quality and Governance Committee has a deep dive into learning disabilities. ACTION: JW to add this to a future Quality and Governance Committee Agenda. JK highlighted that with regard to NHS 111 and noted that KPIs were at

JK JW


9.1.16 9.1.17 9.1.18 9.1.19

a similar position as the 999 service through December 2014 at between 65 and 68% across a target of 95%. Call abandonment had improved. January 2015 call answering was improving and it was noted that the new recovery plan and trajectories are in place. Sickness has been a key pressure in terms of delivering the service from Monday to Friday and at the weekend due to volume of demands coming through and management response to these pressures. Media attention on NHS 111 was discussed and this had focused on comments from leading experts with differing opinions on the service. KW advised that two audits on the service have been undertaken one in Devon and one in Dorset both showed attendances to hospital have not been compromised by the NHS 111 service. The Trust will be conducting the same audit for Somerset. JK confirmed that the Trust is on plan to deliver £600k surplus for March 2015. There are some significant variances within the financial position including £5m non-recurrent money to support winter resilience a lot of which is related to A&E. Contra to A&E, Urgent care is experiencing material financial pressures. There has been some slippage in capital but JK was not concerned. Mobimeds have been deferred to next year. Assuming that the ICT plan is delivered this will bring capital in on the revised plan and will cover that in extra figures closing in January 2015. HS asked for an update on the UCS CQUIN. JK advised the risk is potentially £120k regarding the Somerset NHS 111 CQUIN. At a meeting recently with Somerset CCG they have advised they are not going to qualify the work done this year on CQUIN but will allow the Trust to retrospectively undertake the training against the CQUIN and afford us the additional months in first quarter to allow us to recover the position. The Trust Board of Directors took assurance from the Integrated Corporate Performance Report.

10.0 Governance

10.1 Board Assurance Framework 2014/15

10.1.1 10.1.2

KW presented the Board Assurance Framework 2014/15. KW recognised the need to review the Board Assurance Framework and that work will be ongoing. New templates have been developed by the Governance Team and these would be submitted to the Trust Board. ACTION: It was agreed that HS would ask the Audit Committee to

HS


10.1.3

go through some of the strands of the Board Assurance Framework in depth and report back to the Trust Board. The Board Assurance Framework was agreed by the Trust Board of Directors. It was recorded that an amended version would be received at the next meeting.

10.2 Corporate Risk Register

10.2.1 10.2.2

The Corporate Risk Register was reviewed and KW noted that the requested updates to the register had been encompassed. The Register had been reviewed by the Director Team. The Trust Board of Directors accepted the Corporate Risk Register and noted that there would be a more detailed discussion on the risk register at the February 2015 Trust Board Seminar.

10.3 Information Governance Quarterly Report

10.3.1 10.3.2 10.3.3 10.3.4 10.3.5

FG presented the Information Governance (IG) Quarterly Report for assurance and stated that this report has been reviewed previously at the Quality and Governance Committee in January 2015. Had expected to see increase in FOI requests following increase in demand on the service in December 2014. The IG Toolkit had undergone an internal audit review. FG stated that the challenge is to get all staff to do the IG training. ACTION: MM to send out the links to the Non Executive Directors to complete IG training as required yearly. FG reported that there have been three IG Group meetings undertaken in past three months so a lot of actions have been covered off within the work plan. The Trust Board of Directors accepted the Information Governance Quarterly Report and took assurance from it.

MM

10.4 Use of Emergency Powers

10.4.1

MM presented the Use of Emergency Powers for compliance. The Trust used the Emergency Powers on four occasions and MM requested the Trust Board to ratify the details.


10.4.2 The Use of Emergency Powers was ratified by the Trust Board of Directors.

10.5 Lease – Dursley

10.5.1 10.5.2

NLC reminded the Trust Board that in October 2014 Dursley Ambulance Station was to be demolished and staff move to the Fire Station in Dursley. NLC requested approval of the Trust Board of Directors for the use of the Trust Seal to exercise the lease of the new Fire Station in Dursley. The use of the Trust Seal was approved by the Trust Board of Directors.

10.6 Training Report

10.6.1 10.6.2 10.6.3 10.6.4 10.6.5 10.6.6

EW advised for assurance purposes. Regular Deep Dives in terms of Quality and Governance Committee. EW highlighted the main areas of statutory and mandatory training undertaken in the Trust. SME for 2014/15 is down to 24.5%. The area of concern is the North Division and this will impact on the 2015/16 training provision. The training action plan for managing Quarter 4 was agreed prior to the Dispatch on Disposition trial. The team has a programme of targeting staff who have not completed SME. Booking and scheduling of training has been discussed by the Executive Directors. Further discussions will take place around offering individuals in the North Division an extra day of leave to encourage them to pre-book training. Minimal numbers of staff undertake online training. It has been noted that 12 hours is allowed for a training day but the training only takes 8 hours. The 4 hours left could be used for online training further discussions will also take place regarding this. There has been success with Emergency Care Assistant (ECA) Courses with the delivery of 11 courses in last year against a plan of 5. Integration training is currently at 80%. ECS Training was discussed and it was noted that there is slippage of 3 weeks. This is due to the cancellation of training due to winter pressures and the Trust being at REAP Level 5. Dementia training is going well. This is reported to the National team and elements are included in mandatory work book.


