Agenda - Welcome to SWASFT - welcome · 2018-01-04 · Trust Public Board of Directors Meeting – 31 March 2016 Page 1 of 2 Agenda Trust Public Board of Directors Meeting Date Thursday

Trust Public Board of Directors Meeting – 31 March 2016 Page 1 of 2

Agenda Trust Public Board of Directors Meeting

Date Thursday 31 March 2016 Time 10.00

Venue Boardroom, Trust HQ, Abbey Court, Eagle Way, Exeter EX2 7HY

Chair Mrs H Strawbridge, Chairman

Members:

Mrs H Strawbridge (HS), Mr K Wenman (KW), Mr T Fox (TF), Mr H Hood (HH) Mrs V James (VJ), Mr P Love (PL), Dr I Reynolds (IR), Prof. M Watkins (MW), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AS), Mrs J Winslade (JW), Mrs E Wood (EW)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms L Bowden (LB), Mr N Le Chevalier (NLC)

Circulation Mr C Nelson, Joint Branch Secretary, Unison, Ms J Fowles Joint Branch-Secretary, Unison, Council of Governors

Administration Mrs J Smalley (JS)

Opening business

No Topic Format Presenter

1 Welcome, Introduction & Apologies Apologies: Mary Watkins

Verbal HS

2 Declarations of Interest Verbal All

3 Patient Story Presentation HS

4 Report from the Chairman Verbal HS

5 Report from the Chief Executive Verbal KW

6 Questions from the Public Verbal HS

7 Minutes of Previous Meeting – 28 January 2016 Paper 1 HS

8 Action Point Register Paper 2 HS

Trust Public Board of Directors Meeting – 31 March 2016 Page 2 of 2

Strategic Items for assurance

9 Integrated Corporate Performance Report Paper 3 KW

10 Corporate Risk Register and Board Assurance Framework Paper 4 JW

11 2015 Staff Survey Update Paper 5 EW

12 Patient Safety and Experience Report Paper 6 JW

13 Information Governance Year to Date Report Paper 7 FG

14 Communication and Engagement Paper 8 LB

15 Draft Regulatory Framework 2016/17 Paper 9 JW

16 Board Annual Declarations Paper 10 MM

Items for approval

17 Membership Engagement Strategy Paper 11 MM

18 Code of Conduct for Trust Governors Paper 12 MM

19 Speak Up, Speak Out Policy Paper 13 MM

20 Committee Terms of Reference Paper 14 MM

Sub Committee reporting for assurance

21 Audit Committee Assurance Report – March 2016 Verbal PL

Closing business

22

Any Other Business

Identification of New Risks (incl. Health & Safety)

Identification of New Legislation

Verbal HS

Trust Public Board of Directors Meeting – 28 January 2016

Page 1 of 18

Minutes Trust Public Board of Directors Meeting Thursday 28 January 2016, 10.00hrs 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 P Love PL Non-Executive Director Mr H Hood HH Non-Executive Director Mrs V James VJ Non-Executive Director Mr I Reynolds IR 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: Ms C Warner CW Interim Head of Communications and Engagement Mr N Le Chevalier NLC Director of Operations Mr M McAuley MM Trust Secretary Observers: Mr B McInerney BM Member of the public Mr C Holmes CH Public Governor, Gloucestershire Ms D Nix DN Public Governor, Wiltshire and Swindon


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No Agenda Item Action

1.0 Welcome, Introduction & Apologies

1.1 1.2

HS thanked everyone for attending the meeting. HS welcomed Bren McInerney, Dee Nix and Craig Holmes. Apologies were received from Mr Tony Fox and Lord Paul Tyler.

2.0 Declarations of Conflict of Interest

2.1 No declarations of interest were declared.

3.0 Patient Story

3.1 3.2 3.3 3.3.1 3.3.2 3.3.3 3.3.4

HS gave apologies from the patient speaker who had been due to attend today. The Trust Board of Directors took the opportunity to discuss the recent media coverage received by the Trust. Recent Media Coverage The Trust Board of Directors talked about the recent media coverage. The Board reiterated their focus on patient safety and the quality of services that they provide. The Board acknowledged that tragic circumstances must be learned from and all steps taken to ensure that they are avoided in the future. The Trust Board welcomed the independent review into the allegations that were made and wanted to ensure that all relatives and families of patients and staff were appropriately supported. Dispatches Television Programme South Central Ambulance Service (SECamb) had their CQC Report highlighted in a recent Dispatches Programme. SECamb had received a lot of coverage about their NHS 111 Service and the managing of calls after transfer to the clinical hub. Discussion on above The Board discussed the tragic circumstances surrounding the death of William Mead. The Board recognized that the story had heightened the publics’ awareness of sepsis.


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4.0 Report from the Chairman and Non-Executive Directors

4.1 4.2 4.3

HS reported that she and CW, Head of Communication and Engagement have continued to meet with new MPs within the area. The most recent visit was to Sheryl Murray MP in Liskeard and this meeting was a success. HS has been invited to be a member of the NHS Improvement Joint Advisory Chairs Group. The Group has 25 Chairs from the NHS who will attend regular meetings looking at how Monitor and the TDA will work when brought together. This is important work and HS was pleased to assure the Trust Board of Directors of her involvement. HS reported that the Staff Meetings had received a positive response. This has been substantiated more in the results of the staff survey.

5.0 Report from the Chief Executive

5.1 5.2 5.3 5.4

KW reported to the Trust Board of Directors that since the Board last met Heather Strawbridge had received an OBE in the New Year’s Honours. On behalf of the Trust Board of Directors KW congratulated HS. The Trust has been donating a number of vehicles at end of life in this organistion and equipment to ICT Fire and Rescue, an emergency rescue service provider as well as a training institution based in Thika (Kiambu County) Kenya. The Trust has a memorandum of understanding with the service provider. The Trust supports the training. Two members of staff went to visit. ACTION: KW will email further pictures to the Board. It has been good to receive feedback from the support and development provided by the Trust. The Trust has received the interim response to the Staff Survey 2015. This has been encouraging despite level of pressure staff are under. The return was 40.6%. The Trust has improved on 30 questions out of 60. The Trust was better than most other Trusts on 55 elements. The Survey has been very positive. This will be presented by EW to a future Trust Board of Directors Meeting. ACTION: EW to provide a report on the Staff Survey to the next Trust Board of Directors Meeting in March 2016. KW informed the Trust Board of Directors that the Trust has received notification that the CQC Inspection will take place 6 to 10 June 2016.

KW EW


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6.0 Questions from the Public

6.1 6.2 6.2.1 6.2.2 6.2.3

HS introduced Bren McInerney. BM recognised the immense pressure the service is under and that he had shared the recognition of the leadership delivered by KW across the ambulance service in the South West; and he commended KW for his level of social intelligence. BM gave recognition to CW for supporting Kingfishers and its development. Kingfisher’s has a membership of 144 adults with disabilities. Question from BM James Titcombe is the father of Joshua, a baby boy who died when only nine days old after signs of his deteriorating condition were missed by Morecambe Bay NHS Trust. ‘Whilst this case related to the Maternity Unit this could happen in any area in the NHS and beyond. What is the Trust Board’s view of the content of the book Joshua’s Story which was published in December 2015’: JW responded to the question on behalf of the Trust Board of Directors. JW has the privilege of working in quality and governance. JW commented that it is devastating to hear of situations when there has been a lack of transparency that affects the grieving process. This is a tragic and heartbreaking story followed by catalogue of issues which are not isolated to this case. It takes several years for families to find the truth. This Trust has works hard to maintain an open culture around quality and safety. The Trust has not had any cases of Duty of Candour where the Trust has not met the requirement. The Trust meets with the families to gain their view on the incident and ensure this is embedded within the learning. Staff are always supported whether they are involved with minor or serious incidents. EW is working with the Speak Up Speak Out campaign which came from the Robert Francis Report after Mid Staffs. This is about learning and supporting staff to change. The one thing that JW took away from the meeting with Melissa Mead was that she thanked the Trust for being open and transparent with her. HS noted that the Trust has always encouraged staff to report when things go wrong and also when they nearly go wrong in order to stop things happening and to share learning. It is crucial that the Trust shares this learning across this Trust and further. JW works transparently with other organisations and partners, working with commissioners and other Trusts who have been part of the patient pathway.


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6.2.4 6.2.5 6.2.6 6.3 6.3.1 6.3.2 6.3.3

VJ supported the view that the Trust is a learning organisation. VJ has attended Serious Incident panel reviews and has seen that staff attend. The Trust supportively and carefully takes them through the investigative process and any recommendations of learning. As a Board member VJ is assured by that. BM will be talking to James Titcombe on Friday, 29 January 2016 and the conversation will be around the leadership, culture, attitudes and behaviours and the demonstration of those. James will be visiting in March 2016. HS thanked BM for raising this issue today. Question from Adrian Rutter, Lead Governor and Public Governor for Devon HS noted that AR is not in attendance today but this question is in respect of the Governors’ duty to represent the interests of members of the Trust and the wider public. The question refers to the paper considered by the Trust Board of Directors on 26 November 2015 – “Communication and Engagement Quality and Performance Report” ‘Regarding agenda item 13 “Communication and Engagement Quality and Performance”, which clearly sets out the Trust’s strategy with regard to communicating outwards, could the Board please explain how they satisfy themselves that the Trust meets the challenges endemic to all entities wishing to reply and response to external communications promptly, appropriately and effectively, and therefore builds relationships through two-way ‘push and pull’ communications and engagement.’ HS stated that it would be most appropriate to address this question at a Council of Governors Meeting. DN and CH to report back to AR the recent media coverage of the Trust and also the communications update from today. The Trust Board of Directors agreed that this question would be presented to the Non-Executive Directors at the next Council of Governors Meeting. ACTION: Question to be taken by Non-Executive Directors, MM to add to the Agenda for the Council of Governors Meeting.

NEDs/ MM

7.0 Minutes of the Previous Meeting – 26 November 2015

7.1 The Minutes of the previous meeting of 26 November 2015 were approved as a correct record of proceedings.


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8.0 Action Point Register

8.1 The Trust Board reviewed the Action Point Register 30 July 2015 (8.10) ICPR – Action completed 30 July 15 (8.12.2) ICPR – Action completed 24 Sep 15 (10.4) Patient Experience report – Action completed 24 Sep 15 (12.5) Learning Disability Programme Report – Action completed 26 Nov 2015 (3.7) – Patiemnt Story – Action complete 26 Nov 2015 (9.5) Rissk Regsiter and BAF – Action complete 26 Nov 2015 (9.311) BAF – Action complete 26 Nov 15 (10.7) Information Governance – Action complete 26 Nov 2015 (16) Audit Committee – Action complete All other risks are in progress and the action point register was updated.

9.0 Operational Planning

9.1 KW provided an update on Operational Planning to the Trust Board of Directors. KW advised that the Trust’s Operational Plan has yet to be confirmed. The Trust is participating in the Ambulance Response Programme (ARP). ARP has created an environment where there have been a number of unknowns both with performance standards and categories of calls. Involvement in this trial has been essential and the Trust has driven this on behalf of national services. NHS England has now taken the lead. The latest aspect of the trial which the Trust has been promoting moves into a number of the 4,000 codes being split so that the Trust can respond in a number of different ways. As the criteria are unknown it has been impossible to prepare an appropriately informed Operational Plan. The start date for the second phase of the pilot is unknown. Therefore the Operational Plan has been delayed. The Trust Board of Directors noted the current position.

10.0 Integrated Corporate Performance Report

10.1 10.2

KW presented the Integrated Corporate Performance Report for assurance to the Board of Directors. KW gave a national update. NHS England commenced 2016 with a new set of Ambulance Quality Indicators (AQIs) for Ambulance Services across the Trust with implementation from January 2016. KW has received responses from 50% of Ambulance Trusts that they have not implemented them fully yet. This Trust has implemented them. Report is


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10.3 10.4 10.5 10.6

last week’s performance for the country. Only two ambulance services delivered Red 1; South East Coast Ambulance Service (SECamb) was one but they had not applied the new AQI guidance. West Midlands Ambulance Service (WMAS) achieved 76% and had applied the guidance. WMAS have dropped 4-5% as a result of the implementation. For Red 2 no service in the country achieved last week. Year to date for Red 2 WMAS is achieving. For Red 1 only this Trust, WMAS and North West Ambulance Service are achieving year to date. The position nationally is very fluid. This is not just about how AQIs are measured; there is a huge amount of pressure on the ambulance service. The system is under enormous pressure. KW reported a correction under the ICPR Handover Delay Section. It is stated that hours lost over 15 minutes were 1,432 hours of cover lost in December 2015 over 15 minutes turnaround time. The figure shows the hours that the Trust charges for which are those lost to Emergency Department handover delays. If the Trust reported all hours of cover lost this figure would be 2,316. The Trust cannot charge for those associated with Medical Assessment Unit handovers or those for the Intensive Therapy Unit. The total figure equates to 200 12 hour shifts lost in December 2015 or 2,500 shifts over a year. JK and NLC met with Commissioners on 27 January 2016 and delivered a presentation on the Trust Investment Strategy. They informed the Commissioners what it is like for the service at the moment. It was noted that Emergency Departments are under pressure and handover delays are a consequence of that pressure. This is about ensuring that Commissioners and Acute Trust are aware of the difficulties faced by the Service. This is about working together and ensuring that there are good relationships at a strategic and local level. JK advised that there is an agreed consistent generic template across Acute Trusts and the trajectory for improvement has been agreed with each Acute Trust. Handover delays have deteriorated by approximately 30% during Quarter 3. Headlines Over New Year the Trust had 3,500 incidents; this is 1,000 more calls than on a normal (day?). The Trust was 13% above core resourcing. The Trust did not achieve key performance targets at 72.6% for Red 1, 62% for Red 2 and just below 90% for A19. There are concerns that quarter to date will not be delivered and that response times may not be achieved. Current Red 1 performance for West is 77.2%, East 77.02%, North 64%. There have been historical issues with resourcing in the North Division


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10.7 10.8 10.9 10.10 10.11 10.12 10.13 10.14

even prior to the acquisition of Great Western Ambulance Service but there has also been a rise in activity in those areas and the percentage of Red calls from NHS 111 in the North has added to this and is causing significant issue. The Trust is not able to re-triage these calls once they are passed to the Clinical Hub a resource has to be dispatched. By having to dispatch a resource immediately the Trust is responding to potentially non-life threatening cases whilst compromising life threatening calls. FG stated that Red calls from NHS 111 equate to 33% in the North Division compared to 26% in the East and West Divisions. This is reported to Care UK who provide the NHS 111 Service in the North and to Commissioners in detail. MW sought assurance that the Commissioners know that there are problems with some of the Providers? The Trust has offered to work in partnership and offered potential solutions which have been rejected. JK reported that there had been an improvement from Care UK prior to Christmas 2015, but this has decreased in January 2016. At the Commissioners Meeting on 27 January 2016 the Trust presented different narrative, focusing on demand on 999. North activity is above contract and the source of this demand is from NHS 111. Initiatives Last week the Trust introduced five extra 24-hour Rapid Response Vehicles (RRVs) over and above resource in the North Division. The new Meal Break Policy in the North commences shortly. Work is taking place on having a mobile Make Ready Team to clean vehicles quickly. New standby points have been introduced in Bristol and these are being monitored closely. Collaboration with Emergency Services continues. Fire Service Response Teams have been increased, particularly in Gloucestershire. The Trust has appointed a Tri Service Manager to collaborate with the Fire and Rescue Service and the Police Service on the introduction of more initiatives. Clinical Quality Indicators (CQIs) will be reviewed in more detail. The ICPR details these up to August 2015. The Trust receives the data three months in arrears. The latest figures show that on two CQIs the Trust made an improvement on outcomes towards cardiac arrests and return of


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10.15 10.16 10.17 10.18 10.19 10.20 10.21

spontaneous circulation (ROSC). Three indicators were compromised and these are where the patient needs to get to a Treatment Centre at a given time e.g. for stroke. The Trust is governed by the level of resource and whether local facilities are open. The Trust stayed the same for three of the CQIs. PL commended the step improvement. There has been a positive benefit from the Ambulance Response Programme with the Hear and Treat rate at 13.33%. There has been investment of clinicians in the hubs. The Ambulance Quality Indicators are being reviewed and AGS is chairing the National Group leading on these. Major changes are expected in this area over the coming months. HS invited Craig Holmes, Public Governor Gloucester to inform the Trust Board of Directors regarding Community First Responder activity in the Gloucester area. CH reported that the number of incidents attended by the CFRs has decreased. KW acknowledged that the North Division is under pressure with resource delivery and activity increase. CFR availability is being reviewed by the Director of Operations along with the Community Responder Manager. ACTION: MM to forward CH’s concerns to FG/KW. NLC to provide a report on utilisation of CFRs for review at the next Trust Board of Directors Meeting in March 2016. HS thanked CH for raising this with the Trust Board of Directors. Workforce Update - EW provided an update on Trust vacancies. The Trust had expected to be over established by the end of March 2016 but will be slightly under by 20-30 vacancies. The reason for this is not based around recruitment but around internal moves with secondments out of staff from frontline duties. The next steps are to work around tolerance with development of staff off frontline. Staff sickness – EW reported that staff sickness has reduced. There has been improvement in the management of long term sickness. Good practice has been encouraged with return to work interviews. There has been improved reporting through the Global Rostering System (GRS). These reports give more visibility around triggers and certain parameters. Comparative data is provided. Staff can be held to account. Appraisals – WE reported that appraisals have remained an issue due to the Trust being at Amber and at REAP Level 4 for the majority of 2015. Discussions are taking place with staff side colleagues.


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10.22

Trust financial position – JK reported that the Trust’s financial position has been positive. For Quarter 3 Monitor awarded the Trust a green status. JK advised there has been dialogue between national lead organisations and leaders within the NHS. The Trust is planning for a small surplus but this will be subject to further discussions. This is with the agreement to reinvest penalties. Internal meetings continue to ensure a full understanding of financial dynamics. The Trust Board of Directors took assurance from the Integrated Corporate Performance Report.

11.0 Corporate Risk Register and Board Assurance Framework

11.1 11.2 11.3 11.4 11.5 11.6

JW presented the Corporate Risk Register and Board Assurance Framework for assurance to the Trust Board of Directors. JW stated as previously reported that the Risk Register is changing. The new narrative was noted. The new risk platform tender goes out on 1 February 2016. The tender will drive the new risk strategy for risk scoring and mechanisms for the risk register. Deep dives will be undertaken in A&E Operations and then IM&T Risks which will form part of the risk assurance process moving forward. There is a different approach to the Board Assurance Framework (BAF). With a summary of all risks. NHS 111 call answering is broadly delivering against trajectory. Focus is on Red 2 targets which remain high risk for the Trust with increased activity. The Forecast Score is unknown. There has been a deep dive on the increase in activity. There has been no increase in score. The biggest issue is around how the system outside of the Trust manages patients who are needing urgent and emergency care support. From June to December 2015 there was an increased forecast score and this has not reduced due to confidence in being able to manage patients outside the system. JW stressed the commitment with Commissioners to work with the Trust on the two risks of activity and Red 2. KW reported there is a national position on paramedic banding. At the National Ambulance Services Partnership Forum on 4 February 2016 two ambulance services will be nominated to NHS Employers who will send the Job Evaluation Team to interview staff in those services. The Trust Board of Directors took assurance from the Corporate Risk Register and Board Assurance Frame.


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12.0 Major Incident Preparedness Statement

12.1 12.2

KW presented the Major Incident Preparedness Statement. This is an assurance statement following the Paris attacks to ensure emergency services are able to respond to attacks. This report provides assurance to the Trust Board of Directors on a number of areas where awareness and training has increased. The Trust Board of Directors approved and took assurance from the Major Incident Preparedness Statement.

13.0 Developing Forward Plans 2016/17

13.1 13.2 13.3 13.4 13.5

JK presented the Developing Forward Plans 2016/17 to provide the Trust Board of Directors with the sense of process and development of plans for 2016/17. The Trust is required to plan for 2016/17 and to develop a system plan for 2016/21. JK drew attention to the role of NHS Improvement. NHS Improvement will be reviewing the Trust’s Plan. The Trust is in dialogue with Monitor and has flagged with them the challenges with producing the plan. The first deadline is for the Trust Board of Directors to receive the unapproved submission on 8 February 2016. This would have been shared on 5 February 2016 with the Chairman. There will be an opportunity for the Trust Board of Directors to discuss the plan at the Trust Seminar on 25 February 2016. The final approved version will be submitted in April 2016. JK clarified that the plan is drafted under Monitor’s guidance. The approach for 2016/17 is to take the first six months as work plan to understand the evidence base from the Ambulance Response Programme. The Trust will then produce an 18 month plan running from 1 October 2016 to 31 March 2018. JK noted that the 5% tolerance for the Ambulance Response Programme will be removed. The Trust Board of Directors took assurance from the discussion regarding the plans for 2016/17.


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14.0 Council of Governors Forward View

14.1 14.2 14.3 14.4 14.5

Craig Holmes, Public Governor Gloucestershire and Deputy Chair of the Audit and Planning Sub Group of the Council of Governors and Dee Nix, Public Governor Wiltshire & Swindon and member of the Audit and Planning Sub Group presented the Council of Governors and Members of the Public View on the Forward Plans of the Trust for consideration by the Trust Board of Directors. CH reported that 44% of the public stated that response time was key for them. They accepted that the quality of the person attending them would be good. They want a resource to turn up when they are in need. Utilisation of Community First Responders (CFRs) was discussed. HS advised that she has attended CFR Meetings. KW and HS are supporting an Awards Evening for Community First Responders as they are so valued. NLC advised there has been an increase in Responder Managers across the Trust to support this work. The Trust has recently appointed a joint manager via joint funding as a point of contract with St John Ambulance. With regard to response times CH suggested that this could be incorporated into the Governor Engagement Survey. The last ones were developed with William Thomas as the Chair of the Membership and Communications sub group of the Council fo Governors. HS thanked the Council of Governors for the valuable feedback that they had got from time spent with the public. DN commented that in the area North East of the Trust there have been a lot of private defibrillators (defibs) installed. DN reported that the communities are full of praise for the Trust but do have concerns that they may wait longer for a response because they have a defib. KW responded that wherever a public access defib is placed has no bearing on how quickly an ambulance responds. It was noted that the 19 minutes target does not include defibs. The whole issue of whether a defib stops the clock in terms of performance standards is with the government for review. The Association of Ambulance Chief Executives has been lobbying the government. The purpose of the model of change of service with the change in codes sets is to review the service model delivered. Trusts may need to move to more ambulances than cars. ACTION: DN to provide details of any incidents with regard to defibs or response delays for the Trust Board of Directors to investigate. It was noted that community defibs are not instead of they are as well as and it would be helpful if the Governors could ensure this message is fed back.

DN


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14.6 14.6 14.7 14.8

Education was discussed and the misuse of the service was feedback along with the fact that it is not a taxi service. DN reported that at a recent Emergency Planning Meeting for her area there had been a positive message from the Fire Service about working with the Trust. HS gave thanks to DN and CH. HS asked them to forward thanks from the Trust Board of Directors to all the Governors for the work they do. The Board received the Council of Governors Forward view

15.0 Communication and Engagement

15.1 15.2 15.3 15.3.1 15.3.2 15.3.3 15.4

CW provided an update on Communication and Engagement for assurance to the Trust Board of Directors. The Trust Board of Directors noted the Quarter 3 objectives. CW highlighted the following; Stay Well This Winter Campaign This was rolled out before the real definition of Winter. There has been a blended approach with NHS and Social Care colleagues to make use of pulling together national campaigns. This has worked well with positive coverage. Launch of Staying Well Service The Staying Well Service has generated positive news coverage and has received excellent feedback from staff. Patient Stories This has been opportunity with positive coverage. The team is following up with the stories. Frontline staff are good at informing the team about these stories and the patients are given the opportunity to meet with the crews. The Trust Board of Directors Too assurance from the Communications and Engagement update.


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16.0 Information Governance Toolkit

16.1 16.2 16.3 16.4 16.5 16.6

FG presented the Information Governance Toolkit Report. FG reported increases in Freedom Of Information Requests. These are being managed by the Information Governance Team. Information Governance Training of staff is at 60%. The target is for 95% of staff to complete the training by year end. Discussions are taking place with Directors. Networking is taking place with regard to the Care Record Programmes. Dorset and Gloucestershire are in the process of procuring care systems following on from the BNSSG Connecting Care System. FG is involved with work nationally with regard to ECS. This work is sponsored by HSCIC. HS asked if there would be a revision of categories for Information Governance Adverse Incidents. FG responded that these are National categories. JW advised that the platform for incidents will change in Quarter 1. Successful bidders may be able to change the code sets. The Trust Board of Directors took assurance from the Information Governance Toolkit Update.

17.0 Standing Financial Instructions of the Trust (SFI)

17.1 17.2 17.3 17.4

MM presented the Standing Financial Instructions of the Trust for approval from the Trust Board of Directors. MM reported on the changes to in-house limits. These are based on information provided by the Procurement Team and have been reviewed by the Audit and Assurance Committee. MM recommended to that the Trust Board of Directors approved the changes to the in-house limits. MW agreed with the SFIs but commented that for euros to pounds conversion rate fluctuation there should be an extra line so that this does not have to be written in every time the bandings change. PL commented that this would still keep it below the OJEU level. There should be a line to state that it is below. The Trust Board of Directors agreed that this is simpler in the longer term but if there is significant change this would be brought back to the Trust Board of Directors. The Standing Financial Instructions of the Trust were approved by the Trust Board of Directors.


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18.0 Governors Expenses Policy

18.1 18.2 18.3

MM presented the Governors Expenses Policy. Amendments and the small housekeeping update to the Policy Register were noted by the Trust Board of Directors. The Trust Board of Directors noted the fundamental change in the mileage rate from 53p to 56p in line with the NHS approved mileage rate. It was noted that if the Government rate reduces this will reduce the NHS approved mileage rate. The Trust Board of Directors approved the Governors Expenses Policy.

19.0 Quality Approach

19.1 19.2 19.2.1 19.2.2 19.2.3 19.3 19.4

JW presented the Quality Approach for assurance to the Trust Board of Directors. HS praised JW and her team for this report which is outstanding. JW highlighted the following three points; The Quality Forum has been developed where discussions on risks and work on this will be discussed. Chris Nelson, Staff Side Branch Secretary attended the last meeting and was supportive of the direction of travel. It was noted that patients are at the centre of this. It has been agreed that learning and improvement has to be the basis of quality be able to utilise learning nationally and locally. System information will be used where possible. Further developments will take place. The Trust demonstrates the value of quality. Staff involved with the Quality Forum felt that if quality continues to develop there will be a financial value seen. JW will present the full Quality Strategy to the next Trust Board of Directors in March 2016. The full Quality Strategy would be presented to the Quality Committee for approval. ACTION: JW to take this forward. The Trust Board of Directors took assurance from the Board and approved the strategic approach to development.

JW


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20.0 Quality Committee

Assurance Report – January 2016

Final Minutes – October 2015

20.1 20.2 20.3 20.4 20.5 20.6 20.7

VJ presented the Quality Committee Assurance Report following the meeting on 14 January 2016. VJ reported that the meeting in January 2016 had been well attended. The new style of reporting had been introduced to the committee. Presenters had been provided with the template which makes for a more concise and easier report. This had been well received. The Committee had felt that there were three key areas that the Directors Group should review. These were the increasing referrals to the safeguarding team, medicine management and compliance with the medicines management policy across the entire trust and Infection Control, particularly the deep clean programme for vehicles particularly through December 2015. NLC reported that the Trust was at REAP 4 in December 2015 and the Make Ready Operatives (MROs) were used to move the vehicles around more and they had to get all available vehicles on the road. The MROs have been doing overtime during January 2016 in order to deal with the backlog and maintain the excellent standard provided by the Trust. VJ asked that it was noted that no harm or risk to patients had taken place in the above areas. ACTION: Directors Group to review Safeguarding, Medicines Management and Infection Control. JS to discuss with KW and add to further Directors Group Agendas. Key achievements were noted with Right Care 2 and CQUINs on track for full achievement this year. ACTION: MM to add the list of papers that were submitted to the Quality Committee to the Assurance Report. The Quality Committee had commended the Staying Well Service which has been well received across the organisation with a lot of positive feedback. The Quality Committee had received an update on learning disability and had commended work undertaken by South Western Ambulance Group led by Sara Coburn, Patient Engagement Manager. The Visitor Access Policy had been amended and approved at the Quality Committee. The Minutes of the Quality and Governance Committee Meeting of 8 October 2015 were noted by the Trust Board of Directors. It was noted that the Quality and Governance Committee Minutes from 17 December 2015 have been submitted for approval at the next Quality Committee in

JS MM


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20.8

April 2016. The Trust Board of Directors noted the report of the Quality Committee for assurance.

21.0 Audit Committee

Assurance Report – January 2016

Final Minutes – November 2015

21.1 21.2 21.3 21.4

PL presented the Audit and Assurance Committee Assurance Report following the meeting on 14 January 2016. This was the first meeting of the newly reshaped Committee. PL noted that the Executive Directors have been asked to produce a mission statement on areas relevant to the Trust to feed into risk mapping and development. PL noted that the timeliness of Audit Reports has improved. Following internal audit the Urgent Care Service had received a rating of amber. There is a detailed action response plan for that report and JW is reviewing the areas and see if areas can be accelerated. External Audit outlines Audit Plan had been review. PL reported that as part of the independence test they require a declaration from the Non-Executive Directors regarding engagement with PwC. The Minutes of the Audit Committee on 12 November 2015 were noted by the Trust Board of Directors. The Trust Board of Directors took assurance from the Audit and Assurance Committee Assurance Report.

22.0 For Information

Report from West of England Academic Health Science Network Board

22.1 MW asked whether the Academic Health Science Network (AHSN) is of value. FG advised that the West of England AHSN have provided some funding for reporting on ECS. West of England stands above with their support. MW commented that the report does not reflect this. FG advised this is specific to the West of England. ACTION: JK to compile a list of subscriptions to organizations for presentation to the Trust Board of Directors in March 2016.

JK

23.0 Any Other Business

23.1 There was no further business.


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24.0 Identification of New Risks (incl. Health & Safety)

24.1 No new risks were identified.

25.0 Identification of New Legislation

25.1 No new legislation was identified.

Signed: (Chair)

Dated:

A final, signed copy of the minutes are available from the meeting administrator on request

Date of MeetingMinutes

Reference

Agenda Item

(Topic)Action Allocated To Deadline Progress Date Completed

30-Jul-15 9.3.3

Corporate Risk

Register, Board

Assurance

Framework (BAF)

and Assurance Log

HS requested that when the scoring is reviewed it is important to

have clear definitions of 5 by 5. ACTION: JW and MM noted this

request.

JW 24/09/2015

UPDATE: Action yet to be completed. To be

incorporated into the new risk platform where all risks

will be consistency scored at the Risk Assurance

Group before being uploaded in the new platform.

30-Jul-15 9.3.8

Corporate Risk

Register, Board

Assurance

Framework (BAF)

and Assurance Log

Audit of 999 calls related to capacity for every 10 calls triaged the

Clinical Supervisor is taken off the telephone. The team has

diverted some clinical time to try and improve the percentage.

Incidents related to triage are not due to lack of audit. NLC will

be reviewing this and will assess the need to employ more

auditors in September 2015. MW asked whether the Trust

should get a third party to undertake the audits as this may be a

cost effective solution. JW advised that Internal Audit would not

be able to undertake this work as they would have to be trained

on NHS Pathways, however an outside agency may be a

possibility. ACTION: JW and JK to discuss at Directors Group

for consideration.

JW/JK 06/10/2015

UPDATE: There is an improving picture with call audits,

the Trust remains below the advised level however there

is a month on month improvement in the number and

quality of call audits. The process is embedded within

operation teams where learning occurs collectively and it

is unlikely that an external organisation would add

significant value. It would also be outside of the provide

license requiremnets.

ACTION COMPLETED

NEW ACTION : Update report on call Audit

Compliance on Confidential March Board agenda

ACTION COMPLETED

24-Sep-15 12.4.Learning Disability

Programme Report

IR asked whether audit or dip testing is undertaken with regards

to learning disability understanding. JW advised that his has not

been undertaken. ACTION: Directors Group to discuss further

whether there could be a Learning Disability understanding

question within the staff survey so that staff can identify whether

training has taken place. FG advised that the electronic patient

record could also be reviewed and analysed to assist with an

audit.

Dirs 6.10.15

Discussed with HR and will be brought forward for

inclusion within the 2016 Staff Survey.

UPDATE: Staff Survey on the Board agenda for March

2016.

ACTION COMPLETED

24-Sep-15 15.2. Data QualityHS requested a presentation on how the Trust uses data

collected for the Council of Governors MM to liaise with FGMM/FG 28.01.2016

UPDATE: MM and FG to review content. FG to attend

COG on 7 July 2016.

Trust Public Board Meeting Action Point Register - 2015-16

At each Trust 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.

24-Sep-15 18.2. Audit Committee

HS advised that at the next Trust Board Seminar Meeting a

discussion will be held with regard to how the Committees fit

together and how the Trust will get the best out of each one. MM

to add to the Agenda for the October 2015 Trust Board Seminar

MM 29.10.15

UPDATE: Changes to the Committee Structure have

been agreed and new TOR are being developed by each

Committee. Audit Committee training being linked to this.

New TOR will be presented for approval at the Trust

Board in March 2016.

UPDATE: Terms of reference for Audit and Quality on

Board agenda for March 2016.

26-Nov-15 8.25 ACQIsAGS and JW to provide an update at the Trust Board of Directors

Meeting in March 2016.AGS / JW

31.03.15 Update to be provided in May 2016

26-Nov-15 9.8 BAF

The Risk Assurance Group needs to review why strategic goal 2

has risks and strategic goal 3 has none. JW and MM to take

forward.

MM / JW 31.03.2016

UPDATE: Risk Assurance Group to meet on 8 February

and review the mapping of the existing risks and the

developemnt of new ones in line with the strategic goals.

Update to the Trust Board in March 2016.

UPDATE: BAF shows risks mapped against strategic

goals

26-Nov-15 10.3Information

Governance

HS noted that in previous years the Trust Board of Directors has

undertaken IG Training. FG agreed that this was of benefit to the

members and to the Trust. Non-Executives to do online training

by end of quarter 4.

MM 28.03.2016 In progress

26-Nov-15 11Patient Safety and

Experience Report

With regard to the Friends and Family Test data KW asked if it

would be possible to get other ambulance services data. JW to

include this for next report.

JW 28.01.16

UPDATE: Benchmarking data that is available is minimal

with many Trusts doing it differently. Working with

commissioners to agree local change.

Update to the March 2016 Board.

28-Jan-16 5.2Report from the

Chief Executive

KW will email further pictures to the Board. It has been good to

receive feedback from the support and development provided by

the Trust.

KW 31.03.2016 ACTION COMPLETED

28-Jan-16 5.3Report from the

Chief Executive

EW to provide a report on the Staff Survey to the next Trust

Board of Directors Meeting in March 2016. EW 31.03.2016

UPDATE: Staff Survey on the Board agenda for March

2016.

ACTION COMPLETED

28-Jan-16 6.3.3Questions from the

public

HS stated that it would be most appropriate to address this

question at a Council of Governors Meeting. DN and CH to

report back to AR the recent media coverage of the Trust and

also the communications update from today. The Trust Board of

Directors agreed that this question would be presented to the

Non-Executive Directors at the next Council of Governors

Meeting. ACTION: Question to be taken by Non-Executive

Directors, MM to add to the Agenda for the Council of Governors

Meeting.

MM 31.03.2016

UPDATE: Added to the agenda for Council of

Governors meeting on 21 April 2016.

ACTION COMPLETED

28-Jan-16 10.8Integrated Corporate

Performance Report

NLC to provide a report on utilisation of CFRs for review at the

next Trust Board of Directors Meeting in March 2016.NLC 31.03.2016

UPDATE: Paper to be presented to the May 2016

Board

28-Jan-16 14.6

Council of

Governors Forward

View

DN to provide details of any incidents with regard to defibs or

response delays for the Trust Board of Directors to investigate. It

was noted that community defibs are not instead of they are as

well as and it would be helpful if the Governors could ensure this

message is fed back.

MM 31.03.2016 ACTION COMPLETED

28-Jan-16 19.3 Quality Approach

JW will present the full Quality Strategy to the next Trust Board of

Directors in March 2016. The full Quality Strategy would be

presented to the Quality Committee for approval. ACTION: JW

to take this forward.

JW 31.03.2016UPDATE: Quality Committee to receive in April 2016

and Board to reciev in May 2016.

28-Jan-16 20.2 Quality Committee

Directors Group to review Safeguarding, Medicines Management

and Infection Control. JS to discuss with KW and add to further

Directors Group Agendas.

JS 31.03.2016

28-Jan-16 20.3 Quality CommitteeMM to add the list of papers that were submitted to the Quality

Committee to the Assurance Report. MM 31.03.2016

UPDATE: Assurance report updated and included in future reports

ACTION COMPLETED

28-Jan-16 19.3Academic health

Science Network

JK to compile a list of subscriptions to organizations for

presentation to the Trust Board of Directors .JK 31.05.2016

UPDATE: Subscriptions information will be collated post year end

and presented to the Board in May 2016.

Trust Board of Directors Meeting

Page 1 of 1

Trust Board of Directors Meeting 31 March 2016

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 2016

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: 21 March 2016

SWASFT Integrated Corporate Performance Report

INTEGRATED CORPORATE PERFORMANCE REPORT Page 2 of 60

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;

• Performance ‘deep dives’ as appropriate.

Mapping to the 2015/16 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 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 approach to planning clinical led commissioning. 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

PAGE 3 of 60

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:

Performance In Line With Plan: 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. However where performance is below a national or contractual target this is taken into account when assigning this performance exception category;

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;

Escalated Performance Issue: 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

A&E (999) Activity levels (demand) in February 2016 was 4.93% above contracted volumes. Year to date activity levels are 1.75% above contracted volumes and 4.77% higher than the activity level seen for the same period in 2014/15;

There is variability in the activity increases across the Divisions with the North Division being 2.84% above contract for the year to date, compared to 0.03% above contract in West Division and 2.83% under contract in East Division;

Percentage of A&E calls abandoned and Time

to Answer Calls in February 2016 were above (worse than) the local thresholds;

The staff turnover rate remains high at 15.84% at the end of February 2016 (reducing to 14.20% excluding redundancies);

Staff Appraisal rates were below the internal KPI target of 85% but this is linked to the Red Measures to Improve Performance Plan;

Information Governance Toolkit is RAG rated as Amber against the plan to deliver level 2 rating for 2015/16.

Performance In Line With Plan

Re-contact rates following treatment at scene were lower (better than) the local performance threshold;

Percentage of A&E calls abandoned are lower (better than) the local threshold for the year to date;

Time to answer calls were below (better than) the local threshold measures for the 50

th, 95

th and 99

th

percentile metrics for the year to date;

Ambulance calls closed with telephone advice

and managed without transport to A&E

department are above (better than) 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 cardiac arrest, survival to discharge rates, are above local thresholds;

Urgent Care Service QR12: In the county of Dorset performance for Less Urgent Base Consultations and Less Urgent Home Visits were above (better than) the 95% performance target;



Performance In Line With Plan (continued)

Urgent Care Service QR12: In the county of Gloucestershire performance for Less Urgent Base Consultations were above (better than) the 95% performance target;

NHS 111 call abandonment rates were below (better than) the national KPI level of 5% in February 2016 in the counties of Dorset, Devon and Cornwall;

Tiverton UCC performance against the 4 hour

treatment time was above the 95% target;

The Trust continues to perform above (better than)

the local Right Care, Right Place, Right Time trajectories for improvements in non-conveyance rates to Emergency Departments;

Compliance with Infection Prevention and Control.

Escalated Performance Issue

1,829 of operational resource hours were lost to

chargeable handover delays at acute

hospitals in February 2016. This equates to an average of 63 hours lost per day across the Trust.

Improvement Expected

Red 1 performance in February 2016 was below (worse than) the national performance target of 75%;

Red 2 and Red 19 performance were below (worse than) national targets in February 2016 however this is in part related to the Ambulance Response Programme (ARP).

Green 1, Green 2, Green 3 and Green 4 call performance in February 2016 was below target;

The number of frontline operational vacancies has an impact on performance however the position in the East and West Divisions has improved following recruitment delivered in October 2015 (in line with the Trust A&E Operating Plan) with improvements in the

North Division during Quarter 4 of 2015/16; NHS 111

call answering performance is below (worse than) the 95% national KPI level in February 2016;

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

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

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

Acute STEMI patients receiving the appropriate care bundle was marginally below the local threshold;

Urgent Care Service QR12: An improvement is expected for both the Gloucestershire and Dorset OOH performance for those measures where performance is below the national target levels;

Two PTS KPIs in the BNSSG contact are below agreed levels for the period April 2015 to February 2016 but are showing improvement;

Sickness levels across the trust are improving in line with the A&E Operating Plan for 2015/16.



3. Summary of Benchmarked Position based on January 2016 Data

3.1. The following benchmarking data compares the performance of the Trust with other ambulance services in England. National benchmarking data is only available for January 2016 and not for February 2016.

National Benchmarking Against Other Ambulance Trusts 3.2. National average performance (all ambulance services) against all three Red performance

metrics in January 2016 was below the national targets:

Red 1: 69.90%

Red 2: 63.30%

A19: 91.10%

National Average Performance – Rolling 12 Months Performance

Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

Red 1 72.07% 73.41% 75.63% 76.72% 74.79% 74.53% 73.65% 72.90% 73.35% 71.92% 72.56% 69.90%

Red 2 67.55% 69.58% 72.37% 73.22% 71.37% 70.58% 69.73% 68.93% 68.81% 67.38% 67.15% 63.30%

A19 93.47% 94.12% 95.03% 95.31% 94.36% 93.78% 93.55% 93.17% 93.02% 92.58% 92.55% 91.10%

Impact of the Ambulance Response Review Programme (ARP) on SWASFT (including

the introduction of Dispatch on Disposition)

3.3. As part of the Ambulance Response Review (including the introduction of Dispatch on

Disposition) SWASFT has reported Red 1 performance above the national average performance throughout 2015/16.

3.4. In January 2016, SWASFT was below the national average performance for Red 2 (60.60% compared to the national average of 63.30%) and A19 performance (88.80% against the

national average of 91.10%). Note: Performance against both of these targets has been impacted by the introduction of Dispatch on Disposition in SWASFT. SWASFT was the first ambulance service in the UK to move to this way of dispatching resources and therefore this needs to be taken into account in comparing the performance of SWASFT with other UK ambulance services.

3.5. As part of the second phase of the ARP, dispatching resources on disposition was introduced into four more ambulance trusts in the UK with effect from October 2015. Also as part of this next stage of the ARP, SWASFT has made further changes to the dispatch processes in November and December 2015 in line with national guidance and agreement.

3.6. The impact on patient care and Trust performance as a result of these changes is reviewed

internally on a daily basis and reviewed nationally within the ARP Working Group on a weekly basis. The data provided by SWASFT will be used to help inform further national developments.

3.7. It has been agreed that the impact on Red 2 performance for SWASFT is a reduction in

performance of 5%. If this is added to the reported performance of 60.60% in January 2016 then SWASFTs adjusted performance that should be used to compare SWASFT nationally is 65.60%, 2.30% above the national average for Red 2 in January 2016.