10.6.7 10.6.8 10.6.9 10.6.10 10.6.11 10.6.12 10.6.13

The Trust has launched a new CPD website with packages and programmes for staff. Consultation has taken place with Health Education South West for additional funding for training. The team is working towards a National Level 4 Award linking into the talent strategy which will provide ECAs with an additional apprenticeship type award. CK asked whether sickness and absence is impacting the training. EW advised that this has not been analysed. HS 2013/14 noted outstanding training and asked what the impact is and whether this is on the risk register. EW confirmed that training is on the corporate risk register and in terms of the CQC EW and JW have been liaising. JW commented that a CQC inspection would be more concerned regarding disparity between training in the different Divisions. The North Division requires focus for consistency. ACTION: The Trust Board of Directors noted that a brief on Training is being submitted to the Quality and Governance Committee in March 2015 and the Trust Board of Directors requested a report following that meeting. EW to forward. The Trust Board of Directors accepted the Training Report and took assurance from it.

EW

10.7 Committee Assurance Reports

Audit Committee

Quality and Governance Committee

10.7.1

Audit Committee Assurance Report CK gave a brief following the Audit Committee. Benchmarking was a common theme and this will be reviewed in the future. The role of the Audit Committee and other Committees will be discussed at the February 2015 Trust Board Seminar. CK noted that review of the risk process was very satisfactory. The Claims Process against the Trust had been discussed and there were two points raised; one was the capacity to deal with claims within the trust and the cost to settle the claims as this is imposed from externally and the cost needs to be kept in focus in the long term. CK reported that the Estate Strategy had been deferred and the project management review was deferred due to


10.7.1.2 10.7.2 10.7.2.1 10.7.2.2

capacity and the Committee did not wish to jeopardize project delivery. Progress on internal audit was reported as satisfactory. The Trust Board of Directors noted that all roles of Committees will be reviewed at the Trust Board Seminar and that once reviewed the Terms of Reference for the Committees will be submitted to a future Trust Board of Directors. The Trust Board of Directors took assurance from the Audit Committee Assurance Report. Quality and Governance Committee Assurance Report VJ presented the Quality and Governance Committee Assurance on behalf of MW. VJ confirmed that there had been two Deep Dives reviewed regarding NHS 111 and training for NHS 111 staff in relation to safeguarding. VJ reported that the Quality and Governance Committee will be closely monitoring the Learning Disability target within the Monitor Report and providing the Trust Board of Directors with assurance on that. The Trust Board of Directors took assurance from the Quality and Governance Committee Assurance Report.

11.0 Minutes of Previous Meeting 27 November 2014

11.1 The Minutes of 27 November 2014 were approved as a correct record of proceedings.

12.0 Any Other Business

12.1 No further business was discussed.

13.0 Identification of New Risks (incl. Health & Safety)

13.1 No new Risks were identified.


14.1 No new Legislation was identified.

15.0 Identification of Exception Reporting Triggers

15.1 There was no exception reporting trigger.

16.0 For Information – Committee Meeting Final Minutes


16.1 Quality and Governance Committee – 18 September 2014

Audit Committee – 18 September 2014

Quality and Governance Committee – 13 November 2014

Charitable Funds Committee – 31 July 2014

16.1.1 The following minutes were accepted for information by the Trust Board of Directors: Quality and Governance Committee Minutes of 18 September 2014, Audit Committee Minutes of 18 September 2014, Quality and Governance Committee of 13 November 2014 and Charitable Funds Committee of 31 July 2014.

It is also to be noted that the following committee meeting have been held since the last meeting of Board of Directors:

Quality and Governance Committee – 8 January 2015

Audit Committee – 15 January 2015

Finance and Investment Committee – 15 January 2015 Signed:

(Chair)

Dated:

A final, signed copy of the minutes are available from the meeting administrator on request


Page 1 of 1


Title: Care Quality Commission Inspections – The New Approach


Helen Braid, Interim Compliance Manager

Presented by: Jennifer Winslade, Executive Director of Nursing and Governance

Main aim: For the Board of Directors to receive a presentation in respect of the way in which the Care Quality Commission now inspects the providers of regulated services.

The presentation also provides an overview of the work which is underway to ensure that the Trust is prepared for this new inspection regime.

Recommendations: The Board of Directors is asked to note the presentation in respect of the new approach to inspections by the Care Quality Commission.

Previous Forum: Directors Group, 10 March 2015





Implications


CQC Inspections – The New Approach

We have already started to prepare for a future

inspection. The Compliance Team have:

• Analysed the new Fundamental Standards and

Key Lines of Enquiry to complete a gap analysis of

existing evidence;

• Reviewed reports on inspected Trusts;

• Attended seminars, webinars, peer meetings and a

Quality Summit;

• Met with the SCAS team to learn from their

experience as a pilot for the new inspections

We have already started to prepare for a future

inspection. The Compliance Team have:

• Prepared a first draft high level project plan;

• Proposed names for a Core Team, to include

key staff being given dedicated time to support

the process;

• Proposed names of managers whose expertise

will be invaluable to the process (prior to and

during an inspection).

Future work • Agree approach / resourcing with the Directors’ Group;

• Risk assessment to identify areas of concern - mock

inspections for those areas/functions identified;

• Internal and external communications strategy;

• Engage fully with staff to seek their views on what

works and what can improve;

• Prepare Board, governors, managers, and staff who

will be interviewed.

• SCAS peer review?

When will we be inspected? • Notifications are now made on a monthly basis.

• The earliest date will be August 2015.