3.8. The graphs below compare UK performance and include SWASFTs Red 2 adjusted performance. Based on this SWASFT is above average Red 1 and 2 UK performance.

January 2016 (1 Month) Benchmarking Against Other Ambulance Trusts



Year to Date Benchmarking Against Other Ambulance Trusts 3.9. For the period April 2015 to January 2016 SWASFT was above the national average for Red

1 and for Red 2 (adjusted position).



4. Monitor’s Risk Assessment Framework 4.1. Since 1 April 2013 all NHS Foundation Trusts have needed a license from Monitor, the

independent regulator, stipulating conditions they must meet to operate. This includes financial sustainability and governance requirements. Monitor’s Risk Assessment Framework (RAF) sets out the approach to assessing compliance with these conditions, including information on the two risk ratings that are allocated to a Trust on a quarterly basis to indicate any concerns:

The Governance Risk Rating – is explained further in the following paragraphs;

The Financial Sustainability Risk Rating – this is set out in more detail in section 12.

4.2. Monitor uses the Governance Risk Rating to describe their views of the governance of the Trust. Monitor generates this rating by considering a range of information and forms a view as to whether this is indicative of a potential breach of the Governance Condition. Further details on how the Rating is derived can be found within Appendix C.

Quarter 4 of 2015/16 Forecast Performance: Category A8 Red 1 and Red 2 4.3. One element of the Governance Risk Rating includes a service performance score. This is

assessed using a Trust’s performance against a set of national measures, which includes performance against the national ambulance response time targets. Additional indicators applicable to SWASFT are set out within Appendix C.

4.4. To support an ongoing review of the Trust’s Governance Rating the Integrated Corporate Performance Report includes a monthly assessment of Trust performance against these targets, based upon forecast quarter end performance figures.

4.5. The Trust has signaled a risk to delivering Red 1 performance for Quarter 4 of 2015/16. The Trust is currently forecasting Q4 Red 1 performance of 71%, which is 4% below national target levels of 75%. Delivery of Red 1 on a daily basis remains extremely challenging with a very small number of Red 1 incidents each day across the South West.

4.6. Red 2 performance has been impacted by the ARP. The Trust has been able to agree a

position with NHS Commissioners that recognises this impact for performance management purposes. The Trust delivered Red 2 performance of 65.67% in the East and West Divisions for Quarter 3 and 66.59% Red 2 performance in the North Division. Trust wide Red 2 performance for Quarter 3 was 66.07%.

4.7. Following the introduction of additional changes as part of ARP and revisions to the national

Ambulance Quality Indicators guidance documentation in January 2016 the Trust has seen a further reduction in Red 1 and Red 2 performance.

4.8. As at the end of February 2016 the Trust is forecasting Red 2 performance of 56.75% for Q4

and 85.96% for Red 19 performance.



5. Accident and Emergency (999) Performance

This section reviews the activity and the factors contributing to performance.

Accident and Emergency (999) Activity Levels 5.1. The Trust has a single A&E contract for 2015/16, based on a contract currency of ‘incidents’,

covering all operational areas of the Trust. The baseline contract for 2015/16 incorporates an

uplift of 3.29% compared to the actual incident numbers reported in 2014/15.

Month of February 2016

5.2. Incident volumes during the month of February 2016 in isolation were 4.93% above contract. Further information can be found in Section 10 of this report.

5.3. Trust activity and performance is monitored across 3 Divisions as follows:

West Division: Kernow CCG, NEW Devon CCG and South Devon & Torbay CCG;

East Division: Somerset CCG and Dorset CCG;

North Division: Bath & North East Somerset CCG, Bristol CCG, South Gloucestershire CCG, Wiltshire CCG, North Somerset CCG, Swindon CCG and Gloucestershire CCG.

Table 1: Comparison of Activity against the Contract in the Month of February 2016

Actual Activity

February 2016

Contract Activity

February 2016 % Variance

West Division A&E Incidents

24,834 23,693 +4.82%

East Division A&E Incidents

18,160 18,191 -0.17%

North Division A&E Incidents

30,053 28,105 +6.93%

Total

A&E Incidents 73,439 69,989 +4.93%

5.4. The table above compares actual activity levels to the contract and table 2 below compares actual activity levels to the same month last year (please note there were 28 days in February 2015 compared to 29 days in February 2016 therefore some increase in year on year activity levels would be expected in the region of 3% to 3.5% in relation to the additional day).

Table 2: Activity in the Month of February 2016 compared to February 2015

Actual Activity

February 2016

Actual Activity

February 2015 % Variance

West Division A&E Incidents

24,834 23,345 +6.38%

East Division A&E Incidents

18,160 17,571 +3.35%

North Division A&E Incidents

30,053 26,650 +12.77%

Total

A&E Incidents 73,439 68,382 +7.40%

5.5. When comparing the activity volumes year on year the source of the activity increase can be

identified. Whilst there has been growth in the number of incidents received from the public calling 999, this increase is in line with contracted volumes.

5.6. The most significant proportionate increase is in activity transferred to 999 from NHS 111.

This is 17.29% higher for the year to date 2015/16 compared to the equivalent period last year. Table 3 compares one year with another.



Table 3: Source of the Activity increase comparing this year to last

Source of Incident April 2014 to

February 2015 April 2015 to

February 2016 Variance

Public Incidents 549,466 564,503 +2.74%

NHS 111 Incidents 123,771 145,171 +17.29%

HCP Incidents 119,668 121,462 +1.50%

Total Incidents 792,905 831,135 +4.82%

5.7. The source of the increase varies by CCG however the year on year increase in NHS 111 activity transferred to the 999 service in the North Division for the period April 2015 to February 2016 is higher than the increase in the East and West Divisions.

1 April 2015 to 29 February 2016 (YTD) 5.8. Table 4 below compares activity volumes for the period 1 April 2015 to 29 February 2016 at a

CCG level and looks at the percentage movement in incident volumes for each source of incident.

Table 4: Source of Activity Increase by CCG (2015/16 YTD compared to 2014/15 YTD)

Public HCP 111 Total

BANES 2.88% 6.16% 27.29% 7.22%

BRISTOL 4.69% 0.88% 24.08% 7.46%

DORSET -2.34% 0.83% 12.37% 0.21%

GLOS 2.20% 2.08% 24.28% 5.88%

KERNOW 1.29% -12.03% 41.24% 3.28%

NEW DEVON 4.87% -0.20% 1.90% 3.60%

NORTH SOMERSET 4.64% 7.18% 27.20% 8.86%

SOMERSET 1.68% -1.40% 3.94% 1.52%

S DEVON & TORBAY 3.66% -3.39% 5.93% 2.86%

SOUTH GLOS 5.42% -5.03% 30.52% 8.95%

SWINDON 1.33% -2.29% 35.51% 4.57%

WILTSHIRE 2.31% -5.04% 24.37% 5.34%

TOTAL 2.74% 1.50% 17.29% 4.82%

Variance %

5.9. It should be noted that the growth in NHS 111 incident volumes in the West Division will have

been impacted by the staged launch of the NHS 111 service in Kernow CCG during 2014/15. Therefore comparable figures for the previous year are not available, but the comparison is provided in the table above for completeness.

Weekly Incident Volumes 5.10. In February 2016, as stated in the table above, incident volumes were 7.40% higher than

those reported in February 2015. Part of this increase when looking at monthly volumes can be attributed to the additional day in February 2016, however when looking at weekly incident volumes an increase of 3.7% compared to the same period last year has been seen.

5.11. Weekly incident numbers have increased steadily, increasing from an average of 16,765

incidents per week in January 2015 to 17,727 incidents per week in February 2016 (an extra 962 incidents per week or 137 incidents per day).



5.12. Of those incidents, the proportion of incidents classified as Red 1 or Red 2 responses requiring an 8 minute response at scene has increased at a greater rate. In February 2015 the Trust reported an average of 6,116 Red 1/Red 2 incidents per week compared to 6,975 incidents in February 2016, this represents a 14.05% increase in incidents requiring an 8 minute response at scene.

5.13. The rise from an average of 6,116 Red 1/Red2 responses per week (February 2015) to over

6,975 Red incidents in February 2016 represents an increase of 859 Red incidents per week or 123 additional Red incidents per day compared to last year. In the early weeks of March 2016 the Trust has seen further increases and reported 7,599 Red incidents for the week commencing 7 March 2016.

5.14. The shift in the acuity of incidents to these more serious incidents is spread across incidents originating from NHS 111 and the Public.

5.15. Red 1 and Red 2 responses are more resource intensive:

On average a higher number of resources per incident for Red responses;

Longer job cycles to manage higher acuity incidents;

A high proportion of Red incidents result in a conveyance of a patient to hospital.



5.16. As a result of the higher acuity incidents and the increased volume of incidents requiring an 8 minute response there have been additional pressures placed on Trust operational resources during since January 2016.

Handover Delays

5.17. There has been a further deterioration in handover delays in February 2016. The total time lost to chargeable handover delays in February 2016 increased to 1,829 hours or an average of 63 hours lost per day. (Note that chargeable delays are those delays recorded over 30 minutes. 15 minutes is however recognised as the ‘zero tolerance’ standard).

Table 5: Average Hours Lost per Day to Chargeable Handover Delays 2015/16

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Average Hours Lost per Day over 30 minutes

37 34 32 35 37 43 49 50 46 62 63

5.18. Total time lost to handover delays in excess of 15 minutes in February 2016 was 190 hours

greater than the time lost in February 2015 representing a 12% increase or an increase in the time lost by an average of 7 hours per day across the month.

5.19. The year on year increase in handover delays and particularly the recent further stepped

increase has impacted on performance and reduced the time ambulance resources have been available to respond to incidents across the South West.

5.20. The Trust continues to work extremely closely with its commissioner colleagues and

colleagues in the acute hospitals to help manage the flow of patients into hospital. Capacity challenges in a significant number of acute hospitals remain however and therefore the ability to manage increased activity levels is becoming increasingly difficult in some areas.

5.21. The Trust has local action plans with hospitals to reduce delays but the impact of these plans

is variable and the time lost to all handover delays over 15 minutes in length (chargeable and non-chargeable) is increasing and peaked at 145 hours of lost operational resource on a single day in February 2016.

CAD Upgrade – February 2016

5.22. As part of the A&E Operating Plan for 2015/16 the Trust has introduced a new, integrated Computer Aided Dispatch System across all three of the Clinical Hubs. The first stage of this integration project was the upgrade to the South systems (Exeter and St Leonard’s Hubs) during November 2015. The second stage to this programme involved the upgrade to the Hub systems in the North Division which was successfully completed on 24 February 2016.

5.23. The integrated system will provide uniform functionality across all three hubs and increased

visibility and control of operational resources across the South West. As the North Hub becomes more familiar with the new systems and the benefits from the integrated system will be realised, but in the short term there have been increased pressures within the Clinical Hub particularly in terms of call answering performance and dispatch.

Electronic Care System Roll Out

5.24. The Trust continues to roll out the Electronic Care System (ECS) across the Trust during 2015/16. This programme has been staged across the operational areas of the Trust with ten of the 17 having been completed by 29 February 2016.



Demand Management in 2015/16 5.25. The Trust engaged in a round of meetings during Quarter 1 of 2015/16 with each CCG to

review and agree response time’s performance trajectories and local Right Care actions. The Trust met with all 12 CCGs.

5.26. A Demand Management Plan was agreed with NHS Commissioners in July 2015 and focuses on:

The management of transfers from NHS 111 to 999;

Reviewing Care Home activity;

Frequent Callers as part of a trust wide CQUIN scheme;

Hospital specific reductions in hospital handover delays;

Actions to improve the contribution of Community Responders;

Identification of locations within the health community which may benefit from the introduction of a Public Access Defibrillator.

5.27. The Demand Management actions have been consolidated into a ‘Measures for Improvement (MIP) Performance Plan’.



6. Ambulance National Quality Measures

6.1. This section provides a 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: Red 1 Performance in February 2016 was 8.97% 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.

• This remains a challenging target due to the small number of Red 1 incidents across the South West.

• Red 1 performance for the month of February 2016 was 66.03%, 8.97% below the national target of 75%.

• The Trust recorded 1,572 Red 1 incidents in February 2016 (an average of 54 Red 1 incidents per day across the whole of the South West). Of these incidents 1,038 received a response within the 8 minute performance target.

• 78.75% of Red 1 incidents received a response within 10 minutes and 86.45% within 12 minutes.

Risk Assessment: The Trust delivered Red 1 performance above national target levels for Quarters 1, 2 and 3 of 2015/16, but performance in both January and February 2016 has been below target and a risk has been signalled for Q4.

Actual Performance

Variance to National

Target

Variance to Internal

Trajectory

Month: February 2016 Actual Performance

66.03% (8.97%) (9.97%)

Quarter Four 2015/16 Forecast Performance

71.06% (3.94%) (4.94%)

Year to Date 2015/16 Actual Performance

74.35% (0.65%) (1.65%)

Year End 2015/16 Forecast (1 April 2015 to 31 March 2016)

74.41% (0.59%) (1.59%)

6.1. In February 2016 the Trust responded to 66.03% of all Red 1 incidents within 8 minutes, 73.73% within 9 minutes, 78.75% within 10 minutes and 86.45% within 12 minutes. 94.15% 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 daily by Operational Managers to identify any learning or barriers to performance that can be addressed to improve future Red 1 performance.



Red 1 Performance by Clinical Commissioning Group (CCG) – February 2016

February 2016 Red 1 Performance Map

Accident and Emergency Service Line: Category A Performance: Red 2 Performance Exception Status: Performance in February 2016 was below the national performance target.


• The Trust has agreed a contract variation with Commissioners confirming that the Trust should deliver 70% performance for Red 2 in 2015/16 accounting for the impact of ARP

• Red 2 performance in February 2016 was 54.48%.

Risk Assessment: • The Trust implemented a ‘Measures to Improve Performance Plan’ (MIP) during Quarter 2 of 2015/16 which

impacts on all areas of Red performance including Red 2. This MIP has been reviewed and updated to reflect the actions required to deliver performance improvements through Quarter 3 and 4 of 2015/16.

The risk to performance delivery has been assessed by the Trust. Risks to delivery are identified as activity above planned levels, transfers from NHS 111 to 999 and deteriorating handover delays.

Clinical

Commissioning

Group

No. of

Incidents

Feb 16

Red 1 %

Feb 16

No. of

Incidents

2015/16

Red 1 %

2015/16

Kernow 154 63.64% 1,690 71.95%

South Devon & Torbay 93 72.04% 918 78.98%

NEW Devon 254 72.83% 2,650 80.60%

Somerset 140 67.14% 1,486 75.37%

Dorset 251 73.31% 2,569 83.18%

North Somerset 68 51.47% 663 67.72%

Bath & NE Somerset 48 72.92% 509 73.67%

Bristol 156 66.67% 1,723 73.88%

South Gloucestershire 75 58.67% 6,38 63.95%

Gloucestershire 156 55.13% 1,845 65.04%

Wiltshire 103 57.28% 1,165 62.15%

Swindon 69 63.77% 729 79.01%

TRUST 1,572 66.03% 16,603 74.35%



Actual Performance


Target

Variance to 70%

Adjusted Target


54.48% (20.52%) (15.52%)


56.75% (18.25%) (13.25%)


65.10% (9.90%) (4.90%)


64.26% (10.74%) (5.74%)

Red 2 Performance by Clinical Commissioning Group (CCG) – February 2016 February 2016 Red 2 Performance Map

Clinical

Commissioning

Group

No. of

Incidents

Feb 16

Red 2 %

Feb 16

No. of

Incidents

YTD

Red 2 %

YTD

Kernow 2,827 44.61% 29,617 59.03%

South Devon & Torbay 1,685 60.83% 16,310 69.39%

NEW Devon 4,382 60.04% 44,496 69.71%

Somerset 2,361 49.05% 24,925 62.53%

Dorset 4,151 52.98% 42,137 67.57%

North Somerset 1,103 48.41% 11,658 61.80%

Bath & NE Somerset 812 57.39% 8,648 66.36%

Bristol 2,709 60.83% 27,978 67.98%

South Gloucestershire 1,161 44.62% 12,461 57.03%

Gloucestershire 2,862 56.29% 30,588 64.11%

Wiltshire 2,095 49.59% 22,379 56.97%

Swindon 1,092 69.14% 11,487 76.44%

TRUST 27,325 54.48% 283,220 65.10%



Accident and Emergency Service Line: Category A Performance: Red 19 (95%) Performance Exception Status: Performance in February 2016 was below the national performance target.


• The Trust delivered Red 19 performance of 83.89% in February 2016.

Risk Assessment: • The Trust implemented a ‘Measures to Improve Performance Plan’ (MIP) during Quarter 2 of 2015/16 which

impacts on all areas of Red performance including Red 2. This MIP has been reviewed and updated to reflect the actions required to deliver performance improvements through Quarter 3 and 4 of 2015/16.

The risk to performance delivery has been assessed by the Trust. Risks to delivery are identified as activity above planned levels, transfers from NHS 111 to 999 and deteriorating handover delays.

Actual Performance


Target

Variance to Internal

Trajectory


83.89% (11.11%) (11.22%)


85.96% (10.96%) (9.15%)


90.37% (4.63%) (4.70%)


89.92% (5.08%) (5.15%)

Red 19 Performance by Clinical Commissioning Group (CCG) – February 2016

February 2016 Red 19 Performance Map

Clinical

Commissioning

Group

No. of

Incidents

Feb 16

Red 19 %

Feb 16

No. of

Incidents

YTD

Red 19 %

YTD

Kernow 2,970 73.37% 31,175 83.54%

South Devon & Torbay 1,775 90.37% 17,216 93.90%

NEW Devon 4,613 86.08% 46,878 91.16%

Somerset 2,496 78.17% 26,322 87.35%

Dorset 4,397 85.04% 44,288 92.60%

North Somerset 1,170 81.28% 12,307 88.87%

Bath & NE Somerset 860 86.40% 9,152 90.83%

Bristol 2,859 89.19% 29,428 95.30%

South Gloucestershire 1,233 83.86% 13,093 92.72%

Gloucestershire 3,018 85.35% 32,432 89.63%

Wiltshire 2,195 80.23% 23,529 85.77%

Swindon 1,161 91.82% 12,216 96.14%

TRUST 28,835 83.89% 298,583 90.37%



Exception Report: Red Performance in February 2016 6.2. The Trust developed a ‘Measures to Improve Performance’ (MIP) plan which was introduced

during Quarter 2 of 2015/16. The MIP was reviewed in October 2015 and refreshed to reflect the actions required to deliver performance improvements through Quarter 3 of 2015/16.

6.3. The MIP focuses actions on the following areas:

Abstraction Management including the management of sickness;

Rota’s and Relief;

Staff Training;

Clinical Hub;

Demand Management;

Call Cycles;

Procedures and Processes;

Communications (internal and external);

Other Identified Actions.

6.4. The actions identified above are in addition to those already identified within the A&E Operating Plan for 2015/16. The A&E Operating Plan provides a detailed list of Service Developments and associated actions to be completed during the year.

6.5. An additional set of actions have been agreed for Quarter 4 and focus on:

Clinical Hub – Improving call handling capacity and call answering performance; Clinical Hub – Improving the Clinical Support available in the Hub; A range of actions focusing on increasing frontline operational resources; A focus on Call Cycle length; Completion of CAD implementation and the staff familiarisation programme.

6.6. The key actions from the updated MIP are summarised in the table below:

Planned Mitigating Action being

taken by the Trust Timescales for Action

Performance Improvement / Impact

Expected

Abstraction Management: Increased Operational focus on all Abstractions

• A renewed focus on Sickness Management.

• Implementation of Trust agreed Time Off in Lieu (TOIL) policy

• Identify all ‘other’ abstractions that can be reduced / removed.

• Increased managerial rigour for unauthorised absences.

• Review of current annualised hours contracts.

• Focus on improving staff retention.

• Daily resourcing information provided through the Trust Resourcing team.

• Weekly Resource Management Meetings held across the Trust.

• Bi-monthly ‘deep dives’ on operational sickness absences by Heads of Operations and the HR Department representatives.

• Increase available resource hours on the road to respond to incidents.

• Improved retention levels leading to a more stable workforce. Reduces abstractions for new starters.

• Trust sickness has reduced. For the period April 2015 to February 2016 the Trust sickness rate of 5.29% compared to 6.28% for the equivalent period last year.

• Most significant reductions in long term sickness, with focus moving to short term sickness during Q3 and Q4.

Clinical Hub: Introduction of a New, Single, Common CAD Across the Trust Area

• Introduction of a single common Computer Aided Dispatch (CAD) system across the Trust.

• Delivery of a new, enhanced, Trust-wide CAD system to improve resource visibility and deployment across the South West area.

• Upgrade to the South Clinical Hub November 2015.

• Period of checks and resilience tests completed December. .

• Implementation in the North 24 February 2016.

• Post implementation period of familiarisation and additional staff support to improve the efficiency of call handling and resource dispatching.

• Uniform and enhanced CAD functionality within the Clinical Hubs will enable to Trust to support the delivery of operational resources across the Divisional boundaries within the SWASFT geographical area.

• It is expected that the benefits of a Trust-wide uniform system will start to impact in Q4 of 2015/16.






Expected

Clinical Hub: Increase Call Handling Resource

• Improve Call Answering performance across both Clinical Hubs.

• Introduce additional call advisors.

• Release NHS Pathways trained staff from other roles.

• Overtime shifts to be reviewed to deliver increased support at key operational times across the week.

• Review of NHS Pathways trained staff in March 2016.

• Improving call answering performance delivers reduced call cycles for the most serious incidents.

Clinical Hub: Increase Clinical Support

• Target both Clinical Hubs.

• Introduce additional clinical resources.

• Identify GPs who could support.

• Consider additional administrative support for GPs

• Increase Clinical floorwalkers in NHS 111 SWASFT services.

• Overtime shifts to be reviewed to deliver increased support at key operational times.

• Additional GP shifts to be offered during March 2016.

• Improve the clinical management of all incidents.

• Increase number of incidents that can be resolved through clinical advice or referral.

• Reduce the level of inappropriate 999 responses.

Call Cycles – Performance Management

• Time at acute hospital between the handover of the patient and a crew becoming clear.

• Individual performance data to be reviewed, including:

• Red Mobilisation Times;

• Average Times at Scene;

• Average Handover to Clear Times at Acute Hospitals.

• Operational Officers to identify barriers to crews becoming clear.

• Monthly management information and benchmarking data produced for Operational Officers.

• Individual performance review meetings to be held with staff based on the management information provided.

• Identify outliers in call cycle times.

• Remove barriers to turning around crews at acute hospitals.

• Expecting to see improvements in the average call cycle for conveyed incidents by reducing time lost at acute hospitals when a handover of a patient occurs.

Increasing Operational Resources

• Increase the number of operational resources available.

• Introduce additional resources through overtime payments and continuation of current third party resources / privates.

• Review of current operational secondments

• Introduction of additional overtime shifts and third party resources in March 2016.

• Provide additional red response capacity in key areas of high demand across the Trust.

Demand Mitigation: Joint action with 12 CCGs to manage demand to contracted levels

• Review local Care, Residential and nursing homes with high levels of ambulance activity.

• Improve engagement to support Community Responders.

• Identification of locations that would benefit from the location of a Public Access Defibrillator.

• Identification of any activity undertaken by SWASFT which would more appropriately be directed elsewhere (e.g. local falls support services, Community Nurses).

• Demand Management Plans to be delivered during 2015/16 according to the timescales set.

•

• Demand (activity) management.

Improvement Trajectories agreed for reducing Handover delays, Care Homes

Overall aim of the demand management schemes is to offset growth






Expected

Demand Mitigation: Working with NHS 111

• Reducing the number of inappropriate calls transferred.

• Identification of activity undertaken by SWASFT which would more appropriately be directed elsewhere (e.g. local falls support services, Community Nurses).

• Regular liaison between the ambulance service and NHS 111 service

• Ongoing

• Working with NHS 111 Providers to review the volume of calls and particularly the appropriateness of red calls being transferred to the ambulance service.

• SWASFT 999 clinicians in the NHS 111 control rooms

Demand Mitigation: Handover Delay Action Plans

• Implementation of actions plans at acute hospitals to reduce the amount of operational resource time lost to extended handover delays of patients..

• Draft plan templates developed and approved in November.

• Action plans to be implemented during Quarter 4 of 2015/16.

• Reduction in operational time lost.

• Clarity of the local barriers and actions being taken

• Clear escalation plans

• The improvement expected is delivery of the trajectories agreed with commissioners

Other Identified Actions: Review of the current Operational Model for Delivery

• The review will focus on the location and profile of current resources to deliver the best match to current demand.

• To complete this review the Trust has commissioned Occupational Research in Health (ORH) to review all available information to produce:

• An independent review of the current position;

• Support in reviewing potential options for operational models of delivery for 2016/17 and beyond.

• Scope and specification for this completed in August 2015.

• Interim meetings to discuss outputs and further areas for review October and November

• A staged approach to the review has been agreed - report outlining the key findings of initial review January 2016.

• Following stage one of this review the Trust, working with the consultants, has identified a number of key areas for focus and modelling in stage two of the review which will be completed in Q4 of 2015/16.

• The review is designed to identify short and long term changes that can be made to deliver improvements in performance.

• Stage two focuses on operational rotas, profile of resources by hour/day and mix of resource types by area to ensure they remain fit for purpose..

• Identify any further potential benefits to be obtained from the Dispatch on Disposition process by changes to the current operational model across the Trust.

Other Identified Actions: Introduction of Additional Red Response Resources – North Division

• Introduction of additional operational resources to respond exclusively to Red 1 and Red 2 incidents in the North Division.

• 5 additional 24/7 response resources introduced during January 2016 continuing Q4.

• Continuation of additional third party resources confirmed through to end of April 2016.

• Additional Red response capacity in key areas of high demand across the North Division.

• Increase in REAP level to RED with effect from 16 March 2016.

• Increase in REAP level has a number of implications including:

• Cancelation of all non-performance related meetings

• Cancelation of all LDR training.

• Introduction of daily conference calls to discuss operational pressures.

• Increase in Operational Officer deployment where possible.

• Increase in REAP level confirmed and communicated across the Trust on 16 March 2016.

• Increased Trust wide focus as per the REAP plan, reducing the level of abstractions for non-operational duties.



Urgent Care Service Line

QR12: Urgent and Less Urgent Base (Treatment Centres) and Home Visits Performance Exception Status: The Trust is expecting both standards to be met and move to full compliance for both Out of Hours contracts in Dorset and Gloucestershire.

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

Treatment Centres

• Urgent Consultations were partially compliant against the NQR in the county of Dorset (91.79%) and partially compliant in Gloucestershire (92.83%) for February 2016

• For Less Urgent Consultations the Trust was fully compliant in both counties in February 2016 - in Dorset (96.88%) and Gloucestershire (98.99%).

Home Visits

• Trust performance for Urgent Consultations started within 2 hours was partially compliant in Dorset (92.05%, 278 of 302 consultations) and non-compliant in Gloucestershire (82.80%, 207 of 250 consultations).

• Trust performance for Less Urgent Consultations started within 6 hours was fully compliant in Dorset (97.96%) and non-compliant in Gloucestershire (88.95%).

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

individual basis to commissioners at the contract meetings.

February 2016 Performance Actual Performance Variance to National Quality

Requirement

Dorset Gloucestershire Dorset Gloucestershire

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

91.79% 92.83% (3.21%) (2.17%)

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

96.88% 98.99% 1.88% 3.99%

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

92.05% 82.80% (2.95%) (12.20%)

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

97.96% 88.95% 2.96% (6.05%)

Urgent Base Consultations started within 2 Hours

Year to Date Performance (95%) 90.61% 93.85% (4.39%) (1.15%)

Less Urgent Base Consultations started within 6 Hours

Year to Date Performance (95%) 97.47% 98.42% 2.47% 3.42%

Urgent Home Visit Consultations started within 2 Hours

Year to Date Performance (95%) 93.31% 87.03% (1.69%) (7.97%)

Less Urgent Home Visit Consultations started within 6 Hours

Year to Date Performance (95%) 96.39% 91.52% 1.39% (3.48%)



Urgent Consultations at Base Sites (Treatment Centres)

Urgent Home Visits




taken by the Trust

Timescales for

Action

Performance Improvement /

Impact Expected

Gloucestershire Out of Hours Service

The Trust has reviewed the level of activity

being classified as Urgent

Additional triage capacity is now provided at peak times via GPs working remotely

Continued discussions with both NHS Commissioners and the NHS 111 Provider in the North Division to ensure NHS 111 referrals to the Out of Hours service are appropriate

Ongoing engagement regarding patient flow to the Treatment Centres from the Emergency Department at Gloucestershire Royal Hospital.

Remote triage (at weekends) went live in September 2015.

Further review of the Emergency Department patient flow completed in January 2016 with a follow-up meeting in February 2016.

The Trust is developing an updated Standard Operating Procedure (SOP) to be discussed at a meeting at the end of March 2016.

The addition of remote triage will add capacity at peak times and thus improve overall responses to patients.

Improved flow of patients from the Emergency Department will ensure that appropriate patients are directed appropriately

There has been a recognition of a need for

localised audit and quality support

Training of clinicians to undertake audit in the Hub has been completed.

Recruitment to a lead nurse role is to be undertaken to support the audit of nursing staff.

Continued development of the GP audit tool.

Recruitment completed and appointment made in January 2016 – start date to be confirmed.

Review of the GP audit process completed in February 2016.

Increased audit, feedback and support capacity in Gloucester will drive improvements in the quality of call management

Progress has been made on the development of an IT based tool for audit to support GPs – work being led by the Associate Medical Director.

Review of activity profiles and associated

resource profiles in Gloucestershire

A full review of activity and resourcing will be completed which will ensure that staffing in all areas is mapped to meet the activity requirements whilst also being deliverable within the financial envelope of the contract

From this work restructure rotas and resourcing plans accordingly – this work is to be planned across early 2016 to deal with different staff groups and appreciating contractual notice periods for rota changes.

Review completed in October 2015

Implementation of new rotas/plans commenced in November 2015 with the initial focus on Hub staff.

Financial review completed in March 2016 and options have been presented to Commissioners on 17 March 2016. An implementation plan and associated timescales are currently under development.

Deliver the optimum resource profiles to match the demand for both Home Visits and Treatment Centre appointments in Gloucestershire




taken by the Trust

Timescales for

Action

Performance Improvement /

Impact Expected

Dorset and Gloucestershire Out of Hours Services

Retrospective Review of Incidents where

Performance Targets are Missed

Retrospective review of incidents where a performance target is missed for both Home visits and Treatment Centre appointments.

Daily review of the reasons for missed performance target will identify any recurrent challenges in the service to inform future development plans, process or resource profile changes.

Daily reports detailing all incidents where performance targets are missed are now provided with reviews undertaken by Hub Supervisor or the Operational Management team.

Identification of the reasons for the service missing performance targets will assist in the development of bespoke performance improvement actions for the service in Gloucestershire and Dorset

Urgent Care Service Integration Activities in Dorset

Improved integration between Urgent Care

Service Line services

Full project plan to implement the required changes to facilitate the integration within Urgent Care Services in the Dorset Hub is under development.

The plan is to meet the specification (and aspirations in line with the integrated Hub guidance) to the end of 2016/17.

The plan will cover all dependencies including IM&T, establishment across all roles, reporting, finance, training, etc.

Project plan to be completed by the end of January 2016 for activities in 2016/17.

Additional planning underway to further develop the Hub across 2017/18.

Initial project plan was presented to Dorset CCG on 18 March 2016. Further work has commenced to fully understand and scope the dependencies for this project.

Progress towards integration – delivering improved performance, quality and financial efficiency.

Longer term plan to take the Hub to a position as described in the future planning for urgent care from NHS England.

Improved reporting across the integrated hub –

linking service lines, KPIs and reporting

requirements

Performance from both a governance/quality and KPI aspect is reported on for each service-line.

Discussions have already commenced with commissioners to develop combined reports which have a greater usefulness and which may be able to influence the wider discussions regarding the changes in urgent care commissioning.

Discussions commenced in October 2015.

Draft reports to be scoped during Q3 & Q4 of 2015/16 for possible shadow implementation from April 2016 with the support of Dorset CCG.

Improved reporting may result in stringer links between service-lines and from this clarification about the impact of change



NHS 111 Service: 60 Second Call Answering and Call Abandonment Rates Performance Exception Status: Until end January 2016 performance was improving in line with agreed trajectory. Since this time performance has been below expectations.

Reason(s) for the performance exception category assigned in the reporting period: • The trust did not deliver the national call answering target in February 2016 but did deliver the national target for

call abandonment across all three contracts (Devon, Cornwall and Dorset).

• Local call answering performance improvement trajectories have been agreed with Commissioners and performance is monitored on a weekly basis.

• For the week commencing 29 February 2016 the Trust answered 85.90% of calls within 60 seconds in the county of Dorset (12.47% below the trajectory for the week) and answered 65.66% of calls across Devon and Cornwall within 60 seconds (29.12% below the trajectory for the week).

• The reduction in performance is linked to high levels of turnover in part time call advisors.

Risk Assessment: • The expectation is that the Trust will meet its performance trajectories however a number of risks have been

signalled to commissioners.

February 2016 Performance

Actual

Performance


Target

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

Dorset 89.71% (5.29%)

Devon 79.49% (15.51%)

Cornwall 79.70% (15.30%)

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

Dorset 1.95% (3.05%)

Devon 3.21% (1.79%)

Cornwall 2.90% (2.10%)

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

Dorset 84.90% (10.10%)

Devon 70.08% (24.92%)

Cornwall 70.34% (24.66%)

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

Dorset 3.58% (1.42%)

Devon 8.55% 3.55%

Cornwall 8.77% 3.77%



Planned Mitigating Action being taken

by the Trust Timescales for Action


Expected

Demand Management & Resource Planning

Continued review of activity and resourcing will be undertaken to ensure optimal delivery – currently focus is on clinical cover.

Introduction of clinical floor walkers at weekends.

Review of NHS 111 calls passed to the 999 service.

Review of staffing and impact of increased staff turnover and sickness abstractions in the NHS 111 Hub seen in recent months.

Review of clinical cover to be completed by end October 2015. A subsequent internal review is now being undertaken.

Considerations for rota/shift changes taking into consideration contractual requirements to be developed during Quarter 4 of 2015/16.

Improved mapping of clinical cover against demand/need – this will enhanced performance against the clinical KPIs and improve patient experience.

Recruitment: Recruitment of additional Call Advisors and Clinical Supervisors and revise shift patterns

Based on the revised rota patterns and discussions with NHS Commissioners the Trust has developed a Recruitment Plan for NHS 111 Call Advisors and Clinicians

Renewed focus on clinical KPIs once Clinician numbers improve.

On-going recruitment to fill vacancies. The majority of current vacancies relate to part-time evening and weekend positions

Additional recruitment plans have been developed, with additional recruitment and training plans from April 2016 in both Hubs.

To deliver improved call answering and provide greater resilience to meet shortfalls in resourcing at short notice.

Increase in current establishment of call advisors and clinicians to provide additional resilience to the NHS 111 service, particularly during the weekend peak periods of demand.

Operational Management

Increased call auditing and coaching – a plan with identified actions has been drawn up to increase the number and quality of audits undertaken

An enhanced focus on managing individual performance

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

Coaching and audit courses delivered during Quarter 3 of 2015/16.

Identify coaching opportunities to support staff and improve morale.

Deliver performance improvements including improved call answering performance.



Urgent Care Service Line

Tiverton Urgent Care Centre 4 Hour Waiting Time Target Performance Exception Status: The Trust achieved 99.92% in February 2016. 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 2016, 1,187 of the 1,188 patients attending the Unit were seen within the 4 hour target giving performance of 99.92% against the 95% performance target.

• This has been delivered consistently along with a local standard to triage patients within 15 minutes.

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.



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 2015/16 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 2015/16. These

performance thresholds are designed to monitor performance and highlight at an early stage any deterioration in performance and are reviewed annually with NHS Commissioners.

7.4. The Trust continues to participate in national working groups to help develop revised guidance for both the Clinical and System Indicators to

try and deliver improvements in data quality and reporting consistency for all ambulance trusts in England. Revised national guidance documentation for all Ambulance Quality Indicators was released by NHS England in December 2015 and was introduced with effect from 5 January 2016. The Trust has implemented the revised guidance and this will be reflected in performance metrics from January 2016.

Table 3: AQI System Indicators

AQI Trust Performance Performance vs Local Thresholds

(where appropriate) Benchmark Exception Reporting

Calls abandoned

Call Abandonment Rate February 2016

2.25% Year to Date

0.85% Local Threshold

1.50%

National Average January

2016 0.60%

In the reporting period the percentage of calls abandoned was higher (worse) than local threshold, but remains above (better than) the local threshold for the year to date.





Time Taken to Answer calls

April 2015 to February 2016

50th

3 secs 95

th 17 secs

99th

58 secs Local Thresholds

50th

3 secs 95

th 19 secs

99th

60 secs

No national average figures

available for this metric

In the reporting period the call answering times at all percentile measures were below (better) than the local thresholds.

Time from call categorisation to arrival at scene

April 2015 to February 2016 50

th 7.4 mins

95th

24.8 mins 99

th 41.4 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.

Actions being undertaken within the A&E Operating Plan for 2015/16 to improve performance against this metric are included within the Red Performance Plan detailed earlier in this report.

Re contact with the Ambulance Service following telephone advice

February 2016 11.55%

Year to Date 12.91%

Local Threshold 11.00%


2016 6.30%

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

A regular clinical review of the re-contacts is undertaken to identify any other trends or areas to be addressed.

Nationally reported figures for ambulance trusts show considerable variance, between 1.70% and 14.70% in January 2016.

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.





Re contact with the Ambulance Service following treatment at scene

February 2016 4.99%

Year to Date 5.56%



2016 5.50%

In February 2016 re-contact rates following treatment at scene were lower (better than) than the local threshold, however remains above the threshold for the year to date.

A regular clinical review of the re-contacts is undertaken to identify any other trends or areas to be addressed.

There are considerable variances in the figures reported nationally by ambulance trusts against this metric. In January 2016 re-contact rates varied between 1.40% and 8.90%.

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

Patients Managed Appropriately– Calls Closed with Telephone Advice


Year to Date 12.03%



2016 10.20%

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)


Year to Date 52.65%



2015 38.10%

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

For 2015/16 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 is also included within the Right Care section of this report.



Table 4: 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

November 2014 to October 2015


24.00%

National Average

April 2015 to October

2015 27.76%

In the reporting period the Trust was above the local threshold.

The Trust has appointed a Quality Improvement Paramedic to focus on cardiac arrest ROSC and survival.

Cardiac arrest has been chosen as one of the indicators for the 2016/17 Quality Account.

Return of spontaneous circulation following cardiac arrest (Utstein)

November 2014 to

October 2015 48.64%


National Average

April 2015 to October 51.73%

In the reporting period the Trust was above the local threshold.

The Trust has appointed a Quality Improvement Paramedic to focus on cardiac arrest ROSC and survival.

Cardiac arrest has been chosen as one of the indicators for the 2016/17 Quality Account.




reporting period


(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Outcome from acute STEMI - (PPCI)



84.00%

National Average


2015 86.76%

The Clinical Development Officers continue to 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 review of the factors that increase breaches against the 150 minute time target has been undertaken and presented to the Clinical Effectiveness Group.

The roll out of the electronic patient record will assist in performance against this metric as it will increase the access to telemetry to a wider area of the Trust, facilitating direct STEMI confirmation with CCUs.

The ability to convey a patient to a PPCI centre within 150 mins of the call is largely dependent on operational performance with regard to the initial response time and time awaiting DCA back-up, where required.

Outcome from Acute STEMI – Care Bundle

November 2014 to

October 2015 85.25%


National Average


2015 78.31%

The local performance threshold for 2015/16 has been increased from 85.00% to 90.00%.

The Trust continues to report performance significantly higher than the national average, but for the period November 2014 to October 2015 the Trust was below the Local Threshold of 90.00% at 85.25%.

The Trust is targeting pain assessment and management as an area of improved performance within the current care bundle. This will be addressed through a Quality Improvement programme engaging frontline clinicians led by the Trust Quality Improvement Paramedics.

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



57.00%

National Average


2015 58.98%

Performance against this metric is challenging due to the very rural nature of the geographical area covered by SWASFT with longer distances to Hyperacute Centres.

At present performance for the rolling 12-month period the Trust is 8.32% below 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.

The ability convey a patient to a stroke centre within 60 minutes of the call is largely dependent on operational performance with regard to the initial response time and time awaiting DCA back-up, where required.




reporting period


(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Outcome from Stroke for Ambulance Patients – Care Bundle



97.00%

National Average


2015 97.71%

In the reporting period: performance is higher (better) than local threshold

Outcome from Cardiac Arrest – Survival to Discharge



9.00%

National Average


2015 9.05%


Outcome from Cardiac Arrest – Survival to Discharge (Utstein)



27.00%

National Average


2015 29.17%




8. NHS Commissioner Local Standards and Thresholds

8.1. This section includes those local standards and thresholds agreed with local NHS Commissioners as part of the 2015/16 contract negotiations. The definitions are set out in Appendix C.

Table 5: NHS Commissioner Standards and Targets for 2015/16

Measure Local

Target

February

2016

Quarter 4

Forecast

Green 1 Calls 90% 76.37% 76.25%

Green 2 Calls 90% 62.65% 65.00%

Green 3 Calls 90% 82.34% 85.00%

Green 4 (999) Calls 90% 62.91% 63.50%

Green 4 (HPC) Calls 70% 54.00% 57.50%

Compliance with Infection Prevention and Control Standards at Ambulance Stations 75% 76.00%

Compliance with Infection Prevention and Control Standards for Double Crew Ambulances 75% 80.00%

Vehicle Deep Cleaning Compliance with Schedule 90% 93.30%

Green Incident Performance Performance Exception Status: Performance against the locally agreed targets for Green 1, Green 2, Green 3 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 local performance targets in February 2016.

• Following the introduction of ARP the Trust is reviewing all areas of resource dispatch and response times. This change of process will focus on delivering the most appropriate response to meet the clinical need of the patient for all incidents within the Trust (including Green incidents).

• In parallel the Trust is undertaking a pilot for NEW Devon CCG on behalf of all commissioners to review Green 4 calls. The pilot commenced on 18 January 2016.

• By reducing the number of inappropriate deployments of operational resources the Trust is looking to increase the availability of resources to respond to all incidents, including Green incidents which will improve the response times to these less critical incidents.

• This is also a targeted piece of work that the Trust is undertaking with assistance from ORH in Q4 of 2015/16.

Handover Delays at Acute Hospitals Performance Exception Status: The number of handover delays at acute hospitals and time lost has increased since last month.

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 are subject

to locally agreed handover escalation procedures.

• There were a total of 1,999 handover delays in excess of 30 minutes in February 2016, of which 270 were

over 60 minutes in length.

• In terms of the impact on operational resources, there were nine hospitals where the Trust lost in excess of 100 operational resource hours to chargeable handover delays in February 2016 – Royal Cornwall Hospital (216 hours), Torbay Hospital (201 hours), Southmead Hospital (187 hours), Musgrove Park Hospital (161 hours), Poole Hospital (156 hours), Derriford Hospital (149 hours), Bristol Royal Infirmary (135 hours) and Royal Bournemouth Hospital (123 hours).