What will be inspected? Key Lines of Enquiry

Are services:

Safe; Effective; Caring; Responsive and Well Led

What the CQC will be looking for

A clear vision and strategy, understood at all

levels of the Trust; which is

• informed by strong stakeholder relationships

and patient feedback;

• supported by robust policies and procedures;

and

• delivered in a well-led, transparent, patient and

staff focussed environment.

Old inspection regime -v- the new SWASFT 2014 NWAS 2014

(pilot for new inspections with SCAS)

• Two inspectors • Inspection team of over 50

Visited:

• Trust HQ

• 6 ambulance stations

• One A&E unit

Visited:

• 3 EOCs

• 41 ambulance stations (some more than once)

• 27 A&E Units, an outpatients unit, urgent care

unit, paediatric ward, delivery suite and a

coronary intervention centre

• 2 HART locations

Spoke with 10 patients and 6

relatives

Spoke with over 100 patients and their families

Spoke with 38 staff – call handlers,

managers and ambulance crews.

Spoke with over 220 frontline staff; 50 management

and admin staff; and 35 call centre staff

Also:

• Over 10 third manning shifts;

• Over 60 vehicle checks.

Pre-inspection • Notification – 20 weeks prior to inspection week.

• Provider Information Return – SCAS required to

produce over 800 documents within 25 days.

• CQC Information Gathering – advertising for feedback;

holding listening events and contacting stakeholders.

• Initial meeting – Head of Inspection Team and Chief

Executive to agree specifics of inspection and

provisional date for Quality Summit.

Inspection • Will last 4 or 5 days;

• Inspection team of approximately 50;

• CEO Presentation to Inspection Team;

• 1-2-1 Interviews (Board, Governors, Managers);

• Focus Groups;

• Visits and Engagement;

• Closing Meeting.

Post inspection • Focussed unannounced inspection up to 30

days after initial inspection;

• Draft report – 10 days for accuracy check;

• Quality Summit;

• Action Plan;

• Ratings and Final Report published.

Ratings Rating Meeting the

Fundamental

Standards

and KLOEs

High Level Characteristics 722 Inspections

Rated to Date

Inadequate Not meeting Significant harm has occurred or is likely to

occur, shortfalls in practice, ineffective of no

action taken to put things right or improve.

55 7.62%

Requires

Improvement

Not meeting or

meeting

May have elements of good practice, potential

or actual risk, inconsistent responses when

things go wrong.

204 28.26%

Good Meeting + Consistent level of service that people have a

right to expect, robust arrangements in place

for when things do go wrong.

449 62.18%

Outstanding Meeting ++ Innovative, creative, constantly striving to

improve, open and transparent.

14 1.94%

What will the outcome look like?

(actual example) Safe Effective Caring Responsive Well-Led Overall

Urgent and

emergency

services

Inadequate Requires

Improvement Good Inadequate

Requires

Improvement Inadequate

Medical care Requires

Improvement

Requires

Improvement

Good

Requires

Improvement

Requires

Improvement

Requires

Improvement

Surgery Requires

Improvement

Requires

Improvement

Good

Requires

Improvement

Requires

Improvement

Requires

Improvement

Critical care Requires

Improvement

Good

Good

Requires

Improvement

Good

Requires

Improvement

Maternity and

gynaecology

Requires

Improvement

Good

Good

Requires

Improvement

Good

Requires

Improvement

Services for

children and

young people

Good

Good

Good

Good

Good

Good

What will the outcome look like?

Overall

Requires

Improvement

Safe Requires improvement

Effective Requires improvement

Caring Good

Responsive Requires improvement

Well-led Requires improvement

What will the outcome look like? • Actions the Trust must take;

• Actions the Trust should take;

• Enforcement actions:

– Civil: warning notices; varying conditions of

registration or cancelling registration; or prosecution.

– Criminal: penalty notices; cautions; prosecutions.

Focus - SCAS and NWAS Reports Safe

• Use of DNA orders

• “special notices” about patients needs and issues

• Patient records – security / access to

• Vehicle maintenance / cleanliness

• Infection control procedures

• Equipment availability and medicines management;

• Safeguarding / Mental Capacity Act / Deprivation of Liberties

• Incident reporting

• Staff welfare

• Use of REAP and Major Incident planning.

Focus - SCAS and NWAS Reports Effective

• Procedures re mental health patients and those in need of a

place of safety

• Use of pain relief medication

• ROSC

• Patient pathways / conveyance levels / hear and treat

• Performance management and action planning

• SME

• Career progression / specialist training

Focus - SCAS and NWAS Reports Caring

• Are patients treated with kindness, dignity and respect?

• Patient involvement in their treatment options.

Focus - SCAS and NWAS Reports Responsive

• How the Trust provides for bariatric patients, those with

mental health issues, who can’t speak English or who are

hard of hearing

• Staff awareness of Deprivation of Liberties

• Care pathways for those with mental health issues / in crisis;

• Performance against targets

• Patient awareness of complaints procedure

• Complaints handling performance and staff awareness of

learning from complaints.

Focus - SCAS and NWAS Reports Well Led

• Staff awareness of Strategy and Vision

• Governance arrangements / financial management

• Views of Trust risks – management – v- staff views

• Visibility of management / use of team meetings

• Staff, public and stakeholder engagement

• Quality indicators

• Interaction between Board and Governors

• Staff morale

• Emergency planning

Ambulance outcomes SCAS NWAS

Compliance Actions 0 1

Actions which must be taken 4 7

Actions which should be taken 19 24

SCAS –

“Like the old inspections x 100”

Quality & Governance Committee Thursday 8 January 2015 M:\Committee Papers\Quality & Governance Committee\201415\March 2015\24. Minutes of previous meeting 8 Jan 15\Minutes QG 08012015.docx

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Minutes Quality and Governance Committee Thursday 8 January 2015 – 13:00 hours Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Exeter, EX2 7HY

Chair Professor Mary Watkins, Non Executive Director

Administration Mrs J Smalley, EA and Business Manager to Chairman & Chief Executive

Members in attendance:

Prof. M Watkins MW Non-Executive Director Mr C Kinsella CK Non-Executive Director Mr T Fox TF Non-Executive Director Mrs V James VJ Non-Executive Director Mr K Wenman KW Chief Executive Mrs J Winslade JW Executive Director of Nursing and Governance Mrs E Wood EW Executive Director of HR and OD

Dr A Smith AGS Executive Medical Director Non Members in attendance: Mr D Beet DB Director of Urgent Care Services Mr A South AS Deputy Clinical Director Mr N Le Chevalier NLC Director of Operations Mr M McAuley MM Trust Secretary Ms H Braid HB Interim Compliance Manager Ms V Williams VW Head of Patient Safety and Risk Mr C Nelson CN Unison Regional Lead (East and West) Mrs J Jacobi JJ Quality Lead South West Commissioning Support Mr R Crocker RC South West Commissioning Support Unit Guests in attendance:

Mr F Gillen FG Executive Director of IM&T

Mr R Horton RH Community Responder Manager Mrs A Payne AP Health, Safty and Security Manager

Minutes: Ms S Francis SF EA to Executive Medical Director


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No Agenda Item Action


1.1 Apologies: Jane Jacobi, Tony Fox, Adrian South, Neil Le Chevalier.

2.0 Declarations of Conflict of Interest

2.1 There were no declarations of conflict of interest.

3.0 Report from the Chairman

3.1 There was no report from the Chairman on this occasion.

4.0 Items referred from Board of Directors, Directors Group or other Trust Committees

4.1 There were no items referred from board of Directors, Directors Group

5.0 Action Point Register

5.1 The Action Point Register was updated and would be circulated with the Minutes of the meeting.

6.0 Quality Focused Deep Dives

6.1 Deep Dive: Governance Framework

6.1.1 6.1.2 6.1.3 6.1.4

VW when through the deep dive for Governance Framework. VW pointed out that the decision making process for the Trust Board of Directors and Council of Governors are set out within the Standing Orders within a legally binding Constitution. The Constitution was amended during 2013 to account for changes made by the Health & Social Care Act to the role of governors but no further amendment has been made during 2014. It was noted that CK is taking over the Audit Committee. The Audit Committee are undertaking another review of the internal audit into the audit committee with strengthening links between the two organization’s. HS commented that the governance for organisational deep dive is a crucial time that the Board gets to grips behind the issues.


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6.1.5 6.1.6 6.1.7 6.1.8 6.1.9 6.1.10 6.1.11

4.1.3 – 4.1.4 The Committee felt that this was descriptive rather than evaluative and there was a need to be clearer about dates. It was recommended that the paper be amended to be more clear about dates and to be more both descriptive and evaluative. Action: Report to be redrafted for the next meeting and to receive the report with highlighted amendments. MM to liaise with NC before next meeting. 4.2.3 Associate/Deputy Directors’ Group – AGS reported that he was the Chair of the Clinical Effectiveness Group and not Deputy Clinical Director. 4.2.6 Strategy and Policy Register. HB undertook an audit of the register and review and publication of documents as required by the Trust’s Framework for Policy Development. A number of issues were identified including various different versions of Trust policies were identified in the North as well as East and West divisions. HB reiterated to the Committee that the reason why we do internal audits links with Risk Watch. We are continually strengthening links with internal audit. At its October meeting the Audit Committee also reviewed the Trust’s internal audit process and agreed a number of actions to strengthen its implementation. HB gave a brief resume on the agreed actions. HB clarified that the Quality Governance Plan would be completed by the end of March 2015. The Quality and Governance Committee noted the report and requested the report be amended and brought back to the next meeting as an addition.

6.2 Deep Dive: CQC Compliance

6.2.1 6.2.2

HB presented the Care Quality Commission Deep Dive to provide assurance for the Committee. The Trust has been registered with the CQC since 1 April 2010, without compliance conditions, for three regulated activities: treatment of Disease Disorder or Injury; Transport Services including Triage Provided Remotely; Diagnostic and Screening Services. 2014 CQC Activity. In February 2014, the CQC commented an unannounced inspection of the Trust. The inspection occurred over 5 days and involved 4 inspectors who visited give of the Trusts sites. This was a routine inspection to check compliance with the essential standards of