• The Trust continues to work closely with NHS Commissioners in targeting hospitals with consistently long delays particularly during periods of high activity levels. Four hospitals have been prioritised based upon consistently high delays; these are Royal Bournemouth Hospital, Poole Hospital, Derriford Hospital and Royal



Cornwall Hospital. The Demand Management Plan targets a 25% improvement in delays at these four hospitals and a 10% improvement in all other hospitals. This is not being achieved.

February 2016 Year to Date

Operational Time Lost to Chargeable Handover Delays in Excess of 15 Minutes

1,829 Hours 14,853 Hours

Number of Chargeable Handover Delays between 30 and 60 Minutes

1,729 Incidents 12,323 incidents

Number of Chargeable Handover Delays in Excess of 60 Minutes

270 incidents 1,664 incidents



9. Patient Transport Contract 2015/16 Key Performance Indicators

Table 6: PTS Service Line: Bristol, North Somerset and South Gloucestershire KPIs 2015/16

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%)

92.12%

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%)

95.77%

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%)

100.00% 9f Telephone answering (Green >95%, Amber 85-95%, Red <85%)

96.01%

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

89.31%

(-0.69%)

(89.03% in February 2016)

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%)

90.66%

(-6.34%)

(90.78% in February 2016)

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%)

90.54%

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%)

95.88%

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.

100.00%

9.1. Further analysis of those metrics that are currently below KPI levels for the year to date (metrics 2a and 2b) is being undertaken with a view to identifying internal actions that are required to deliver sustained improvements against both of the performance metrics.



10. Right Care, Right Place, Right Time 2

10.1. The Right Care2 proposal ‘A Healthy System Productivity Offering in the Form of Right Care2’ was produced by South Western Ambulance Service NHS Foundation Trust (SWASFT) ahead of the 2014/15 contracting round.

10.2. SWASFT is the only English ambulance service offering commissioners a bespoke

programme which actively focuses on supporting patients to be treated at home, or to receive assessment and / or treatment at a location other than an Emergency Department (ED).

10.3. Right Care 2 is progressing in line with the plan and quarterly milestones have been defined

for 2015/16. Feedback from operational staff is increasing, with over 4,000 individual incidents fed back to the Right Care team. The team is able to identify key issues within the feedback from staff, identifying clear areas of focus for SWASFT working in partnership with the local health system to address. The identified actions and progress are monitored within the Right Care local monthly assurance meetings and reports are provided throughout the year.

10.4. The Trust continues to host ‘Right Care Champions’ events which include representatives

from commissioning and Health Care Professionals. The events focus on agreeing solutions that can be implemented trust wide and at a local level with all actions recorded and tracked post event.

10.5. Performance against the 2015/16 target of 55.05% is monitored each month and as at the

end of February 2016 the Trust reported a non-conveyance percentage of 57.09% which was 2.04% ahead of (better than) the target.



10.6. The trust wide Right Care 2 proposal for 2016 /17 has been aligned to the High Impact

Actions. Locally agreed initiatives with each CCG for 2016/17 are also being developed. Meetings with each CCG have taken place during February and early March 2016 to review local Right Care actions and agree priorities for local 2016/17 schemes.

10.7. The delivery of Right Care will be supported by the rollout of the new Electronic Patient

Clinical Record across the Trust which continues in 2016/17. This new system will support staff to access 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.



11. Internal Trust Headline Performance Indicators for 2015/16

11.1. The performance metrics set out in the table below are included in the ICPR as the internal Trust headline measures for 2015/16.

Metric Internal

Target

February

2016

Quarter 4

Forecast

Staff Appraisal Completion 85% 49.44%

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

Compliant Green Green

Information Governance Toolkit Level 2 Amber Amber

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 was 49.44% as at the end of February 2016. The under performance against the 85% KPI level is predominantly due to operational pressures seen as a result of the Trust operating at REAP level 4 (now replaced by REAP level Amber) for extended periods throughout 2014/15 and 2015/16.

Information Governance Toolkit Performance Exception Status: Information Governance Toolkit has been RAG rated as Amber at the end of February 2016.

Reason(s) for the performance exception category assigned in the reporting period: • Audit South West completes an annual audit of The Trust’s IG Toolkit prior to the year-end submission. The

Terms of Reference for this audit were agreed with the Director of IM&T in September 2015. The initial audit took place in mid-October 2015 with 12 of the 35 requirements being reviewed and a follow-up audit planned for early in 2016.

• Of the policies identified in the initial audit as being beyond the required review date, only one policy remains to be updated.

• The initial report identified that the primary area for attention is in relation to Information Governance.

• For the Information Governance Toolkit requirement, which references Information Governance Training a combination of online training compliance being below the 95% target and timescale for introduction of a replacement e-learning solution will make achievement of Level 2 challenging for this requirement in the 2015/16 submission as outlined in the internal audit referenced above.

• Currently 68% (63% at the end of January 2016) of staff have completed their IG Training for 2015/16 against the 95% target.

• The Information Governance department is reviewing with service lines what Information Governance is already incorporated within induction training and new systems training for staff, outside of the online assessment tools. It has been identified that a number of internal training courses include Information Governance training and therefore may meet the Toolkit requirements for 2015/16.

• To achieve Level 2 for the Information Governance Toolkit all 35 requirements must be at level 2 or above.

• Discussions at the local Information Governance network have indicated that many NHS and other public sector organisations have expressed concern at meeting 95%

• Representations have been made to the HSCIC, but at present many organisations will be declaring Level 2 by submitting action plans to detail how shortfalls in compliance will be achieved in 2016/17. Although this does not address the root causes of compliance failure it is a pragmatic approach in the face of lack of recognition and support at the national level.



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 Escalation Action Plan (REAP) level;

Service line activity;

The Trusts financial position;

Capacity and Capability.

Resourcing Escalation Action Plan (REAP) Level 12.2. The Trust 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. In July 2015, as part of the Measures to Improve Performance plan the Trust reviewed all actions under the current REAP arrangements. As part of the current escalation the Trust moved to an enhanced level of REAP 4+ which introduced additional measures and local actions to support operational delivery on a day to day basis. The Trust remained at REAP level 4+ throughout August and September 2015.

12.4. Following improvements to performance seen towards the end of September 2015 the Trust returned to REAP level 3 with effect from 1 October 2015 and remained at REAP level 3 throughout November 2015. In light of performance challenges the Trust moved to REAP level 4 with effect from 10 December 2015.

12.5. In November 2015 the new UK Ambulance Service REAP was approved nationally and

revised national guidance documentation was released by the National Ambulance Resilience Unit (NARU). This guidance included new definitions for 4 REAP levels across ambulance services (replacing the previous REAP levels 1 to 6) to align ambulance REAP levels more consistently to those used in other areas of the health community:

o REAP Level 1 – Green – Steady State;

o REAP Level 2 – Amber - Moderate Pressure;

o REAP Level 3 – Red – Severe Pressure;

o REAP Level 4 – Black – Extreme Pressure.

12.6. The SWASFT REAP Plan has been reviewed and updated as an annex to the National plan

and was approved by Trust Directors and has been produced on a partnership basis internally and externally and builds on national plans that are in place to manage variations in demand through a process of escalation throughout the year. In December 2015 the Trust confirmed the revised REAP Level of Amber (level 2) and remains at this level at the time of this report.

12.7. On 5 February 2016, following local challenges in performance, the Trust moved to REAP Level of Red in the North Division. The Trust moved to Trust wide REAP level of Red with effect from 16 March 2016.



Accident and Emergency Service Line Activity 12.8. Accident and Emergency activity is measured for contracting and performance management

purposes and for 2015/16 the currency is ‘incidents’.

12.9. 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.

12.10. 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.

Accident and Emergency Service Line Incidents by Month compared to Contract:

Actual Contracted Variance %

April 2015 72,409 70,832 2.23%

May 2015 76,521 73,781 3.71%

June 2015 74,249 72,455 2.48%

July 2015 76,779 76,950 -0.22%

August 2015 76,802 74,599 2.95%

September 2015 72,812 71,934 1.22%

October 2015 76,708 75,120 2.11%

November 2015 74,191 73,593 0.81%

December 2015 79,161 81,355 (2.70%)

January 2016 78,069 76,263 2.37%

February 2016 73,439 69,989 4.93%

Year to Date 831,140 816,871 1.75%

Accident and Emergency Service Line Incidents by CCG:

Actual Contracted Variance % Actual Contracted Variance %

Kernow CCG 7,887 7,593 3.87% 90,689 90,450 0.26%

NEW Devon CCG 12,330 11,773 4.73% 137,843 137,759 0.06%

South Devon & Torbay CCG 4,617 4,327 6.70% 51,197 51,439 -0.47%

Somerset CCG 6,821 6,774 0.69% 79,000 80,489 -1.85%

Dorset CCG 11,339 11,417 -0.68% 130,246 134,859 -3.42%

Bath & North East Somerset CCG 2,192 1,969 11.33% 23,578 22,671 4.00%

Bristol CCG 6,629 6,026 10.01% 71,802 69,462 3.37%

North Somerset CCG 2,705 2,563 5.54% 30,906 29,169 5.95%

South Gloucestershire CCG 2,963 2,669 11.02% 32,327 30,591 5.67%

Gloucestershire CCG 7,532 7,264 3.69% 84,164 82,771 1.68%

Swindon CCG 2,624 2,474 6.06% 28,330 28,080 0.89%

Wiltshire CCG 5,408 5,140 5.21% 59,903 59,131 1.31%

Total 73,439 69,989 4.93% 831,140 816,871 1.75%

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.



The Trusts Financial Position 12.11. The financial position reported at the end of February 2016 is included within this report.

Financial headlines for the period 1 April 2015 to 29 February 2016 are set out below. The full financial appendices are included at Appendix G.

12.12. Monitor updated the Risk Assessment Framework in August 2015 and the Trust is now

assessed against the Financial Sustainability Risk Rating which replaces the Continuity of Services Risk Rating. The Trust delivered a Financial Sustainability Risk Rating of 4.00 in line with plan at the end of February 2016.

Feb 2016

Metric Result Rating

(1 to 4)

Capital Service Capacity (times) 5.67 4

Liquidity (days) 7.58 4

I&E Margin (%) 0.05% 3

Variance in I&E Margin as % of Income -0.21% 3

Financial Sustainability Risk Rating 4

12.13. 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 Financial Plan 2015/16.

12.14. The Trust delivered a surplus of £108k at the end of month eleven against a planned surplus of £550k (and a cash balance of £30,159k as at 29 February 2016). This position includes an under spend on pay relating to vacancies offset by the use of overtime, agency and third parties.

12.15. The Trust received a letter from Monitor dated 15 January 2016 requesting specific consideration of the Trust year end forecast. This has been reviewed at month ten and there is no change to the forecast of £100k. However, the Trust will further review at month twelve and if possible will look to manage an improved outturn.

12.16. The adverse position against plan reflects the reinvestment of fines levied by commissioners

for the failure of performance targets (Red 2 and A19) as set out in the A&E contract. This has been offset in part by timing variances and slippage in developments.

12.17. The annual Cost Improvement target for 2015/16 is £7,899k. The Trust is forecasting delivery of the CIP plans.

12.18. The Capital Plan for 2015/16 was revised at month six from £14,691k to £12,173k to reflect the delay of projects until 2016/17. As at month eleven the Trust is £1,986k behind the revised year to date plan of £11,461k (83% of plan). The delay in ICT and estates projects is the reason for the current shortfall against plan and these further delays until 2016/17 is reflected in the current year end forecast of £10,801k (89% of plan).



Capacity and Capability

Key Performance Indicator February

2016

YTD

2015/16

Staff Sickness % YTD (Target 4%) 5.75% 5.29%

Staff Turnover Rate 15.84%

Staff Turnover Rate (excluding redundancies) 14.20%

Trust Total Staffing (WTE) 4,009.61

Trust Total Funded Establishment (WTE) 4,085.49

Total Staffing vs Funded Establishment (WTE) (75.88)

Trust Total Vacancy Rate (%) -1.86%

Operational Qualified Establishment (WTE) 1,642.63

Operational Qualified Vacancy Rate (%) -3.46%

Operational Non-Qualified Establishment (WTE) 918.01

Operational Non-Qualified Vacancy Rate (%) +3.94%

Staff Numbers and Turnover

12.19. As at 29 February 2016 the Trust reported an establishment of 4,009.61 Whole Time Equivalents (WTE) against a funded establishment of 4,085.49 WTE. The Trust therefore has 75.88 WTE vacancies (1.86%) compared to the funded establishment.

12.20. On-going recruitment continues for additional frontline resources to address residual vacancies across the Trust. A further 4% of additional frontline resource was deployed by way of bank, agency and overtime.

Recruitment Update

12.21. Through the Graduate Paramedic and Paramedic candidate attraction campaigns, since April 2015 the Trust has employed 158 (148.33 WTE) Paramedics. An additional four are due to start during March 2016. In addition to the new recruits, 42 internal OU staff have stepped up into Paramedic positions.

12.22. During Quarter 4 the Trust is expecting the internal Paramedic Progression and Eastern

European training programmes to complete which will result in an additional 79 staff stepping up into Paramedic positions.

12.23. The Paramedic candidate attraction campaign is ongoing and assessments of shortlisted

candidates are taking place throughout March 2016.

12.24. During February 2016, the Trust launched the 2016/17 Graduate Paramedic Campaign and

the early assessment is that this has resulted in a number of applications having been received. Assessments for these candidates are due to take place in March and April 2016.

12.25. In February 2016 the Trust reported sickness of 5.75%, 1.75% above the internal target of

4.00%. Actions being undertaken by the Trust to address the current sickness abstractions across the Trust are detailed in the exception report below.



Planned Mitigating Action being taken by the Trust to reduce Sickness Levels

Following a comprehensive review further changes have been made to the Trusts Sickness Absence

Policy.

A Sickness Management Action Plan has been developed to monitor the delivery of associated initiatives, including training of managers, changes to systems and reporting methods and improved staff communication about the impact of absence. All Operational Officers and Managers have been briefed in a series of Operational Leadership Days held in May and June 2015.

Deep Dives into the management of sickness are taking place each quarter with areas for improvement being identified and action plans being put in place. This scrutiny ensures the policy is being adhered to and that we continue to drive sickness down.

The area of primary focus during Quarter 3 of 2015/16 was short notice sickness.

Active reconsideration of all staff on long term sickness against temporary secondments and alternative duties is being undertaken regularly with a database maintained 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 new process to facilitate this has been developed.

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.

Occupational Health services are now being provided by Optima due to Capita withdrawing from the contract. Existing KPIs are being met and further KPIs will be agreed at the contact review at 6 months.

The Health and Wellbeing consultation has concluded and the business case was presented to Directors in July 2015. Health and Wellbeing forums are now 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.

The Trust introduced a new Staying Well service in November 2015, to provide staff with immediate access to sources of personal support and guidance.



Appendix A: ICPR Mapping Matrix: Trust Performance Measures for 2015/16 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)



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; NHS Litigation Authority – Level 1. Central Alerts (CAS);

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;



Three Part

Definition of

Quality

National Outcome

Framework Domain

Heading


NHS Commissioners

Ambulance National

Quality Measures



Local Standards

and Targets

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.



Appendix B: Trust Approach to the Management of Performance Exceptions in 2015/16

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.

Performance In Line With Plan 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.

However where performance is below a national or contractual target this is taken into account when assigning this performance exception category. The focus of the ICPR is on providing the Board of Directors with ongoing assurance that performance can be maintained.

Escalated Performance Issue 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.



Appendix C: National Measures Definitions and Glossary

National Ambulance Quality Measures

Performance

Measure

2015/16

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

Red 19 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 – The Financial Sustainability Risk Rating Monitor will regularly consider a Trust’s planned and actual financial performance and assign a Financial Sustainability Risk Rating to assess financial risk. This Risk Rating incorporates the previous Continuity of Services Risk Rating with two additional measures. Focused on financial elements only it comprises of four financial criteria:

Capital servicing capacity: the degree to which the organisation’s generated income covers its financing obligations;

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

Income and expenditure (I&E) margin: the degree to which the organisation is operating at a surplus/deficit;

Variance from plan in relation to I&E margin: variance between a foundation trust’s planned I&E margin in its annual forward plan and its actual I&E margin within the year.

Calculating the Financial Sustainability Risk Rating for NHS Foundation Trusts



* Scoring a 1 on any criteria will cap the weighted rating to 2, potentially leading to investigation. ** Scores are rounded to the nearest number, i.e. if the Trust scores 3.6 overall, this will be

rounded to 4, if the Trust scores 3.4, this will be rounded to 3. *** A 2* rating may be awarded to a Trust where there is little likelihood of deterioration in its

financial position. Monitor will use the thresholds set out within the diagram to assign a rating of 1, 2, 3 or 4 to each of the criteria once they have been calculated. The Risk Rating is the average of the four figures, rounded up.

Monitor Risk Assessment Framework – The Governance Risk Rating The Risk Rating is generated by considering the metrics set out within the table below. In relation to the Access and Outcome metrics, each ambulance trust is monitored on a quarterly basis against the national ambulance performance standards. In addition to these, as the Trust operates the contract for Tiverton Minor Injuries Unit, the 4 hour waiting time target for Emergency Departments is also included within the Trust’s quarterly reports to Monitor.

Category Metrics Governance concern triggered by

CQC Information

CQC judgments CQC warning notice issued

Civil and/or criminal action initiated

Access and Outcomes Metrics (see table below)

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

For minor injury units (e.g. Tiverton) compliance to the Emergency Department 4 hour wait target

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

Financial Sustainability 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.

* Where this score is 4.0 or greater, this represents a governance concern for Monitor. In addition if a Trust breaches a target systematically (i.e. for three consecutive quarters) this could reflect a governance concern and consequently trigger Monitor to review further information or undertake possible regulatory action.

Access and Outcome Metrics 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 (Red 19) 95% 1.0

Minor Injury Units – patient waiting time less than 4 hours 95% 1.0

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

1

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

(DH, 2008)



The Governance Risk 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 an Under Review rating and 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:

More detail on the monitoring and assessment regime can be found in Monitor’s Risk Assessment Framework at www.gov.uk

http://www.gov.uk/



Ambulance Clinical Quality Indicators

Ambulance Quality

Indicator

What is the Indicator Measuring & Why

is it Measured? Measure

Local

Performance

Threshold

2015/16

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 19 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

7.50%



Ambulance Quality

Indicator



Local

Performance

Threshold

2015/16

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

52.00%

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.

90.00%

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%



Ambulance Quality

Indicator



Local

Performance

Threshold

2015/16

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

97.00%

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.

9.00%

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.

27.00%



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



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



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



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.



Appendix D: Local Measures Definitions and Glossary

A&E Local Key Performance Indicators

Measure 2015/16

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 (999) 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) 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



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 2015/16 Month: Feb-16 Year: 2015/16

National

TargetTrend YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4

Red 1 Category A - Red 1 Performance 75.00% 74.35% 79.05% 75.41% 75.29% 75.28% 76.17% 75.04% 76.90% 73.06% 75.26% 71.95% 66.03% 76.55% 75.52% 75.05%

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 incident (mins)n/a 14.5 13.3 14.4 14.1 14.4 14.8 13.8 14.1 14.6 14.1 15.0 16.9 13.9 14.3 14.3

Red 2 Category A - Red 2 Performance 75.00% 65.10% 68.30% 66.34% 65.89% 66.71% 69.00% 68.11% 69.43% 65.13% 63.86% 60.58% 54.48% 66.82% 67.95% 66.07%

A19 A19 Performance 95.00% 90.37% 92.66% 91.78% 91.07% 90.73% 91.71% 91.47% 91.75% 90.87% 90.27% 88.84% 83.89% 91.82% 91.30% 90.94%

Performance

Threshold 2015/16Trend YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

CO1.1 Call Abandonment Rate (% of calls abandoned before answering) 1.50% 0.85% 0.74% 0.48% 0.90% 0.66% 0.63% 0.40% 0.54% 0.67% 1.05% 0.96% 2.25%

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% 12.91% 13.97% 14.19% 12.94% 13.35% 13.16% 13.40% 12.99% 12.86% 11.73% 12.10% 11.55%

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% 5.56% 5.88% 5.81% 5.90% 5.72% 5.69% 5.89% 5.76% 4.95% 4.99% 5.36% 4.99%

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

(seconds)3 3 2 2 3 3 2 2 2 2 3 3 4

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

(seconds)19 17 15 12 19 17 14 11 11 11 20 19 35

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

(seconds)60 58 54 52 68 68 56 50 53 48 60 60 71

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 7.4 7.1 7.3 7.3 7.3 7.1 7.1 7.1 7.1 7.1 7.7 8.9

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 24.8 23.0 23.9 24.2 25.3 24.2 24.0 24.0 23.6 23.0 25.7 32.3

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 41.4 36.9 39.7 38.6 42.1 38.7 40.5 39.5 35.6 40.0 39.7 64.4

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

(where clinically appropriate) - calls closed with telephone advice7.50% 12.03% 12.92% 12.73% 12.04% 11.46% 11.55% 10.28% 10.79% 12.32% 12.61% 12.52% 13.12%

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&E52.00% 52.65% 52.09% 52.28% 52.87% 53.04% 53.25% 52.34% 51.90% 53.19% 53.60% 52.77% 51.53%

CO1.11 Number of Emergency Patient Journeys n/a - 381,646 34,371 35,641 34,687 35,787 35,668 34,774 36,638 32,365 34,103 34,554 33,058

Performance

Threshold 2015/16Trend

Rolling 12

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

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

(overall)24.00% 25.37% 26.33% 24.93% 27.38% 23.44% 26.05% 27.00% 23.60% 25.17% 22.19% 22.73% 29.79% 25.09%

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

(Utstein Comparator Group)45.00% 48.64% 48.78% 46.81% 53.19% 42.86% 41.46% 47.50% 48.48% 53.85% 43.59% 44.23% 60.47% 53.33%

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% 74.69% 73.55% 74.19% 70.75% 74.29% 74.56% 75.83% 70.99% 76.79% 74.82% 73.64% 80.58% 78.45%

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

and who receive an appropriate care bundle90.00% 85.25% 88.24% 89.22% 88.57% 88.44% 88.77% 85.45% 89.15% 82.68% 84.58% 76.24% 83.15% 79.80%

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% 47.73% 51.60% 50.79% 48.72% 49.22% 56.35% 50.86% 51.30% 50.00% 43.58% 41.25% 40.23% 42.86%

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

face) who receive an appropriate care bundle97.00% 97.15% 96.86% 97.59% 97.88% 97.99% 96.96% 98.02% 97.36% 97.07% 98.32% 96.45% 95.82% 95.60%

CO1.7 Outcome from Cardiac Arrest - Survival to Discharge - overall survival rate 9.00% 9.38% 14.33% 9.21% 8.33% 9.12% 7.79% 9.00% 8.71% 13.33% 7.36% 7.58% 10.99% 7.12%

CO1.7 Outcome from Cardiac Arrest - Survival to Discharge - Utstein Comparator Group survival rate 27.00% 28.24% 46.34% 23.40% 25.53% 27.08% 23.08% 27.50% 18.18% 43.59% 23.08% 21.15% 37.21% 23.81%

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 2015/16.

Appendix Fii - A&E Local Performance Targets Month: Feb-16 Year: 2015/16

KPI Trend YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4

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

minutes90.00% 78.49% 82.71% 75.41% 76.47% 79.55% 80.35% 78.23% 81.98% 78.47% 77.05% 76.17% 76.37% 78.10% 79.34% 79.19%

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

and emergency response within 30 minutes90.00% 75.45% 80.92% 78.62% 76.36% 76.37% 78.13% 77.85% 77.97% 75.85% 74.12% 71.04% 62.65% 78.62% 77.43% 75.96%

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

within 30 minutes90.00% 90.25% 95.04% 93.42% 91.73% 89.03% 93.42% 88.37% 89.17% 89.66% 90.13% 88.14% 82.34% 93.43% 90.35% 89.66%

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% 70.09% 74.27% 70.22% 70.02% 71.83% 72.05% 72.72% 70.02% 69.62% 70.14% 65.47% 62.91% 71.50% 72.19% 69.93%

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% 62.32% 67.85% 60.24% 61.77% 66.16% 65.80% 62.46% 61.12% 60.39% 65.56% 59.16% 54.00% 63.31% 64.81% 62.35%


Activity Percentage of Incidents through Hear & Treat Pathway - 12.75% 13.55% 14.13% 13.90% 13.62% 13.41% 12.57% 13.01% 11.50% 11.59% 11.15% 11.84% 13.87% 13.21% 12.03%

Activity Percentage of Incidents through See & Treat Pathway - 36.41% 35.78% 36.24% 36.10% 36.49% 36.67% 35.77% 35.63% 36.58% 37.38% 37.50% 36.27% 36.05% 36.32% 36.54%

Activity Percentage of Incidents through See & Convey to Non Emergency Department Locations - 7.93% 7.90% 7.68% 8.19% 8.13% 8.27% 8.72% 8.20% 8.30% 7.95% 7.08% 6.88% 7.92% 8.37% 8.15%

Activity Percentage of Incidents through See & Convey to Emergency Departments - 42.91% 42.77% 41.95% 41.81% 41.76% 41.66% 42.94% 43.16% 43.62% 43.08% 44.26% 45.02% 42.16% 42.10% 43.28%

Non

ConveyancePercentage of Incidents Closed without Conveyance to Emergency Departments 55.05% 57.09% 57.23% 58.05% 58.19% 58.24% 58.35% 57.06% 56.84% 56.38% 56.92% 55.73% 54.99% 57.84% 57.90% 56.72%


Handover

DelaysTime lost to Chargeable Handover Delays in excess of 15 minutes (hrs) 0 14,853 1,102 1,045 961 1,090 1,148 1,302 1,520 1,508 1,432 1,916 1,829 3,109 3,540 4,460

Handover

DelaysNumber of Chargeable Handover Delays between 30 minutes and 60 minutes 0 12,323 876 818 760 747 932 990 1,223 1,301 1,133 1,814 1,729 2,454 2,669 3,657

Handover

DelaysNumber of Chargeable Handover Delays in excess of 60 minutes 0 1,664 153 102 65 89 98 128 186 203 161 209 270 320 315 550


A&E Contract A&E Actual Incidents vs Contracted Incidents 100.00% 101.75% 102.23% 103.71% 102.48% 99.78% 102.95% 101.22% 102.11% 100.81% 97.30% 102.37% 104.93% 102.82% 101.30% 100.00%

Ambulance Performance Targets

Right Care, Right Place, Right Time 2

A&E Service Line Key Performance Indicators

Contract Activity

Appendix Fiii - PTS KPIs and Local Performance Targets Month: Feb-16 Year: 2015/16

KPI Trend YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

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% 92.12% 93.28% 93.07% 91.49% 90.98% 91.93% 92.48% 91.96% 92.29% 90.62% 92.69% 92.65%

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% 95.77% 97.16% 95.95% 95.41% 94.44% 95.78% 94.95% 94.92% 95.78% 96.25% 96.75% 96.04%

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

2a Patients should not arrive more than 45 minutes before their booked arrival time 90.00% 89.31% 88.37% 90.28% 89.01% 89.00% 88.69% 89.73% 89.52% 90.38% 87.50% 90.77% 89.03%

2b Patients should not arrive after their booked arrival time 97.00% 90.66% 91.80% 90.00% 90.10% 89.77% 92.10% 89.19% 92.00% 90.38% 91.83% 89.62% 90.78%

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

journey time90.00% 90.54% 90.88% 88.86% 89.52% 89.75% 90.11% 91.18% 92.24% 91.50% 92.18% 89.80% 90.00%

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

journey time90.00% 95.88% 95.52% 95.05% 95.28% 95.51% 96.07% 96.19% 96.25% 96.29% 96.83% 95.98% 95.77%

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% 96.01% 95.72% 93.94% 95.50% 97.12% 95.53% 96.92% 95.89% 95.65% 96.63% 96.92% 96.27%

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 - 2015/16

Contract KPIs

Appendix Fiv - Urgent Care Services Quality Requirements Month: Feb-16 2015/16

QR YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

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% 85.00% 87.68% 88.59% 90.50% 85.36% 83.70% 85.55% 83.90% 85.08% 81.94% 81.93% 82.44%

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 0.95% 0.76% 0.67% 0.88% 1.33% 1.28% 1.22% 1.37% 1.66% 0.74% 0.97% 1.22%

QR5 Providers must regularly audit a random sample of patients' experiences of the service 1.00% 0.50% 0.49% 0.63% 0.52% 0.65% 0.19% 0.73% 0.41% 0.45% 0.70% 0.44% 0.29%

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

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

QR8a No more than 5% of calls abandoned before being answered 5.00% 3.58% 8.51% 8.06% 7.01% 2.65% 3.88% 0.71% 0.87% 0.73% 2.36% 1.26% 1.95%

QR8b Calls to be answered within 60 seconds of the end of the introductory message 95.00% 84.90% 73.22% 68.87% 70.81% 86.17% 81.01% 94.28% 92.61% 94.42% 89.97% 93.13% 89.71%

QR9a All immediately life threatening conditions to be passed to the ambulance service within 3 minutes 100.00% 94.44% 75.00% 100.00% 100.00% 91.67% 100.00% 92.31% 92.31% 81.25% 100.00% 100.00% 100.00%

QR9b Patient callbacks must be achieved within 10 minutes 100.00% 19.58% 22.05% 16.98% 16.38% 20.70% 18.17% 25.14% 20.51% 18.08% 21.36% 19.50% 18.55%

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














Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant







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




Urgent Care Services - NHS 111 Dorset

Urgent Care Services - NHS 111 Devon


QR1 Providers must report regularly to NHS Commissioners on their compliance with the Quality Requirements Compliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A


the patient is registered by 8.00 a.m. the next working day. 95.00% 88.49% 87.90% 87.91% 89.81% N/A N/A N/A N/A N/A N/A N/A N/A N/A


all those who may be providing care to patients with predefined needsCompliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A


review the clinical performance of each individual working within the service)Compliance 0.76% 0.76% 0.67% 0.80% N/A N/A N/A N/A N/A N/A N/A N/A N/A

QR5 Providers must regularly audit a random sample of patients' experiences of the service 1.00% 0.85% 1.31% 0.54% 0.71% N/A N/A N/A N/A N/A N/A N/A N/A N/A


procedureCompliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A



Non

Compliant

Non

Compliant

Non

Compliant

Non

CompliantN/A N/A N/A N/A N/A N/A N/A N/A N/A

QR8a No more than 5% of calls abandoned before being answered 5.00% 12.52% 13.40% 13.14% 10.67% N/A N/A N/A N/A N/A N/A N/A N/A N/A

QR8b Calls to be answered within 60 seconds of the end of the introductory message 95.00% 62.70% 66.85% 59.70% 61.60% N/A N/A N/A N/A N/A N/A N/A N/A N/A

QR9a All immediately life threatening conditions to be passed to the ambulance service within 3 minutes 95.00% 95.24% 100.00% 87.50% 100.00% N/A N/A N/A N/A N/A N/A N/A N/A N/A

QR9b Patient callbacks must be achieved within 10 minutes 98.00% 20.06% 23.69% 18.02% 18.43% N/A N/A N/A N/A N/A N/A N/A N/A N/A



impaired sight

100.00% 100.00% 100.00% 100.00% 100.00% N/A N/A N/A N/A N/A N/A N/A N/A N/A



framework

Compliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A


SUI Guidance on reporting of Information Governance incidents appropriately.Compliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A














Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant

Non

Compliant







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




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% 97.39% 99.85% 99.88% 91.39% 95.40% 95.40% 97.27% 97.63% 98.04% 97.88% 98.62% 97.83%




review the clinical performance of each individual working within the service)Compliance Compliant Compliant Compliant Compliant Compliant

Non

Compliant

Non

CompliantCompliant 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




their contracted serviceCompliance 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

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

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% n/an/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 Urgent Consultations (presenting at base) started within 2 hours 95.00% 90.61% 92.81% 92.59% 95.40% 91.35% 89.06% 93.50% 96.21% 98.02% 78.36% 85.11% 91.79%

QR12 Less Urgent Consultations (presenting at base) started within 6 hours 95.00% 97.47% 96.90% 97.39% 97.50% 98.45% 97.98% 97.51% 97.82% 97.69% 97.19% 97.24% 96.88%

QR12 Emergency Consultations (home visits) started within 1 hour 95.00% n/an/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 Urgent Consultations (home visits) started within 2 hours 95.00% 93.31% 91.53% 93.11% 94.80% 95.50% 91.80% 95.14% 93.53% 91.99% 93.12% 94.06% 92.05%

QR12 Less Urgent Consultations (home visits) started within 6 hours 95.00% 96.39% 95.55% 93.21% 96.90% 98.89% 97.65% 97.36% 95.45% 94.28% 96.73% 97.87% 97.96%



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.


QR1 Providers must report regularly to NHS Commissioners on their compliance with the Quality Requirements Compliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A


next working day95.00% 97.15% 99.93% 99.98% 89.55% N/A N/A N/A N/A N/A N/A N/A N/A N/A


all those who may be providing care to patients with predefined needsCompliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A


review the clinical performance of each individual working within the service)Compliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A

QR5 Providers must regularly audit a random sample of patients' experiences of the service Compliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A


procedureCompliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A


their contracted serviceCompliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A

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 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 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

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 N/A

QR10d At the end of an assessment, the patient must be clear of the outcome Compliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A


appropriate locationCompliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A

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 N/A N/A N/A N/A N/A N/A N/A N/A

QR12 Urgent Consultations (presenting at base) started within 2 hours 95.00% 94.22% 98.25% 87.93% 96.55% N/A N/A N/A N/A N/A N/A N/A N/A N/A

QR12 Less Urgent Consultations (presenting at base) started within 6 hours 95.00% 97.43% 97.86% 96.69% 97.99% N/A N/A N/A N/A N/A N/A N/A N/A N/A

QR12 Emergency Consultations (home visits) started within 1 hour 95.00%n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)

n/a

(0 cases)N/A N/A N/A N/A N/A N/A N/A N/A N/A

QR12 Urgent Consultations (home visits) started within 2 hours 95.00% 91.31% 92.68% 88.48% 93.57% N/A N/A N/A N/A N/A N/A N/A N/A N/A

QR12 Less Urgent Consultations (home visits) started within 6 hours 95.00% 96.92% 97.50% 96.05% 97.54% N/A N/A N/A N/A N/A N/A N/A N/A N/A



impaired sight

Compliance Compliant Compliant Compliant Compliant N/A N/A N/A N/A N/A N/A N/A N/A N/A

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% 99.94% 99.46% 100.00% 100.00% 99.98% 99.99% 99.97% 100.00% 99.99% 100.00% 99.99% 99.99%




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




their contracted serviceCompliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant

QR10All 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

QR10aDefinitive Clinical Assessment for Urgent adult cases presenting at treatment location to start within 20 minutes

of arrival in the treatment centre95.00% 73.02%

54.17%

(24 cases)

71.43%

(7 cases)

100.00%

(4 cases)

94.74%

(19 cases)

80.00%

(5 cases)

77.78%

(9 cases)

62.50%

(8 cases)

72.73%

(11 cases)

75.00%

(16 cases)

64.29%

(14 cases)

77.78%

(9 cases)

QR10aDefinitive Clinical Assessmnet for children who are ill and have an urgent Out of Hours to start within 15

minutes of arrival in the treatment centre95.00% 42.50%

100%

(1 case)

0.00%

(1 case)

50.00%

(2 cases)

0.00%

(2 cases)

n/a

(0 cases)

50.00%

(4 cases)

40.00%

(5 cases)

100.00%

(4 cases)

37.50%

(8 cases)

30.00%

(10 cases)

33.33%

(3 cases)

QR10bDefinitive Clinical Assessment for Less Urgent cases presenting at treatment location to start within 60 minutes

of arrival in the treatment centre95.00% 94.61% 86.89% 93.27% 87.40% 86.58% 92.56% 98.09% 95.83% 94.44% 96.12% 98.38% 99.31%

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


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% 79.17%100.00%

(3 cases)

75.00%

(4 cases)

50.00%

(2 Cases)

100.00%

(2 Cases)

n/a

(0 cases)

50.00%

(2 Cases)

100.00%

(2 Cases)

100.00%

(1 Case)

n/a

(0 cases)

42.86%

(7 cases)

100.00%

(1 Case)

QR12 Urgent Consultations (presenting at base) started within 2 hours 95.00% 93.85% 90.14% 87.50% 92.68% 91.89% 93.00% 95.35% 96.79% 95.24% 93.10% 94.18% 92.83%

QR12 Less Urgent Consultations (presenting at base) started within 6 hours 95.00% 98.42% 98.34% 98.47% 99.06% 99.20% 97.50% 98.81% 98.56% 98.90% 97.43% 97.53% 98.99%

QR12 Emergency Consultations (home visits) started within 1 hour 95.00% 67.44%66.67%

(3 cases)

50.00%

(4 cases)

66.67%

(3 cases)

75.00%

(4 Cases)

60.00%

(5 Cases)

75.00%

(4 Cases)

80.00%

10 Cases)

100.00%

(1 Case)

100.00%

(1 Case)

60.00%

(5 cases)

33.33%

(3 cases)

QR12 Urgent Consultations (home visits) started within 2 hours 95.00% 87.03% 81.30% 88.65% 89.50% 85.92% 84.65% 90.05% 89.31% 90.64% 88.55% 86.46% 82.80%

QR12 Less Urgent Consultations (home visits) started within 6 hours 95.00% 91.52% 90.85% 93.18% 93.89% 93.87% 90.30% 90.62% 86.12% 97.72% 93.04% 88.69% 88.95%



impaired sight



Percentages of Cases completed within 4 Hours 95.00% 99.76% 99.30% 99.85% 99.86% 99.71% 99.71% 99.78% 99.84% 100.00% 99.83% 99.60% 99.92%

Urgent Care Services - Tiverton Minor Injuries Unit


Urgent Care Services - Gloucestershire 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-16 2015/16

National

TargetYTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Sickness Staff Sickness Level 4.00% 5.29% 5.38% 5.00% 4.93% 4.56% 4.83% 5.05% 5.14% 5.08% 5.95% 6.02% 5.75%

Appraisals Staff Appraisals Completed within 12 month period 85.00% 49.44% 50.42% 55.95% 56.12% 56.60% 55.76% 56.74% 55.84% 53.05% 51.75% 48.71% 49.44%

Infection

ControlCompliance with Infection Prevention and Control Standards at Ambulance Stations 75.00% 76.00% 93.00% 86.00% 82.00% 82.00% 83.00% 75.00% 75.00% 73.00% 77.00% 76.00% 76.00%

Infection

ControlCompliance with Infection Prevention and Control Standards for Double Crew Ambulances 75.00% 80.00% 79.00% 82.00% 82.00% 82.00% 84.00% 82.00% 82.00% 80.00% 80.00% 81.00% 80.00%

Vehicle Deep

CleanVehicle deep cleaning compliance with schedule 90.00% 93.30% 93.60% 92.30% 92.40% 93.20% 93.20% 92.34% 94.88% 93.00% 89.21% 91.93% 93.30%

YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

Patient Safety Adverse Incidents reported relating to medication administration, prescription and supply errors 548 54 54 47 52 41 43 41 51 50 54 61

Patient Safety Central Alert System (CAS) received 112 8 6 7 10 22 9 14 6 14 7 9

Patient Safety Central Alert System warnings (outside deadline) 19 3 0 2 1 1 2 2 2 2 2 2

Safety

MeasuresNumber of Moderate Incidents Reported 6 6 1 0 4 2 3 2 4 2 4

Safety

MeasuresNumber of Moderate Incidents Currently Under Investigation 6 6 4 2 4 4 4 2 5 8 7

Safety

MeasuresNumber of Adverse Incidents Reported 7,018 568 559 531 612 643 528 638 702 579 803 855

Safety

MeasuresNumber of Adverse Incidents Closed 6,450 513 597 704 835 497 490 544 601 289 850 530

Safety

MeasuresNumber of Adverse Incidents Currently Under Investigation 2,174 2,016 1,892 1,721 1,739 1,899 1,996 2,006 2,175 2287 2720

Safety

MeasuresNumber of Security Incident Reported (SIRS) 77 61 74 80 88 71 69 88 88 87 77

Safety

MeasuresNumber of Security Incidents Closed 63 83 51 91 70 63 80 88 73 101 84

Safety

MeasuresNumber of Security Incidents Currently Under Investigation 66 42 32 59 70 74 78 65 93 75 25

Safety

MeasuresSerious Incidents Identified in Month 45 4 12 2 3 0 4 4 4 3 5 4

Safety

MeasuresSerious Incidents Investigated and Presented to Panel 30 2 5 3 5 0 2 1 2 2 3 5

Safety

MeasuresSerious Incidents Currently Under Investigation 14 10 4 7 7 8 11 11 12 16 18

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 1,378 134 121 118 147 124 106 125 105 101 145 152

Patient

ExperienceNumber of MECS Closed (resolved with the Complainant and all investigations completed) 1,173 117 105 122 113 95 117 123 89 89 89 114

Patient

ExperienceNumber of MECS Resolved (with the Complainant but internal investigation ongoing) 8 8 5 10 7 11 10 7 9 6 7

Patient

ExperienceNumber of MECS Open (not resolved with the complainant and currently under investigation) 109 128 102 134 144 121 109 120 135 166 171

Patient

ExperienceTotal PALS Reported 882 77 82 73 91 71 80 85 85 78 90 70

Patient

ExperienceTotal PALS Closed 831 67 72 65 82 63 90 84 70 67 87 84

Patient

ExperienceTotal PALS Currently ongoing 21 18 20 28 21 12 12 17 30 33 14

Patient

ExperienceCompliments Received 1,968 164 171 208 220 169 189 232 174 119 124 198

Local Indicators

Patient Experience

South Western Ambulance Service NHS Foundation Trust - Financial Summary Dashboard Appendix G

Better Payment Practice Code KPI YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Better Payment Practice Code NHS (Value) % 95% 94.04% 88.40% 102.11% 96.63% 100.00% 83.57% 99.95% 99.09% 94.22% 99.96% 98.48% 72.10% 96.43% 92.62% 97.42% >95% <95%

Better Payment Practice Code NHS (Volume)

%95% 96.44% 97.00% 92.00% 95.00% 98.00% 97.00% 98.00% 98.00% 96.00% 99.00% 96.00% 89.00% 94.58% 98.33% 98.01% >95% <95%

Better Payment Practice Code Non NHS

(Value) %95% 92.14% 95.22% 89.52% 86.92% 95.42% 95.64% 82.86% 95.71% 96.11% 96.08% 96.33% 82.37% 90.96% 91.43% 95.97% >95% <95%

Better Payment Practice Code Non NHS

(Volume) %95% 96.45% 96.51% 96.02% 95.78% 95.88% 95.79% 96.90% 96.58% 96.83% 96.30% 96.82% 97.69% 96.10% 96.19% 96.56% >95% <95%

Other Key Financial Metrics KPI YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Debtors >90 Days Past Due as a % of Total

Debtor Balances5.00% 3.86% 5.60% 5.26% 20.95% 19.76% 7.25% 11.77% 5.80% 6.32% 6.55% 5.47% 3.86% 20.95% 11.77% 6.55% <5% >5%

Creditors >90 Days Past Due as a % of Total

Creditor Balances5.00% 0.14% 0.79% 0.00% 0.76% 3.05% 2.40% 1.00% 0.87% 0.50% 0.76% 0.80% 0.14% 0.76% 1.00% 0.76% <5% >5%

Capital Expenditure as a % of Plan (Min) 85.00% 82.67% 366.52% 129.98% 97.73% 73.29% 119.07% 205.10% 100.00% 42.68% 8.92% 33.92% 40.62% 101.01% 93.05% 27.12% >85% <85%

Continunity of Services Risk Rating KPI YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Debt Service Cover 6.34 7.06 6.78 6.71 6.34 6.71 >2.501.25 to

2.50<1.25

Debt Service Metric Score 4.00 4.00 4.00 4.00 4.00 4.00

Liquidity 8.33 14.71 15.68 11.41 8.33 11.41 >0.00 -7.00 to

14.00<-14.00

Liquidity Metric Score 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

Financial Sustainability Risk Rating KPI YTD Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Q1 Q2 Q3 Q4 On TargetOf

Concern

Action

Required

Capital Service Capacity (times) 4.00

6.47 times

4.00

5.11 times

4.00

5.28 times

4.00

5.40 times

4.00

5.46 times

4.00

5.56 times

4.00

5.57 times

4.00

5.11 times

4.00

5.46 times

4.00

Liquidity (days) 4.00

7.9 days

4.00

6.7 days

4.00

7.6 days

4.00

7.7 days

4.00

7.8 days

4.00

7.9 days

4.00

7.6 days

4.00

6.7 days

4.00

7.8 days

4.00

I&E Margin (%) 3.00

0.11%

3.00

0.09%

3.00

0.08%

3.00

0.07%

3.00

0.06%

3.00

0.06%

3.00

0.05%

3.00

0.09%

3.00

0.06%

3.00

Variance in I&E Margin as % of Income 3.00

-0.15%

3.00

-0.17%

3.00

-0.19%

3.00

-0.20%

3.00

-0.20%

3.00

-0.21%

3.00

-0.21%

3.00

-0.17%

3.00

-0.20%

3.00

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

Comments:The capital plan was revised at the end of September 2015 from £14,691k to £12,173k to reflect the delay of projects until 2016/17. The adjustmnent is incorporated within the Month 7 figures within the capital position above.

As at the end of February 2016 the Trust is £1,986k behind the revised year to date plan of £11,461k (82.67% of plan) due to delay in ICT and Estates projects.

South Western Ambulance Service NHS Foundation Trust Appendix Gi

2014/15

Outturn

Statement of Comprehensive Income Actual Budget Variance Actual Budget Variance Actual

Period Ending 29/02/2016

Month 11

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Income:

A&E Income (167,423) (167,615) 192 (182,638) (182,856) 218 (178,039)

UCS Income (23,251) (21,734) (1,517) (25,131) (23,557) (1,574) 3 (24,341)

PTS Income (3,653) (3,559) (94) (3,979) (3,882) (96) (3,869)

HART Income (6,025) (6,025) - (6,573) (6,573) - (6,574)

Other Income (8,219) (8,376) 158 (13,242) (9,891) (3,352) 3 (16,599)

Total Income (208,571) (207,309) (1,262) (231,563) (226,759) (4,804) (229,439)

Expenditure:

Employee Benefits (Pay) 153,811 155,541 (1,730) 1 169,117 169,909 (792) 1 164,224

Drugs 889 836 53 975 909 66 753

Medical 4,337 3,925 413 2 5,533 4,282 1,251 5,919

ICT 5,618 4,555 1,063 2 6,472 4,981 1,491 8,289

Estates 5,858 5,890 (32) 2 6,939 6,429 510 6,922

Fleet Expenses 4,221 4,118 103 4,681 4,597 84 4,872

Fuel 5,113 5,557 (443) 5,579 6,007 (429) 6,398

Vehicle Insurance 1,901 1,900 - 1,668 2,073 (405) 1,546

Vehicle Leasing 749 517 232 826 564 262 755

Education & Training 793 1,473 (680) 2 1,060 1,593 (533) 1,809

Other 13,509 10,270 3,238 1 15,530 11,194 4,336 1 13,936

Total Operating Expenses 196,799 194,582 2,217 218,380 212,539 5,841 3 215,423

EBITDA (11,772) (12,727) 955 (13,182) (14,219) 1,037 (14,016)

Profit/Loss on Asset Disposal 19 - 19 17 - 17 77

Depreciation 9,886 10,241 (355) 10,820 11,198 (379) 10,150

Impairments 300 300 - 1,974

Total Operating (Surplus)/Deficit (1,867) (2,486) 619 (2,046) (2,721) 675 (1,816)

Total Interest Receivable (80) (60) (20) (79) (65) (14) (95)

Total Interest Payable 105 116 (11) 117 126 (9) 124

PDC Dividend 1,734 1,880 (146) 1,908 2,060 (152) 1,627

Net (Surplus)/Deficit (108) (550) 442 (100) (600) 500 (159)

Comments:

1 Use of third parties to offset vacancies

2 Timing of expenditure against plan

3 Additional income above plan offset by additional expenduiture

Year to Date Forecast

South Western Ambulance Service NHS Foundation Trust Appendix Gii

31-Mar-15

Statement of Financial Position Actual Actual Budget Variance Actual Budget Variance

Period Ending 29/02/2016

Month 11

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Non-Current Assets

Property, Plant & Equipment & Intangible Assets, Net 83,371 82,846 87,103 (4,257) 1 83,537 87,163 (3,626)

Trade & Other Receivables Non-Current 397 225 375 (150) 212 373 (161) -

Total Non-Current Assets 83,768 83,071 87,478 (4,407) 83,749 87,536 (3,787)

Current Assets

Inventories 2,207 2,182 2,175 7 2,231 2,280 (49)

NHS Trade Receivables, Current 1,162 1,859 1,600 259 1,200 1,200 -

Non NHS Trade Receivables, Current 596 545 450 95 475 475 -

Other Receivables, Current 758 919 657 262 1,192 610 582

Prepayments, Current, Non-PFI related 2,309 1,461 1,308 153 2 2,104 2,085 19

Other Financial Assets, Current 154 898 1,390 (492) 3 74 69 5

Cash and Cash Equivalents 34,062 30,159 26,348 3,811 4 31,234 26,040 5,194

Current Assets 41,248 38,023 33,928 4,095 38,510 32,759 5,751

Non Current Assets Held for Sale - - - - -

Total Current Assets 41,248 38,023 33,928 4,095 38,510 32,759 5,751

TOTAL ASSETS 125,016 121,094 121,406 (312) 122,259 120,295 1,964

Current Liabilities

Deferred Income (398) (4,777) (1,297) (3,480) 5 (282) (75) (207)

NHS Trade Payables (272) (81) (316) 235 (250) (250) -

Non-NHS Trade Payables (3,378) (670) (2,150) 1,480 (3,100) (3,100) -

Capital Accruals (2,996) (153) (1,372) 1,219 6 (1,349) (717) (632)

Other Liabilities (5,264) (5,162) (5,020) (142) (5,206) (5,100) (106)

Borrowings (497) (497) (496) (1) (482) (481) (1)

Other Financial Liabilities (10,763) (8,721) (9,103) 382 7 (10,726) (9,233) (1,493)

PDC Dividend Payable, Current (717) (870) 153

Provisions for Liabilities and Charges (7,265) (6,879) (6,635) (244) (6,999) (6,705) (294)

Total Current Liabilities (30,833) (27,657) (27,259) (398) (28,394) (25,661) (2,733)

Net Current Assets/(Liabilities) 10,415 10,366 6,669 3,697 10,116 7,098 3,018

TOTAL ASSETS LESS CURRENT LIABILITIES 94,183 93,437 94,147 (710) 93,865 94,634 (769)

Non-Current Liabilities

Finance Leases, Non-Current (604) (609) (604) (5) (609) (604) (5)

Long Term Borrowings (2,218) (1,974) (1,973) (1) (1,746) (1,745) (1)

Other Financial Liabilities, Non-Current (228) (1) - (1)

Provisions, Non-Current (4,216) (3,828) (4,103) 275 (3,893) (4,168) 275

Trade and Other Payables, Non-Current

Total Non-Current Liabilities (7,266) (6,412) (6,680) 268 (6,248) (6,517) 269

TOTAL ASSETS EMPLOYED 86,917 87,025 87,467 (442) 87,617 88,117 (500)

Represented By

Public Dividend Capital 43,025 43,025 43,025 - 43,025 43,025 -

Income & Expenditure Account 35,771 36,201 36,640 (439) 8 36,222 36,719 (497)

Revaluation Reserve 8,121 7,799 7,802 (3) 8,370 8,373 (3)

TOTAL TAXPAYERS EQUITY 86,917 87,025 87,467 (442) 87,617 88,117 (500)

Comments:

1 Capital behind plan:- Estates (£2,336k), ICT (£1,984k), Mobimeds (£141k) and HART (£126k), but Fleet £90k above plan = (£4,497k) and depreciation £357k behind budget and sale of assets (£117k) = Total (£4,257k)

2 Prepayments above plan due to profile of insurance payments compared to plan and computer scheme prepaid.

3 Other Financial Assets:- Winter Pressure income received earlier than plan.

4 Cash ahead of plan:- Fixed Assets £4,257k, Deferred income £3,480k, but Trade Payables (£1,715k), Capital Accruals (£1,219k), Other Financial Liabilities (£382k), Receivables (£617k)Prepayments (£153k) = £3,651k

5 Deferred Income - Training, Winter Pressures and delayed projects.

6 Capital Accruals - ICT spend now delayed.

7 Other Financial liabilities:- Reduction in PO accruals.

8 Income and Expenditure Account:- Surplus less than plan.

Year to Date Forecast

Appendix Giii

Month End 29/02/2016 Period 11

2015/16

Annual CIP Target 7,899

Total CIP Identified 7,899

Total Savings Delivered YTD 7,241 8.33%

CIP Target YTD 7,241

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 937 859 859 0 937 937 0 GREEN

3 Staff Turnover 1,400 1,283 1,283 0 1,400 1,400 0 GREEN

4 Non Pay Expenditure Review 1,000 917 917 0 1,000 1,000 0 GREEN

5 Fuel Cost Reduction Action Plan 750 688 688 0 750 750 0 GREEN

6 Dividend 212 194 194 0 212 212 0 GREEN

Total 7,899 7,241 7,241 0 7,899 7,899 0

South Western Ambulance Service NHS Foundation Trust

Overall CIP 2015/16 Summary Dashboard

Trust Public Board of Directors Meeting – 31 March 2016

Page 1 of 1

Trust Public Board of Directors Meeting 31 March 2016

Title: Corporate Risk Register and Board Assurance Framework

Prepared by: Marty McAuley, Trust Secretary

Vanessa Williams, Head of Risk and Patient Safety

Presented by: Jenny Winslade, Executive Director of Nursing and Governance

Main aim: To provide the Board of Directors with the updated Risk Register and Board Assurance Framework

Recommendations: The Board of Directors is asked to take assurance from the information provided.

Previous Forum: None

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(4) 20

Underlying Causal Risks:

Accountable Director

Director of Operations

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on

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lin

e

Fo

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Co

nseq

uen

ce (

po

st

acti

on

s)

Fo

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Lik

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Fo

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Pe

rfo

rma

nc

e T

arg

ets

Re

d 1

X X X

The potential for not achieving and sustaining the

Red 1 target which could impact on patient

safety, staff experience, financials, Monitor's Risk

Assessment Framework and the Quality Premium

Payment.

Chie

f E

xecutive

SG

1

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 Trust wide REAP levels;

●Implementation of Early Exit procedure within Clinical Hubs;

●Clinical Floor walkers within 111 to prevent inappropriate Red 1 dispositions;

●Implementation of Enhanced Pre Hospital Care within Clinical Hubs;

●Roll out of Public Automatic Defibrillators;

•Development of divisional Operational Implementation Plans;

●Developments identified within MAVIS implemented;

●Red 1 performance trajectory agreed with each CCG;

● Trust wide hospital handover SOP agreed with Commissioners;

●Use of agency paramedics and private ambulance services to address

establishment levels;

●Ambulance Response Review;

•Daily review of Red 1 'misses';

•Twice-weekly Trust Performance Briefings focusing on barriers to performance

and mitigating actions, these become daily when Trust is at REAP level Red;

●Implementation of revised REAP;

•Fortnightly performance focus group meetings to deep dive into areas of concern;

•Daily and weekly conference calls;

•Review of all missed Red 1s;

•Red 1 action plan.

V. SERIOUS

(5)

LIKELY (4) 20 •Fortnightly Performance meetings;

•Monthly reports to IQPMG;

•ICPR report for Trust Board;

•Reports to Monitor.

• Ongoing internal monitoring and improvement;

●National review of performance targets by NHS England;

●Implementation of A&E Operating Plan;

•Monitor impact of change in clock start position associated with

Ambulance Response Review (Dispatch on Disposition);

•Ongoing review and escalation of inappropriate 111 dispositions

including categories of calls transferred;

•Ambulance Response Review implementation with revised categories

of calls is likely to increase the percentage of Red 1 calls.

Jun-16 V. SERIOUS

(5)

UNLIKELY

(2) 10

↑

Performance Targets Red 1

The potential for not achieving and sustaining the Red 1 target which could impact on

patient safety, staff experience, financials, Monitor's Risk Assessment Framework and

the Quality Premium Payment.

Confidential

Corporate and Directors Risk Register 16 March 2016

Risk

http://hqweb/metatraffic2/track.asp?mtr=../../images/swastftlogo_new.jpg

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V.

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Likely

(4) 20


Performance Targets Red 2

Performance Targets A19



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(sin

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Op

era

tio

na

l R

es

ou

rce

s (

A&

E)

X X X

Potential reduced resource levels below core

within A&E service line at times of peak demand.

Dir

ecto

r o

f O

pe

ratio

ns

SG

1

SERIOUS

(4)

LIKELY

(4)

16 ●Centralisation of the Resource Operations Centre (ROC) and GRS implemented

across Trust;

●Workforce plan sets out resource forecast and planning;

●Workforce Planning Establishment Group (WPEG) in place to review workforce

forecasting, plans and actions;

●Provision of staff by third parties, agencies, bank and overtime;

•Absence Management Training being delivered as part of Leadership and

Management development programme;

●University Liaison Officer appointed to actively recruit students;

●National recruitment marketing campaign;

●Additional conversion from ECA to Paramedic to increase number of

Paramedics;

• Restricted leave over busy periods;

•Ambulance Response Review in place which improves deployment of resources;

●Common CAD implemented which will enable resources to be moved around to

meet demand;

●Implementation of Staying Well Service to provide support for staff.

V.SERIOUS

(5)

POSS (3) 15 •Monthly establishment reports to IQPMG

(Commissioner meetings);

•ICPR reports to Board;

•Positive progress against recruitment trajectory.

●Payment of relocation incentives;

●Additional bank staff being appointed;

•Implement actions contained within Staff Survey Action Plan (EW) to

address wellbeing issues;

●Trust agreed replacement for OU course with UWE;

●Ongoing dialogue with Commissioners regarding handover delays

being led by CSU;

●Payment of incentivised shifts;

●Consideration of increased payments for bank staff;

●Recruitment plan in place to achieve Corporate establishment by

December 2015 (East and West divisions) and March 2016 (North

division);

●PR firm appointed to market the Trust as an employer;

•Increased use of private ambulance services for 999 calls;


Ambulance Performance Review (Dispatch on Disposition);

•Measures to Improve Performance (MIP) Plan for Q4.

Sep-16 V. SERIOUS

(5)

POSS (3) 15 S CO1,

CO2,

CO3, CO4

Qu

alit

y R

isk W

atc

h

20

/09

/20

13

HR

81

5A

↓

Pe

rfo

rma

nc

e T

arg

ets

Re

d 2

X X X

The potential for not achieving and sustaining

Red 2 target which could impact on patient

safety, staff experience, financials and Monitor's

Risk Assessment Framework.

Ch

ief

Exe

cu

tive

SG

1

SERIOUS (4) LIKELY (4) 16 •Robust business plan and corporate objectives monitored by Directors Group;


●Implementation of Early Exit procedure within Clinical Hubs;

●Individual OM trajectories developed, disseminated and monitored;


●Roll out of Public Automatic Defibrillators;

●Roll out of Airwave Responder Pagers;

●Developments identified within MAVIS implemented;

●Use of agency paramedics and private ambulance services to address

establishment levels;


•Measures to Improve plan in place;

•Appointment of Joint Liaison post with St John Ambulance regarding the

positioning and development of responder groups;

•Twice-weekly Trust Performance Briefing to identify any barriers to performance

and mitigating actions, these become daily when the Trust is at REAP Red;

•Letter from NHSE to NHS Improvement acknowledging Trust will not achieve Red

2 during Ambulance Response Review;

•Implementation of demand management plan.

SERIOUS

(4)

LIKELY (4) 16 •Demand Management Plan shared with CCGs;


•ICPR report to Board of Directors.


•Implementation of A&E Operating Plan;

●Implementation of divisional Operational Implementation Plans;

●National review of performance targets by research organisation;


•Review of demand management with CCGs ;

•Use of clinical floor walkers in 111 to review appropriateness of

dispositions;


Ambulance Response Review (Dispatch on Disposition);

•Measures to Improve Performance (MIP) Plan for Q3 and Q4;

•ORH conducting modelling exercise of resources against demand;



•Implementation of revised performance measures from 5 April 2016

which will replace Red 2.

Mar-16 SERIOUS

(4)

LIKELY (4) 16 M CO1,

CO2,

CO3, CO4

Qu

alit

y R

isk W

atc

h

11

.05

.20

15

D7

88

B

↓

Major IT Service Failure

Operational Resources (A&E) Delay in the arrival of back up resource

Clinical Hub Rationalisation

The potential for not achieving and sustaining A&E Performance targets which could

impact on patient safety, staff experience, financials, Monitor's Risk Assessment

Framework and the Quality Premium Payment.

Confidential


Risk


Pe

rfo

rma

nc

e T

arg

ets

A1

9

X X X

The potential for not achieving and sustaining

A19 target which could impact on patient safety,

staff experience, financials and Monitor's Risk

Assessment Framework.

Ch

ief

Exe

cu

tive

SG

1

SERIOUS (4) LIKELY (4) 16 • A&E service line operating plan approved and monitored at A&E service line

• Effective capital programme in place for vehicles and equipment

• Trust workforce strategy focused on frontline staff



● Trust wide hospital handover SOP agreed with Commissioners;

●Modelling A19 performance and demand and use of agency paramedics and

private ambulance services to address establishment levels;


•Daily monitoring of A19 performance;

•'Measures to Improve' Plan;

•Bi-weekly Trust Performance Briefings to identify barriers to delivery and

mitigating actions, these become daily during REAP level Red;

•Letter from NHSE to NHS Improvement acknowledging Trust will not achieve Red

2 during Ambulance Response Review;

●Implementation of revised REAP levels.

SERIOUS

(4)

LIKELY (4) 16 •Monthly reports to IQPMG;

•ICPR report to Board of Directors.


•Implementation of A&E Business Programme;

●Assess impact of Ambulance Response Review;


•Re-modelling on A19;

•Development of A19 improvement plan;

•Sustained focus on Red 2 which will have positive impact on A19;

•ORH conducting modelling exercise of resources against demand;

•A19 being replaced by new categorisation as part of national

Ambulance Response Review (5 April 2016).

Mar-16 SERIOUS

(4)

POSS (3) 12 M CO1,

CO2,

CO3, CO4

Qu

alit

y R

isk W

atc

h

11

.05

.20

15

D7

88

C

↓

Ma

jor

IT S

erv

ice

Fa

ilu

re

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.

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

4

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, West and North Hubs);

●Production and implementation of timely ICT business continuity plans;

•Clinical Hub business continuity lead;

•IT on call rota;

●Generator testing has taken place in East and West Hubs;

●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 and delivered;

●Ongoing support in relation to Estates development and employee IT

infrastructure;

•Quality meetings with 'gold' suppliers from June 2015;

•South and North CAD implementation;

●Clinical Hub fallback Business Continuity Plan reflects use of common CAD;

•Whole Trust fallback workshop took place Feb 2016.

V.SERIOUS

(5)

LIKELY (4) 20 •Internal Audit Report on Business Continuity;

•Monthly Project Board meetings for IM&T

projects.

● Staff to be trained and plans tested (Sept 2016, FG);

• Deliver IG Toolkit plan for 2015/16 (March 2016, FG);

• Deliver IT work programme for 2015/16 (June 2016, FG);

•Review of core network underway in HQ (Sept 2016) including links to

Acuma House (Dec 2016, FG) and Ringwood (Sept 2016);

●Implementation of actions arising from serious incident investigation

relating to IT failures;

●East and West Hub Duty Managers to receive training on fallback

arrangements in relation to new BC plan;

●Generator testing programme to be developed for North Division (first

quarter 2016 by Estates dept);

•Relocation of North Hub to new premises which will improve IT

capability (Dec 2016).

Dec 2016 SERIOUS

(4)

POSS (3) 12 L CO1,

CO2,

CO3, CO4

Exe

cu

tive

Dir

ecto

r o

f IM

&T

12

/02

/20

07

ICT

19

9

↔

De

lay

in

Arr

iva

l o

f B

ac

k U

p

Re

so

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.

Dir

ecto

r o

f O

pe

ratio

ns

SG

1

SERIOUS (4) LIKELY (4) 16 •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);

●Interim status plan in North division prior to delivery of new CAD;

●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;

●REAP Escalation Plan;

•A&E Operating Plan;

•Measures to Improve Performance plan;

•Use of third party resources to increase resource availability.

SERIOUS

(4)

LIKELY (4) 16 •Live web reporting;

•Fortnightly performance review meeting.

•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 (NLC/FG);

●Ambulance Response Review continuing;

●Implementation of A&E Operating Plan for 2015/16;

●Contract negotiations;

•Review of number of overruns.

March

2016

SERIOUS (4) UNLIKELY

(2) 8 M

Exe

cu

tive

Dir

ecto

r o

f D

eliv

ery

02

/02

/20

12

D1

76

↔

Cli

nic

al

Hu

b R

ati

on

ali

sa

tio

n

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.

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

4

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;

●Communications Strategy developed;

●Head of Terms agreed for new North hub premises;

●Clinical Hub layout agreed;

●Implementation of MIS training;

●Information on handover and arrival screens disseminated internally and

externally;

•Implementation of new CAD across Trust.

V.SERIOUS

(5)

POSS (3) 15 •FIC approval;

•Project report presented quarterly to Board.

●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 (July 2016);

●Implementation of Telephony Platform (July 2016);

●Roll out of NHS Pathways training in North division (March 2016);

•Roll out of NHS Pathways in North hub (Sept 2016).

Jul-16 V. SERIOUS

(5)

UNLIKELY

(2) 10 S C01, C02,

C04

De

pu

ty D

ire

cto

r o

f F

ina

nce

5 D

ece

mb

er

20

14

D8

75

↔

Da

ta Q

ua

lity

Iss

ue

s (

Hu

bs

) The use of the Data Warehouse within the North

Division Clinical Hub impacting on the ability to

view live performance data.

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

3

SERIOUS (4) POSS (3) 12 ●Process in place for producing performance data;

●Development of Performance Cube;

•Controls within Clinical Hub Rationalisation project;

•Implementation of new CAD within South division.

SERIOUS

(4)

POSS (3) 12 ●CAD Procurement Project;

●Structured review of Data Warehouse system as part of CAD project;

●Develop resilience within team to be able to cleanse data;

●Implementation of new CAD within North division.

Sep-16 MOD (3) UNLIKELY

(2) 6 S

Clin

ica

l H

ub

Ris

k R

eg

iste

r

02

/12

/20

13

IT8

27

↔

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(Cu

rre

nt)

Ris

k

Ra

tin

g

V. SERIOUS

(5)

POSS (3) 15


Increase in Activity

Handover Delays

24/7 Working



Ris

k T

itle

Qu

ality

Ris

k

Pe

rfo

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nc

e R

isk

Fin

an

cia

ls R

isk

Underlying Causal

Risk

Ac

co

un

tab

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ire

cto

r

Str

ate

gic

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al

Ori

gin

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qu

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Sc

ore

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ore

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e

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Cu

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Lik

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ore

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Ris

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ng


Ac

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n D

ea

dlin

e

Fo

rec

as

t

Co

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e (

po

st

ac

tio

ns

)

Fo

rec

as

t L

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d

(po

st

ac

tio

ns

)

Fo

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t ri

sk

ra

tin

g

(po

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ac

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ns

)

Pro

xim

ity

Ris

k

Co

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rate

Ob

jec

tiv

es

Ris

k S

ou

rce

Da

te a

dd

ed

to

re

gis

ter

Re

f

Ris

k R

ati

ng

Mo

ve

me

nt

(sin

ce last

up

date

)

Inc

rea

se

in

Ac

tiv

ity

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.

Ch

ief

Exe

cu

tive

SG

3

SERIOUS (4) POSS (3) 12 •Use of rolling average for activity commissioning;

•Activity reports sent to Commissioners on a daily and 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;


●111 Quality Development Plan;

●Ongoing work with stakeholders and other providers of services;

●Revised Interhospital Transfer Procedure implemented;

●Right Care 2;

●'Choose well' campaign;

●Introduction of additional Clinical Supervisors within Hubs;

●111/999 Liaison Group in place;

•Measures to Improve Performance Plan Q4 in place;

•System level demand management plans agreed with Commissioners and

monitored through the Integrated Quality and Performance Management Group;

●Implementation of revised REAP levels;

•Winter Plan in place approved by Commissioners;

•Fortnightly performance focus group meetings to deep dive into areas of concern;

•Internal daily conference calls to review demand management;

•Review of Demand Management Plan;

●Introduction of common CAD to assist in managing demand.

SERIOUS

(4)

LIKELY (4) 16 •Commissioners Demand Management Plan

(contained within the Trust's MIP) with agreed

actions to manage demand which is recognised as

an issue shared across the health community;

•Minutes of Performance Management Briefings

where pressures are identified and addressed;

•Winter Plan approved by Commisioners;

•Daily NHS Improvement WInter Update calls to

identify and addresss pressures (co-ordinated

externally);

•Changes in clock start for Red 2 and Green calls

as part of Ambulance Response Programme,

agreed by Expert Reference Group;

•Daily and monthly activity reports to

Commissioners.

•Performance to be monitored through contract meetings;

●Review of performance activity against demand;

●Review activity profiles;

●Review source of activity, specifically inappropriate callbacks and

abandonments;

●Additional resources to meet anticipated uplifts in demand including

agency and private providers;

●Continuation of Ambulance Response Review;

●Continue to work with 111 providers;

•Review of demand management with CCGs;

•Use of private and agency resources utilised at peak times;

•Review of status plan management;

•Negotiation of 2016/17 contract;

•Implement actions identified within the Q3 Measures to Improve

Performance Plan;

•Use of clinical floor walkers within 111 to review appropriateness of

dispositions;

•Rota review to be undertaken by external organisation;



•Independent organisation undertaking modelling exercise looking at

16/17 demand and performance.

•ORH demand management modelling taking place.

Jun-16 SERIOUS

(4)

LIKELY (4) 16 M CO1,

CO2,

CO3, CO4

Str

ate

gic

Fo

rwa

rd P

lan

nin

g R

isk R

eg

iste

r

24

Se

pt

20

12

F7

86

↔

Ha

nd

ov

er

De

lay

s a

t H

os

pit

al

- Im

pa

ct

on

Pa

tie

nt

Sa

fety

an

d R

es

ou

rce

s

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.

Ch

ief

Exe

cu

tive

SG

3

V.SERIOUS

(5)

ALMOST

CERTAIN

(5)

25 •Provision of Bronze Commander to ED;

•Joint working between Trust and acute trusts to resolve issue through local action

plans between OMs 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;

•24/7 Logistics Cell in place to escalate handover delays as appropriate;

●Strategically deployed trolleys placed in acute hospitals to improve turnaround

times;

●Issue highlighted to CSU by Director of Operations;

●Trust wide hospital handover SOP agreed with Commissioners;

●Automatic implementation of handover SOP when Trust is at REAP Red;

•Reviewing handover delays with individual CCGs;

•Monthly contract Boards discuss handover delays and take appropriate action;

•Handover delays monitored at Trust Daily Performance Briefing;

•Implementation of revised REAP.

V. SERIOUS

(5)

POSS (3) 15 •Fortnightly Performance meetings;


•ICPR report for Trust Board;

•Demand Management Plan agreed with

Commissioners on reduction of handover delays.

●Continue to monitor situation and submit adverse incident reports for

each handover delay of more than 90 minutes;

•Review of handover procedure with Commissioners;

•OMs liaising with acute hospital trusts;

●Contract discussions;

●Trust monitoring impact of implementation of ECS on handover times;

•Introduction of NEWS scoring system;

•Demand Management Plan agreed with Commissioners in reduction

of handover delays;

•Development of ECS as an electronic means of capturing handover

timings.

Jun-16 V. SERIOUS

(5)

POSS (3) 15 M CO1,

CO2, CO4

Ris

k A

sse

ssm

en

t

11

Ap

ril 2

01

3

D8

05

↔

24

/7

Wo

rkin

g

X X

Impact of 24/7 working on Trust income,

resources and demand.

Ch

ief

Exe

cu

tive

SG

3

V.SERIOUS

(5)

LIKELY (4) 20 Appropriate commissioning;

Workforce planning.

V.SERIOUS

(5)

POSS (3) 15 •Undertake operational modelling exercise;

•Ongoing monitoring of risk;

Mar-17 V. SERIOUS

(5)

POSS (3) 15 M

Qu

alit

y

Ris

k

Wa

tch

20

Au

gu

st

20

15

F8

89

↔

Devolution

People with Unmet Needs

External Influences on the Trust Resources Impacting on the Trust's ability to

respond, funding, patient care and experience, performance and staff experience

Confidential


Risk


De

vo

luti

on

Potential impact of any devolution within the Trust

area on commissioning arrangements,

performance, variances in response, resource

availability, non contract activities and resilience

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f

Fin

an

ce

SG

3

SERIOUS

(4)

POSS (3) 12 •Contracts in place with Commissioners; SERIOUS

(4)

POSS (3) 12 •A&E modelling of resource and demand

•Monitor situation.

Mar-17 SERIOUS

(4)

POSS (3) 12 M

Qu

alit

y R

isk W

atc

h

20

/08

/20

15

F8

88

↔

Ca

lle

rs w

ith

Un

me

t N

ee

ds

People with unmet needs, who may be vulnerable

frequently contacting Trust services (A&E, 111

and UCS) impacting on:-

• Trust performance through increased activations

and decrease in Trust performance levels;

• Call taking ability through increased numbers of

calls;

• Recontact data;

• Other 999 callers local to frequent caller;

• Residents local to frequent callers due to

ambulance activity locally leading to complaints.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d G

ove

rna

nce

SG

1

SERIOUS (4) POSS (3) 12 •Clinical Supervisors and Clinical Supervisor Administrator review frequent callers

monthly;

•Safeguarding distributing frequent caller data to other agencies;

•Warnings on addresses of frequent callers;

•Clinical Supervisors to take calls of identified frequent callers when available;

•Frequent caller process followed to manage frequent callers;

•Operational staff attend local multiagency meetings as arranged by clinical

Supervisors/Safeguarding/other agencies;

•Acceptable behaviour contracts issued as part of the process;

●Frequent Caller process reviewed;

●Permanent Frequent Caller Leads appointed in North and West Hubs (including

UCS);

●Frequent Caller CQUIN halved the number of calls received from the top 10 care

homes by 50%;

●Management of Frequent Caller Process now in place;

●Monthly Frequent Caller meetings in place;

●Frequent Caller Policy

SERIOUS

(4)

POSS (3) 12 •111 and OOH Frequent Caller reports provided to

Commissioners as part of quality indicator reports;

•Reports provided to Commissioners as part of

CQUiN.

•Hub to obtain national guidance on "what is a frequent caller to 999"

as currently no proposed national definition;

●Clinical Hub Clinical Lead to develop Frequent Caller report (NLC);

●Commissioners discussing managing frequent caller demand.

Sept

2016

SERIOUS

(4)

POSS (3) 12 M

De

live

ry D

ire

cto

rate

Ris

k R

eg

iste

r

08

/02

./2

01

3

D7

99

↔

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(Cu

rre

nt)

Ris

k

Ra

tin

g

V.

Serious

(5)

Poss

(3) 15


Audit Compliance

Impact of REAP

Training - Clinical Skills

Regional Care Plan Strategy


Ris

k T

itle

Qu

ality

Ris

k

Pe

rfo

rma

nc

e R

isk

Fin

an

cia

ls R

isk

Underlying Causal

Risk

Ac

co

un

tab

le D

ire

cto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

se

qu

en

ce

Sc

ore

Ori

gin

al L

ike

lih

oo

d

Sc

ore

Un

mit

iga

ted

(Ori

gin

al/In

he

ren

t)

Ris

k R

ati

ng

Controls in Place

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(C

urr

en

t)

Ris

k R

ati

ng


Ac

tio

n D

ea

dlin

e

Fo

rec

as

t

Co

ns

eq

ue

nc

e (

po

st

ac

tio

ns

)

Fo

rec

as

t L

ike

lih

oo

d

(po

st

ac

tio

ns

)

Fo

rec

as

t ri

sk

ra

tin

g

(po

st

ac

tio

ns

)

Pro

xim

ity

Ris

k

Co

rpo

rate

Ob

jec

tiv

es

Ris

k S

ou

rce

Da

te a

dd

ed

to

re

gis

ter

Re

f

Ris

k R

ati

ng

Mo

ve

me

nt

(sin

ce last

up

date

)

Au

dit

Co

mp

lia

nc

e

X

Failure to meet call taking audit compliance could

have the potential to compromise patient safety

and the requirements of software licences.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d

Go

ve

rna

nce

SG

2

SERIOUS (4) LIKELY (4) 16 ●Executive leadership and management strengthened;

●Interim additional CQI team in place (on temporary basis in A&E Hub);

●Model of CQI revised utilising Senior Call Advisors to undertaken 500 audits per

month within 111;

•Clinical Development Plan for UCS Service line;

•Quality Development Group Action Plan.

SERIOUS

(4)

LIKELY (4) 16 •Reports to Commissioners (monthly for 111). ●Review of Audit process underway including structure, frequency and

performance management;

●Review of UCS structure underway;

●Review of Clinical Hub structure in light of change to triage system in

North Hub;

● NHS Pathways review implementation;

●A&E Business Plan;

•Feedback to staff in place;

•Overtime offered to auditors and members of audit pool in A&E hub to

increase number of A&E audits undertaken;

•Installation of new audit tool for A&E Hub to assist quality and speed

of returns;

•Undertake review of new A&E audit tool software for UCS use;

•Executive Director of Nursing & Governance meeting with service line

to discuss priorities and agree actions;

•Implement actions contained within Clinical Development Plan.

Sept

2016

SERIOUS

(4)

POSS (3) 12 S CO1,

CO2,

CO3, CO4

Ris

k W

atc

h

04

/06

/20

14

N8

51

↔

Sa

feg

ua

rdin

g C

om

pli

an

ce

X

Potential for non-compliance with Safeguarding

requirements as a result of:

•an increase in the number of referrals received

affecting capacity and patient safety (potentially

due to the availability of reporting via the EPCR

and additional training);

•insufficient capacity within the Safeguarding

team to manage referrals;

•some Safeguarding referrals not reaching the

intended destination (Safeguarding Dept) from

frontline staff.

New Composite risk incorporating the 3

Safeguarding risks previously on the risk register.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d

Go

ve

rna

nce

SG

1

SERIOUS (4) LIKELY (4) 16 Extension until 1 September 2016 to secondment of additional triage post within

the Safeguarding team;

Safeguarding referrals processed in accordance with RAG rating with review of all

outstanding referrals taking place at the end of each week;

•IT system in place involving an email being sent to staff advising that the referral

has been submitted;

•Staff advised to notify Safeguarding service if confirmation email not received;

●Management of Allegations Policy;

●Safeguarding Lead in post;

●Training provided to HR and Delivery Directorates;

●Code of Conduct;

●Review of Saville, Stoke Mandeville and Morecombe Bay reports;

SERIOUS (4) LIKELY (4) 16 •Reports to Quality Committee

•Reports to Directors Group

Head of Safeguarding to provide additional guidance to staff regarding

quality referrals;

Head of Safeguarding to meet with EPCR project lead;

Weekly monitoring of referral process;

•Issue reminders to advise staff to notify Safeguarding service if

confirmation email not received;

●Safeguarding Lead to undertake thematical analysis.

Sept

2016

SERIOUS

(4)

LIKELY (4) 16 M

Ris

k A

ssu

ran

ce

Gro

up

2 M

arc

h 2

01

6

NG

88

1

com

po

site

ris

k

UC

S C

lin

ica

l C

ap

ac

ity

x

Potential for insufficient clinical capacity within

the 111 and OOH service affecting patient safety

and staff morale.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d

Go

ve

rna

nce

SG

1

SERIOUS (4) LIKELY (4) 16 •Meeting held with UCS clinicians and draft Clinical Development Plan circulated

to all UCS clinicians for review;

•Change in threshold for NPAs taking general calls;

•Monthly meetings with Royal College of Nursing;

•Chief Executive and Executive Director of Nursing & Governance attending

clinicans meetings;

•Weekly calls to oversee implementation of Clinical Development Plan;

•Integrated clinician meeting.

SERIOUS (4) LIKELY (4) 16 Finalise Clinical Development Plan;

Implement actions on Clinical Development Plan;

Establish a Recruitment and Retention Working Group;

Develop a career pathway for UCS clinicians;

Establish an UCS specific LCC;

Consider remote working;

Establish a Clinical Working Group to review and oversee clinical

actions included within the Clinical Development Plan;

Review OOH triage capacity;

IT Working Group.

Sept

2016

SERIOUS (4) POSS (3) 12

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d

Go

ve

rna

nce

2

Ma

rch

20

16

N8

90

new

UCS Clinician Capacity

Executive Director of Nursing and Governance

Safeguarding Compliance

Ambulance Clinical Quality Indicators

Electronic Care System Progress

Medicines Management Systems and Processes

Gazzetteer

Clinical Hub Triage System

Appraisals

A&E Clinical Capacity

Potential for Not Providing a Quality Service, affecting Patient Safety and Experience,

Staff Morale, Reputation and Compliance

Confidential


Risk


A&

E C

lin

ica

l C

ap

ac

ity

x

Potential for insufficient clinical capacity within

the A&E service line affecting patient safety and

staff morale.

Draft risk for approval

Dir

ecto

r o

f O

pe

ratio

ns

SG

1

SERIOUS (4) LIKELY (4) 16 TBC SERIOUS (4) LIKELY (4) 16

TBC

TBC

D8

91

draft

Re

gio

na

l C

are

Pla

n S

tra

teg

y Lack of Regional Care Plan Strategy resulting in

different approaches by individual CCGs to care

records impacting on the ability to use different

systems.

Exe

cu

tive

Dir

ecto

r

of

IM&

T

SG

3

MOD (3) LIKELY (4) 12 ●Care Record Working Group established;

●Promotion of Summary Care Record;

●Ongoing monitoring of Enhanced Summary Care Record.

MOD (3) LIKELY (4) 12 ●Implement actions arising from Care Record Working Group;

●Agree strategy;

●Communications underway with Local Area Team and CCGs;

●Monitor initiatives taking place across region, e.g. Connecting Care.

Apr-16 MOD (3) UNLIKELY

(2) 6 S

Exe

cu

tive

Dir

ecto

r

of

IM&

T

28

/11

/20

14

IMT

87

8

↔

Imp

ac

t o

f R

EA

P L

ev

els

, a

nd

Su

mm

er,

Win

ter

an

d P

ea

k p

res

su

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 RED

Directors Group agreed to update risk score as a

result of REAP level movement

Ch

ief

Exe

cu

tive

SG

4

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 DIrector

of Operations;

•Demand Management Plan for Clinical Hub;

•Updated escalatory management plan;

•New REAP monitoring introduced for NHS 111 service provided by the Trust;

•Revised REAP escalation plan implemented with divisional REAP levels;

•Measures to Improve Performance plan;

•Bi-weekly Trust Performance Briefing focussing on barriers to performance and

mitigating actions, these become daily when REAP becomes Red;

•Ambulance Response Review;

●Implementation of new REAP levels (January 2016);

•Daily conference calls.

SERIOUS (4) LIKELY (4) 16 •ICPR to Board. • 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);

•Meeting with all Strategic Resilience Groups to establish working

arrangements and escalation plans.

Mar-16 SERIOUS

(4)

UNLIKELY

(2) 8 L CO1,

CO2,

CO3, CO4

Ris

k R

eg

iste

r R

evie

w D

ay 2

00

7

22

/02

/20

07

EP

21

8

↑

Tra

inin

g -

Cli

nic

al

Sk

ills

X

Lack of awareness, skills and accountability by

staff of personal responsibility for clinical practice

and maintaining competence could result in

inappropriate clinical practice and compromise

patient care.

Poor Attendance at SME could result in poor

clinical practice

Exe

cu

tive

Dir

ecto

r o

f H

R a

nd

Org

an

isa

tio

na

l D

eve

lop

me

nt

SG

2

SERIOUS

(4)

LIKELY

(4)

16 ●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;

●Training exception reports presented to Quality Committee;

●Overtime provided to assist in completion of training;

●Training plan for 2015/16 approved by Directors Group;

●Mandatory training workbook issued to all staff for completion within 6 months;

●New Learning Development Officer structure implemented;

•SME courses run on overtime;

•Placement educators in place.

•Staff educated during refresher training - personal responsibility for clinical

practice stressed;

•All staff who are members of a regulatory body are required to maintain a CPD

portfolio;

• Additional training request forms available to all staff;

• Performance review system in place;

•Clinical supervision and OO structure established;

•Right Care Award launched Jan '15;

•Specialist Paramedic education pathway;

•An educational platform has been made available to clinical and non-clinical

staff across the Trust;

•Developed Clinical Career Pathways as part of the Talent Management Strategy;

• Roll out of CPD and access on the Trust intranet.

SERIOUS

(4)

UNLIKELY

(2) 8 ●TNA presented to Directors Group.

●Reports to Quality Committee received the latest

SME LLD stats. 80% SME expected to be

completed March 2016 and 98% either on SME or

LDR.

●New reporting in place and shared at Committee.

●Clinical Effectiveness Group Jan 2016 signed off

SME needs.

●Corporate meetings on future L&D provision

providing clarity on budget needs, training

schedules.

●Corporate visability of SME elements provided

and CPD activities, demonstrating skill set

underway for publication March 2016

●Director of Operations and Head of Education developed plan to

address outstanding training (10 days to take place in 2015/16 to

address SME from 2014/15) and future training moving forward;

●Review of ECS training for 2015/16;

•All staff to be provided with 2 hours overtime to complete workbooks

and 2 hours overtime to complete e-learning;

•Trust paying for Bank staff to attend SME training;

•Agreement in place for every member of frontline staff to have an 'on

the road' assessment during 2015/16.

•Work closely with training dept to support practitioners in developing

individual learning programme;

•Head of Education has been working with a national group to develop

on line - nationally accredited courses- in paediatrics and obstetrics;

• Development of Capita E-Learning Programme;

•'Learn with SWAST' training opportunity being developed with

accompanying webpage to support the centralisatin of CPPD

programmes;

•Annual TNA linked to abstraction plan.