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6.2.3 6.2.4 6.2.5 6.2.6 6.2.7 6.2.8 6.2.9

quality and safety. HB reported that the Trust was compliant with the 5 outcomes reviewed. At a recent relationship meeting the Lead Inspector indicated that he was very happy with the Trust’s proactive approach to communication and the efficient way in which responses to his queries were made. HB stated that the Intelligent Monitoring Report (IMR) which contains a set of key indicators that look at a range of information including patient experience, staff experience and performance, will be a public document. HB reported that there are changes to the Inspection and Regulatory Regime. The new regulations are “clearer statements of the standards of care below which care should never fall”. The first CQC inspection report under the new regime was published on 10 December for North West Ambulance Service NHS Trust. The report did not provide ratings but did set out actions that the Trust must and should take. The summary of the NWAS CQC inspection was briefly went through by HQ, of note one of the Areas of improvement mentioned “improve access to clinical supervision for all clinical staff”. The meeting group decided that the Exec Group to take a look at this. Action: Executive Group to look at this. Pilot inspections have been carried out at a couple of Trusts and HB will be meeting with the Head of Compliance at South Central Ambulance Service on 5 February to learn more about their experience of the inspection at first hand to assist with the Trust’s preparation for its first inspection under the new regime. Discussion around the lack of control of where the inspectors can and cannot go and if they don’t go everywhere can they really make a judgment? It’s about getting the balance right. MW asked how many of our staff are encouraged to become CQC inspectors, it would be a minimum 10 days a year, and it would be good to encourage more people to undertake this. This would count towards CPD. The Quality and Governance Committee noted the Deep Dive for CQC Compliance and took assurance from this.

6.3 Deep Dive: Community Responders

6.3.1 6.3.2

Rob Horton presented the Deep Dive on Community Responders. The Trust utilises a variety of responders to supplement core ambulance


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6.3.3 6.3.4 6.3.5 6.3.6 6.3.7 6.3.8 6.3.9 6.3.10 6.3.11

resources. Community and Staff responders are also utilised as part of the community initiative. A new department structure was agreed in 2013/14 and was implemented during the last year. The restructure has been one of the most significant factors to the improvement in support of the performance to the department. The main emphasis has been on enhancing the robust governance processes, to ensure the efficient safe management of responders and the safety of the patients. The new Responder Governance Policy was implemented on 1 August 2014. MW asked if all responders are checked through the DBS system and also that their licences are checked. RH confirmed that this is the case. RH also confirmed that any responder who does not retain their post proficiency training every six months and who lapses their training by 12 months will not be able to respond. RH confirmed that funding has been arranged for the new Ambulance Community First Responder course. RH also reported that work is continuing with police agencies to keep track of the stolen community defibrillators. The introduction of Tetra Messenger across the region has made an improvement to the dispatch process. This device now provides the Clinical Hub with a GPS tracking ability of all Community Responders which aids in better and more accurate utilisation. HS complimented the role of the community responder and thanks should be relayed to them as they play a much bigger role in the community and would like them to know how valued they are. AGS asked that thanks be passed onto the responders. HB commented that a couple of years ago the Trust wrote a personal letter to each responder for thanks, engaging with local authorities is also helping building bridges. VJ queried whether neighbouring organisations have an insight to the value of the service? Agreed to refer to Board Seminar. MW expressed her thanks to RH for the report especially points 4.7.4 and 7.3. The report was request to be produced earlier for next year. The Quality and Governance Committee noted the Deep Dive for CQC Compliance and took assurance from this.


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7.0 Quality and Performance – Highlight Reports

7.1 Clinical Effectiveness Highlight Report

7.1.1 7.1.2 7.1.3

AGS presented the Clinical Effectiveness Highlight Report. It was noted that there had been two meetings since the last Quality & Governance Meeting in November. AGS went through the highlights of the report including the Paediatric Major Trauma Audit. The audit examined the care delivered to all patients identified as experiencing major trauma during a sample period. The report emphasized that suspected pelvic trauma is the most commonly triggered element of the tool. The Quality and Governance Committee accepted the Clinical Effectiveness Highlight Report and took assurance from the report.

7.2 Health, Safety and Security Highlight to include physical assault update

7.2.1 7.2.2 7.2.3 7.2.4 7.2.5

AP presented the Health, Safety and Security Highlight Report giving the Committee an update on actions undertaken since the Committee met in November 2014. This report included information regarding Physical Assaults Sustained by Front Line Staff. AP went through the Physical assaults report. During the period 1 April 2014 to 30 November 2014 there were 91 incidents of staff being subjected to a physical assault by patients or relatives. Of these assaults 10 involved more than one member of staff being injured. Action: A further bulletin to be published to include numbers of staff assaults. AP emphasised that seven of the injured staff took sick leave following a physical assault, this was identified as stress related. Discussion took place around working with staff on how we can make the system better regarding stress related sickness absence after a physical assault. CN assured that this link will take place. AP commented that this a link with meeting with communities – safe community groups, police, and fire county council meeting with them to look at how we can help. AP was asked if there is an enhanced approached to managing this from a health and safety prospective, AP confirmed this was correct. RC queried what happens afterwards? It is hoped that there is a resolution to the conflict before it happens. With regards to conflict resolution


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7.2.6 7.2.7 7.2.8 7.2.9

training, the Trust used to use an external company, NHS Protect, however, not doing this in house. This type of physical assault is relatively small, however assurance was sought that it is being managed appropriately. A trajectory to further improve warning makers is currently being worked on and working with HR. The Recommendations part of the report needs to be amended to recognise the improvement trajectory to protect staff from further assaults. AP is in liaison with local partnerships looking at Community Safety groups. The Quality and Governance Committee noted the report and asked that the Recommendations section of the report be amended recognise the improvement trajectory to protect staff from further assaults.