Mar-16 SERIOUS

(4)

UNLIKELY

(2) 8 S CO1,

CO2,

CO3, CO4

Exe

cu

tive

Dir

ecto

r o

f H

R a

nd

Go

ve

rna

nce

20

/09

/20

13

HR

81

6

↓

Am

bu

lan

ce

Cli

nic

al

Qu

ali

ty

Ind

ica

tors

Trust performance and/or publication of

benchmarking ACQI targets may impact on:-

Clinical care;

Future Compliance;

Staff morale; and

Trust reputation.

Exe

cu

tive

Me

dic

al D

ire

cto

r

SG

4

SERIOUS (4) POSS (3) 12 •Effective and fully staffed Clinical Hub with rolling recruitment programme;

•ACQIs monitored, managed and reviewed as part of Corporate Objectives

through the Performance Management Framework and reported bi-monthly to

Lead Commissioners;

•PCR reviewed to enable improved data capture and feedback provided to

clinicians;

•Monthly review of re-contacts with Trust within a 24 hour period;

•ACQIs reported within ICPR on monthly basis to the Board of Directors;

•Two sub-groups established - Clinical and System Indicators to increase focus,

monitor data and improvement;

●ELAN live in East and West Hubs;

●ACQIs reviewed by Information Assurance Steering Group (IASG);

•Implementation of new CAD within South and North Hubs;

•Quality Improvement Paramedics appointed.

SERIOUS

(4)

POSS (3) 12 •IQPMG report and minutes (external assurance);

•ICPR report;

•Minutes of Clinical Effectiveness Group.

• Ongoing internal monitoring and improvement (ongoing, AGS);

●Introduction of Electronic PCR to improve data capture and data

quality on clinical indicator performance (ongoing until July 2016);

●Implement plan for commencement of new ACQI definitions;

●Commissioners reviewing ACQIs;

●Medical Directorate undertaking review to identify ways of improving

performance against clinical indicators.

Jul-16 SERIOUS (4) UNLIKELY

(2) 8 L

Dir

ecto

rs G

rou

p

03

/08

/20

10

D6

10

↔

Ele

ctr

on

ic C

are

Sy

ste

m (

EC

S)

Pro

gre

ss

Potential delay to the implementation of the

Electronic Care System (ECS) (including patient

record) project as a result of conflicting priorities

could result in financial benefits not being

realised and impact on the ability to provide timely

and accurate data against ACQIs and other

assessments.

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

3

• Monitoring situation;

• Bi-weekly updates to Directors Group;

• Project manager in place;

• Regular project meetings

• Executive Director of IM&T in regular liaison with HSCIC as SRO;

• Project workbook;

●ECS Programme Board;

•Regular meetings with suppliers;

●Internal resources identified to deliver implementation;

●Approved Implementation Plan agreed with suppliers.;

●All posts recruited to for roll out of implementation;

●Training in progress;

●ECS rolled out in East and West Divisions;

●Trust worked with Emergency Departments to agree referral form;

•System upgrades undertaken.

SERIOUS

(4)

POSS (3) 12 ●Operations testing of system;

●Document set for Operations being developed;

●Monitoring of pilot testing;

●Meeting to take place to review pilot;

●Roll out of ECS programme

●System upgrades being made during roll out;

●ECS being rolled out within North Division.

Jun-16 SERIOUS (4) UNLIKELY

(2) 8 S

Exe

cu

tive

Dir

ecto

r o

f IM

&T

19

.04

.20

10

IT5

61

↔

Ap

pra

isa

ls

Failure to achieve the internal KPI for completion

of appraisals and the production of poor quality

structured appraisals could impact on quality,

individual morale, and performance.

Ch

ief

Exe

cu

tive

SG

2

SERIOUS (4) LIKELY (4) 16 •Monthly reporting to ICPR and Board;

•Trust policies and procedures;

•Updated appraisal system launched;

•Regular reminders issued;

•Appraisal management included within Leadership Development Programme;

●Dedicated manager identified with responsibility for implementation of appraisal

system;

●Reports to Quality Committee;

●Exception reporting for areas where appraisal performance does not meet

targets;

●Trajectories in place and addressed at local staff survey action plan meetings;

●Quality Audit completed and presented to Deputy Director of HR for review;

●New Performance Appraisal process in place - all Ops Managers have received

training;

●Launched 'My Career Conversation' Bands 1-7 and 8 plus.

●Development of leadership development centres to link with 'My Career

Conversation'.

SERIOUS

(4)

POSS (3) 12 ●Quality Committee 14/01/2016 revisited targets.

●Improved staff survey view of appraisals;

•Reporting to Board via IPCR.

•Implement quality audits;

●Internal audit review;

●Annual Accountability Agreement to link with objectives (including

appraisals);

●Appraisals being linked to incremental points;

●LDO's discuss 'My Career Conversation' at LDR's.

●Link to 'Talent Strategy' and aspire and the use of 'My Career

Conversation' to create talent pools to be launched March 2016.

Mar-16 POSS (3) POSS (3) 9 M

Exe

cu

tive

Dir

ecto

r o

f H

R a

nd

Go

ve

rna

nce

21

/12

/20

12

HR

97

0

↔

Sa

fety

ne

ttin

g

Risk of lack of adequate safety netting for

patients who access the service.

Exe

cu

tive

Me

dic

al

Dir

ecto

r

SG

1

SERIOUS

(4)

POSS (3) 12 ●Training and Education provided to staff;

•Dorset and Somerset Falls Referral process launched July 2012;

•SPoA operating within Dorset;

•Monthly 24 hour review of non-conveyed patients and re-contact review;

●Right Care 2 team in place;

•Review of arrangements presented to DIrectors Group;

•Right Care 2 Programme.

SERIOUS

(4)

POSS (3) 12 •Risk should be mitigated with roll out of Electronic Patient Record as

supports onward transmission to patient's GP;

●Complete full audit of non-conveyance.

Sep-16 SERIOUS (4) UNLIKELY

(2) 8 M

Co

ron

er

CL

31

5

↔

Me

dic

ine

s M

an

ag

em

en

t Syste

ms a

nd

Pro

ce

ss

es I

mp

lem

en

tati

on

Inconsistent application of medicines

management systems and processes may result

in inadequate medicines management and

controlled drugs processes affecting patient and

staff experience.

Exe

cu

tive

Me

dic

al D

ire

cto

r

SG

2

SERIOUS

(4)

POSS (3) 12 ● Medicines Management Policy implemented throughout the Trust (2016);

●Controlled Drugs Policy revised to include HMR 2012 and associated

instructions;

• Hub and spoke system implemented in East and West;

●Trust taken over supply of medicines to units in Gloucestershire;

•Medicines Management leads nominated on each ambulance station;

• Full time dedicated Pharmaceutical Advisor;

•Review of Controlled Drug standards against NHS Protect report undertaken;

•Updated short station review implemented to monitor morphine sulphate 10mg

injection use by all ambulance stations and air bases;

•UCS now managing all drug supply to both Dorset and Somerset;

●Medicines Management Group monitors Adverse Incident reports, results of

SSR, and CD Occurrence reports;

•Implementation of new morphine pouches and SOP for management of personal

morphine;

•Non-controlled drug Medicines Management Policy approved and in place;

● Revised Medicines Management SOPs disseminated across Trust to harmonise

procedures;

●Implementation of Medicines Management module for Adastra;

•Revised Medicines Management system launched across theTrust during Jan

2016;

SERIOUS

(4)

POSS (3) 12 •Medicines audits completed at all stations during

Dec 2015 and Jan 2016;

•Station quality development audits;

•Monthly station medicines audits reported to

Medicines Management Group.

●Standardisation of morphine management across Trust in progress;

• Employ Local Counterfraud Officer and Quality Leads to monitor SSR

responses;

•Supply outstanding stations in North currently supplied by GWH.

•Every station/airbase to have a maximum and minimum stock list

approved by OLM and uploaded to intranet;

•Introduce sealed drug bags on all stations);

●New drug bags to be issued to East and West divisions during April

2016.


(2) 8 M

Me

dic

ine

s M

an

ag

em

en

t G

rou

p

CL

44

↔

Ga

ze

tte

er

Gazetteer updates not taking place in a timely

manner could result in resources being

dispatched to an incorrect locationE

xe

cu

tive

Dir

ecto

r o

f IM

&T

SG

4

•GPS and satellite navigation on vehicles updated bi-annually;

•Map books available on vehicles;

•Manual gazetteer update process in place for local updates;

•Monthly meetings with Heads of Operations to agree priority of system changes in

Clinical Hubs;

•Upgrade of C3 application (which included gazetteer improvements);

●Paper recommending quarterly updates agreed by Quality and Governance

Committee (Sept 2013);

●Implementation of Gazetteer updates within North division, East and West

Division underway;

•Programme of Gazetteer updates implemented;

•Introduction of address base premium;

•New CAD provides improved Gazetteer.

SERIOUS

(4)

POSS (3) 12 •Ongoing work on Trust's reporting infrastructure to ensure that

migration to Polygon reporting standard will be effective;

•Audit electronic sat nav maps on all vehicles (FG);

•Next Gazetteer updates due to take place in March 2016 (FG);

●Work ongoing within CAD Project to provide regional gazetteer;

•Introduction of new address seeking capability within new CAD.

Sep-16 SERIOUS

(4)

UNLIKELY

(2) 8 M

Dir

ecto

rs G

rou

p

08

/07

/20

13

IT8

10

↔

Cli

nic

al

Hu

b

Tri

ag

e S

ys

tem

The use of two separate triage systems within the

Clinical Hubs could result in patients being triaged

differently. This impacts on patient experience

and performance.

Exe

cu

tive

Dir

ecto

r

of

IM&

T

SG

4

SERIOUS (4) POSS (3) 12 ●All 3 divisions are using accredited triage systems;

●Fallback plans in place;

●Clinical Hub Replacement Programme;

●Decision made regarding preferred triage system;


SERIOUS

(4)

POSS (3) 12 ●Implementation of one triage system across the Trust (Sept 2016). Sep-16 LOW (2) RARE (1) 2 S

Clin

ica

l H

ub

Ris

k

Re

gis

ter

02

/12

/20

13

IT8

26

↔

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(Cu

rre

nt)

Ris

k

Ra

tin

g

V.

SeriousPoss 15



Ris

k T

itle

Qu

ality

Ris

k

Pe

rfo

rma

nc

e R

isk

Fin

an

cia

ls R

isk

Underlying Causal

Risk

Ac

co

un

tab

le D

ire

cto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

se

qu

en

ce

Sc

ore

Ori

gin

al L

ike

lih

oo

d

Sc

ore

Un

mit

iga

ted

(Ori

gin

al/In

he

ren

t)

Ris

k R

ati

ng

Controls in Place

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(C

urr

en

t)

Ris

k R

ati

ng


Ac

tio

n D

ea

dlin

e

Fo

rec

as

t

Co

ns

eq

ue

nc

e (

po

st

ac

tio

ns

)

Fo

rec

as

t L

ike

lih

oo

d

(po

st

ac

tio

ns

)

Re

f

Ris

k R

ati

ng

Mo

ve

me

nt

(sin

ce last

up

date

)

Ca

re Q

ua

lity

Co

mm

iss

ion

Failure to achieve compliance with the

requirements of the Care Quality Commission

registration and new inspection regime (from

2015/16) could result in non-compliance, leading

to loss of reputation, and impact upon foundation

trust risk ratings.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d

Go

ve

rna

nce

SG

4

V.SERIOUS

(5)

UNLIKELY

(2)

10 ● Registered without compliance condition for three activities

● CQC Relationship meetings take place regularly;

● Internal Audit Report of Compliance with 4 CQC regulations each year, CQC

Compliance is also considered when specific workstreams are audited;

● Monitoring of Serious Incidents;

● Ongoing collection of evidence and gap analysis undertaken against

requirements of new regime;

● CQC inspection in February 2014 - no compliance concerns;

● Liaison with SCAS in February 2015 to learn about new regime (they were first

pilot);

● Briefing provided to Directors' Group in March 2015 - explaining impact of new

regime;

● Quality Development Group established;

● Full plan prepared.

V.SERIOUS

(5)

POSS (3) 15 ● Requirements to be monitored at Quality and Governance

Committee;

•Review mock PIR returns;

● Development of Quality Assurance Map.

Mar-16 V.SERIOUS

(5)

UNLIKELY

(2)

SP

56

2

↑

Infe

cti

on

Co

ntr

ol

Co

mp

lia

nc

e

Risk of not being compliant with Hygiene Code.

Exe

cu

tive

Me

dic

al D

ire

cto

r

SG

1

SERIOUS

(4)

POSS (3) 12 ●New Infection Control nurse in post;

●Executive Director of Nursing and Governance is the Trust DIPC;

•Established Infection Control Group in place;

•Quality Development Group Action Plan;

•Programme of station visits.

SERIOUS

(4)

POSS (3) 12 Reports to Quality Committee ●Implementation of A&E Operating Plan;

•Ongoing monitoring of compliance by Infection Control Group.

Mar-16 SERIOUS

(4)

POSS (3)

M8

80

↔

Info

rma

tio

n G

ov

ern

an

ce

an

d S

ec

uri

ty

Re

qu

ire

me

nts

Potential non-compliance with Information

Governance and Information Security

Requirements as a result of:

the potential loss or theft of paperwork containing

personal information;

failure to follow appropriate technical solutions to

protect personal/confidential information;

information being out of date, incomplete,

inaccurate or deleted;

non-compliance with the process for completion

and delivery of records.

Composite Risk of IG risks

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

4

MOD (3) LIKELY (4) 12 ●Maintain Information Governance training and education programme;

●Clinical Records Management Policy sets out process for PCRs;

●Corporate Records Management Policy;

●Data flows mapped and risk assessed;

●Regular monitoring of adverse incidents;

•SOP on Secure Transfers of Information available on IG Directorate page of the

Intranet and promoted in the Bulletin;

●Monitoring the use of emails by IT and auto alert on any key words in emails sent

insecurely;

●Use of IM&T Services Policy;

●Information Security Plan;

●Data Quality Policy;

●Information Assurance Steering Group;

●Monthly data quality checks completed and submitted to the Information

Management team;

●Data Quality Lead appointed.

SERIOUS

(4)

POSS (3) 12 •Bi-monthly assurance reports to Quality

Committee and Quarterly reports to the Board;

●Include issue within IG communications plan and consider the use of

posters, aide memoires, etc.;

●Changes to be made to Corporate marking scheme (MM, March

2016);

●Roll out of ECS.

●Include issue within IG communications plan and consider the use of

posters, aide memoires, etc.;

•Review of IG training;

●Proposal to extend ESR to include IG e-learning module for ease of

use and tracking.

●Information Security Manager reviewing more intelligent email

monitoring software with a view to quarantining emails before they are

sent;

●Ongoing completion and submission of data quality checks;

●Monitor implementation of revised Data Quality checking process and

provide report to IASG;

•Internal Audit review of Data Integrity.

Mar-16 MOD (3) UNLIKELY

(2)

IMT

85

2

com

po

site risk

Off

Pa

ym

en

t

Arr

an

ge

me

nts

Procurement issues associated with legislation

regarding Off Payment arrangements

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

tiv

e D

ire

cto

r o

f

Fin

an

ce

SG

4

LOW (2) ALMOST

CERTAIN

(5)

10 Ongoing monitoring of agency and consultant spend on monthly basis. LOW (2) ALMOST

CERTAIN

(5)

10 Robust governance register to be developed. Mar-16 LOW (2) LIKELY (4)

F8

79

↔

Care Quality Commission

Infection Control Compliance

Off Payment Arrangements


The potential for not meeting Regulatory Requirements.

Confidential


Risk


Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(Cu

rre

nt)

Ris

k

Ra

tin

g

V.SERIOUS

(5)

POSS (3) 15


Corporate Financials (A&E)


Ris

k T

itle

Qu

ality

Ris

k

Pe

rfo

rma

nc

e R

isk

Fin

an

cia

ls R

isk

Underlying Causal

Risk

Ac

co

un

tab

le D

ire

cto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

se

qu

en

ce

Sc

ore

Ori

gin

al L

ike

lih

oo

d

Sc

ore

Un

mit

iga

ted

(Ori

gin

al/In

he

ren

t)

Ris

k R

ati

ng

Controls in Place

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(C

urr

en

t)

Ris

k R

ati

ng


Ac

tio

n D

ea

dlin

e

Fo

rec

as

t

Co

ns

eq

ue

nc

e (

po

st

ac

tio

ns

)

Fo

rec

as

t L

ike

lih

oo

d

(po

st

ac

tio

ns

)

Fo

rec

as

t ri

sk

ra

tin

g

(po

st

ac

tio

ns

)

Pro

xim

ity

Ris

k

Co

rpo

rate

Ob

jec

tiv

es

Ris

k S

ou

rce

Da

te a

dd

ed

to

re

gis

ter

Re

f

Ris

k R

ati

ng

Mo

ve

me

nt

(sin

ce last

up

date

)

Na

tio

na

l P

os

itio

n O

n

Pa

ram

ed

ic B

an

din

gs

X

The potential national increase in bandings for

Paramedics from 5 to 6 could create a significant

financial cost to the Trust.

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

tive

Dir

ecto

r

of

Fin

an

ce

SG

4

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;

●Element of national pay review negotiations;

•Sub group of National Staff Council due to make recommendations in

November 2015;

•PEEP recommendations on BSc suggests implementation from

2021/22.

●Funding requirement raised with the Commissioners

Mar-16 V. SERIOUS

(5)

POSS (3) 15 S CO1,

CO2,

CO3, CO4

De

pu

ty D

ire

cto

r o

f F

ina

nce

05

/12

/20

14

HR

87

3

↔

Co

rpo

rate

F

ina

nc

ials

(UC

S)

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.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d G

ove

rna

nce

SG

4

SERIOUS (4) LIKELY (4) 16 ●Stabilisation of 111 performance;

●Robust management of abstractions;

●Ongoing budget monitoring;

•Staff engagement plan in place;

●Financial controls in place;

•Recovery plans in place for 111;

● 2015/16 budget setting finalised;

•Business case approved and implementation commenced;

•Gloucestershire OOH weekly performance review;

•Signed contracts in place.

SERIOUS

(4)

LIKELY (4) 16 ●Implementation of rota changes;

●Review of services provided by SPoA;

●Further work to be conducted on OOH rotas;

●Review of penalty arrangements;

●Deliver revised Performance Recovery action plan;

●Review of UCS structure including management structure;

•Reconciliation of GRS, ESR and local rotas;

•Review of GP rota and payment systems;

●Monthly Director ledescalation plans in place;

•Budget setting process to identify recovery plan for 2016/17 (31

March 2016).

Mar-16 SERIOUS

(4)

POSS (3) 12 S CO1,

CO2,

CO3, CO4

Dir

ecto

rs G

rou

p

18

Ju

ly 2

01

4

N8

50

↔

Co

rpo

rate

F

ina

nc

ials

(A&

E)

X

Potential adverse financial variances the A&E

Service line impacting on the overall financial

position of the Trust. Possible variance due to

commissioner affordability, increased cost

pressures, ability to identify recurrent cost

improvements and increases in demand

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f

Fin

an

ce

SG

4

V.SERIOUS

(5)

LIKELY (4) 20 ●Robust management of abstractions;

●Ongoing budget monitoring;

●Financial controls in place;

● Lead Commissioner arrangements

● Strong stakeholder engagement

● Cost improvement governance framework in place

● Mitigation Escalation Action Plan (MEAP) process in place

V.SERIOUS

(5)

LIKELY (4) 20 ●Contract negotiations

●Budget setting 2016/17

●Review of penalty arrangements;

●Identification of MEAP schemes

●Identification of CIP schemes

●Review of cost pressures

Mar-16 V.SERIOUS

(5)

UNLIKELY

(2) 10

De

pu

ty D

ire

cto

r o

f F

ina

nce

2 M

arc

h 2

01

6

F8

92

NEW

Wo

rkfo

rce

Inte

gra

tio

n

Iss

ue

s

X

Outstanding A4C Appeals

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

ti

ve

Dir

ecto

r o

f

Fin

an

ce

SG

4

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-16 V. SERIOUS

(5)

RARE (1) 5 M

CO4

Sta

ff G

rie

va

nce

s

24

.12

.10

HR

47

↔

Potential inability for the Trust to manage its financial position within the resources

available leading to a deterioration in the Trust financial standing

Living Wage

Urgent Care Services Contract

Procurement Compliance

Use of Agency Staff (UCS)

CAD Project

Estates Strategy

Clinical Hub Rationalisation (delays)

Changing Commissioning Arrangements

Deputy Chief Executive/Executive Director of Finance

National Position on Paramedic Bandings

Corporate Financials (UCS)

Workforce Integration Issues

Cost Improvement Strategy

Resourcing

Confidential


Risk


Co

st

Imp

rov

em

en

t S

tra

teg

y

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.

De

pu

ty C

hie

f E

xe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4

V.SERIOUS

(5)

POSS (3) 15 •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;

• Implementation plans developed with clear accountability identified and

implemented;

• Recognition Agreement in place and ongoing dialogue with staffside;

•Workforce Planning aligned to CIS programmes;

●IBP updated and disseminated;

•2 year and 5 year Monitor Plans in place (2014/15);

•1 year Operational Plan in place (2015/16);

•Budget setting for 2015/16 finalised;

●Quality Impact Assessments to be signed off for each CIP;

•Cost Improvement Strategy workshop held on 11 August 2015;

•Cost Improvement Strategy approved and signed off for 2015/16.

V. SERIOUS

(5)

POSS (3) 15 ●Internal Audit Report Jan 2016 • In the event of downside instigate MEAP or CEAP;

•Monitoring of implementation plans;

•Undertake review of operational remodelling;

• Review local OM budget savings (ongoing, NLC);

●Delivery of enabling strategies;

●Implementation of updated IBP;

• Implementation of A&E Operating Plan being led by Director of

Operations;

•Quarterly monitoring against 1 year Monitor Operational Plan;

•Deputy Clinical Director to 'sign off' Cost Improvement Strategy;

•2016/17 Cost Improvement Strategy to be agreed at March 2016

Board.

Mar-16 SERIOUS

(4)

POSS (3) 12 M CO1,

CO2,

CO3, CO4

Ch

ief

Exe

cu

tive

9 D

ece

mb

er

20

10

F6

77

↔

Urg

en

t C

are

Se

rvic

es

Co

ntr

ac

t 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.D

ep

uty

Ch

ief

Exe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

an

d E

xe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d G

ove

rna

nce

SG

4

SERIOUS

(4)

LIKELY

(4)

16 • 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;

•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;

●Senior leadership team fully engaged;

•Signed contracts until 2018 for Dorset and Glos OOH services and Dorset 111.

SERIOUS

(4)

LIKELY (4) 16 ●Contracts

●Commissioning arrangements

●Development pipeline

•Action Plan in place to deliver performance targets;

• Contract discussions ongoing between UCS Service Line, Finance

and Commissioners;

•Implementation of revised performance management system;

●Review of non medical clinical workforce;

●Review of UCS structure;

●Consideration of integration opportunities.

●Bidding as part of Devon UCS tender.

Sep-16 SERIOUS (4) POSS (3) 12 M

Fin

an

ce

Te

am

16

/10

/20

09

F5

44

↑

Liv

ing

Wa

ge

X

Impact of 'Living Wage' on Trust finances,

competitive position and demand (as a result of

the potential impact on other providers)

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4

SERIOUS

(4)

POSS (3) 12 Employment contracts in place;

Job evaluation process within Agenda for Change.

SERIOUS

(4)

POSS (3) 12 Monitor government strategy;

Evaluate impact of living wage on the Trust in the medium term.

Mar-17 SERIOUS (4) POSS (3) 12 L

De

pu

ty

Dir

ecto

r o

f

Fin

an

ce

20

/08

/20

15

ne

w ↔

Pro

cu

rem

en

t C

om

pli

an

ce Failing to comply with procurement processes

could result in legal challenges. This would

impact on the Trust's reputation and finances, and

timescales for project completion.

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f

Fin

an

ce

SG

4

MOD (3) LIKELY (4) 12 ●Standing Financial Instructions in place;

●EU Procurement regulation;

●Public sector contract 2006:

●Specification writing course took place for managers (Dec 2013);

●Standardised tender documents;

●Department of Health Tender terms and conditions implemented;

●Procurement workplan;

●Waivers published in FIC report;

●Procurement Policy approved and disseminated;

•Dedicated Procurement page on intranet.

MOD (3) LIKELY (4) 12 ●Report provided to Directors and Audit and

Assurance to highlight improved position.

●Monitor compliance with SFIs;

●Undertake review of waivers.

●Work ongoing in relation to UCS agency.

Mar-16 MOD (3) LIKELY (4) 12 M

Fin

an

ce

Ris

k R

eg

iste

r

05

/03

/20

14

F8

40

↔

Us

e o

f A

ge

nc

y S

taff

(U

CS

)

Use of staff (OOH) from agencies by not going

through the national procurement framework

resulting in patient safety and governance

implications.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d

Go

ve

rna

nce

SG

2

SERIOUS (4) POSS (3) 12 ●Crown Commercial Services (CCS) presented details of available frameworks to

UCS managers, Procurement and HR;

●Extension to contract with current provider for drivers agreed with Procurement;

●Trust using GPs and nurses from agencies which are part of the Procurement

Framework and applying appropriate checks;

●New checking procedure implemented within UCS for those staff who are

recruited outside the Framework.

SERIOUS

(4)

POSS (3) 12 •Internal Report and Action Plan ●HR and Procurement to continue to work with UCS managers to

ensure use of agency staff is through the national framework.

●Procurement workstream in place.

Mar-16 SERIOUS

(4)

UNLIKELY

(2) 8 S

Fin

an

ce

Ris

k R

eg

iste

r

05

/03

/20

14

F8

43

↔

CA

D P

roje

ct

Potential delays to the implementation of the new

virtualised CAD as a result of issues with the

software could have financial implications and

would delay the benefits realisation of single

virtualised hub.

Risk to be CLOSED - CAD Implemented

across Trust

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

4

MOD (3) LIKELY (4) 12 ●Project Group



●Dedicated project team;

●Weekly meetings between key leads to ensure effective communication of issues

and risks;

●Project Administrator appointed to monitor Controls;

●Project Manual developed detailing work packages and deliverables from key

stakeholders;


MOD (3) LIKELY (4) 12 ●Ongoing monitoring by Project team;

●Ongoing positive liaison with CAD supplier;

●Escalate issues through the Programme Board.

Sep-16 MOD (3) POSS (3) 9 S

CA

D P

rog

ram

me

Te

am

21

/10

/20

14

IMT

87

7

↔

Cli

nic

al

Hu

b

Ra

tio

na

lis

ati

on

Potential delays to the implementation of the new

virtualised hub including NHS Pathways and

telephony could have financial implications and

would delay the benefits realisation of single

virtualised hub.

New Draft Risk

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

4

MOD (3) LIKELY (4) 12 ●Project Group



●Dedicated project team;

●Weekly meetings between key leads to ensure effective communication of issues

and risks;

●Project Administrator appointed to monitor Controls;

●Project Manual developed detailing work packages and deliverables from key

stakeholders;


MOD (3) LIKELY (4) 12 ●Ongoing monitoring by Project team;

●Ongoing positive liaison with CAD supplier;

●Escalate issues through the Programme Board

●Development of new Clinical Hub structure

●NHS Pathways training to be completed

●NHS Pathways business to be refreshed and operationalised

●Single telephony to be implemented

Sep-16 MOD (3) POSS (3) 9 S

CA

D P

rog

ram

me

Te

am

21

/10

/20

14

IMT

87

7

NEW

Re

so

urc

ing

Governance of Resourcing

resulting in financial issues as a result of GRS

and ESR not matching

Dir

ecto

r o

f

Op

era

tio

ns

SG

4

LOW (2) ALMOST

CERTAIN

(5)

10 •Manual review in UCS of GRS and ESR corrected issues identified at that time;

•Data analysis role appointed to.

LOW (2) ALMOST

CERTAIN

(5)

10 •Internal Audit Review regarding link between GRS and ESR;

•ESR Healthcheck to be undertaken by HR.

Sep-16 LOW (2) ALMOST

CERTAIN

(5)

10 S

Qu

alit

y R

isk

Wa

tch

11

/06

/20

15

D8

84

↔

Ch

an

gin

g C

om

mis

sio

nin

g

Arr

an

ge

me

nts

Changes to funding priorities and commissioning

structures as a result of NHS reform may lead to:-

• Loss of commissioning knowledge and

understanding / changes in personnel could

impact on future contract negotiations;

• There is a risk that Clinical Commissioning

Groups may wish to move away from the

previously agreed ‘principles of commissioner

convergence’;

• CCGs may wish to move away from lead

commissioning arrangements.

De

pu

ty C

hie

f E

xe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4

V.SERIOUS

(5)

POSS (3) 15 • Quarterly meeting of Commissioning DDMG and SWAST Directors (CSU, all

CCGs);

• Bi-monthly contract meeting (North Commissioners and East & West);

• CQUIN work programme established and potential schemes generated for

2015/16 for agreement by Commissioners;

•Ongoing engagement with new Clinical Commissioning Groups;

●SWASFT representation at all A&E contract meetings at Director and Deputy

Director level;

●Single A&E Contract;

●2 year Financial Framework agreed;

●Trust has good working relationship with CSU;

●Programme of contract meetings established;

●Confirmation of Lead Commissioner and deputy;

●Commissioners published timeline for contract discussions and signing.

V.SERIOUS

(5)

UNLIKELY

(2) 10 •Development of patient prospectus;

●Engagement plan to be developed;

●CCGs to agree terms of contracts for signature;

●Performance reports to be produced at CCG level;

●Focussed discussions to take place at FIG (Commissioners).

Mar-16 V.SERIOUS

(5)

UNLIKELY

(2) 10 M

De

pu

ty C

hie

f E

xe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

13

/08

/20

10

CE

60

2

↔

Esta

tes S

trate

gy

Estates Strategy - potential failure or delay in

implementation of individual projects and the

possibility of additional costs incurred due to

external influences.

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

4

V.SERIOUS

(5)

UNLIKELY

(2)

10 •Strategic estates team now integrated within larger Estates dpartment for one

single joined department which will enhance joint working;

•Close collaboration between existing teams - some sites already marked for

disposal - planning assumptions around disposal in Strategy;

•Agreed list of major estates projects which will be the subject of business cases;

•Executive Director of IMT member of Estates Project Board to project manage

larger capital projects;

•Estates Strategy signed off by Board of Directors;

●Estates strategy priorities agreed for 2015/16;

•Monthly estates project boards held and attended by Chief Executive, Director of

Operations and Executive Director of IM&T;

●Capital, revenue and strategic project plans under continuous monitoring

arrangements via Directors Group, Project Board and FIC;

•Acting Estates Manager in post.

V.SERIOUS

(5)

UNLIKELY

(2) 10 •Reports to Board and FIC;

•Estates Strategic Project Board chaired by Chief

Executive.

•Consider impact of potential delays on financials, review flexibility of

financial model, early discussion with local planning authority and

potential developers;

•Consider ability to sell and obtain market value for estate, alongside

willingness of staff to relocate;

•Underpinning business cases to be reviewed by FIC prior to Board

receiving Estates Strategy;

●Estates staff capacity under continuous review;

●Communications Strategy to be developed for each project;

•Internal Audit review;

•Recruitment of new Estates Manager and Estates Officer

Mar-17 V.SERIOUS

(5)

UNLIKELY

(2) 10 M

Inte

gra

tio

n P

lan

nin

g R

isk R

eg

iste

r

14

/09

/20

12

IP7

63

↔

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(Cu

rre

nt)

Ris

k

Ra

tin

g

SERIOUS

(4)

ALMOST

CERTAIN

(5)

20


NHS 111 Devon Contract

111 Demand Profile


Ris

k T

itle

Qu

ality

Ris

k

Pe

rfo

rma

nc

e R

isk

Fin

an

cia

ls R

isk

Risk Description

Ac

co

un

tab

le D

ire

cto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

se

qu

en

ce

Sc

ore

Ori

gin

al L

ike

lih

oo

d

Sc

ore

Un

mit

iga

ted

(Ori

gin

al/In

he

ren

t)

Ris

k R

ati

ng

Controls in Place

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(C

urr

en

t)

Ris

k R

ati

ng


Ac

tio

n D

ea

dlin

e

Fo

rec

as

t

Co

ns

eq

ue

nc

e (

po

st

ac

tio

ns

)

Fo

rec

as

t L

ike

lih

oo

d

(po

st

ac

tio

ns

)

Fo

rec

as

t ri

sk

ra

tin

g

(po

st

ac

tio

ns

)

Pro

xim

ity

Ris

k

Co

rpo

rate

Ob

jec

tiv

es

Ris

k S

ou

rce

Da

te a

dd

ed

to

re

gis

ter

Re

f

Ris

k R

ati

ng

Mo

ve

me

nt

(sin

ce last

up

date

)

Ca

ll A

ns

we

rin

g P

erf

orm

an

ce

(1

11

)

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.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d G

ove

rna

nce

SG

1

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 monthly meetings;

●Automated Caller Dispatch Queues (ACDQ) implemented in both 111 hubs;

●Development of Performance Management Framework for call answering;

●Executive and management leadership strengthened including appointment of

permanent managers within the 111 teams;

●Review of staff profiling complete;

●Recruitment campaign targetted at specific demographics;

●Review and analysis of data to inform modelling and activity profiles;

●Integrated Voice Response (IVR);

● Non-Pathways Agents (NPA);

●Performance Recovery Plan in place;

●Review of source of activity, specifically inappropriate callbacks and

abandonments;

●Provision of management information;

●Increased audit capacity;

●Review of clinical delivery model complete;

•Bi-weekly Trust Performance Briefing meetings where actions are identified to

address anticipated performance issues;

•Revised performance recovery plan and metrics agreed with CCGs;

•Separation of Dorset from Devon and Cornwall services.

SERIOUS

(4)

ALMOST

CERTAIN

(5)

20 •Business case for Dorset approved by Directors

Group;

•Work with Devon and Cornwall Commissioners to

improve the service resulting in an approved

performance trajectory;

•Minutes of NHS 111 updates to Directors Group;

•Minutes of weekly UCS Implementation Group;

•Amber/Medium Internal Audit Report.

•Weekly monitoring of performance;

●Review of core cover and staff absence;

●Implement actions within Performance Recovery Plan;

●Ongoing work with key stakeholders, specifically looking at patient

pathways;

●Additional resources to meet anticipated uplifts in demand;

●Ongoing recruitment to funded establishment;

●Performance management of all staff through productivity metrics;

●Further development of IVR and NPA role;

●Review framework for providing feedback to staff on call taking;

•Staff engagement plan;

•Dorset 111 Service Business Plan;

•Devon and Cornwall trajectory and milestones agreed;

•Additional training capacity sourced;

•Further work on early exit from Pathways to be undertaken.

Mar-16 SERIOUS

(4)

LIKELY (4) 16 S CO1,

CO2,

CO3, CO4

Exe

cu

tive

Dir

ecto

r o

f IM

&T

30

/04

/20

13

D8

06

↔

NH

S 1

11

De

vo

n

Co

ntr

ac

t

X X X

The loss of the NHS 111 Devon contract has the

potential to adversley affect performance, staff

retention, business continuity arrangements,

patient safety and staff morale.

Exe

cu

tive

Dir

ecto

r o

f

Nu

rsin

g a

nd

Go

ve

rna

nce

SG

4

SERIOUS (4) LIKELY

(4)

16 •The Trust has two remaining NHS 111 Contracts;

•Business Continuity Manager in post;

•Bi-weekly performance briefings take place to identify any issues which require

addressing.

SERIOUS

(4)

LIKELY (4) 16 •Business Continuity Plan in place. Review and update the Trust's UCS Business Continuity Plan;

•Commissioners to look at impact as part of contract performance

processes.

Sep-16 SERIOUS (4) LIKELY

(4)

16 S

Exe

cu

tive

Dir

ecto

r o

f

Nu

rsin

g a

nd

Go

ve

rna

nce

2 M

arc

h 2

01

6

N8

93

NEW

11

1 D

em

an

d P

rofi

le

X X X

Changes in demand profile and variances in

peaks in demand above expected call volume

Exe

cu

tive

Dir

ecto

r o

f

Nu

rsin

g a

nd

Go

ve

rna

nce

SG

3

SERIOUS (4) LIKELY

(4)

16 •Weekly performance meetings;

•Monthly Commissioner meetings;

•Ongoing monitoring and reporting of activity;

•Bi- weekly performance briefings where performance issues are identified;

•Use of bank staff.

SERIOUS

(4)

LIKELY (4) 16 •Minutes of NHS 111 updates to Directors Group;

•Minutes of weekly UCS Implementation Group;

•Reports to Commissioners.

•Weekly monitoring of performance;

●Ongoing review of core cover and staff absence;

●Ongoing work with key stakeholders, specifically looking at patient

pathways;

●Additional resources to meet anticipated uplifts in demand;

●Ongoing recruitment to funded establishment;

•Review staffing profile.

Sep-16 SERIOUS (4) LIKELY

(4)

16 M

Exe

cu

tive

Dir

ecto

r o

f

Nu

rsin

g a

nd

Go

ve

rna

nce

2 M

arc

h 2

01

6

N8

94

NEW

UCS Base and Home Consultation Targets

OOHs GP Cover

UCS Agency

Call Answering Performance (111)

Operational Resources (UCS)


The potential for not achieving and sustaining UCS Service Line Performance targets

which could impact on patient safety, staff experience and financials.

Confidential


Risk


Op

era

tio

na

l R

es

ou

rce

s (

UC

S)

X X X

Potential reduced resource levels (clinicians and

non-clinicians) within UCS service line at times of

peak demand.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d G

ove

rna

nce

SG

1

SERIOUS

(4)

LIKELY

(4)

16 ●Centralisation of the Resource Operations Centre (ROC) and GRS implemented

across Trust;

●Workforce plan;


•Management reports provided to CPR, Directors Group and Quality and

Governance Committee;

●Recruitment Plan in place;

•New assessment tool for 111 Call Advisors to improve quality of selection which

should have a positive impact on retention (June 2015);

•Daily Trust Performance Briefing where resource issues and mitigating actions

are identified;

•111 Call Advisor Recruitment Open Evenings held;

•Rota review completed with 111 staff;

●Implementation of Staying Well Service to support staff;

•Resilience from OOH Service and SPoA;

•Virtual Hub;

•UCS Integrated Clinician meetings.

SERIOUS

(4)

LIKELY (4) 16 •Reports to Commissioners. •Implement actions contained within Staff Survey Action Plan (EW);

●GP engagement programme;

●Advanced Nurse Practitioner development;

●Implementation of incentivised shifts where appropriate;

•Business case for Dorset;

•Improvement actions agreed with Devon and Cornwall

Commissioners;

•Ongoing recruitment campaign;

•Clinical Development Plan;

•Clinical Working Groups to be established.


(2) 8 S CO1,

CO2,

CO3, CO4

Exe

cu

tive

Dir

ecto

r o

f H

R a

nd

Go

ve

rna

nce

20

/09

/20

13

HR

81

5 (

B)

↑

UC

S A

ge

nc

y

X X X

The introduction of the NHS Improvement rules

for the use of agency staffing from 01 April 2016

will impact on the availability of operational

resources for UCS. These rules include the use of

compliant agency and fixed maximum prices from

suppliers.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d

Go

ve

rna

nce

SG

4

SERIOUS

(4)

LIKELY

(4)

16 ●Monitoring and awareness of agency usage in place

●National Procurement Frameworks in place

●Use of employed staff , bank, overtime and sessional GPs

SERIOUS

(4)

LIKELY (4) 16 ●GP engagement programme;

●Advanced Nurse Practitioner development;

●Implementation of incentivised shifts where appropriate;

•Ongoing recruitment campaign.

• Procurement work programme in place to get compliance

• Only companies on the agreed frameworks are used

•Specification documents required for each company and service

provided

•Current framework prices above the agency caps

•Weekly return required to NHS Improvement from 01/04/16

Apr-16 SERIOUS (4) UNLIKELY

(2) 8 S CO1,

CO2,

CO3, CO4

Exe

cu

tive

Dir

ecto

r o

f H

R a

nd

Go

ve

rna

nce

20

/09

/20

13

HR

81

5 (

B)

NEW

OO

Hs

GP

Co

ve

r The potential challenge in providing Out of Hours

GP cover due to a national shortage of GPs, high

in hours workloads, re-tendering and annual

leave could impact on GP shifts not being filled

within the OOH services resulting in financial

penalties

Exe

cu

tive

Me

dic

al

Dir

ecto

r

SG

1

SERIOUS

(4)

POSS (3) 12 •QMM meetings with Commissioners;

•GP Lead appointed;

•Performance and Medicines Management audits fed back to GPs;

•Part B of Commissioning meeting includes performance issues;

•UCS GP Lead currently undertaking reviews of GPs causing concern;

•GP tool kit audits;

•Enhanced Medical Directorate structure with increased Medical Director capacity

at a leadership level across Trust;

•Medical Director (Primary Care) in place providing support for OOH.

SERIOUS

(4)

POSS (3) 12 •Review current GP performance documentation;

• Undertake risk assessment of GP performance arrangements;

• Ongoing monitoring of adverse and serious incidents and patient

feedback to identify any causes of concern;

●Develop assurance framework for contracted GPs;

●Undertake review of GP audit process;

•Medical Director Primary Care setting up meeting to develop method

of performance management for GPs.

Sep-16 SERIOUS

(4)

POSS (3) 12 M

Le

arn

ing

Fro

m

Exp

eri

en

ce

Gro

up

25

/01

/20

11

D6

79

↔

UC

S B

as

e a

nd

Ho

me

Co

ns

ult

ati

on

Ta

rge

ts

Failure to achieve home and base consultation

targets as set out within contracts could affect

contract performance

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d

Go

ve

rna

nce

SG

3

SERIOUS

(4)

POSS (3) 12 ▪ UCS business plan;

▪ Statistical reports available on triage and home visits;

▪ Monthly ICPR reports;

▪ GP Lead and 111 Nurse Lead in place;

▪ Clinician audit and 'league tables' underway;

•Nurse/ECP Triage Service being developed to provide a consistent approach to

assessment;

●UCS Service Line meeting with Terms of Reference to include monitoring of

targets;

●Focus on performance within Directors Group meetings;

●Each missed case presented to UCS Service Line meeting and contract pre-

meets for review;

●ECP Strategy;

•Trust reviews every case which is missed;

•Deep dive undertaken by Performance and Planning team.

MOD (3) LIKELY (4) 12 • Continue extra focus on shift cover & rota planning;

• Continue exclusive use of UCS ECPs;

• Improve joint working with District Nurses;

• Improve dispatch process e.g. clinical supervisor, single allocation

visits, merge ECP/GP visits;

●Implementation of Home Visits Performance Improvement Plan;

●Review of home visits underway which includes recommendations for

improvement in terms of clinical care and resource deployment.

Mar-16 MOD (3) UNLIKELY

(2) 6 M

Assu

ran

ce

Fra

me

wo

rk

30

/06

/20

10

D5

81

↔

Cu

rren

t

Co

nseq

uen

ce

Sco

re

Cu

rren

t

Lik

elih

oo

d

Sco

re

Mit

igate

d

(Cu

rren

t) R

isk

Rati

ng

V.SERIOUS

(5)

LIKELY (4) 20


Reputation


Ris

k T

itle

Qu

ality

Ris

k

Perf

orm

an

ce R

isk

Fin

an

cia

ls R

isk

Risk Description

Acco

un

tab

le D

irecto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

seq

uen

ce

Sco

re

Ori

gin

al L

ikelih

oo

d

Sco

re

Un

mit

igate

d

(Ori

gin

al/In

here

nt)

Ris

k R

ati

ng

Controls in Place

Cu

rren

t C

on

seq

uen

ce

Sco

re

Cu

rren

t L

ikelih

oo

d

Sco

re

Mit

igate

d (

Cu

rren

t)

Ris

k R

ati

ng


Acti

on

Dead

lin

e

Fo

recast

Co

nseq

uen

ce (

po

st

acti

on

s)

Fo

recast

Lik

elih

oo

d

(po

st

acti

on

s)

Fo

recast

risk r

ati

ng

(po

st

acti

on

s)

Ris

k R

ati

ng

Mo

vem

en

t (s

inc

e l

as

t u

pd

ate

)

Rep

uta

tio

n

Potential for adverse reputation as a result of

adverse national media, including social media,

poor experience, non-compliant performance and

non compliance with regulatory requirements.

Chie

f E

xecutive

SG

4

SERIOUS

(4)

ALMOST

CERTAIN

(5)

20 ●Proactive Communications team in place;

•Ongoing reviews of Freedom of Information Requests.

V.SERIOUS

(5)

LIKELY (4) 20 Patient survey responses ●Ongoing public relations activity;

•Proactive Communications Plan being prepared;

•Media monitoring and evaluation being set up to understand reputation

scoring (April 2016);

•Board and Directors reports being developed to include reputation

scoring (April 2016).

Mar-16

new

Chief Executive

Potential for adverse Reputation as a result of adverse media, poor experience, non-

compliant performance and non compliance with regulatory requirements.

Confidential


Risk


Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(Cu

rre

nt)

Ris

k

Ra

tin

g

SERIOUS

(4)

POSS (3) 12


Terrorist Activity

Business Continuity


Ris

k T

itle

Qu

ality

Ris

k

Pe

rfo

rma

nc

e R

isk

Fin

an

cia

ls R

isk

Risk Description

Ac

co

un

tab

le D

ire

cto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

se

qu

en

ce

Sc

ore

Ori

gin

al L

ike

lih

oo

d

Sc

ore

Un

mit

iga

ted

(Ori

gin

al/In

he

ren

t)

Ris

k R

ati

ng

Controls in Place

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(C

urr

en

t)

Ris

k R

ati

ng


Ac

tio

n D

ea

dlin

e

Fo

rec

as

t

Co

ns

eq

ue

nc

e (

po

st

ac

tio

ns

)

Fo

rec

as

t L

ike

lih

oo

d

(po

st

ac

tio

ns

)

Fo

rec

as

t ri

sk

ra

tin

g

(po

st

ac

tio

ns

)

Ris

k R

ati

ng

Mo

ve

me

nt

(sin

ce last

up

date

)

Te

rro

ris

t A

cti

vit

y

X X X

Terrorist activity (including cyber threats) 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)

Ch

ief

Exe

cu

tive

SG

4

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;

• Implementation of National Ambulance Service Command and Control guidance;

•REAP escalation process;

•Dedicated on call tactical advisors within Resilience team;

•Implementation of Trust wide National Interagency Liaison Officers (Technical

Advisors);

●PREVENT training delivered to trainers for roll out;

●Introduction of Joint Emergency Services Interoperability Programme (JESIP);

●Revision of Maraudering Terrorist Firearms (MTFA) Incidents training completed;

●New Commander package developed following review of Commander Policy;

•Exercise and planning for a potential IT related incident;

●Delivery of JESIP training programme;

•New Dispatchers and EMAs receive training on EPRR.

V. SERIOUS

(5)

POSS (3) 15 •Daily reports submitted centrally on capacity in

relation to HART, MTFA and SORT;

•Major Incident Exercise reports.

• Implement recommendations arising from exercises and incidents

(lessons learned) (ongoing, NLC);

●Trust to review compliance with PREVENT requirements (JW);

●Commander training to take place for newly appointed Operational

Officers;

●Recruitment of additional SORT and Ambulance Intervention Team

(AIT) (NLC );

●PREVENT workplan and training strategy to be developed by

Safeguarding Lead;

●Initial Operations Response (IOR) - training of all operational staff in

dry decontamination underway;

•Review of JESIP programme by HMIC;

•Extension of MTFA training - doubling capacity;

•Report to be produced for Quality Committee on preparedness;

•One common Special Operations desk (specialising in Terrorist

incidents) to be placed in North to cover whole Trust.

Mar-16 V. SERIOUS

(5)

POSS (3) 15

↔

Re

sil

ien

ce

- B

us

ine

ss

Co

nti

nu

ity

The potential inability to respond to major service

disruption because BCPs have not been tested to

ensure effectiveness which could impact on

continuity of service, patient safety and

experience, and staff morale.

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

4

•Business Continuity Policies implemented across full Trust area;

•ICT BCP reviewed and integrated with departmental BCP's;

•Business Continuity lead appointed and working with leads to develop plans;

•Bronze Commander structure replicated across North division;

●Business Continuity Strategy approved;

●National Peer Review of Business Continuity;

●Executive Director of IM&T confirmed as lead director for business continuity;

●Business Continuity monthly progress dashboard reviewed by Directors Group;

●North Clinical Hub Duty Managers trained in new Fall Back arrangements;

●Annual Accountability Agreements include responsibility for business continuity;

●Implementation of SWASFT5 (business continuity awareness campaign);

● Operational Resilience Capacity Plan in place with dedicated lead to manage

winter and other operational pressures;

●Regular generator testing now takes place;

•Twice weekly Performance Briefings take place with attendees from all Trust

functions.

SERIOUS

(4)

POSS (3) 12 •Reports on compliance with Business Continuity

programme to Directors Group.

•Develop programme of business continuity plan testing;

•All Business Continuity Plans within North division to be tested;

●Clinical Hub fallback Business Continuity Plan in final development

before approval;

●East and West Hub Duty Managers to receive training on fallback

arrangements;

●Implementation of actions arising from internal audit report.

Mar-16 MOD (3) POSS (3) 9

↔

Executive Director of IM&T

Potential inability to respond to business continuity event affecting continuity of

service, patient and staff safety and experience, reputation and regulatory

requirements

Confidential


Risk



Page 1 of 5


Title: 2015 Staff Survey Update

Prepared by: Vicky Evans, Resourcing & OD Manager

Presented by: Emma Wood, Executive Director of HR and OD

Main aim: This report sets out the key findings of the 2015 staff survey, including areas for improvement and makes recommendations to improve 2016 survey completion.

Recommendations: The Board of Directors is asked to approve the next steps and suggested improvements for 2016 which have been supported by the Director Group.

Previous Forum: Directors Group Level 1


Page 2 of 5

1. Introduction 1.1 The 2015 staff survey was administered by the Picker Institute on behalf of the

Trust. The questionnaire was provided in an electronic format to staff, via an e-mail link, and staff had a window of approximately 8 weeks to complete the questionnaire.

1.2 The survey was promoted during the HR roadshows, and team briefings. Regular

prompts and reminders were sent to staff during the 8 week completion window. 1.3 4242 staff were eligible to complete the 2015 staff survey, 1721 returned a

completed questionnaire, resulting in a response rate of 40.6%. This was nearly 2% lower completion than in 2014.

1.4 This report presents the results in the form of problem scores. The problem score

shows the percentage of staff who have a negative response for each applicable question. Therefore, lower problem scores are better.

2. Key Findings

2.1 Despite the slightly lower completion rate the overall results demonstrate an improved position. 60 of the same questions were used in both the 2014 and 2015 surveys. Positively the Trust has improved significantly on 30 of these questions, whilst staying the same on a remaining 30 questions.

2.2 There were no questions where performance was both worse than average or

where performance has slipped since the last survey. 2.3 The most notable areas of improvement are for the following questions::

2.3.1 Immediate manager does not take a positive interest in my health & well-being – which has seen an outstanding 20% improvement, reducing from 36% in 2014 to 16% in 2015.

2.3.2 Do not receive regular updates on patient/service user feedback

in my directorate/department – an improvement of 10%, reducing from 42% to 32%.

2.3.3 Communication between senior management and staff is not

effective– a 10% improvement reducing from 49% to 39%. 2.3.4 Dissatisfied with extent organisation values my work– an

improvement of 9% reducing from 49% to 40%


Page 3 of 5

2.3.5 In last month, saw errors/near misses/incidents that could hurt staff– an improvement of 9% reducing from 29% to 20%.

2.3.6 Care of patients is not organisation's top priority– an improvement

of 8%, reducing from 34% to 26%.

3. Staff Engagement 3.1 Staff engagement refers to the extent to which a member of staff is committed to

the organisations goals and values, how motivated they are to contribute to the organisations success and enhance their own sense of well being.

3.2 Within the 2015 staff survey staff engagement focuses on three themes; 1)

advocacy, 2) involvement and 3) motivation, with higher scores indicating higher overall staff engagement in that area. The report provides a score for the Trust as a whole and also by division and locality. The Trust’s overall engagement score has increased 3 points to 70 since the 2014 survey, with the largest improvement in responses to advocacy-based questions, indicating that more respondents would recommend the Trust as a place to work or receive treatment.

3.3 When comparing results year on year (2014 to 2015) and at directorate level, there

were increases in engagement scores for HR & OD (from 79-83) and Delivery (66-69). There were decreases at directorate level for Finance (83-78).

3.4 Year on year comparisons are problematic for the Medical and Nursing Directorates

as work undertaken to cleanse ESR led to a significant alteration in the headcount numbers assigned to each Directorate. So whilst Medical show an increase from 79 to 80 the headcount reduced by approximately 470 UCS staff moving to the Nursing directorate.

3.5 Nursing, saw a decrease from 79 to 70, but this is now based on a headcount of

549 compared with 35 in 2014. 3.6 Direct year on year comparisons are not currently possible for these two

Directorates as we do not have the breakdown reports to enable the responses to be extrapolated by Directorate. When we are provided with this level of detail we will undertake this further analysis.

3.6 Divisionally, East (68) and West (72) have remained at a similar score with North

reporting an increase from 63 to 68 since the previous survey, with advocacy of the organisation seeing the highest increase, indicating more respondents identifying with SWASFT. Divisional breakdowns can be seen in Appendix B.


Page 4 of 5

4. Areas for Improvement 4.1 Although the Trust has demonstrated positive results, there are still area’s for

further improvement where more than 50% of staff who responded gave a negative

response.

4.2 These areas are shown below along with a comparison for 2014. As can be depicted from the green text, the Trust has already improved in many of these areas since 2014.

Question Area

Lower problem scores are better

2015

Problem Score

2014

Problem Score

Put myself under pressure to come to work despite not feeling well enough

91 93

In last 3 months, have come to work despite not feeling well enough to perform duties

65

68

Last experience of harassment/bullying/abuse not reported 64 60

Not enough staff at organisation to do my job properly 60 66

Appraisal/performance review: training, learning or development needs not identified

56 52

Team members do not often meet to discuss the team's effectiveness

56 56

Dissatisfied with my level of pay 55 60

5. Comparison with the other “Picker” Ambulance Trusts

5.1 The Picker Institute was commissioned to undertake the survey for 6 Ambulance Trusts in 2015. When compared with the average Picker Ambulance Trust on a total of 86 questions, we scored:

Significantly better than average on 55 questions

Average on 29 questions

Significantly worse than average on 2 questions, which were:

Last experience of physical violence not reported, where the Trust scored 42 compared to the Picker average of 36.

Appraisal/performance review: training, learning or development needs not identified, where the Trust scored 56 compared to the picker average of 49.


Page 5 of 5

6. Next Steps 6.1 The OD team will be analysing the final results broken down by locality, which will

be shared with management teams, and local action plans will be developed for the areas for improvement. It is essential to maintain focus in the areas where the Trust has seen significant improvement, and this will also be captured in local plans.

6.2 Progress against the action plans will be monitored by the HR OD team, and

progress will be monitored via the OD team and quality meeting.

7. Recommendations 7.1 The Board of Directors is asked to approve the next steps and suggested

improvements for 2016 set out below, which have been supported by the Director Group:

7.1.1 The introduction of a mixture of completion methods, including paper, text

message and iPad options.

7.1.2 An extended completion window, i.e. opening the survey for a longer

Emma Wood Executive Director of HR and Organisational Development

Trust Public Board of Directors Meeting - 31 March 2016

Page 1 of 31


Title: Patient Safety and Experience Report – 1 November 2015 to 29 February 2016

Prepared by: Governance Team


Main aim: The purpose of this paper is to provide the Board of Directors with a copy of the Patient Safety and Experience Report for assurance.

Recommendations: The Board of Directors is asked to take assurance from the Patient Safety and Experience Report.



Page 2 of 31

Patient Safety and Experience Report November 2015 – February 2016

1. Executive Summary 1.1 The Trust is committed to the delivery of high quality services designed around the

needs of patients, carers and the public, staff, local communities and all relevant stakeholders. We continually seek to improve what we do, but must also consider action where services fall short of what patients and service users expect and deserve.

1.2 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. The purpose of this report is to provide an update on patient safety and experience issues reported during the period 1 November 2015 – 29 February 2016. The paper is supported by a number of appendices which provide the data to support the narrative within the report: Annex A of the report includes a breakdown of data by service line; Annex B sets out incidents by reporting category; Annex C includes a list of definitions; and Annex D provides the patient survey data.

Learning 1.3 The report reviews the learning from serious and moderate harm incidents and

complaints focusing on four core categories of root cause of which the three key areas identified were Clinical Care, Access and Waiting and Communication. The report identifies that there continues to be a theme throughout the categories of harm of the impact of human factors on patient safety, this was noted in previous reports and the thematic review undertaken of 2014/15 incidents. Human Factors has been identified as one of the Trust’s Quality Priorities for 2016/17 and will be the subject of a review overseen by the Trust’s Quality Development Forum. Other areas of learning include actions associated with confirmation bias, incomplete patient clinical records and communications.

1.4 It is noted that demand and the associated impact on the availability of resources

remains a factor within incident and complaint investigations. The Trust is working collaboratively with commissioners to understand and acknowledge the risks and put into place actions to address the concerns.

1.5 The actions identified within this report which are to be taken forward are:

A review of the human factors associated with errors within the telephone triage process identifying key actions to improve safety;

The inclusion of an article on confirmation bias within the Trust’s Reflect newsletter to raise awareness of this issue;

The development of an Emotional Resilience course;

Consideration of a joint policy with the police service regarding silent calls.


Page 3 of 31

2. Patient Safety and Experience Activity

Serious Incidents 2.1 16 serious incidents were confirmed during the reporting period (0.002% of patient

contacts) as compared to 13 during the same period for 2014/15 representing a increase of 23.1%. They represent 0.5% of the adverse incidents reported during the period.

Moderate Harm Incidents 2.2 In the reporting period 12 moderate harm incidents (0.0017% of patient contacts)

were confirmed compared to 12 in the same period for 2014/15 which represents stability within this catergory of harm.

Complaints 2.3 504 complaints were received during the period 1

st November 2015 to 29

th February

2016 (0.075% of patient contacts). This compares to 457 complaints received for the same period during 2014/15), an 11% increase for the same period. Year to date figures show a total of increase of 17%.

2.4 The following table and charts demonstrate how the complaints were split by

service line: Complaints by service line (1 November 2015 - 29 February 2016 and 2014/15 comparison) Total Complaints 01/11/14 to 28/02/15

A&E

PTS

OOH

NHS 111

Other

312 20 25 98 2

Total Complaints 01/11/15 to 29/02/16

A&E

PTS

OOH

NHS 111

Other

373 16 42 71 2

Complaints Currently Under Investigation YTD

A&E PTS OOH NHS 111 Other

138 8 20 24 0


Page 4 of 31

2.5 A Level 3 complaint is a comment, concern or complaint which requires a more

complex investigation or has resulted in a detrimental outcome (of a moderate level) for the patient, or a complaint that was considered as a Serious Incident but deemed not to meet the criteria. Of the 412 complaints closed within the same reporting period, only 28 were deemed to have caused a moderate level of harm, resulting in a Level 3 PE investigation. Of the 28 moderate harm level 3 complaints, 26 related to the A&E service line and two related to the UCS service line

Adverse Incidents 2.6 The Trust received 3,007 adverse incidents and Health Care Professional Feedbacks

(HCPFs) during the reporting period (0.45% of patient contacts). This compares with 2874 adverse incidents and HCPFs during the same four month period in 2014/15, an increase of 133 (5%).

2.7 Whilst there continues to be a year on year decrease in incidents reported relating to

NHS 111, there has been a 25% increase in incidents reported relating to the A&E service line. During the reporting period, 2,052 incidents relating to A&E were reported compared with 1,647 during the same period in 2014/15.

2.8 To break this down further, whilst incidents relating to A&E service lines reported

from external sources have increased by 18%, incidents reported internally by members of Trust staff have increased by 25% (1,896 incidents in 2015/16 compared with 1,513 in 2014/15). 197 of these incidents can be attributed to the recently implemented Non Injury Faller Process. This process, developed by the Trust’s Right Care team, seeks to address incidents of enforcement of ‘no lifting’ policies by care providers, where an ambulance response has been requested in order to simply assist with lifting an uninjured patient.

2.9 Significant increases in reporting figures have also been noted for incidents relating

to ambulance delays and incidents of ‘inappropriate or unnecessary 999 calls’. The latter being mainly from ambulance crews concerned about the outcome of triage undertaken by NHS111, predominantly by an external 111 provider. Additionally there was a significant increase in reports relating to ‘delays/difficulties in obtaining clinical assistance’, these typically relate to issues arising within the care pathway;

68% 4%

6%

22%

0%

Complaints by Service Line YTD 2014-15

A&E

PTS

OOH

NHS 111

Other

74%

3%

8%

14% 1%

Complaints by Service Line 2015-16

A&E

PTS

OOH

NHS 111

Other


Page 5 of 31

referrals on to community services such as GPs and mental health services, lack of adherence to hospital admission criteria, lack of response to hospital ATMISTs etc. The reporting of these incidents are again strongly encouraged as part of the Trust’s Right Care initiative, ensuring that patients receive the most appropriate care and supporting the healthcare economy.

2.10 The following table and charts demonstrate how the adverse incidents and HCPFs

were split by service line:

Adverse Incidents by service line (1 November 2015 – 29 February 2016 and 2014/15 comparison) Total Incidents 01/11/14 to 28/02/15


1,647 1 129 732 365

Total Incidents 01/11/15 to 29/02/16


2,055 6 122 528 296

Adverse Incidents Currently Under Investigation


1,040 5 295 1,167 223

59%

0% 4%

25%

12%

Adverse Incidents by Service Line YTD 2014 - 15

A&E

PTS

OOH

NHS 111

Other70%

0% 5%

14%

11%

Adverse Incidents by Service Line YTD 2015 - 16

A&E

PTS

OOH

NHS 111

Other


Page 6 of 31

3. Learning

3.1 The following table sets out the root causes identified following investigation into serious and moderate harm incidents and moderate complaints (i.e. investigations undertaken and complete) during 1 November 2015 – 29 February 2016. These have been grouped under subject codes, taken from complaint coding to allow comparison across complaints and incidents.

3.2 The number of level 3 complaints, deemed to have caused moderate harm to the

patient through the investigation appears to be high this is due to the fact that there are normally multiple root causes identified during a complaint investigation due to the multifaceted nature of the complaint and the service lines involved.

Root Causes Serious

Incidents Moderate Incidents

Moderate Complaints

Total

Clinical Care – missed sepsis,

moving and handling including lack of immobilisation,

incorrect use of equipment,

incomplete assessment, remote caller

incorrect pathway

poor PCR completion,

misinterpretation of clinical signs

clinical triage

Inadequate safety netting when discharged at home

Poor pain management

Missing neurological symptoms associated with headache or CVE

No capacity assessment

4

3

23 actions 30

Access and Waiting – demand/limited resources,

below core resourcing,

delayed call backs,

management of resources,

welfare calls not made

resource not dispatched at first opportunity,

incorrect hospital,

confirmation bias

Duplicate Call policy not followed

1 3

12 actions 16


Page 7 of 31

Root Causes Serious Incidents

Moderate Incidents

Moderate Complaints

Total

Communication – failure to probe on questioning,

poor communication with control and patients at RTC,

poor location information taken by control,

delayed response to remote location, information disregarded,

handover from OOH to 999,

lack of clarity around remote callers

Not reporting accidental injury to patients on Datix

‘Silent call’ passed to police not ambulance

Poor communication with relatives

1 0 6 actions 7

Infrastructure – Hub system error

IT process error

1

0 0 1

No Root Cause Identified 1 0 0 1

3.3 The table above illustrates that the area of Clinical Care is the most commonly

identified root cause with the highest number of remedial actions. It is important to recognise that this category also includes the care afforded by telephone triage. These incidents are often difficult to categorise and may also appear in the communication category under a failure to probe or similar.

3.4 A theme of Human Factors has been identified previously and an in depth analysis

of the issues associated with human factors will be taken forward within the relevant service lines supported by the Patient Safety Manager. Further work on the theme of staff behaviour will be undertaken and this has been discussed at the Trust’s Quality Development Forum.

3.5 Examples of learning from each of the identified root cause themes are set out

below:

Clinical Care

3.6 Within this period there have been four Patient Safety incident investigations relating to clinical care and 23 clinical care actions highlighted as a result of complaints. There have been no overriding themes identified by the Patient Experience and Patient Safety teams. Clinical Care has been identified as a topic to be reviewed by the Quality Development Forum in 2016/17.

3.7 In terms of concerns relating to clinical care issues during face to face

assessments, the learning points were:

Confirmation bias – this is an emerging theme that has been previously muted within Serious Incident review meetings and is a theme that has also been highlighted through complaint investigations. Confirmation bias occurs when a


Page 8 of 31

clinician allows other factors to cloud their assessment and diagnosis of a patient – for instance if a patient is nervous of travelling to hospital they may tailor their answers to convince you they are feeling better than they are. Clinicians should continue with a full assessment and questioning in order to understand the full picture. Confirmation bias can lead to clinicains making inadequate treatment plans for their patients as they have negated to consider all of the differential diagnoses. An article regarding confirmation bias will be included within a future edition of the Trust’s Reflect publication.

Incomplete Patient Clinical Records (PCR) – this theme has been idenfied through the complaint investigations. Examples of incomplete PCRs within this reporting period include, the recording of less than two complete sets of observations and the lack of a systematic assessment using the ‘Medical model’. This has led to poor decision making with regards to non-conveyance and safety netting. The Individuals concerned have received further training from the Trust’s Learning and Development Team or GP Lead.

The Trust has also noted an ongoing theme in relation to spinal care. This was highlighted previously as a trend and the Medical Directorate revisited the guideline producing a supplement. Initially the reporting figures reduced however it has become evident that cases have still been occurring and have been coming to light via delayed reporting routes. There appears to be a discrepancy in understanding and application of the spinal guidelines which is resulting in staff not treating patients with potential spinal injuries appropriately. Currently there are five serious incidents relating to spinal care. In order to address this immediately an article reinforcing the guidelines is to be placed in the Trust’s weekly bulletin and a special edition of Reflect will be produced prior to any recommendations from the serious incident investigations themselves. It should be stated that these cases are outside the reporting period of this paper but are still worthy of noting to the Board.

Human Factors 3.8 Human factors can influence how people behave and perform. In the context of

the Trust, human factors are environmental, organisational and job factors, and individual characteristics which influence behaviour.

3.9 In this reporting period, learning in respect of behaviours has identified learning

resulting in:

Remedial training on clinical guidelines and supervised shifts;

Reflective practice.

The human factors that influence those behaviours will be part of a bigger piece of work which will be undertaken by the Patient Safety team and overseen by the Trust’s Quality Development Forum.


Page 9 of 31

3.10 The Trust has met with an expert in Human Factors investigations methodology and will be liaising with the Academic Health Science Network regarding moving this area of work forward.

3.11 As stated in the last report, telephone triage inherently is subject to issues of

Human Factors and potential error given the nature of the the system. One of the Trust’s Quality Priorities for 2016/17 is to undertake a review of patient safety incidents where telephone triage errors were identified as a concern and analyse these using an agreed human factors model with a view to developing proposals for improvement.

Access and Waiting 3.12 Of the remedial actions relating to access and waiting, a small number of actions

relate to dispatching errors. There was no identified relationship between each of

the cases and individual learning actions for the staff involved were put into place. 3.13 In the period 1 November 2015 to 29 February 2016 demand and resourcing

continued to be an issue. As referred to in previous PSE reports, the Trust continues to face two acute challenges; demand for services which is growing by more than 6% per year; and challenges in resourcing to meet that demand. The Trust aims to deliver the very best service it can to its patients within these constraints, despite that a number of complaints and incidents have identified demand and the availability of resources as a root cause. In order to address this issue, the Trust has developed an improvement plan and holds twice weekly performance briefings attended by representatives from all key functions. It has been agreed that the Trust and Commissioners will work collaboratively to understand where they can best concentrate resources in order to provide the greatest improvement and to focus on the external factors which impact demand.

3.14 Demand and resourcing shortfalls with the Trust’s OOH GP services have impacted

directly on achieving timely consultations and return telephone calls from OOH GPs. This has also impacted on ambulance response times as attending ambulance crews have had to remain on scene waiting for a GP to return their call. Assurance has been provided by the Urgent Care Operations Manager (Dorset) that that the GP rotas are reviewed daily to maximise cover.

Communication 3.15 The area of communication skills has been identified as a theme by the Trust’s

Quality Development Forum in relation to complaints and adverse incidents, this has subsequently been linked to emotional resilience of staff. It is anticipated that the Trust’s new Peer Support Network will support staff in this area and in addition it was proposed that the Trust develop an Emotional Resilience course for accreditation.

3.16 Individual action has taken place as a result of complaints regarding the attitude of

staff which includes attendance at a Customer Care course.


Page 10 of 31

3.17 As a result of two complaints regarding communication incidents staff were

reminded of the need to report incidents of accidental injury to patients in accordance with the Trust’s Adverse Incident Policy. Such reporting would also give the Trust the opportunity to proactively contact patients to apologise.

3.18 As a result of a silent call being passed to the Police Service, as opposed to the

Ambulance Service, the Trust is considering whether a joint policy with British Telecom and the Police Service might be appropriate. At present, such calls would only be passed to the ambulance service if noise could be heard on the line. Such joint working could result in a more timely response to patients in need of clinical assessment.

4. Transparency

Duty of Candour 4.1 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.

4.2 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.

4.3 There are stipulated timescales and notification requirements in relation to the

completion of the investigation and communication with patients or their next of kin. One of the requirements is that contact is made with patients or their next of kin within 10 working days of the confirmation date of a serious or moderate incident.

During the reporting period, this timescale was met for 13 of the 28 moderate and serious incidents confirmed. It is of note that at the time of completing the report, that 10 of these were not completed within the 10 working day deadline due to the nature of the incidents. The outcome of the risk assessment completed for each case was that the Duty of Candour contact should take place later in the investigation process. For the remaining five incidents; two cases were outstanding, one case the Trust were unable to trace NoK details, one case the NoK was ascertained as the patient’s friend, however the Trust could not prove that they were the patient’s legal representative and for one case it was deemed that contact was not in the best interests of the NoK due to sensitivities and legal issues.

Pro-Active Apologies 4.4 The Trust introduced the proactive apology process in July 2014 as it was

considered that there were some instances where a patient’s experience of the service received was not of the standard that the Trust would normally expect and that an apology would be appropriate. Proactive apologies are related to incidents


Page 11 of 31

where no prior contact has been made or a where a complaint has been received by the patient.

4.5 One proactive apology was made during the reporting period, this case related to

an incident involving a carry chair. It is of note that the Patient Safety team now encourage local management teams to verbally apologise to patients and their families when deemed necessary as an acceptable and more welcomed response.

5. Patient Engagement

Compliments 5.1 A total of 669 compliments were received during the reporting period. The content

of compliments often refers to the elements of care that were most important to the author of the feedback. Quite often, compliments highlight the compassion displayed to them or their loved ones and this is regularly cited to be the most important aspect of their experience.

5.2 The Patient Engagement Team now record the presenting condition, where

available, referred to in the details of incidents from which plaudits arise. The conditions referred to during this reporting period included chest pains (including heart attack/cardiac events), maternity related cases and falls.

5.3 Formalising a ‘thank you’ to clinical staff is often part of the healing process for

patients, and those around them. Some of the consistent themes relating to plaudits are that staff:

Ensured that the journey (drive) to the receiving unit was as comfortable as possible to reduce minimize pain/discomfort;

Ensured that patients understood the care being provided and that they, and their family, were comfortable with the situation before leaving the scene;

It was important to some patients to share their exceptionally positive experiences of the service they received to balance negative reporting.

Patient Surveys 5.4 The Trust is required to conduct patient experience surveys for NHS111, GP Out of

Hours and PTS in accordance with its contractual requirements. Whilst there is currently no contractual requirement to undertake a 999 service patient survey, the Patient Engagement Team hopes to develop this activity during 2016/17. Full patient survey data is included at Annex D.

5.5 During the period 1 November 2015 to 29 February 2016 the Trust carried out

NHS111 and GP Out of Hours patient experience surveys.

NHS111 Survey - highlights

The response rate for the NHS111 survey during the period was 25%.


Page 12 of 31

Concerns regarding triage and disposition results have been presented by survey respondents.

73% of respondents cited being very satisfied with the service they received from NHS 111

GP Out of Hours Service - highlights

The response rate for the GP Out of Hours survey was 23%.

Comments from survey respondents are largely partially or entirely positive.

89% of survey respondents indicated that they felt listened to by healthcare professionals during their encounter with the service.

5.6 Comments from patients who responded to the surveys included:

NHS 111 – ‘A useful and good service. I hope it prevents many unnecessary 999 calls. I did have to answer too many questions’.

GP OOH – ‘Long list of pointless and irrelevant questions before we got to the substance of why we called.’

GP OOH – ‘I was treated with dignity and respect at all times and received good advice and care.’

NHS 111 – ‘I received an excellent, rapid and responsive service which was a huge help to me at a time of crisis - in my own home. I am extremely grateful.’

5.7 From the quantitative and the qualitative results of the surveys, evidenced in part

within the paragraphs above and the attached appendices, the Trust can take assurance that the services are delivering a good quality patient experience in many cases. There will, however, be occasions when the service delivered does not meet the expectations of patients, and the main themes for comments from patients who expressed that their experience was not entirely positive were:

Waiting times/delays – survey respondents have cited delays in being seen by clinicians which often adds stress/worry to those concerned.

Triage – survey respondents continue to highlight their dissatisfaction regarding the level and detail in the triage process.

Local service/previous service provision – survey respondents have highlighted a preference for a service similar to the previous OOH provision that would allow patients to be seen by local clinicians. Survey respondents have also cited a preference to be seen/treated by clinicians who are known to them (i.e. own GP with access to medical records etc).

5.8 As the surveys are returned to the Trust anonymously, it is not possible to reconcile

comments whether positive or otherwise to particular staff or events.


Page 13 of 31

Friends and Family Test (FFT) FFT for Patients

5.9 The FFT asks service users ‘How likely are you to recommend our service to friends and family if they needed similar care or treatment?’ Answers are given on a 5-point scale of ‘extremely likely’ to ‘extremely unlikely’, with a further option of ‘don’t know’ and the opportunity to comment further. For our Trust the patients who are eligible to answer the FFT are only those who have received see and treat care (999 and GP OOH) and those travelling with the PTS service. NHS 111 patients are currently ‘out of scope’; the Trust asks the FFT question via the patient experience surveys however this is only for best practice and this information is not reported to NHS England.

5.10 Nationally the picture for the FFT in ambulance services is that response rates are

very low. The subject of the value of the FFT has been taken to the national ambulance groups including the Association of Ambulance Chief Executives. Furthermore, efforts have been made to suggest alternate means for gathering patient feedback to NHS England, however these have been rejected to date.

5.11 The Trust has moved the FFT invitation onto the back of the new ‘Left at Home’

leaflet that clinicians leave with patients who are not conveyed. We hope that this will improve response rates as clinicians will not need to remember to offer a separate document to patients.

5.12 It is important to keep in mind when reviewing other ambulance service data that

each service collects FFT data in a different way and this prevents the data being comparable.

5.13 A table is appended to the report which details the FFT for ambulance services in

December 2015 – this is the most current national picture available. 5.14 FFT data for the reporting period is set out at Annex A. .


Page 14 of 31

Staff FFT 5.15 The Trust is required to carry out the Friends and Family Test with its staff to help in

promoting the cultural shift in the NHS, whereby staff will have further opportunity and confidence to speak up, and where the views of staff are increasingly heard and are acted upon. The outcome of the Trust’s Staff FFT is set out below:

Responses1 % of Total

Number of Employees

% would recommend the Trust to friends and family if they needed care or treatment

% would recommend the Trust as a place to work

Yes No Yes No

2014/15

Q1

162 3.5% 86% 4% 59% 28%

Q2

72 1.7% 83% 11% 56% 32%

Q32 1700 42% n/a n/a n/a n/a

Q4

1409 34% 83% 5% 43% 35%

2015/16

Q1

1349 31% 85% 4% 46% 33%

Q2 1198 27% 85% 3% 46% 33%

5.16 The staff FFT exercise was not undertaken during Q3 as the staff survey was

circulated. The HR team will develop local action plans to target those outcomes where the Trust performs less well. These will be generated following the outcome of this year’s staff survey and will include the feedback and results generated from Q1 and Q2 Staff FFT.

Feedback The Trust uses a number of mechanisms to consider the most common themes and trends within patient feedback (both positive and negative); word clouds provide an opportunity for the most frequently used words within complaints and compliments to be highlighted.

2 Test was replaced by Staff Survey in Q3 2014/15.


Page 15 of 31

Words Most Frequently Used by Those Praising the Service

Words Most Frequently Used by Complainants

6. Litigation and Regulation

Regulation 28 Reports from the Coroner 6.1 Under the Coroners and Justice Act 2009, coroners have a duty to make a report

where (a) anything revealed by their investigation gives rise to a concern that circumstances creating a risk of other deaths will occur in the future; and (b) in the coroner’s opinion, action should be taken to prevent this.


Page 16 of 31

6.2 During the reporting period the Trust has received one Regulation 28 report. The

recommendations relate to the Trust’s policy regarding the Mental Capacity Act and the interpretation and application thereof. Unfortunately, the Trust had not been invited to attend the Inquest on this occasion and so had not had an opportunity to clarify the position beforehand.

6.3 The Trust sent a comprehensive response to the coroner within the 56 day deadline detailing:

The different roles frontline and PTS staff play and how this would impact on their application of the Mental Capacity Act;

Confirmation of the process when crews are presented with a patient refusing to be conveyed to hospital;

The dynamic risk assessment conducted by staff on scene when managing the above situations.

6.4 The Coroner’s office has acknowledged receipt of the Trust’s response which will

be forwarded by the Coroner’s office to the patient’s family and the CQC and will be published on the Chief Coroner’s website.

Clinical Negligence Claims 6.5 The Trust has received 2 clinical negligence claims during the reporting period of 1

November 2015 to 29 February 2016. Details are given below:

Reference Service Description of allegations

CN 698 A&E The crew failed to treat the claimant and they subsequently died.

CN 702 111 The patient is reported as having died of septicaemia following contact with their GP, 111 and an OOH GP.

6.6 One clinical negligence claim was closed during the reporting period

Reference Service Description of allegations Outcome

CN 563 A&E Alleged failure to immobilise patient after they were assaulted and stabbed, patient suffered a spinal injury.

Withdrawn

*Reference numbers are issued by Datix and indicate the total number of claims (not just clinical negligence as different prefixes are used for Personal Injury and other claims etc but the numbers follow consecutively, i.e. the next number would be 655 regardless of the prefix


Page 17 of 31

Parliamentary and Health Service Ombudsman 6.7 The Parliamentary and Health Service Ombudsman (PHSO) is the final arbiter for

complaints about the NHS in England where an individual believes there has been an injustice or hardship because an organisation has not acted properly or fairly or has given a poor service and not put things right.

6.8 The PHSO has legal powers to advise the Trust to:-

Compensate if appropriate;

Return the complainant to the position in which they would have been if the maladministration or poor service had not occurred (where possible);

Remedy injustice or hardship. 6.9 During the period 1st November 2015 to 29th February 2016, the Trust was asked to

submit two complaint files for independent review by the PHSO. 6.10 As at 29th February 2016 both cases were still under review by the PHSO, together

with two other case files, one submitted in July 2015 and another submitted in October 2015.

6.11 During this reporting period, the Trust also received written confirmation that two

complaint files, one submitted in July 2015 and another in August 2015, had not been upheld by the PHSO.

6.13 In addition to the above, the Trust also received written confirmation that one file

submitted in March 2015 had been upheld in part by the PHSO. The PHSO’s recommendations state that the Trust should send the complainant a written apology for the failings identified in their report and an action plan to demonstrate that learning has taken place. Both recommendations will be complete during the first week of March 2016.

6.14 A full breakdown of PHSO cases is presented in a separate report to the Board of

Directors on a bi-annual basis.

Learning Disability Programme 6.15 The Trust’s compliance with Learning Disability (LD) requirements is regulated by

the Care Quality Commission (CQC) and Monitor. The Trust will be required to respond to a number of questions regarding LD as part of the new CQC inspection regime. In addition, Monitor’s Access and Outcome indicators require the Trust to certify compliance with access to healthcare for people with a LD, which is given equal weighting alongside the indicators for Red 1, Red 2, A19, and the A&E Wait for Tiverton Urgent Care Centre. The importance of the LD work programme is recognised by The Trust with the programme overseen by the Quality Committee and the Board of Directors.


Page 18 of 31

6.16 The Trust’s patient group, SWAG is going from strength to strength; the group are planning to meet and interview the Trust’s Chief Executive in the spring and have spent some time during the reporting period devising questions for the event and planning to film the interview.

6.17 During the reporting period the Patient Engagement Manager attended the Big

Meeting hosted by Somerset Advocacy. This was a great opportunity for the Trust to introduce themselves to the LD community in Somerset and talk to them about setting up a regular meeting in the area. The meeting went very well and the group have offered lots of ideas for future engagement. Conversations are continuing as to the funding and management of such a group.

7. Recommendation 7.1 Board members are requested to take assurance from this report. Governance Team

Annex A Accident and Emergency Service Line

Feedback received from: Apr – Oct Nov Dec Jan Feb 2015/16

YTD Nov-Feb 2014/15

Total 2014/15

Compliments 1253 157 131 144 177 1862 557 1783

Friends & Family Test

Number of returns 159 14 12 5 10 200 NA n/a

% that would recommend the Trust 89 93 83 80 6 87 NA n/a

PALS (General Enquiries) 421 63 64 73 56 677 206 625

Comments, Concerns & Complaints3 617 78 76 106 113 990 312 866

Ombudsman Referrals Upheld 1 in part 0 0 0 1 in part

2 in part 0 1

Never Events 0 0 0 0 0 0 0 0

Serious Incidents Confirmed4

(including from Complaints) 9 3 3 4 3 22 10 39

Moderate Incidents 19 1 3 2 3 28 11 35

Pro-Active Apologies 21 0 1 0 0 22 33 51

Adverse Incidents 2,696 431 408 506 553 4,594 1,513 5,405

HCP Feedback 251 25 20 68 44 408 134 508

Regulation 28 Recommendations Received 1 0 0 0 0 1 2 3

Clinical Negligence Claims Received 4 0 0 1 0 5 X 20

From 1 November 2015 to 29 February 2016, the A&E service line managed 356,686 patient contacts. (Source: Information Cell). Based on this, the A&E service line had:

1.7 compliments per 1000 patient contacts

1.04 complaints per 1000 patient contacts

5.75 adverse incidents per 1000 patient contacts 0.03 serious incidents per 1000 patient contacts

3 Serious Incidents from complaints included in Serious Incident numbers.

4 These figures may be different to previous reports due to Serious Incidents being subsequently downgraded. Downgrades will be reported at the end of the year.

Patient Transport Services

Feedback received from: Apr – Oct Nov Dec Jan Feb 2015/16

YTD Nov-Feb 2014/15

Total 2014/15

Compliments 4 1 1 5 2 13 5 15






Ombudsman Referrals Upheld 0 0 0 0 0 0 0 0

Never Events 0 0 0 0 0 0 0 0


(including from Complaints) 0 0 0 0 0 0 0

0



Adverse Incidents 12 1 0 1 0 14 0 13

HCP Feedback 5 2 1 0 1 9 1 10


Clinical Negligence Claims Received 0 0 0 0 0 0 0 1

From 1 November 2015 to 29 February 2016, the PTS service line managed 33,870 patient contacts. (Source: Information Cell). Based on this, the PTS service line had:



0.17 adverse incidents per 1000 patient contacts

0 serious incidents per 1000 patient contacts



GP Out of Hours Service

Feedback received from: Apr- Oct Nov Dec Jan Feb 2015/16

YTD Nov-Feb 2014/15

Total 2014/15

Compliments 37 3 4 5 5 54 15 38






Ombudsman Referrals Upheld 0 0 0 0 0 0 0 1 in part

Never Events 0 0 0 0 0 0 0 0


(including from Complaints) 3 0 0 0 0 3 0 3




HCP Feedback 91 5 2 8 8 114 30 65


Clinical Negligence Claims Received 0 0 0 0 0 0 1 2

From 1 November 2015 to 29 February 2016, the GP Out of Hours Service (including Tiverton Urgent Care Centre) managed 34,917 patient contacts. (Source: Information Cell). Based on this, the GP Out of Hours service line had:




0 serious incidents per 1000 patient contacts



NHS111 Service

Feedback received from: Apr-Oct Nov Dec Jan Feb 2015/16

YTD Nov-Feb 2014/15

Total 2014/15

Compliments 49 8 6 6 13 82 44 143


9

Number of returns 836 98 84 107 127

1252 NA n/a

% that would recommend the Trust 89 89 92 89 990

89 NA n/a


Comments, Concerns & Complaints10

120 15 19 14 23 191 95 247


Never Events 0 0 0 0 0 0 0 0


(including from Complaints)

4 1 0 1 1

7 3 6




HCP Feedback 256 165 22 41 58 542 577 1,569


Clinical Negligence Claims 2 0 0 0 1 3 1 1

From 1 November 2015 to 29 February 2016, the NHS111 Service managed 243,681 patient contacts. (Source: Information Cell). Based on this, the NHS111 service line had:




0.01 serious incidents per 1000 patient contacts.

9 NHS 111 is not within the scope of the Friends and Family Test. This is a national decision.



Other Trust Activity

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’.

Feedback received from: Apr- Oct

Nov Dec Jan Feb 2015/16

YTD Nov-Feb 2014/15 Total 2014/15

Compliments 49 1 1 2 2 55 34 131

Friends & Family Test n/a n/a n/a n/a n/a n/a n/a


Comments, Concerns & Complaints 1 0 0 0 1 2 2 7


Never Events 0 0 0 0 0 0 0 0


(including from Complaints)

3 0 0 0 1 4 2 3




HCP Feedback 44 6 6 13 5 74 16 22


Clinical Negligence Claims 0 0 0 0 0 0 0 0

12

These figures may be different to previous reports due to Serious Incidents being subsequently downgraded. Downgrades will be reported at the end of the year.