7.3 Long Term sickness following work related injury Highlight Report

7.3.1 7.3.2 7.3.3 7.3.4 7.3.5

AP presented the report on Long Term sickness following work related injury Highlight Report. The report highlighted that during the 12 month period there were 665 episodes of long term sickness by 605 staff. Of those episodes, 70 were recorded as injuries at work, 62 were preceded by an accident report to the Trust via Datix. The remaining eight episodes related to stress related sickness and planned operations. Of note, since the HSE Inspection in 2009, six staff have been trained as back Care Advisors. These staff are going to work with staff more closely to ensure that they are fit to come back to staff. LDO officers to go on train the trainer course, in the north. Still more we can do on back injuries – i.e. preventative (MW) do you have the resources to move this forward – yes think so (AP). AS quite keen to take this forward. CN queried regarding GRS at what point is it considered sick from work? AP replied that when the caller calls in the question should be asked is the injury at work. AP is meeting with Lisa Rigby, ROC North & Sickness Team Leader, at the end of this month regarding this. The Quality and Governance Committee noted the Long Term sickness following work related injury Highlight Report and took


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assurance from this.

7.4 Patient Safety & Experience Highlight Report

7.4.1 7.4.2 7.4.3 7.4.4 7.4.5

JW presented the Patient Safety & Experience Highlight Report. Patient Safety - JW reported that the team also implements the Duty of Candour plan. Duty of Candour became statutory on 27 November 2014 and the Trust is reviewing its processes to ensure they meet the confirmed requirements. Patient Experience – The team introduced a new complaint process on 1 October 2014 which provides a triage of complaints ensuring that the lower level complaints are processed at a local level allowing for greater accountability for operational team in the management of concerns raised. A review of implementation of the new process will be undertaken in March 2015. Patient Engagement - In October 2014 the Trust undertook a pilot patient survey with Plymouth Hospital whereby a number Governors support by Trust staff spend a day at the Emergency Department at Derriford. The Accessibility (Learning Disability) Programme is being implemented. The Quality and Governance Committee noted the Patient Safety & Experience Highlight Report and took assurance from this.

7.5 Medicines Management Highlight Report

7.5.1 7.5.2 7.5.3

AGS presented the Medicines Management Highlight Report. AGS highlighted that the new drugs will be quarantined until the training ream have disseminated the new information and learning to staff. MB queried whether this will hold back the implementation of new drugs, AGS reassured that this would not be the case, and there is a structured process. AGS reported that there is a delay in the implementation of a single system of medicines management largely as a result of changes to the operational structure. It is hoped that progress will be made with a series of visits to meet all the new operational managers. SO will be attending these meetings to discuss standardizing practice. Action: AGS to review progress on the procurement of an electronic system of medicines management.


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7.5.4

The Quality and Governance Committee noted the Medicines Management Highlight Report and took assurance from this.

7.6 Quality Account Highlight Report

7.6.1 7.6.2 7.6.3

The Quality Highlight Report was presented by AGS. Quarter 2 evidence was submitted to Bristol Commissioning Unit on 15 October 2014. The Trust is currently awaiting confirmation that all milestones have been met. Concerns were raised regarding the Q1, Q2 and Q3 milestones for the UCS schemes were at risk of not being achieved were escalated to JW. AS to meet with DB and report back to meeting in March. Action: AS to meet with DB and report back to meeting in March

7.7 Information Governance Quarter 3 Report

7.7.1 7.7.2 7.7.3 7.7.4

FG presented the Information Governance Quarter 3 Report. A performance update was submitted in October 2014 which showed the Trust maintaining its satisfactory rating. The volume of Freedom of Information Act Requests received were down on comparative year to date figures for the previous year. There was a rise in requests in November which was also experienced by other Ambulance Trusts. MW queried whether the recently issued new guidance on the use of CCTV in meeting data protection challenges whilst undertaking legitimate use of surveillance cameras will impact on the Trust? The committee discussed whether the Board would benefit from discussion on this; MW suggested that this could be discussed further at Board Seminar for an hour. The Quality and Governance Committee accepted the Information Governance Quarter 2 Report and took assurance from it.

7.8 Safeguarding Highlight Report

7.8.1 7.8.2

JW presented the Safeguarding Highlight Report providing an update to the Committee for assurance on work undertaken since the previous meeting in November 2014. A request for a more detailed report changes on safeguarding legislation to


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7.8.3 7.8.4 7.8.5 7.8.6 7.8.7 7.8.8 7.8.9

be returned to the meeting in March. Action: JW to submit an updated report to Q&G in March. There have been issues around capacity and safeguarding, to help with this there is now a Band 5 Triage post which will sift and triage all referrals. The new Named Professional for Dorset and Somerset started on 17 November 2014. This is a secondment post until 31 March 2015. The Both posts will be subject to review of the effectiveness of both posts. JW reported that ST is now also the designated Allegations Officer. Although there is a rise in allegations this does not mean there is a rise in risk. Health and wellbeing sessions first took place on 15 December 2014 which concentrated on the current welfare provision for staff through to allegations, disciplinaries and SI’s. Staff to be assured to complete safeguarding reports whilst on shift even though it may be busy. The new triage post is helping and takes on part of the work. CN commented that staff do not have the time to complete the forms back at the station, staff to be given time to complete forms. AGS remarked that ePCR would be the answer. Look at including in the March highlight report to see if there is change in the amount of safeguarding referrals. Proactive dispatchers will take notes over the radio and put that into the CAD then can be activated by the group and then can be picked up. Triage post and admin post will take phone in referrals as well. FG reported that he witnessed first-hand working with an ECP over the busy new year period and commented that crews spent 15 minutes on admin per job. The Quality and Governance Committee accepted the Safeguarding Highlight Report and took assurance from it and delighted about the 2 new staff.

7.9 HR, Recruitment and Workforce Report Highlight Report

7.9.1 7.9.2

EW presented the HR, Recruitment and Workforce Highlight Report. Total work force numbers as at the end of November 2014 is 4,261 of which 969 are employed on a part time contract basis. The Paramedic Conversion Programme Liaison Paramedic starts on 2 February 2015.


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7.9.3 7.9.4 7.9.5 7.9.6 7.9.7

There have been changes in GRS parameters on reporting short term sickness. At the last meeting the JNCC signed off new version of sickness policy. The new Occupational Health provider Optima took over from Capita on 1 December 2014, it has been reported that they are now seeing more staff more speedily and swifter. The ECP Programme is being finalised, noted that the Hear and Treat module will be a standalone module. Noted that there is income from LETB who are providing funding to pay for training. MW congratulated EW for a good report. The Quality and Governance Committee accepted the HR, Recruitment and Workforce Report Highlight Report and took assurance from it.

7.10 Training Highlight Report to include Dementia Update

7.10.1 7.10.2 7.10.3 7.10.4

EW presented the Learning & Development Department Report. The new Mandatory Workbook has been published and given to staff to complete in their own time by 1 April 2015. SME Training 2013/14 in North Division: 24.5% staff are yet to be trained, due to lack of capacity for staff extraction and low attendance on SME days following the cancellation of SME due to operational constraints. EW stated that compliance for North Division is under trajectory, this is due to operational constraints. To mitigate this, the department agreed to suspend training during Quarter 3, however, there is a plan to arrange SME in Quarter 4 to ensure that SME can be completed to the required performance target at the end of Quarter 4. This will be taken to the next Directors meeting. With regard to longer term impact EW will report to the Board at the next meeting in January. EW to pick this up. Action: EW to present plan and to also report on the longer term impact at the next Directors Meeting on 26 March 2015. ECA courses continue to be provided, there are 11 courses now planned during 2-14/15. There is a plan to hold a full day of training for 60 staff. The ECA courses are delivered using the QCF Diploma in Healthcare Support Worker Level 3 (Emergency Care Assistant).


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7.10.5 7.10.6 7.10.7 7.10.8 7.10.9

Due to operational constraints, training has been cancelled over the winter pressures period in Devon, Somerset and Dorset. Training will commence in January with at least three weeks slippage per area projected. EW gave a brief overview regarding Dementia Training. Tier 1 training aims to familiarize staff with recognising and understanding Dementia. All ECAs on the QCF Diploma in Healthcare Support Worker Level 3 will study additional units on dementia and understanding mental health problems. Of note CIPD website has been launched. VW asked how do we relate this to the Council of Governors regarding workforce. This will be picked up in the annual report. Staff Governor lost who would have been able to feedback – this is being put out to ballot.

7.11 NHS 111 Quality Development Plan

7.11.1 7.11.2 7.11.3

JW presented the paper on NHS 111 Quality Development Plan. The key actions required are to improve the service. Emma Williams, Head of Operations - Urgent Care Service, will be revising the trajectory plan and closing some actions. Question was asked if a summary of the meeting held on 23 December with NHS England and Commissioners will go to the Board. JW confirmed that a new trajectory was agreed with Commissioners during this meeting and also agreed separate improvements and developments and what is going to deliver 60 second call answering. Productivity – how we work with CAs, improving recruitment and retention, retaining staff, also looking at clinical module. There are a few nice to do action but also what needs doing within 60 second call answering. Action: JW to bring to Board a highlight report regarding call answering. HS confirmed that would be helpful for the Board to have that information which will be discussed in the confidential section of the Board meeting. The Quality & Governance Committee thanked JW for the report on NHS 111 Quality Development Plan and agreed that a highlight report regarding call answering should be submitted to the confidential section of the Trust Board of Directors Meeting for information.


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8.0 Governance and Compliance

8.1 Corporate and Executive Director Risk Registers

8.1.1 8.1.2 8.1.3 8.1.4 8.1.5

JW presented the Corporate and Executive Director Risk Registers. The reports were produced on 5 December, now a month old, is there a more timely way to present the reports? It was confirmed that although the reports were a month old the detail behind the action plans is actioned and detailed through. Performance targets – A19 performance removed from this risk and put into a new separate one on the Directorate risk register. ORCP Lead added as control. Additional controls have been added to 111 call answering performance. Workforce establishment – risk description updated. New risk around national position bandings for Band 5. Appraisals, Safeguarding Referrals and Adastra AB Platform to be transferred to the Directors Risk Register. Directors Risk Register: A19 performance target – no change. New risk around clinical hub rationalisation identified as part of the Service Delivery risk register for Commissioning intentions. Duty of candour – updated controls and actions. Regional Care Plan Strategy – new risk identified by FG – lack of regional care plan strategy resulting in different approaches by individual CCGs to care records impacting on the ability to use different systems. JW thanked VW for the updates provided on both of the risk registers. The Quality and Governance Committee thanked VW. The Committee accepted the Risk Registers and took assurance from them.

9.0 Strategic Issues – Strategies and Policies for approval

9.1 Personal and Sensitive Information – Access and Disclosure Policy

9.1.1 9.1.2

FG presented the paper on Personal and Sensitive Information – Access and Disclosure Policy. The purpose of the policy is to provide a management framework for the access to and disclosure of personal and sensitive information. AGS commented that with regards to information sharing, we are signing a lot of them and there is a willingness to share information without breaching the law. What we can and can’t share is, however, a very grey area.