Annex B Incidents by Reporting Category - April 2015 to February 2016

Apr-Oct Nov Dec Jan Feb

2015/16 YTD

Nov-Feb 2014/15

Total for

2014/15

Access, Appointment, Admission, Transfer, Discharge

SIs 0 0 0 0 0 0 0 1

MIs 0 0 0 0 0 0 0 0

AIs 169 30 45 44 72 360 172 580

HCPF 12 1 0 5 24 42 2 19

Abusive, violent, disruptive or self-harming behaviour

SIs 1 0 0 0 0 1 0 0

MIs 0 0 0 0 0 0 0 0

AIs 0 0 0 0 0 0 0 0

HCPF 0 0 0 0 0 0 0 0

Clinical assessment (investigations, images and lab tests)

SIs 5 0 0 1 0 6 0 18

MIs 6 1 1 0 0 8 0 14

AIs 119 54 27 56 76 332 8 12

HCPF 3 1 1 1 0 6 0 4

Consent, Confidentiality or Communication

SIs 0 0 0 0 0 0 0 0

MIs 0 0 1 0 0 1 0 1

AIs 320 45 44 74 77 560 252 1009

HCPF 88 11 5 19 9 132 31 222

Conveyance

SIs 9 3 3 3 3 21 8 17

MIs 11 1 2 2 4 20 6 13

AIs 982 142 124 191 175 1615 536 1763

HCPF 131 17 14 42 9 213 80 276

Diagnosis, failed or delayed

SIs 1 0 0 0 0 1 0 0

MIs 0 0 0 0 0 0 0 1

AIs 2 0 0 0 0 2 0 0

HCPF 0 0 0 0 0 0 1 1

Patient Information (records, documents, test results, scans)

SIs 1 0 0 0 0 1 0 0

MIs 0 0 0 0 0 0 0 0

AIs 78 9 14 6 10 117 66 231

HCPF 10 0 0 6 0 16 6 18

Infrastructure or resources (staffing, facilities, environment)

SIs 1 0 0 0 0 1 1 5

MIs 0 0 0 0 0 0 1 11

AIs 371 43 49 92 134 689 279 849

HCPF 244 160 20 40 59 523 577 1365

Medical device / equipment

SIs 0 0 0 0 0 0 1 1

MIs 2 0 0 0 0 2 0 0

AIs 452 72 70 64 56 714 262 540

HCPF 4 1 0 0 0 5 0 2

Medication

SIs 0 0 0 0 0 0 0 1

MIs 3 0 0 0 0 3 1 2

AIs 315 51 50 51 57 524 209 603

HCPF 19 0 0 3 4 26 5 15

Other

SIs 0 1 0 0 1 2 0 0

MIs 0 0 0 0 0 0 0 0

AIs 3 0 0 0 0 3 2 25

HCPF 0 0 1 0 0 1 0 0

SIs 0 0 0 0 0 0 0 0

MIs 0 0 0 0 0 0 0 0

Security AIs 1 0 0 0 0 1 0 0

HCPF 0 0 0 0 0 0 0 0

Treatment and intervention

SIs 1 0 0 1 1 3 3 8

MIs 3 0 0 0 0 3 4 6

AIs 703 127 104 89 82 1105 330 991

HCPF 136 12 10 15 11 184 56 252

Totals

SIs 19 4 3 5 5 36 13 51

MIs 25 2 4 2 4 37 12 48

AIs 3515 573 527 667 739 6022 2116 6603

HCPF 647 203 51 131 116 1148 758 2174

Annex C Definitions Risk Pyramid Ratio of low, moderate and serious incidents. The Trust is moving towards the correct proportions with the greatest number of incidents in the negligible/low category; and with the smallest number in the serious category.

Serious Incident Those that occur that have the potential to or actually impact patient safety or an organisation’s ability to deliver ongoing health care. Their occurrence demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm to patients or staff, future incidents of abuse to patients or staff, or future significant reputational damage to the organisations involved.

Moderate Harm Incident A patient safety incident that resulted in a moderate increase in treatment and that caused significant, but not permanent, harm to one or more patients. A moderate increase in treatment is defined as a return to surgery, an unplanned readmission, a prolonged episode of care, extra time in hospital or as an outpatient, cancellation of treatment, transfer to another area such as intensive care as a result of the incident or a scenario that causes or is likely to cause psychological harm for a continuous period of at least 28 days.

Adverse Incident Any event or circumstance arising that could have or did lead to unintended or unexpected harm, loss or damage to any individual or the Trust. Adverse incidents may or may not be clinical and may involve actual or potential injury, mis-diagnosis or treatment, equipment failure, damage, loss, fire, theft, violence, abuse, accidents, ill health, near misses and hazards.

Duty of Candour (DoC) A duty to be open with our patients, informing them of any moderate or serious patient safety incident in which they have been involved. When ‘being open’, the Trust should

acknowledge the incident occurred, apologise to the patient or next of kin, and explain why the incident occurred and what actions will be put in place to try and prevent a recurrence.

Complaint A complaint is defined as any expression of dissatisfaction from a patient, or their duly authorised representative, or any person who is affected by, or likely to be affected by, the action, omission or decision of the Trust and/or its’ staff, whether justified or not.

Moderate Level 3 Complaint A comment, concern or complaint which requires a more complex investigation or has resulted in a detrimental outcome for the patient or a complaint that was considered as a Serious Incident but deemed not to meet the criteria.

Annex D

The table below shows the responses to three important aspects of the surveys from across UCS; the responses are totalled from NHS 111 and GP OOH. The questions concern –

Being treated with respect and dignity

Feeling involved in decisions regarding care and treatment

Feeling listened to (this refers to both call takers and clinicians as relevant)

November December January February

Res

pec

t an

d D

ign

ity

Degree Totals

Proportion of

Responses (%) Degree Totals

Proportion of


Proportion of


Proportion of

Responses (%)

Yes, completely 126 93




Yes, to some extent 8 6




No 1 1 No 2 2 No 1 1 No 6 4

NS/CR 0 0 NS/CR 1 1 NS/CR 1 1 NS/CR 2 1

Invo

lved

in

trea

tmen

t d

ecis

ion

s

Degree Totals

Proportion of


Proportion of


Proportion of


Proportion of

Responses (%)

Yes, definitely 99 72








No 10 7 No 8 7 No 7 5 No 12 8


Did

yo

u f

eel l

iste

ned

to

(i

ncl

ud

es a

ll ca

ll ta

kers

to

clin

icia

ns)

Degree Totals

Proportion of


Proportion of


Proportion of


Proportion of

Responses (%)









No 5 4 No 5 5 No 3 2 No 7 4


FFT for ambulance services in December 2015

PTS Responses Eligible

Patients Would Rec.

Would not Rec.

Response rates

SWAST 3 7,979 100% 0% 0.4% ISLE OF WIGHT NHS TRUST 9 818 44% 0% 1.%

CHELSEA AND WESTMINSTER HOSPITAL NHS FOUNDATION TRUST 5 426 80% 0%

1.%

GUY'S AND ST THOMAS' NHS FOUNDATION TRUST 354 24,442 91% 1%

1.%

IMPERIAL COLLEGE HEALTHCARE NHS TRUST 124 27,841 87% 13%

0.4%

LONDON AMBULANCE SERVICE NHS TRUST 2 3,823

Not completed

Not completed

0.5%

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST 1 8,214

Not completed

Not completed

0.01%

YORKSHIRE AMBULANCE SERVICE NHS TRUST 109 81,065 95% 2%

0.1%

NORTH WEST AMBULANCE SERVICE NHS TRUST 491 76,664 95% 4%

0.6%

NORTH EAST AMBULANCE SERVICE NHS FOUNDATION TRUST 125 54,263 88% 1%

0.2%

EAST MIDLANDS AMBULANCE SERVICE NHS TRUST 0 6,258 NA NA

0

WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST 3 47,123

Not completed

Not completed

0.006%

EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST 47 41,348 96% 0%

0.1%

SOUTH EAST COAST AMBULANCE SERVICE NHS FOUNDATION TRUST 4 35,708

Not completed

Not completed

0.1%

SOUTH CENTRAL AMBULANCE SERVICE NHS FOUNDATION TRUST 78 42,809 73% 19%

0.2%

ARRIVA TRANSPORT SOLUTIONS 274 84,990 83% 10% 0.3%

LIMITED

NSL CARE SERVICES HQ 779 104,166 97% 1% 0.7%

999 See and Treat Responses Eligible

Patients Would Rec. Would not

Rec. Response rate

SWAST 12 29,591 83% 17% 0.04%

ISLE OF WIGHT NHS TRUST 0 424 NA NA 0

LONDON AMBULANCE SERVICE NHS TRUST 3 24,590 Not

completed Not completed 0.01%

YORKSHIRE AMBULANCE SERVICE NHS TRUST 8 14,233 100% 0% 0.06%

NORTH WEST AMBULANCE SERVICE NHS TRUST 44 22,236 91% 7% 0.2%

NORTH EAST AMBULANCE SERVICE NHS FOUNDATION TRUST 20 7,494 100% 0%

0.3%

EAST MIDLANDS AMBULANCE SERVICE NHS TRUST 13 16,650 92% 8% 0.08%

WEST MIDLANDS AMBULANCE SERVICE NHS FOUNDATION TRUST 4 27,989

Not completed Not completed

0.02%

EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST 28 26,026 96% 4% 0.1%

SOUTH EAST COAST AMBULANCE SERVICE NHS FOUNDATION TRUST 25 24,968 92% 8%

0.1%

SOUTH CENTRAL AMBULANCE SERVICE NHS FOUNDATION TRUST 7 16,171 100% 0%

0.04%


Page 1 of 9


Title: Information Governance Year to Date Report

Prepared by: Debbie Bridge, Information Governance Manager

Presented by: Francis Gillen, Executive Director of IM&T

Main aim: To provide assurance on delivery of the Information Governance programme

Recommendation: The Board of Directors is asked to note for assurance the information provided.



Page 2 of 9

Information Governance Year to Date Report 1. Introduction 1.1 This paper is presented to report on the YTD position covering the period April

2015 – February 2016 including:

The Information Governance (IG) Toolkit Freedom of Information (FoI) Act requests Data Protection (Subject Access Requests) Records Management Adverse Information Governance incidents

2. Information Governance Toolkit

2.1 The IG Toolkit is an annual self-assessment tool which covers a very broad range of IG issues including the general management and governance of the Trust, confidentiality and information security, data quality, training and business continuity. Significant work is required on an annual basis to ensure the Trust meets Level 2 for all 35 requirements which is the minimum expected by Commissioners.

2.2 Audit South West completes an annual audit of The Trust’s IG Toolkit prior to the year-end submission. The initial audit took place in October 2015 with 12 of the 35 requirements being reviewed. The initial report was released in November 2015 and the follow up audit is due and will take place in early March 2016. The initial report identified that the primary area for attention is in relation to Information Governance Training and the need to demonstrate 95% compliance. Of the policies identified in the initial audit as being beyond their review date one policy has still to be updated.

2.3 Local IG network discussions have indicated many NHS organisations have

expressed real concern at meeting the 95% compliance target and indeed whether the target is reasonable and achievable given the current challenges and constraints the NHS is facing. Representations to the HSCIC have not been helpful or productive and many organisations will be declaring Level 2 by submitting action plans to detail how shortfalls in compliance will be achieved in 2016/17. Although this doesn’t address the root causes of compliance failure it is a pragmatic approach in the face of lack of recognition and support at the national level.

2.4 Currently 72% of staff have completed the online IG Training for 2015/16, the IG Department is now reviewing with service lines what additional IG Training is already incorporated into induction and new systems training with a view to including these staff in the published figures where appropriate, currently reviews show this would increase the figure to 77%. It is proposed that future IG Training


Page 3 of 9

will be based on an e-learning solution delivered through an additional module available as part of the ESR (Electronic Staff Record) and accessed through the Trust intranet.

3. Freedom of Information (FoI) Act Requests

3.1 The volume of FoI requests received YTD has shown a 22% increase on comparative figures for the previous year. Of the 218 requests completed since the 1st April 2015, 208 have been replied to within the 20 day legislative time limit, a performance of 95.4% compared to the target of 95%.

3.2 Breakdown of FOI requests

Table 1: Shows a breakdown of requests by requestor type, the theme of many requests where the requestor type is unknown indicates a significant proportion are likely to be generated by commercial organisations, The majority of requests therefore appear to originate from the business sector and media sources.

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

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 14

Trust 15/16 24 14 26 22 17 25 25 18 19 27 31

0

5

10

15

20

25

30

35

Chart 1: Monthly Totals of FoI Requests received


Page 4 of 9

Table 1: FOI Requests by requestor type

Requestor 2014/15 2015/16 (YTD)

Unknown 39.8% 43.3%

Media 27.3% 21.9%

WDTK (What Do They Know Website) 8.3% 9.3%

Student/University 6.0% 8.5%

Commercial 8.8% 6.5%

Local Authority / Gov Dept /MP (Researcher) 1.4% 4.5%

Ambulance Service (Current/Ex) 2.8% 2.4%

Action Group / Charity 2.8% 2.0%

Trade Union 1.0% 0.8%

Patient or Representative 1.0% 0.4%

Solicitor 1.0% 0.4%

Table 2: Shows a breakdown of requests by topic, the contracts classification is likely to come largely from the commercial sector, other topics which dominate relate to SWASFT’s key activities, staffing and resources.

Table 2 FOI Requests by Topic

Topic 2014/15 2015/16 (YTD)

Contracts / Facilities / Services / Training Provision / Corporate Protocols

17.4% 23.9%

Ambulance Activity / Performance / Protocols (Non Clinical) / Resourcing

19.4% 23.5%

Staffing (Policies (Guidance) / Structure / Absence / Pay / Redundancy / Disciplinary / Conduct / Leaving Reasons / Recruitment)

14.8% 18.6%

Clinical Activity / Protocols / Outcomes / Drugs 10.2% 7.7%

Fleet / Lease Cars / Driving Protocols / Speeding (Parking) Tickets / Medical Equipment

7.4% 6.5%

Private Providers / Agency Staff 4.2% 5.3%

Finance (Costs / Expenses / Systems) 5.6% 3.6%

First Responders 3.2% 2.8%

Complaints / Datix / SIs / Claims 4.2% 2.8%

Handovers 4.2% 2.0%

Mixed Requests 4.6% 1.6%

Assaults / Warning Markers / Thefts / Freq Callers / Hoax / Inappropriate Calls

5.1% 1.6%


Page 5 of 9

4. Data Protection Act (Subject Access Request) Disclosures

4.1 There has been a 16% increase in requests YTD with 2049 requests received compared to 1773 in the same period last year. The number of requests received in February 2016 shows a step increase to those received within the same period in previous years. The increase in requests is primarily originating from Drs (GPs and Hospital Consultants) and Solicitors. The Drs requests are believed to have been prompted by the introduction of ePCR now patients and hospitals no longer having ready access to paper copies of ambulance PCRs, medical claims activity reflects the changing nature of opportunistic litigation.

4.2 Requests from the Police continue to dominate those received, accounting for

52.6% of the requests received YTD as shown in Chart 3.

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

Trust 2013/14 109 142 138 175 177 158 186 176 125 176 158 150

Trust 2014/15 145 125 160 179 161 163 171 174 149 183 163 159

Trust 2015/16 156 179 207 198 168 199 179 183 149 200 231

0

50

100

150

200

250

Chart 2: Monthly Totals of Subject Access Requests received


Page 6 of 9

5. Records Management

5.1 The IG department administers the archiving of paper based records on behalf of the Trust. The Trust’s current archive provider is Iron Mountain; historically Crown Records Management and Restore have been used and some archive records are still accommodated within these organisations. These records will eventually either be moved into Iron Mountain or disposed of in accordance with record retention schedules. Keeping archived records beyond their retention period is not only in contravention of the Data Protection Act but also has significant cost implications for the Trust.

5.2 Table 3: Shows a breakdown of archived records and the associated costs. This

report has only recently been set up to illustrate the costs to the Trust of archiving records thereby underlining to records owners the importance of reviewing records promptly at the end of their retention schedule.

Table 3: Archived Records Activity & Costs

1080 486 486 1105 507 487

52.6%

23.7% 23.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

0

200

400

600

800

1000

1200

Police Solicitor and MedicalReporting

Other (Data Subject / NHSetc.)

Chart 3: Requests by Source YTD 2015/16

Requests Received Requests Closed % by Requestor


Page 7 of 9

6. Information Governance Adverse Incidents

6.1 All adverse incidents should be reported on Datix following the Trust’s Incident reporting policy. These incidents have been reviewed to identify those relating to Information Governance and the incidents have been coded according to national definitions.

Table 4: Incidents by Type 2015/16 (YTD)

Category Breach Type 2013/14 2014/15 2015/16 (YTD)

A- Corruption or inability to recover electronic data

0 0 0

B- Disclosed in Error 27 (16%) 30 (14%) 38(20%)

C- Lost in Transit 0 3 (1%) 20 (10%)

D- Lost or Stolen hardware 1 (1%) 0 3 (2%)

E* Lost or Stolen Paperwork 96 (59%) 155 (71%) 49 (26%)

F- Non-Secure Disposal Hardware 0 0 0

G- Non-Secure Disposal Paperwork 4 (2%) 2 (1%) 3 (2%)

H- Uploaded to website in error 0 0 0

I- Technical Security Failing (including hacking)

0 2 (1%) 0

J- Unauthorised Access/Disclosure 0 1 (1%) 13 (7%)

K- Other 36 (22%) 26 (12%) 66 (34%)

*Please note these are usually PCRs which can’t be sourced but are not confirmed lost/stolen

The most significant issue has traditionally been missing PCRs although these figures are steadily reducing with e-PCR rollout. Most of the IG Incidents reported relate to accuracy availability and security of information. Although these are IG Incidents they do not fit the national profile which specifically relates to data breaches. In light of this we have provided a breakdown of the category K – Other to indicate the area of concern.


Page 8 of 9

Table 5 shows the type of incident by the information they relate to.

Finally Table 6 and Chart 4 show where these incidents are happening. This shows a wide variation in the number of incidents being reported across the Trust. Table 6

0 20 40 60 80 100

111

HART

Hub

Ops East

Ops North

Ops West

PTS

Support Services orUnclear

UCS

Chart 4: IG Adverse Incidents by Function

13/14 14/15 15/16


Page 9 of 9

6.2 The Information Commissioner has the power to fine organisations up to £500,000 for breaches of the Data Protection Act. During 2015/16 (YTD) three fines have been issued to public sector organisations, as shown in Table 7 below. There have been 17 other fines totalling £1.6 million issued to private sector organisations during the same period.

Table 7: Fines issued in 2015/16 by the Information Commissioner to public sector organisations for breaches of the Data Protection Act

Date How Much

What For No. of Persons/ Patients Impacted

10 March 2016

£5,000 To David Lammy MP for making nuisance calls. Mr Lammy instigated 35,629 calls over two days, playing a recorded message that urged people to back his campaign to be named the Labour party candidate for London Mayor.

35,629

04 November 2015

£200,000 To the Crown Prosecution Service - laptops containing videos of highly sensitive Police interviews were stolen.

43

18 May 2015

£160,000 To South Wales Police - Losing a video recording which formed part of the evidence in a sexual abuse case.

Despite containing a graphic and disturbing account, the discs were unencrypted and left in a desk drawer.

1

7. Other Information Governance issues & topics

7.1 The government has announced that there will be 'no legal changes' to Freedom of Information legislation following its controversial review.

7.2 The Article 29 Working Party has issued a statement on the implementation of the

EU General Data Protection Regulation. The document reveals that the Working Party's four priorities are: (1) Setting up the EDPB (European Data Protection Board) structure and its

administration; (2) Preparing the One-Stop-Shop and the consistency mechanism; (3) Issuing guidance for data controllers and processors; and (4) Communication around the EDPB and the Regulation.

8. Recommendation

8.1 The Board of Directors is asked to note for assurance the information provided.

Debbie Bridge Information Governance Manager

Trust Board of Directors Meeting – 31 March 2016

Page 1 of 2

Trust Board of Directors Meeting 31 March 2016

Title: Reputation – Media Monitoring

Prepared by: Louise Bowden, Head of Marketing, PR and Communications

Presented by: Louise Bowden, Head of Marketing, PR and Communications

Main aim: To provide assurance that the Trust’s reputation in the media is being monitored and that appropriate communication actions are being planned.

Recommendations: The Board of Directors is asked to take assurance from the information provided.

Previous Forum:

Trust Board of Directors Meeting – 31 March 2016

Page 2 of 2

Reputation – Media Monitoring

1. Media monitoring

1.1 Previously the Trust has relied on free-use media monitoring. The main concern with this reliance has been that it only captures online media mentions and not all print and broadcast media coverage.

1.2 This approach also does not give the Trust the opportunity to analyse the media coverage for example to understand reputational impact, whether positive or negative mentions of the Trust’s activities are coming from a handful of publications or journalists, regional, national or trade or whether it is across the media landscape.

1.3 A new media monitoring and evaluation service is now in place which allows the Trust’s profile and reputation to be tracked across online, print and broadcast media. This will allow for assessment of proactive media activity through to media coverage at times of crisis.

1.4 Analysis can also be created around key messages to understand the return on proactive media activity investment of time and resources.

1.5 The insights and understanding from the analysis with this new service will inform future media relations activity, for example targeting particular media with particular stories, or helping to shape the proactive media activity plan.

1.6 It is anticipated that full social media monitoring and analytics will be added to this

service at a future date. 1.7 Appropriate licences for this service have been sought. 1.8 This service has been procured within budget.

2. Recommendation

2.1 The Board of Directors is asked to take assurance from this information.

Louise Bowden

Head of Marketing, PR and Communications


Page 1 of 2


Title: Draft Regulatory Framework 2016/17

Prepared by: Helen Braid, Governance and Assurance Manager


Main aim: To present the Board of Directors with the draft Regulatory Framework 2016/17 for approval.

Recommendations: The Board of Directors is requested to approve the draft Regulatory Framework for 2016/17



Page 2 of 2

Draft Regulatory Framework 2016/17

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 2016/17 for approval.

3. 2015/16 Regulatory Framework 3.1 The attached Framework has been drafted based on identified requirements,

reviews and submissions required for 2016/17. 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 and Engagement Team and a mid-year report on compliance will be presented to the Board of Directors.

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 approve the draft Regulatory Framework for

2016/17

Helen Braid Governance & Assurance Manager


Page 1 of 6


Title: Board Annual Declarations


Presented by: Marty McAuley, Trust Secretary

Main aim: Share with the Board our compliance with the annual declarations prior to inclusion in the Annual Report

Recommendations: The Board of Directors is asked to take assurance from the information provided prior to inclusion in the Annual Report.



Page 2 of 6

Board Annual Declarations

1. Introduction 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

2015/16. Each Director has checked and signed their declarations.

3. Annual Salary Disclosure 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.

3.2 All Board Members have confirmed that they are happy for their salary to be

disclosed in the Annual Report.

4. Fit and Proper Person Declaration

4.1 Board Members have all completed a declaration certifying that they believe they meet the Fit and Proper Person standard and declared ongoing compliance with the standard.


Page 3 of 6

5. Declaration of Independence

5.1 All Non-Executives have signed declarations confirming their independence.

6. Recommendation

6.1 The Board of Directors is asked to take assurance from the information provided prior to inclusion in the Annual Report

Marty McAuley Trust Secretary


Page 4 of 6

ANNEX A

DIRECTOR INTERESTS DECLARED DATE OF CHANGE

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

Jennie Kingston (Deputy Chief

Executive/ Executive Director of Finance)

Director of the Association of Ambulance Chief Executives (non remunerated)

Dr Andy Smith (Executive

Medical Director)

GP Partner, 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

Dr Michael Dixon, No Longer Chair 1

January 2016

Sessional OOH GP service work for Devon Doctors Ltd

Partner, Culm Health Plus

Sessional work for SWASFT Urgent Care service (including Out of Hours GP work, 999 GP work and

Tiverton Urgent Care Centre)

Francis Gillen (Executive

Director of IM&T None

Jennifer Winslade (Executive Director of

Nursing and Governance)

Member of the Department of Health Public Health Nursing and Midwifery Model Group

Ceased October 2015

Member of the Senate Council

Local Advisory Board member for Buckland Saint Mary Primary School (Part of the Redstart Learning

Partnership)

Emma Wood (Executive

Director of HR and OD

None


Page 5 of 6

NED INTERESTS DECLARED DATE OF CHANGE

Heather Strawbridge (Chairman)

Director, Ambulance Services Association (Dormant)

Trustee, NHS Confederation Charity

Chair, Urgent and Emergency Care Steering Group, NHS Confederation

Non-Executive Director, Somerset Care Ltd

Chair, HFMA, Chair, NED and Lay Member Faculty

Trustee, Bridgewater College Academy Trust

Chair, South West Chairs Meetings

Member, Chair's Advisory Partnership, NHS Improvement

Jan-15

Mary Watkins (Non-Executive

Director)

Trustee, Hamoaze House, Plymouth

Member, BUPA Foundation Board; BUPA Medical Advisory Panel;

Member, HEFCE UK Healthcare Education Advisory Committee

Discontinued

Non-Executive Director, Aster Group

Chair of PenCLAHRC Management Board

Chair, Peninsula Medical Foundation Discontinued January 2016

Governor, Plymouth University Appointed February

2015

Appointed a Life Peer; Baroness Watkins of Tavistock Appointed

November 2015

Tony Fox (Non-Executive Director)

Director of Operations Royal Mail Group plc

Board Member of Business in the Community Gender Group (Opportunity Now)

Appointed January 2015

Hugh Hood (Non-Executive Director)

Director of Leadership and Culture, BT plc

Chairman of BT Lancashire Services Ltd

Venessa James (Non Executive

Director None

Ian Reynolds (Non-Executive

Director)

Non-Executive Chairman, CHIME (CIC Audiology Service, Exeter)


Page 6 of 6

Chris 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

Robert Davies (Non-Executive

Director)

Chairman of the Trustees Friends of Holy Cross Church, Newton Ferrers, Devon


Page 1 of 3


Title: Membership Engagement Strategy



Main aim: Share the Membership Engagement Strategy with the Board and seek their approval

Recommendations: The Board of Directors is asked to approve the Membership Engagement Strategy

Previous Forum: Council of Governors – Membership and Engagement Sub Group


Page 2 of 3

Membership Engagement Strategy

1. Introduction

1.1 As part of the governance framework of being a Foundation Trust, it is a requirement that we have a Council of Governors and a Membership Strategy.

1.2 Previously the Strategy focused on membership recruitment, and whilst this

Strategy will continue to monitor and develop a representative membership, the primary of focus will be on how we engage with the membership.

2. Aims of the Membership Engagement Strategy 2.1 The Strategy has the following intentions:

Focus on what SWASFT can and should offer our members;

Broaden our outlook to encompass wider public and community engagement;

Work with Governors to deliver a strategy that enables them to fulfil their duties, informing members and the Trust;

Reaffirm the work undertaken to date in line with previous strategies;

Establish a Trust wide Patient User Group that operates locally for ease of access;

Offer engagement to the wider public, membership, hard to reach groups and underrepresented people through the creation of a single engagement plan delivered by a single engagement team;

Recruit, retain and develop a membership which is actively engaged with the Trust.

2.2 To enable the Strategy to be delivered there will be a set of underpinning pledges.

These are designed as the guiding principles, as such the Trust and Governors will together:

Develop governor interaction with the constituencies and the public they are elected to represent through informal and formal routes.

Embed member and public input in service improvement/design initiatives.

Maximize the opportunities for staff, governors, service users and carers to better inform and educate members, the public, and the Trust.

Adopt differentiated communications strategies, including traditional and social media outlets, appropriate to varying needs of the people that we are working with.

Develop wide ranging feedback mechanisms to demonstrate positive effects of voicing opinions and sharing experiences.

Respect the diversity of the membership and wider community acknowledging that one size does not fit all and our approach will need to be bespoke depending upon what we are doing.


Page 3 of 3

3. Consultation 3.1 The Membership and Engagement Sub Group of the Council of Governors has

been consulted in respect of the new Strategy and of their requests for change have been incorporated.

4. Recommendation

4.1 The Board of Directors is asked to approve the Membership Engagement Strategy.


Membership Engagement

Strategy 2016-2021

Version: 1

Approved by:

Date approved:

Name of originator/author: Trust Secretary

Date issued:

Review date:

Page 2 of 10

Trust Strategy Foreword

SWASFT has a number of specific corporate responsibilities relating to patient and staff safety and wellbeing which should be included within all Trust policy and strategy, as a foreword inside the front cover:

Code of Conduct and Conflict of Interest Policy - The Trust Code of Conduct for Staff and its Conflict of Interest and Anti-Bribery policies set out the expectations of the Trust in respect of staff behaviour. SWASFT employees are expected to observe the principles of the Code of Conduct and these policies by declaring any gifts received or potential conflicts of interest in a timely manner, and upholding the Trust zero-tolerance to bribery.

Compassion in Practice – SWASFT will promote the values and behaviours within the Compassion in Practice model which provide an easily understood way to explain our role as professionals and care staff and to hold ourselves to account for the care and services that we provide. These values and behaviours reflect the Trust’s commitment to developing an outstanding service through the conduct and actions of all staff. SWASFT will encourage staff to demonstrate how they apply the core competencies of Care, Compassion, Competence, Communication, Courage, and Commitment to ensure our patients experience compassionate care.

Duty of Candour – SWASFT will, as far as is reasonably practicable, apply the statutory Duty of Candour to all reported incidents where the Trust believes it has caused moderate or severe harm or death to a patient. This entails providing the affected patient or next of kin (within strict timescales) with: all information known to date; an apology; an explanation about any investigation; written follow-up; reasonable support; and the outcome fed back in person (unless they do not want it). The only exception is where making contact could have a negative impact upon the next of kin. SWASFT employees are expected to support this process by highlighting (early) any incident where they believe harm may have been caused.

Equality Act 2010 and the Public Sector Equality Duty - SWASFT will act in accordance with the Equality Act 2010, which bans unfair treatment and helps achieve equal opportunities in the workplace. The Equality Duty has three aims, requiring public bodies to have due regard to: eliminating unlawful discrimination, harassment, victimization and any other conduct prohibited by the Act; advancing equality of opportunity between people who share a protected characteristic and people who do not share it; and fostering good relations between people who share a protected characteristic and people who do not share it. SWASFT employees are expected to observe Trust policy and the maintenance of a fair and equitable workplace.

Fit and Proper Persons – SWASFT has a statutory duty not to appoint a person or allow a person to continue to be an executive director or equivalent or a non-executive director under given circumstances. They must be: of good character; have the necessary qualifications, skills and experience; able to perform the work they are employed for (with reasonable adjustments); able to provide information required under Schedule 3 (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). The definition of good character is not the test of having no criminal convictions but instead rests upon judgement as to whether the person’s character is such that they can be relied upon to do the right thing under all circumstances. This implies discretion for boards in reaching a decision and allows that people can change over time.

Health and Safety - SWASFT will, so far as is reasonably practicable, act in accordance with the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999 and associated legislation and approved codes of practice. It will provide and maintain, so far as is reasonable, a working environment for employees which is safe, without risks to health, with adequate facilities and arrangements for health at work. SWASFT employees are expected to observe Trust policy and support the maintenance of a safe and healthy workplace.

Information Governance - SWASFT recognises that its records and information must managed, handled and protected in accordance with the requirements of the Data Protection Act 1998 and other legislation, not only to serve its business needs, but also to support the provision of highest quality patient care and ensure individual’s rights in respect of their personal data are observed. SWASFT employees are expected to respect their contact with personal or sensitive information and protect it in line with Trust policy.

NHS Constitution - SWASFT will adhere to the principles within the NHS Constitution including: the rights to which patients, public and staff are entitled; the pledges which the NHS is committed to uphold; and the duties which public, patients and staff owe to one another to ensure the NHS operates fairly and effectively. SWASFT employees are expected to uphold the duties set out in the Constitution.

Risk Management - SWASFT will maintain good risk management arrangements by all managers and staff by encouraging the active identification of risks, and eliminating those risks or reducing them to the lowest level that is reasonably practicable through appropriate control mechanisms. This is to ensure harm, damage and potential losses are avoided or minimized, and the continuing provision of high quality services to patients, stakeholders, employees and the public. SWASFT employees are expected to support the identification of risk by reporting adverse incidents or near misses through the Trust web-based incident reporting system.

Page 3 of 10

1. Introduction 1.1 The South Western Ambulance NHS Foundation Trust (the Trust) is committed to

high quality community engagement throughout the area that it serves. A key element of this engagement is the continuing development of a large and representative membership, where members are informed and can choose to become involved and influential in the development of the Trust.

1.2 The Trust developed its initial Membership Strategy in 2008 as part of its work to

become an NHS Foundation Trust. Since that time a number of changes have occurred. As a result the Trust has taken the opportunity to ensure that the Membership Engagement is fit for purpose and delivers a highly effective membership across its existing operating area.

1.3 To support the delivery of the Strategy, the Trust has combined part of the

governance team with part of the communications team to create a single engagement function. This will enable the Trust to deliver a wider range of engagement activities across the trust.

1.4 The Strategy covers a five year span which will see the next phase of the Council of

Governors elected and the work embedded. 1.5 This Membership Strategy sets out the Trust approach to membership recruitment,

engagement and retention, setting out objectives and anticipated outcomes. 1.6 The Trust prides itself on the strong relationships that have been established with

the community and numerous organisations across its operating area and it is committed to maintaining these relationships whilst also creating links with the community it serves.

1.7 The Trust actively contributes to a range of local initiatives and partnerships to

ensure engagement with as much of the community as possible, including those sections which are often deemed as hard to reach.

1.8 The Health and Social Care Act 2012 restates the duty of Foundation Trusts to

ensure their membership is representative of the community they serve. 1.9 We believe that an active membership base enables the Trust to gather a better

understanding of our service users, carers, staff and communities, and builds a sense of ownership among our members. In accordance with this belief, we wish to see our membership functioning as:

an essential element in ensuring accountability;

a link in the chain of governance;

a source of feedback into continuous service improvement and development;

a means of disseminating health & well-being knowledge throughout the wider community;

Page 4 of 10

2. Aims of this Strategy 2.1 The strategy has the following intentions:

Focus on what SWASFT can and should offer our members;

Broaden our outlook to encompass wider public and community engagement;

Work with Governors to deliver a strategy that enables them to fulfil their duties, informing members and the Trust;

Reaffirm the work undertaken to date in line with previous strategies;

Establish a Trust wide Patient User Group that operates locally for ease of access;

Offer engagement to the wider public, membership, hard to reach groups and underrepresented people through the creation of a single engagement plan delivered by a single engagement team;

Recruit, retain and develop a membership which is actively engaged with the

Trust.

3. Pledges 3.1 To enable the Strategy to be delivered there will be a set of underpinning pledges.

These are designed as the guiding principles, as such the Trust and Governors will together: (1) Develop governor interaction with the constituencies and the public they are

elected to represent through informal and formal routes.

(2) Embed member and public input in service improvement/design initiatives.

(3) Maximize the opportunities for staff, governors, service users and carers to better inform and educate members, the public, and the Trust.

(4) Adopt differentiated communications strategies, including traditional and

social media outlets, appropriate to varying needs of the people that we are working with.

(5) Develop wide ranging feedback mechanisms to demonstrate positive effects

of voicing opinions and sharing experiences. (6) Respect the diversity of the membership and wider community

acknowledging that one size does not fit all and our approach will need to be bespoke depending upon what we are doing.

4. Our Membership 4.1 Membership is considered to be a means of empowering local people by informing

them of the work and aspirations of the Trust (as well as wider health issues), enabling them to make informed decisions.

4.2 Membership allows local people to become involved by taking part in Trust activities

and feeding through their views on the services provided by the Trust.

Page 5 of 10

4.3 Membership also enables local people to become even more influential in the governance and development of the Trust, should they chose, by providing them with the opportunity to vote for a Governor to represent them on the Trust’s Council of Governors or by standing for election to become a Governor themselves.

4.4 A well informed and engaged membership provides the Trust with a highly effective

resource in its work to ensure that its decisions and future development are responsive to the communities that it serves. This is not to say that the Trust will always agree with the view of each of its Members. However, an informed and involved membership will lead to the development of a mutual understanding between the Trust and the public that it serves.

4.5 The Trust’s notion of membership is that members can become informed, involved

and influential. Critically, however, whilst the Trust sets out to enable Members to become engaged at a variety of levels, it is the Members themselves who make the decision regarding their level of involvement.

4.6 In order to recruit and retain a membership which is credibly large and

representative of the population that it serves in terms of age, gender, ethnicity and socio economic classification, the Trust carries out on-going analysis of its membership.

4.7 The Trust has two membership constituencies one for its staff and the other for the

public who live within its operating area. 4.8 Public Membership - The Trust’s public membership currently covers Cornwall,

Devon, Dorset, the Isles of Scilly, Somerset, Gloucestershire, Wiltshire and the area formerly known as Avon (ie Bath & North East Somerset, Bristol, North Somerset and South Gloucestershire).

4.9 Staff Membership -The staff membership is currently split into six staff classes

which are based on role definitions. These classes are Accident & Emergency; Administration & Support; Urgent Care Services; and Volunteers.

4.10 Whilst Members of the public and volunteers have to choose to sign up as members,

employed staff who are eligible for staff membership are automatically opted in as a member.

4.11 A table defining the Trust’s membership by constituency, including population

statistics and the minimum number of members required in each Constituency to enable Governor elections to be held is at Appendix 1.

4.12 The Trust began developing its membership during 2008 and by March 2016

membership stood at stood 14,250 for public and 4,914 for staff.

5. Plans for Future Membership Recruitment 5.1 The Trust has used a range of initiatives to recruit new Members, including targeted

mailings; articles in selected publications; chat rooms (for staff); press releases; membership recruitment companies, community meetings and public events.

Page 6 of 10

5.2 The Trust has gained a wealth of experience in respect of recruitment and the effectiveness of each of the methodologies used. The experience gained from previous recruitment activities has informed the approach that we are taking.

5.3 The Trust Secretary and team, in conjunction with the Trust’s Council of Governors

will lead the Trust’s Membership recruitment activities across its operating area. 5.4 Previously the Membership Strategy has focused on recruitment targets. However,

going forward the focus will be on engaging with the membership. We will strive to maintain a healthy engaged membership that is representative of the Trust’s operating area.

6. Engaging with the Membership

6.1 The Trust aims to develop a large and credible membership, where Members are informed about the Trust. Members can choose to become involved with the Trust by whatever means and at a level they chose; and can ultimately influence the development of the Trust and its services. Effective engagement is critical in achieving this aspiration.

6.2 The Trust acknowledges that its Members will not all wish to engage with the Trust

in the same way or to the same degree and therefore aims to offer Members with the level of engagement that they feel most comfortable with. This not only demonstrates from the outset that the Trust is listening to and responding to its Members, but also ensures that engagement activities are appropriately targeted and so more effective.

6.3 The Council of Governors is the pivotal link between the Trust, its membership and

the communities served by the Trust. In addition to leading the work to recruit and retain Members, the Trust’s Governors are responsible for developing a deepening level of mutual understanding between the Trust and the public that it serves. This educational element of the Governor role is essential for maintaining a satisfactory alignment of expectations both on the part of the membership and the Trust itself.

6.4 As a broad approach, the Trust will offer three broad levels of membership:

(1) Informed - Members chose to receive newsletters and information about the Trust.

(2) Involved - In addition to above, Members are also able to take part in surveys, consultations and attend events, if these interest them.

(3) Influential - In addition to the above, Members will also consider standing for election to become a Governor for the Trust.

6.5 The Trust makes available a range of engagement activities to its Membership, with

Members being free to choose those they wish to participate in. 6.6 There will be four types of Trust Engagement Events that will be built into its

engagement programme

Page 7 of 10

(1) Education and Information

This type of event will cover the large shows where the work of the Trust is promoted. This enables us to deliver large scale events where the public can learn more about the Trust, the work we do and we can share key corporate messages. The opportunity for the Governors to engage with the general public whilst supported by clinical and engagement staff is well established.

(2) Patient Contact Groups

This type of event will be led by the Trust engagement team. It will focus on building the relationship with the groups whilst listening to and learning from their views as users. Patient stories would be used to inform the Board and Governors of the view from the public.

(3) Local Events

This type of event will be led by the Trust engagement team and the clinical workforce throughout the Trust. School visits, community groups and who request the attendance of a member of staff to come and talk or demonstrate part of the service. This enables us to inform the public and build good community relations. These events would normally be smaller, more bespoke and higher in number.

(4) Listening Events

The Trust does not have an extensive patient user group and due to the complexity and size of the geography, it would not be practical to have one single group. Instead, the development of listening events would enable the Trust to build opportunities for Trust members to come together in publically accessible venues throughout the Trusts operational area. The events would be run by the Trust engagement team but supported by the Governors in that constituency. The meetings would give us the chance to hear directly from members how service changes could affect them; gain views of future plans and initiatives and allow us to have a regular opportunity to gain feedback.

6.7 Alongside the Trust Engagement Events the Trust will also improve the access to

information for members. This will include:

Publishing 24/7 twice a year

The launch of “Your Membership News” focusing on our work in a defined geography

Further use of Social Media - Instagram, Twitter and Facebook messaging in line with the communications strategy

Improving access information via a Membership section on the Trust website.

Page 8 of 10

6.8 Governors and Members can support this by:

Letting the Trust know what issues they would like to be addressed in newsletters and on its website;

Attending public events where the Trust is in attendance;

Leading surveys and engagement work with the public

Collecting views from the members and public

Taking part in surveys and consultations being undertaken by the Trust and other health-care providers.

7. Resourcing Membership Development 7.1 The Trust has created a single engagement team who will deliver the objectives set

in this Strategy. 7.2 The majority of activities associated with membership, with the exception of printing

of literature, are carried out in-house. This includes drafting documents, design work, mail shots, website development and attendance at community events.

8. Evaluating Success 8.1 The Strategy will have been successful if, in five years' time, the mutual benefits of

member and public engagement are appreciated and promoted at every level of SWAST service design, development and delivery; and if our members and the communities we are here to serve feel well-informed, know they have a voice that is listened to, and consider their relationship with the Trust to be a positive part of their overall well-being.

8.2 Success measures will include:

Turnout in elections

Attendance at events

Candidates coming forward for elections

Member survey responses and satisfaction monitoring

Number of Governor vacancies.

9. Monitoring and Reporting 9.1 This Strategy, is prepared with Governor support and is managed and regularly

reviewed by the Council of Governors. The Trust will ensure that Governors are supported to enable them to evaluate performance against the objectives of the Strategy and report all findings back to the Trust Secretary and the Board of Directors.

9.2 The Governors will monitor:

recruitment figures and how representative the Trust’s membership is of the area that it serves;

membership numbers to see if existing members are resigning from the membership and if so where geographically and why;

participation in activities, such as voting rates at elections and the number of members standing for election;

community engagement activity; benchmarking of membership activities against other membership organisations;

Page 9 of 10

the questions and concerns of existing and potential members to see if there are any themes of particular interest or concern.

9.3 In addition to this ongoing monitoring, the Council of Governors will also review the Membership Strategy on an annual basis, to ensure that it remains fit for purpose and will make its recommendations to the Board of Directors.