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9.1.3 The Quality and Governance Committee approved the Personal and Sensitive Information – Access and Disclosure Policy.

10.0 Minutes of Previous Meeting 13 November 2014

10.1 The Minutes of the previous meeting of 13 November 2014 were approved as a correct record of proceedings.

11.0 Any other business

11.1 No further business was discussed.

12.0 Identification of New Risks (incl. Health & Safety)

12.1 No new risks were identified.


13.1 No new legislation was identified.

14.0 Exception Reporting Triggers

14.1 No triggers were identified.

15.0 Identification of Onward Communication

15.1 No identification of Onward Communication was discussed.

16.0 For Information (this section issued by email only)

16.1 Clinical Effectiveness Group Minutes

16.1.1 The Clinical Effectiveness Group Minutes of 21 August, 18 September and 23 October 2014 were noted by the Committee for information.

16.2 Quality Risk Watch Register

16.2.1 The Quality Risk Watch Register was noted by the Committee for information.

16.3 Safeguarding Group Minutes

16.3.1 The Safeguarding Group Minutes for 27 September and 28 November were noted by the Committee for information.


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16.4 Experiential Learning Forum Minutes

16.4.1 The Experiential Learning Forum Minutes from 7 August and 22 October 2014 were noted by the Committee for information.

16.5 Information Governance Group Minutes

16.5.1 There were no Information Group Minutes submitted on this occasion.

16.6 Patient Safety and Experience Report

16.6.1 The Patient Safety and Experience Report was noted by the Committee for information.

Date of next meeting: Thursday 12 March 2015, 13:00hrs in the Boardroom, Trust Headquarters Signed:

(Chair)

Dated:

A final, signed copy of the minutes are available from the meeting administrator on request


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Quality & Governance Committee Actions from 8 January 2015 Deep Dive: Governance Framework 4.1.3 – 4.1.4 The Committee felt that this was descriptive rather than evaluative and there was a need to be clearer about dates. It was recommended that the paper be amended to be clearer about dates and to be more both descriptive and evaluative. Action: Report to be redrafted for the next meeting and to receive the report with highlighted amendments. MM to liaise with NC before next meeting. Deep Dive: CQC Compliance HB reported that there are changes to the Inspection and Regulatory Regime. The new regulations are “clearer statements of the standards of care below which care should never fall”. The first CQC inspection report under the new regime was published on 10 December for North West Ambulance Service NHS Trust. The report did not provide ratings but did set out actions that the Trust must and should take. The summary of the NWAS CQC inspection was briefly went through by HQ, of note one of the Areas of improvement mentioned “improve access to clinical supervision for all clinical staff”. The meeting group decided that the Exec Group to take a look at this. Action: Executive Group to look at this. Health, Safety and Security Highlight Report to include physical assault update AP went through the Physical assaults report. During the period 1 April 2014 to 30 November 2014 there were 91 incidents of staff being subjected to a physical assault by patients or relatives. Of these assaults 10 involved more than one member of staff being injured. Action: A further bulletin to be published to include numbers of staff assaults. Medicines Management Highlight Report AGS reported that there is a delay in the implementation of a single system of medicines management largely as a result of changes to the operational structure. It is hoped that progress will be made with a series of visits to meet all the new operational managers. SO will be attending these meetings to discuss standardizing practice. Action: AGS to review progress on the procurement of an electronic system of medicines management. Quality Account Highlight Report Concerns were raised regarding the Q1, Q2 and Q3 milestones for the UCS schemes were at risk of not being achieved were escalated to JW. AS to meet with DB and report back to meeting in March. Action: AS to meet with DB and report back to meeting in March Safeguarding Highlight Report A request for a more detailed report changes on safeguarding legislation to be returned to the meeting in March. Action: JW to submit an updated report to Q&G in March.


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Training Highlight Report to include Dementia Update SME Training 2013/14 in North Division: 24.5% staff are yet to be trained, due to lack of capacity for staff extraction and low attendance on SME days following the cancellation of SME due to operational constraints. EW stated that compliance for North Division is under trajectory, this is due to operational constraints. To mitigate this, the department agreed to suspend training during Quarter 3, however, there is a plan to arrange SME in Quarter 4 to ensure that SME can be completed to the required performance target at the end of Quarter 4. This will be taken to the next Directors meeting. With regard to longer term impact EW will report to the Board at the next meeting in January. EW to pick this up. Action: EW to present plan and to also report on the longer term impact at the next Directors Meeting on 26 March 2015. NHS 111 Quality Development Plan JW presented the paper on NHS 111 Quality Development Plan. The key actions required are to improve the service. Emma Williams will be revising the trajectory plan and closing some actions. Question was asked if a summary of the meeting held on 23 December with NHS England and Commissioners will go to the Board. JW confirmed that a new trajectory was agreed with Commissioners during this meeting and also agreed separate improvements and developments and what is going to deliver 60 second call answering. Productivity – how we work with CAs, improving recruitment and retention, retaining staff, also looking at clinical module. There are a few nice to do action but also what needs doing within 60 second call answering. Action: JW to bring to Board a highlight report regarding call answering. HS confirmed that would be helpful for the Board to have that information which will be discussed in the confidential section of the Board meeting.