Page 10 of 10

Appendix 1 The Trust’s Public Membership

Public Constituency

2010 Mid-Year Population Estimates

% of Trust Area

Population

Minimum Number of Members Required for Governor Elections –

0.05%

Number of Governors

representing each Public

Constituency

Bristol and Bath & North East Somerset

627,684 11.54% 314 2

Cornwall 549,089 10.09% 275 2

Devon 1,157,858 21.28% 579 4

Dorset 761,255 13.99% 381 2

Gloucestershire 885,917 16.30% 443 3

Isles of Scilly 2,193 0.04% 25* 1

Somerset 752,819 13.84% 376 3

Swindon and Wiltshire

702,982 12.92% 351 2

Total 5,439,797 100.00% 2,744 19

*The actual figure would be less than 1 and so a more practical target has been selected for the purposes of a target membership.


Page 1 of 2


Title: Code of Conduct for Trust Governors

Prepared by: Helen Braid, Governance and Assurance Manager


Main aim: To present the Board of Directors with a revised version of the Code of Conduct for Trust Governors for approval.

Recommendations: The Board of Directors is asked to approve the revised Code of Conduct for Trust Governors.



Page 2 of 2

Code of Conduct for Trust Governors

1. Background

1.1 Monitor’s Code of Governance requires the Board of Directors to set the Trust’s

standards of conduct in accordance with NHS values and accepted standards of behaviour in public life. The Code of Governance also requires Governors to act in the best interests of the NHS foundation trust and adhere to its values and code of conduct.

1.3 The current Code of Conduct for Trust Governors was approved in 2013 and has

now been reviewed to ensure that it remains fit for purpose.

2. Purpose

2.1 The purpose of this paper is to provide the Board of Directors with a revised version of the Code of Conduct for Trust Governors for approval.

3. Proposed Amendments to the Code of Conduct 3.1 The revised Code of Conduct is attached, with proposed amendments highlighted in

the text. Proposed amendments include reflecting the current structure of the Council of Governors; attendance requirements to reflect the Trust Constitution; the additional responsibilities resulting from the Health & Social Care Act 2012; the responsibility to comply with the first and proper persons requirements as set out in the Trust’s Licence conditions; attendance and data protection requirements.

3.2 The Code of Conduct was consulted upon with the Council of Governors though it id

for the Board to approve it. The Council were happy with the proposed changes except for the area around confidentiality and its interpretation. The amendment was drafted by the Trust’s legal advisors.

3.3 The Lead Governor and Trust Secretary have discussed the area and agreed on a

simpler version that is easier to understand and implement. This is included in the version presented for approval.

4. Recommendation 4.1 The Board of Directors is requested to approve the revised Code of Conduct for

Trust Governors.

Helen Braid Governance & Assurance Manager

RESPONSIBILITIES AND

CODE OF CONDUCT FOR TRUST

GOVERNORS

Version: 6

Status: Draft

Title of originator/author: Trust Secretary

Title of responsible director: Chief Executive Officer

Developed/revised by group/committee and Date:

Approved by:

Effective date of issue: (1 month after approval date)

Next review date:

Date Equality Impact Assessment Completed

Regulatory Requirement: Monitor’s NHS Code of Governance

Trust Constitution

1. Governorship of the South Western Ambulance Service NHS Foundation Trust: Introduction

1.1. The Trust is governed by the Regulatory Framework. The Regulatory Framework gives the Council of Governors various statutory roles and responsibilities. As these roles and responsibilities are legal, they are therefore mandatory. Members of the Council of Governors should therefore be familiar with the provisions of the Regulatory Framework to ensure they are aware of what it means to be a Governor of the Trust. Governors are required to act at all times in accordance with the Regulatory Framework and this Code of Conduct (the "Code").

1.2. Members of the Council of Governors are also required to adhere as far as reasonably practicable to the spirit of the:

1.2.1. Code of Conduct and Accountability for NHS Boards;

1.2.2. Governing the NHS: A Guide for NHS Boards; and

1.2.3. The NHS Foundation Trust Code of Governance

1.2.4. Your statutory duties: a reference guide for NHS foundation trust governors.

Members of the Council of Governors are also required to adhere as far as reasonably practicable to other relevant Trust policies. References in the policies to 'staff' are to be taken as references to 'Governors'.

A copy of these documents is available on request to the Trust Secretary.

1.3. The Council of Governors for the Trust consists of:

1.3.1. Upup to anyand including 28 February 2014:

1.3.1.1. 28 Public Governors;

1.3.1.2. 10 Staff Governors;

1.3.1.3. 1 Local Authority Governor; and

1.3.1.4. 8 Partnership Governors.

1.3.2. Fromfrom 1 March 2014:

1.3.2.1.1.3.1.1. 19 Public Governors;

1.3.2.2.1.3.1.2. 6 Staff Governors;

1.3.2.2.1.1.3.1.2.1. 31 being elected from the Accident and Emergency and Patient Transport Services Staff Class;(North Division) Staff Class;

1.3.2.2.2.1.3.1.2.2. 1 being elected from the Accident and Emergency (East Division) Staff Class;

1.3.2.2.3.1.3.1.2.3. 1 being elected from the Accident and Emergency (West Division) Staff Class;

1.3.2.2.4.1.3.1.2.4. 1.3.2.2.2. 1 being elected from the Urgent Care Services Staff Class;

1.3.2.2.5.1.3.1.2.5. 1.3.2.2.3. 1 being elected from the Administration and Support Staff Class;

1.3.2.2.6.1.3.1.2.6. 1.3.2.2.4. 1 being elected from the Volunteers Staff Class;

1.3.2.3.1.3.1.3. 1 Local Authority Governor; and

1.3.2.4.1.3.1.4. 8 Partnership Governors.

1.4. The Council of Governors representrepresents the interests of all the Trust’s Members, including stakeholder organisations within the local healthcare community, in the performance, governance and activities of the Trust.

1.5. The Council of Governors shall provide a link between the local community and the Board of Directors. The Council of Governors shall be expected to secure engagement with the local community to ensure a strong link between the views, needs and aspirations of the communities served by the Trust and the decisions made by the Board of Directors about services and how these may be delivered.

1.6. The Governors are expected to work collectively as a Council of Governors.

2. Roles and Responsibilities: General Overview

2.1. The Governors shall have the specific role and function of:

2.1.1. supporting the Board of Directors in setting the long- term vision for the Trust, influencing proposals to make changes to services and acting in a way

that is consistent with the principles and values of the Trust (as set out in Appendix 1 of Annex 8 of the Constitution) and the Trust's Authorisation;

2.1.2. engaging in dialogue with and providing their views to the Board of Directors on the strategic direction of the Trust and targets for the Trust's performance, and monitoring the Trust's performance in terms of achieving those strategic aims and targets which have been set;

2.1.3. preparing and from time to time reviewing the Trust's Membership Strategy of the Trust and its policy for the composition of the Council of Governors and the Non-Executive Directors group;

2.1.4. holding the Board of Directors to account in relation to the Trust's performance in accordance with the terms of Authorisationits Licence;

2.1.5. responding to any matter as appropriate when consulted by the Board of Directors;

2.1.6. developing and recruiting a representative membership in accordance with the Trust's Membership Strategy;

2.1.7. representing the interests of the Members (not just of the constituency which elected them nor the Local Authority or Partnership Organisation (as relevant) that appointed them); and

2.1.8. without prejudice to the provisions of this paragraph 2.1 or those set out in paragraph 3 below, carrying out the functions listed at paragraph 1.2 of Appendix 2 of Annex 5 to the Constitution. at the request of the Board of Directors.

2.2. Notwithstanding the provisions of paragraphs 2.1.1 to 2.1.8 above, the Governors may exercise other functions at the request of the Board of Directors.

2.3. The Governors' main function therefore is to advise the Board of Directors to ensure the Trust acts in a way which is consistent with its objectives.

2.2. 2.4. Governors shall bring their own individual skills and knowledge to bear in the exercise of these functions and shall, in their stewardship of the Trust's affairs, bring an appropriate perspective of the constituency or organisation by which they were elected or appointed, and act collectively and not in pursuit of sectional or personal interests.

3. The Governors’ Duties and Functions

3.1. The general duties of the Council of Governors are:

3.1.1. To hold the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors, and

3.1.2. To represent the interests of the members of the Trust as a whole and the interests of the public.

3.2. 3.1. Governors of the Trust shall carry out the following duties at a general meeting of the Council of Governors (which may be the Annual Members' Meeting):

3.2.1. 3.1.1. subject to paragraphs 22 and 23 (appointment, suspension and removal of Chairman and other Non-Executive Directors) and 23 (appointment of initial Chairman and initial other Non-Executive Directors) of the Constitution, appointing or removing the Chairman and other Non-Executive Directors. Removal of a Non-Executive Director requires the approval of at least three-quarters of the members of the Council of Governors. The initial Chairman and Non-Executive Directors are however to be appointed for the unexpired period of their terms of office or 12 months, whichever is the longer;

3.2.2. 3.1.2. deciding the remuneration and allowances and the other terms and conditions of office of the Non-Executive Directors;

3.2.3. 3.1.3. appointing or removing the Auditor of the Trust;

3.2.4. 3.1.4. considering disputes as to membership referred to the Council of Governors under paragraph 2.1 of Appendix 4 of Annex 8;

3.2.5. 3.1.5. considering resolutions to remove a Governor, pursuant to paragraph 14 (Council of Governors: disqualification and removal) of the Constitution;

3.2.6. 3.1.6. presenting the reports listed at SO 4.4.1 of the Standing Orders for the Council of Governors to each Annual Members' Meeting.

3.2.7. 3.1.7. subject to paragraphs 40A (Amendment of the Constitution) of the Constitution make amendments to the Constitution which will come into effect if more than half of the Board of Directors of the Trust present and voting at a meeting of the Board of Directors approve the amendments; and

3.2.8. 3.1.8. subject to paragraphs 40B (mergers, acquisitions, separations, dissolution and Significant Transactions) of the Constitution approve a merger, acquisition, separation, dissolution and Significant Transaction.

3.3. 3.2. Governors of the Trust shall carry out the following duties at a general meeting of the Council of Governors or otherwise:

3.3.1. 3.2.1. approving (by a majority of the members of the Council of Governors present and voting) an appointment (by the Non-Executive Directors) of the Chief Executive (and Accounting Officer) other than the initial Chief Executive appointed in accordance with the Constitution and the 2006 Act;

3.3.2. 3.2.2. giving their views to the Board of Directors for the purposes of the preparation (by the Directors) of the Trust’s Forward Plan;

3.3.3. 3.2.3. receiving and considering the Annual Accounts of the Trust, any report of the Auditor on them and the Annual Report of the Trust;

3.3.4. 3.2.4. responding as appropriate when consulted by the Directors.

3.3.5. 3.2.5. to hold the Non Executive Directors individually and collectively to account for the performance of the Board of Directors; and

3.3.6. 3.2.6. to represent the interests of the Members of the Trust as a whole and the

3A Limitations imposed on the Council of Governors

3A.1 Governors shall accept that:

3A.1.1 the powers of the Trust shall be exercised by the Board of Directors on behalf of the Trust. These powers are subject to restrictions contained in the Constitution, the 2006 Act and the terms of Authorisation and they may be delegated in accordance with the provisions of paragraph 4.4 (Powers) of the Constitution;

3A.1.2 they are not responsible for the day to day

management of the Trust, nor may they take decisions about the commitment or use of Trust resources; and

3A.1.3 the Council of Governors cannot veto any decision

made by the Board of Directors.

4. General Obligations: Conduct of Governors

4.1. Introduction

4.1.1. This Code outlines the appropriate conduct for Governors of the Trust. It addresses both the requirements of office and of personal behaviour. Ideally any penalties for non-compliance would never need to be applied. However, the Trust reserves the right to impose such penalties

and regards non-compliance with the Code as a serious matter. It is considered an essential guide for Governors, particularly those who are newly elected or appointed and should be read in conjunction with the Regulatory Framework.

4.1.2. As Member representatives dealing with difficult and confidential issues, Governors are required to act with discretion and care in the performance of their roles. Governors are required to maintain confidentiality at all times with regard to any information gained via their involvement in the Trust (see paragraph 4.44.5 (Confidentiality) below).

4.1.3. This Code seeks to expand on and complement the Constitution of the Trust, copies of which will be provided to all Governors. The Constitution is the governance framework which details the way in which the Trust operates. It outlines the qualification and disqualification criteria for Governors together with detailing their roles and responsibilities and it is strongly recommended that Governors familiarise themselves with its content.

4.1.4. Governors (once elected or appointed) shall be required by the Chairman to sign a declaration to confirm that they shall comply with the Code in all respects. A copy of the declaration is attached at Annex 2 of this Code.

4.2. Qualification and Disqualification for Office

4.2.1. Governors shall continue to comply with the qualifications required to hold elected or appointed office throughout their period of tenure, as detailed within the Constitution. The Trust Secretary shall be advised of any changes in circumstances which disqualify any Governor from continuing in office. Governors shall pay particular attention to the eligibility, disqualification and removal, and termination provisions detailed within paragraph 14 (disqualification and removal) and Appendix 1 of Annex 5 (Eligibility to be on the Council of Governors) of the Constitution, including the fit and proper persons requirements as set out in the Trust's Licence conditions.

4.2.2. A Governor may resign from office at any time during the term of that office by giving notice in writing to the Trust Secretary.

4.2.3. All Governors shall also be expected to understand, agree and promote the Trust’s Equality and Diversity Policy a copy of which shall be provided to all Governors, in every aspect of their work.

4.2.4. One of the key objectives of the Council of Governors is to promote social inclusion and, as such, the development and delivery of initiatives should not prejudice any part of the community on the grounds of age, sex, disability, marital status, sexual orientation, ethnic origin or religious belief. The promotion of any personal or political view that undermines this prime objective of the Trust is grounds for dismissal from the Council

of Governors. The interests of the Council of Governors as a whole shall not be compromised by the interests of individual Governors.

4.3. Role and Function of the Council of Governors

Members of the Council of Governors of the Trust shall be required to confirm their commitment to:

4.3.1. actively supporting the agreed vision and aims of the Trust in developing a successful NHS Foundation Trust;

4.3.2. acting in the best interests of the Trust at all times;

4.3.3. contributing to the work of the Council of Governors in order for it to fulfil its role and objectives as outlined in the Constitution of the Trust;

4.3.4. recognising that the Council of Governors exercises collective decision-making on behalf of local people, stakeholders and staff;

4.3.5. acknowledging that, other than when attending meetings and events as Governors, Governors have no rights or privileges over and above those of any other Member of the Trust;

4.3.6. valuing and respecting Governor colleagues, the Directors of the Trust and all members of staff that come into contact with Governors;

4.3.7. respecting the confidentiality of the information received in their role as Governors and acting with integrity and objectivity, and in the best interests of the Trust, without any expectation of personal benefit;

4.3.8. attending meetings of the Council of Governors and any committees, sub-committees or joint committees of which they are members, and any required training events on a regular basis in order to carry out the role of Governor;

4.3.9. conducting themselves in a manner that reflects positively on the Trust, and acting as ambassadors for the Trust; and

4.3.10. abiding by the Trust’s policies and procedures.

4.4. Limitations imposed on the Council of Directors

4.4.1. Governors shall accept that:

4.4.1.1. the powers of the Trust shall be exercised by the

Board of Directors on behalf of the Trust. These powers are subject to restrictions contained in the Regulatory Framework, and they may be delegated in accordance with the Constitution; and

4.4.1.2. they are not responsible for the day to day

management of the Trust nor may they take decisions about the commitment or use of Trust resources (financial or otherwise).

4.5. 4.4. Confidentiality

CONFIDENTIALITY Governors will have access to wide variety of information through formal meetings, public events and discussion with Directors. This will enable them to be informed on the work of the Trust, engage with members of the public and hold the Non-Executives to account. There will be times when Governors will have confidential information. This may be through a confidential Council of Governor meeting or by the Chairman, Chief Executive, Board Member or Trust Staff. This information will be clearly explained to be confidential. If a Governor has any doubt as to the whether information is Confidential Information as a starting point he or she should consider that it is confidential and discuss this with the Trust Secretary or Lead Governor. All Governors must:

hold Confidential

Information Information in strictest confidence;

take all reasonable precautions in dealing with Confidential Information

so as to prevent another person from having access to it;

use such Confidential Information solely for the purpose of discharging

their duties as a Governor as set out in the Regulatory Framework and

the Code;

permit access to Confidential Information only to another person who

needs to know the Confidential Information for carrying out duties for the

benefit of the Trust; and

not take copies of Confidential other than is strictly necessary.

All Governors shall be expected to understand, agree and promote the Trust’s Whistleblowing Policy, a copy of which will be provided to Governors.

5.

4.4.1. All Governors are required to respect the confidentiality of the information they are made privy to as a result of their membership

of the Council of Governors. Disclosing confidential information may result in dismissal from the Council of Governors.

5.1.1. For the purposes of this section 'confidential information' is information of whatever nature which is obtained by a Governor by virtue of their role as a Governor of the Trust. Confidential information can be in written form or other permanent form, electronic form or provided orally.

5.1.2. If a Governor has any doubt as to the whether information is Confidential Information as a starting point he or she should consider that it is confidential and discuss this with the [Trust Secretary/Chairman]

5.1.3. All Governors must:

5.1.3.1. hold Confidential Information in strictest confidence;

5.1.3.2. take all reasonable precautions in dealing with Confidential Information so as to prevent another person from having access to it;

5.1.3.3. use such Confidential Information solely for the purpose of discharging their duties as a Governor as set out in the Regulatory Framework and the Code;

5.1.3.4. permit access to Confidential Information only to another person who needs to know the Confidential Information for carrying out duties for the benefit of the Trust; and

5.1.3.5. not take copies of Confidential Information other than is strictly necessary.

5.1.4. Where a Governor is planning to permit access to Confidential Information to another person in accordance with paragraph 4.5.3.4 above, other than in the ordinary course of conducting Trust business, he must notify and obtain consent from the Chairman or Corporate Secretary of the Trust prior to doing so.

5.1.5. Prior to the disclosure of any Confidential Information to another person a Governor must inform them of the confidential nature of the material and of the provisions they must also adhere to under this Code in relation to the Confidential Information.

5.1.6. If requested by the Trust, a Governor shall obtain a written undertaking from the other person in favour of the Trust which

should state they will abide by the duties of confidentiality established in this Code prior to disclosure.

5.1.7. For the avoidance of doubt whether or not the Trust makes the request set out in paragraph 4.5.6 the Governor must procure that any other person will observe the same restrictions on the use of the Confidential Information as are contained within this paragraph 4.5.

5.1.8. Without prejudice to the generality of paragraph 4.5.1 above a Governor must exercise no less a degree of care in protecting the Confidential Information than he would use to protect his own information of like sensitivity and importance

5.1.9. 4.4.2. All Governors are expected to understand, agree and promote the Trust’s Information Governance Policy and the document entitled Private and Confidential: A Guide for Staff, copies of which will be provided to all Governors, in every aspect of their work.

5.1.10. 4.4.3. Without prejudice to paragraphs 4.4.14.5.1 and 4.4.24.5.9 above, all Governors shall be expected to understand, agree and promote the Trust’s Whistleblowing Policy, a copy of which will be provided to Governors.

5.1.11. Any Confidential Information disclosed shall remain the property of the Trust. Disclosure of any Confidential Information to a Governor or by a Governor to a another person does not imply or confer any licence or permission on the Governor or the other person to use the relevant information for any purpose other than the purpose of fulfilling his or her duties as a Governor.

5.1.12. The obligations of confidentiality do not apply to the extent that a Governor can show that the Confidential Information:

5.1.12.1. is in the public domain other than by breach by the Governor (or another person the Governor provided the Confidential Information to) of its obligations in relation to confidentiality in the Code;

5.1.12.2. is required to be disclosed by the Governor by law provided that the Governor notifies the Chairman of the requirement for disclosure and, prior to making any disclosure, the Governor assists the Trust in taking reasonable steps to resist, avoid or minimise the disclosure.

5.2. Data Protection and Freedom of Information

5.2.1. Governors shall comply with principles and rules of the Date Protection Act 1998.

5.2.2. Governors shall comply with the Trust Publication Scheme and forward any Freedom of Information requests to the Freedom of Information Officer as soon as practicable. Where a Governor receives a Freedom of Information request he shall not reply to this request without forwarding the request to the Freedom of Information Officer and obtaining their advice.

5.3. 4.5. Conflicts of Interest

5.3.1. 4.5.1. Governors shall act with the utmost integrity and objectivity and in the best interests of the Trust in performing their duties. They shall not use their position for personal advantage or seek to gain preferential treatment.

5.3.2. Any Governor who has:

5.3.2.1. 4.5.1.1. any pecuniary, personal or family interest, whether that interest is actual or potential and whether that interest is direct or indirect, in any contract, proposed contract or other matter which is under consideration or is to be considered by the Council of Governors, or which otherwise concerns the Trust; or

5.3.2.2. 4.5.1.2. any interest which is relevant and material to the business of the Trust as set out in paragraph 17 (conflicts of interest of Governors) of the Constitution and the Standing Orders for Governors shall disclose that interest in the prescribed form, to the members of the Council of Governors and the Trust Secretary at the time of the Governor's election or appointment or as soon thereafter as the interest arises. The Trust Secretary shall record this in the register of interests of the members of the Council of Governors.

5.3.3. 4.5.2. Failure to declare a conflict of interest could result in dismissal from the Council of Governors. The Standing Orders for the Council of Governors (specifically, Standing Order 7) make provision for the disclosure of interests and arrangements for the exclusion of a Governor declaring an interest from any discussion or consideration of the matter in respect of which an interest has been disclosed. If a Governor is in doubt as to whether he has a conflict of interest he shall seek advice from the Trust Secretary. It is important that conflicts of interest are addressed and are actioned in the interests of the Trust and all individuals concerned.

5.3.4. 4.5.3. Notwithstanding Paragraph 4.5.14.7.1 above, if a Governor

is present at a meeting of the Council of Governors and has an interest of any sort in any matter which is the subject of consideration, he shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not vote on any question with respect to the matter. If he has declared a pecuniary interest, he shall not take part in the consideration or discussion of the matter. At the time the interests are declared, they should be recorded in the meeting minutes. Any changes in interests shall be officially declared at the next relevant meeting following the change occurring. It is the obligation of the Governor to inform the Trust Secretary in writing of the existence of a pecuniary, personal, family, relevant or material interest. The Trust Secretary shall amend the appropriate register of interests of the members of the Council of Governors upon receipt of new or amended information as soon as is practical.

5.4. 4.6. Meetings of the Council of Governors

5.4.1. 4.6.1. The Council of Governors shall meet at least four times per year, including at an Annual Members' Meetingannual meeting no later than 30 September in each Financial Year apart from the first year, when the Council of Governors shall receive and consider the Annual Accounts and any report of the Auditor on them, and the Board of Directors shallis to present to the Council of Governors the Annual Report in accordance with the Constitution.

5.4.2. 4.6.2. Governors have a responsibility to attend meetings of the Council of Governors. When this is not possible they shall, so far as reasonably practicable submit an apology to the Trust Secretary in advance of the meeting.

5.4.3. 4.6.3. Absence from meetings of the Council of Governors without good reason established to the satisfaction of the members of the Council of Governors is a ground for disqualification. If a Governor fails to attend two or more consecutive meetings of the Council of Governors in any Financial Year, his tenure of office shall be terminated immediately unless the Council of Governors is satisfied by a 75% majority of those members of the Council of Governors present and voting thatat the following Council of Governors' meeting unless:

5.4.3.1. 4.6.3.1. the Chair and Corporate Secretary, in consultation with the Lead Governor and taking into consideration other Governor related activities he may have undertaken, are satisfied that the absence was due to a reasonable cause; and

4.6.3.2. he shall be able to start attending and the Governor will be able to attend meetings of the Council of Governors again within such a period as it considersis considered reasonable, or

5.4.3.2. at least 75% of the Council of Governors present vote in favour of the tenure not being terminated at that meeting.

5.4.4. 4.6.4. Notwithstanding the provisions of paragraph 4.6.34.8.3 above, Governors are subject to the provisions of paragraph 14.5 (disqualification and removal) of the Constitution which provides that the tenure of office of anyif a Governor who fails to attend 2 out of 3 consecutive meetings of the Council of Governors, and who has previously been the subject of a decision in their favour under paragraph 4.6.34.8.3 above, willthat Governor's tenure of office is to be terminated immediately.

4.6.5. Governors are required to participate in an induction programme and any subsequent training programmes.

5.4.5. 4.6.6. Governors are expected to attend for the duration of meetings.

5.4.6. 4.6.7. Governors are expected to attend meetings of those committees, sub-committees and joint committees of which they are members.

5.5. 4.7. Personal Conduct

5.5.1. 4.7.1. Governors are required to adhere to the highest standard of conduct in the performance of their duties. In respect of their interaction with others, they are required to agree and adhere to the commitments set out in Annex 1 to this Code.

5.5.2. 4.7.2. The Council of Governors of the Trust shall follow the principles set out by the WicksNolan Committee and shall therefore adhere to the following principles together with those set out within the Independent Commission’s Good Governance Standard for Public Service and the NHS Foundation Trust Code of Governance.

5.5.2.1. 4.7.2.1. Selflessness

Holders of public office shall take decisions solely in terms of the public interest. They shall not do so in order to gain financial or other material benefits for themselves, their family, or their friends.

5.5.2.2. 4.7.2.2. Integrity

Holders of public office shall not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties.

5.5.2.3. 4.7.2.3. Objectivity

In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for awards or benefits, holders of public office shall make choices on merit.

5.5.2.4. 4.7.2.4. Accountability

Holders of public office are accountable for their decisions and actions to the public and shall submit themselves to whatever scrutiny is appropriate to their office.

5.5.2.5. 4.7.2.5. Openness

Holders of public office shall be as open as possible about all the decisions and actions they take. They shall give reasons for their decisions and restrict information only when the wider public interest clearly demands.

5.5.2.6. 4.7.2.6. Honesty

Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

5.5.2.7. 4.7.2.7. Leadership

Holders of public office shall promote and support these principles by leadership and example.

5.6. 4.8. Accountability

Governors are accountable to the Members of the Trust and shall demonstrate this by their communication (or in the case of Partnership Governors, with the relevant Partnership Organisation) with their electorate in order to best understand their views.

5.7. 4.9. Training and Development

Training and development are essential for Governors in respect of effective performance of their current roles and Governors shall attend any training session as reasonably required by the Trust in order to assist their roles and functions.

Governors are required to participate in an induction programme and any subsequent training programmes.

5.8. 4.10. Reimbursement of Expenses

Governors shall not receive payment for their roles, however they may receive reimbursement for travelling and other costs and expenses incurred and evidenced by receipts where appropriate, at such rates as the Board of Directors decides from time to time in its absolute discretion.

5.9. 4.11. Visits to Trust Premises

On such occasions as it is considered necessary for Governors to visit Trust premises in a formal capacity as opposed to visiting Trust premises in a personal capacity (e.g. to visit service users or as a patient), requests to do so shall be forwarded to the Chairman with clear reasoning behind the request outlined. Where such a request is approved, the Chairman shall liaise with the Trust Secretary to make the necessary arrangements.

5.10. 4.12. Non-compliance with the Code of Conduct

5.10.1. 4.12.1. An alleged breach of the Code by a Governor shall be promptly investigated.

5.10.2. 4.12.2. Non-compliance with this Code may result in the following action:

where non-compliance or any misconduct is alleged, the Chairman shall be authorised to take such action as may be immediately required, including the exclusion of the Governor concerned from a meeting so that the allegation can be investigated;

5.10.2.1. 4.12.2.1. where non-compliance or any misconduct is alleged, it shall be open to the Council of Governors to decide, by three-quarters majority of the members of the Council of Governors present and voting, to lay a formal charge of non-compliance or misconduct;

5.10.2.2. 4.12.2.2. the Governor concerned shall be notified in writing of the allegations, detailing the specific behaviour which is considered to be detrimental to the Trust, and inviting and considering his response within a defined timescale;

5.10.2.3. 4.12.2.3. the Governor concerned may be invited to address the Council of Governors in person if the matter cannot be resolved satisfactorily through correspondence;

5.10.2.4. 4.12.2.4. the Governors, by three-quarters majority of the Council of Governors present and voting, can decide whether to uphold the charge of non-compliance or misconduct detrimental to the Trust;

5.10.2.5. 4.12.2.5. the Governors can impose such sanctions as shall be deemed appropriate. Such sanctions may range from the issuing of a written warning as to the Governor’s future conduct and consequences, non-payment of expenses, suspension and/or removal of the Governor from office.

5.10.3. 4.12.3. Any investigation into alleged misconduct on the part of a Governor shall be reasonable, fair and impartial. Where possible, those undertaking the investigation should not be linked to the Governor in question.

5.10.4. 4.12.4. In order to aid participation of all parties, it is imperative that all Governors observe the points of view of others, and conduct likely to give offence will not be permitted. The Chairman reserves the right to ask any Governor who (in his opinion), fails to observe the Code to leave any meeting of the Council of Governors.

5. Amendment

5.1. [Amendments by the Trust to this Code are to be made by the Board of Directors.]

ANNEX 1: Key Commitments

1.1 1 I acknowledge that the Trust is an apolitical organisation;

1.2 1.1 If I am a member of any trade union, political party or other organisation, I recognise that, should I be elected or appointed, I shall not be representing those organisations (or the views of those organisations) but shall be representing the constituency (public or staff) that elected me, or the organisation that appointed me;

1.3 1.2 I am not an active member of any body or organisation with policies or objectives such that my membership would be likely to cause the Trust to be in breach of its statutory obligations or to bring it into disrepute; -

1.4 1.3 I understand that my role as Governor is to represent the interests and needs of the Trust and the community which it serves and that I should not be influenced by my membership of other bodies or areas of personal interest and that I shall not act as a representative for any such body or interest in my work with the Trust;

1.5 1.4 I shall be honest and act with integrity and probity at all times;

1.6 1.5 I shall not seek to profit from my position as a Governor;

1.7 1.6 I shall respect and treat with dignity and fairness, the public, patients, relatives, carers, NHS staff and partners in other agencies;

1.8 1.7 I shall seek to ensure that my fellow Governors and Directors of the Trust are valued as colleagues and that judgements about colleagues are consistent, fair and unbiased and are properly founded;

1.9 1.8 I shall accept responsibility for my actions;

1.10 1.9 I shall show my commitment to working as a team member by working with my colleagues in the NHS and wider community;

1.11 1.10 I shall seek to ensure that the membership of the constituency I represent or the organisation that appointed me is properly informed;

1.12 1.11 I shall seek to ensure that no one is discriminated against because of their religion, belief, race, colour, gender, marital status, disability, sexual orientation, age, social or economic status or national origin;

1.13 1.12 I shall at all times comply with the Constitution and the Standing Orders for the Council of Governors;

1.14 1.13 I shall respect the confidentiality of the individual patients and comply with the Trust’s Information Governance Policy and the document entitled Private and Confidential: A Guide for Staff whilst also taking account of the provisions of the Trust’s Whistleblowing Policy if applicable;

1.15 1.14 I shall not make, permit or knowingly allow to be made any untrue or misleading statement relating to my own duties or the functions of the Trust;

1.16 1.15 I shall seek to ensure that the best interests of the public, patients, carers and staff are upheld in decision making and the decisions are not improperly influenced by gifts or inducements;

1.17 1.16 I shall support and assist the Chief Executive of the Trust in his responsibility to answer to the Independent Regulator, commissioners and the public in terms of fully and faithfully declaring and explaining the use of resources and the performance of the total NHS in putting national policy into practice and delivering targets;

1.18 1.17 I shall not make any public statement on behalf of the Trust or in

my capacity as a Governor without the consent of the Chairman or the Corporate Secretariat.

1.19 1.18 I shall at all times uphold the principles and values of the Trust as

set out in the Constitution; and

1.20 1.19 I shall uphold the seven principles of public life as detailed by the WicksNolan Committee, as set out in paragraph 4.7.214.9.2 of the Code.

ANNEX 2 Code of Conduct South Western Ambulance Service NHS Foundation Trust Confirmation of acknowledgement and acceptance of compliance with the Code of Conduct Name of Governor……………………………………………………………………… Address………………………………………………………………………………….. ……………………………………………………………………………………………. ……………………………………………………………………………………………. ……………………………………………………………………………………………. South Western Ambulance Service NHS Foundation Trust Council of Governors Code of Conduct Declaration I, …………………………………………………………………………… (Print name) agree to abide by the Code of Conduct of the South Western Ambulance Service NHS Foundation Trust, including any tests required to ensure that I remain a fit and proper person for the role of Governor of the Trust for the purposes of the Trust's Licence conditions. Signature………………………………………………………………………………….. Date………………………………………………………………………………………... Please sign and return this information to the Trust Secretary


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Title: Speak Up, Speak Out Policy



Main aim: Update the Board on the policy renewal date of the Speak Up, Speak Out policy.

Recommendations: The Board of Directors is asked to take assurance from the information provided



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Speak Up, Speak Out Policy

1. Introduction

1.1 The Trust Speak Up, Speak Out policy was due for renewal in February 2016. Its approval route is through the Policy Review Alignment Group (PRAG).

2. National Guidance 2.1 Following his review on whistleblowing in the NHS, Sir Robert Francis launched the

role of Freedom to Speak up Guardians. These local guardians will be responsible for creating an environment where staff are encouraged to raise concerns, where lessons are learned from them, and where care can improve as a result.

2.2 The first national guardian was appointed (Dame Eileen Sills) and national guidance

was expected. Dame Sills resigned shortly after being appointed and the guidance was delayed.

3. Policy Extension 3.1 In the absence of the guidance, the PRAG met and agreed to extend the policy

review date by a further six months. The policy will now be subject to a full review in September 2016.

3.2 This is reported to the Board for oversight.

4. Recommendation

4.1 The Board of Directors is asked to take assurance from the update provided.



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Title: Committee Terms of Reference – Audit and Assurance Committee and Quality Committee



Main aim: To share with the Board of Directors the revised committee terms of reference prior to their approval at Board.

Recommendations: The Board of Directors is asked to take approve the revised terms of reference for the Committee.

Previous Forum: Committee, Board Seminar

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Quality Committee Terms of Reference

Version

Author Marty McAuley, Trust Secretary Nicole Casey, Head of Governance

Approved By Board of Directors

Approved Date 31 March 2016

Date Issued 1 April 2016

Review Date

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1. Purpose 1.1 Develop and implement effective quality systems and processes with a specific

focus on patients, quality of services and patient outcomes.

2. Constitution and Authority 2.1 Established and approved by the Board of Directors as one of its committees. 2.2 The Committee is authorised by the Board to investigate any activity within its

terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee.

2.3 The Committee is authorised by the Board to obtain outside legal or other

independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

3. Role 3.1 Support the development and delivery of the Quality Strategy. 3.2 Under the NHS pillars of quality the Committee should robustly and routinely

monitor patient safety, clinical effectiveness and the experience of the patient. 3.3 To ensure the establishment and maintenance of effective quality governance

arrangements and take assurance that these are effective.

3.4 Monitor the delivery of key patient safety initiatives and quality indicators (such as AQIs and CQUIN targets).

3.5 To support an organisational structure and philosophy promoting a positive and

responsible culture and nurturing continuous quality improvement in the delivery of patient care and patient experience.

4. Membership 4.1 The Committee has a core membership supported by regular and managers

presenting papers. The Executive Director of Nursing and Governance is the Executive Lead.

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Non-Executive Venessa James

Tony Fox

Mary Watkins

Ian Reynolds

Executive Ken

Wenman Jenny

Winslade Dr. Andy

Smith Emma Wood

Staff Nicole Casey

Adrian South

- -

Regular Attendees

Marty McAuley Neil Le

Chevalier Staff Side

Representation Commissioners

4.2 The Committee is empowered to request any other officer employed by the Trust

to attend meetings for the purpose of providing advice, clarification, recommendation or explanation in respect of any matter that falls within the responsibilities of the Committee. As necessary, the Committee may also require the production of any document if it relates to the business of the Committee.

4.3 Membership to be reviewed as part of the ToR review annually

5. Reporting and Accountability 5.1 The Committee is accountable to the Board of Directors. 5.2 After each Quality Committee a report will be produced and presented to the

next available Trust Public Board of Directors meeting for assurance. 5.3 Once approved by the Committee a copy of the Quality Committee minutes will

also be presented to the next available Trust Public Board of Directors meeting for assurance.

5.4 The Quality may escalate items to the Board for approval or discussion as well

as refer items to the Directors group or Audit Committee for further consideration. The Quality Committee may also receive requests from other forums to consider matters.

5.5 The Quality Development Forum, led by the Executive Director of Nursing and

Governance meets before and after the Quality Committee. This Forum enables staff to come together to discuss quality issues and ensure that they are fed into the Quality Committee.

5.6 The Committee shall receive the minutes of all working groups reporting to it

following each meeting of each group (emailed to members).

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6. Chairperson 6.1 The Committee will be chaired by a Non-Executive Director. The Committee

should appoint a Deputy Chair.

7. Administration Support 7.1 The Trust Secretary will provide the administration support to ensure that the

committee cycles, meetings, papers and action point registers are appropriately managed.

7.2 Minute taking will be provided by the EA to the Executive Director of Nursing and

Governance. 7.3 Papers to be issued one week in advance of the meeting via BoardPad or email.

8. Frequency of Meetings 8.1 There will be a minimum of four meetings a year.

9. Quorum 9.1 The committee shall be quorate when four Members are present. There must be

at least one Executive and one Non-Executive member present.

10. Self assessment 10.1 An annual self-assessment will be completed each year by the Committee. 10.2 An annual report monitoring the effectiveness of the Committee will then be

prepared by the Committee Chair and Executive Lead for discussion each year. The agreed report will then be submitted to the Board for assurance. The annual report will include: consideration of all the main duties of the Committee; accountability, including reporting arrangements; input from sub groups; confirmation of completion of the work of the Committee as set out in its annual business cycle; membership and attendance; quoracy and frequency of meetings.

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Annex A: duties 1. Monitoring review and implementation of corporate and quality governance, risk

management and patient safety and quality assurance strategies and action plans, including the Quality Account, CQUINs, and AQIs, and seek assurance on the successful integration of governance arrangements for the Trus

2. Address CQC feedback and guidelines and monitor development and implementation

of work programmes to ensure ongoing compliance with registration

3. Develop and disseminate Safety and Experience reports 4. Consider impact of new technology or innovations on service delivery or resource

requirements 5. Provide regular assurance reports to the Board of Directors and other Committee as

appropriate 6. Refer and receive items for consideration by Directors, Board or Committee 7. Adopt Trust-wide policy on clinical practice as a result of expert agency advice or data

from other sources, such as patient/public involvement 8. Assess benchmark or audit data and recommend action with regard to changing

clinical practice and improving value for money 9. Challenge existing practice in the light of evidence-based medicine or clinical

effectiveness data 10. Ensure standards of patient care are continuously improved by addressing guidance

from the Care Quality Commission and other agencies or professional bodies 11. Assign responsibility for the implementation of the Committee's recommendations 12. Monitor training and development of all members of the trust and ensure training needs

analyses are undertaken 13. Ensure performance management occurs and develop effective support measures for

the management of poorly performing colleagues 14. Develop, facilitate and monitor the implementation of systems to underpin patient

safety and quality and risk management

Audit & Assurance Committee

Terms of Reference

Version 7.0 – DRAFT

Author Kelly Richardson, EA to Deputy Chief Executive/Executive Director of Finance Marty McAuley, Trust Secretary

Approved By Board of Directors

Approved Date 31 March 2016

Date Issued 1 April 2016

Review Date

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1. Purpose/role 1.1 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 and conditions of license.

2. Constitution and Authority 2.1 Established and approved by the Board of Directors as a non-executive committee,

set out in the Trust's constitution as a statutory requirement under Monitors NHS Foundation Trust Code of Governance, and a requirement of the terms of authorisation.

2.2 The Committee is authorised by the Board to investigate any activity within its terms

of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

3. Role 3.1 To review the relevance and rigour of the Board Assurance Framework and the

arrangements that surrounds it. It is not the role of the Audit and Assurance Committee to establish and maintain processes for governance.

3.2 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 and conditions of license.

3.3 To conclude upon the adequacy and effective operation of the Trust's overall internal control system, predominantly focusing on the framework of risks, controls and related assurances underpinning the delivery of the Trust's objectives.

3.4 To obtain assurances about controls and consider whether they are appropriate and provide challenge where necessary.

3.5 Ensure that the underlying data, upon which assurances are based, is robust, reliable and accurate.

4. Membership 4.1 The Committee has a core membership supported by regular attendees and senior

managers presenting papers. Membership is Non-Executive only with the Deputy Chief Executive/ Executive Director of Finance as the Executive Lead supported by the Executive Director of Nursing and Governance.

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4.2 The membership consists of four independent Non-executive Directors one of

whom shall serve as Committee Chair.

Non-Executive Members: Regular Attendees

Paul Love Tony Fox Venessa James Hugh Hood Ian Reynolds

Deputy Chief Executive/Executive Director of Finance Deputy Director of Finance Executive Director of Nursing and Governance

Trust Secretary Internal Audit External Audit Local Counter Fraud

4.3 The Committee is empowered to request any other officer employed by the Trust to

attend meetings for the purpose of providing advice, clarification, recommendation or explanation in respect of any matter that falls within the responsibilities of the Committee. As necessary, the Committee may also require the production of any document if it relates to the business of the Committee.

4.4 Membership to be reviewed as part of the ToR review annually. 4.5 Chairman and Deputy Chairman of the Committee should be appointed. 4.6 The Chairman of the Trust may attend the Audit and Assurance Committee but not

as a formal member. 4.7 At least once a year the Committee should meet privately with the Internal and

External Auditors. 4.8 Executive Directors should be invited when internal audit reports that fall under their

remit are presented to the Committee. 4.9 Other senior managers may also be invited to facilitate the work of the Audit and

Assurance Committee. 4.10 The Chief Executive should be invited to attend, at least annually, to discuss with

the Audit and Assurance Committee the process for assurance for the Annual Governance Statement.

5. Reporting and Accountability 5.1 The Committee is a statutory committee and is accountable to the Board of

Directors. 5.2 After each Audit and Assurance Committee a report will be produced by the

Committee Chairman and presented to the next available Trust Public Board of Directors meeting for assurance.

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5.3 Once approved by the Committee a copy of the Audit and Assurance Committee minutes will also be presented to the next available Trust Public Board of Directors meeting for assurance.

5.4 The Audit and Assurance Committee may escalate items to the Board for approval

or discussion as well as refer items to the Directors group or other Committees for further consideration.

5.5 Any exceptional reporting may be reported directly to the Board by a nominated

member of the Committee. 5.6 An Annual Report monitoring the effectiveness of the Audit and Assurance

Committee will be prepared by the Chairman of the Committee for discussion at the end of each financial year. The agreed report will be submitted to the Board for assurance.

6. Reporting and Accountability 6.1 The Committee will be chaired by a Non-Executive Director. The Committee should

appoint a Deputy Chair.

7. Administration Support 7.1 The Trust Secretary, with support from the EA to the Deputy Chief

Executive/Executive Director of Finance, will provide the administration support to ensure that the committee cycles, meetings, papers and action point registers are appropriately managed.

7.2 Minute taking and will be provided by the EA to Deputy Chief Executive/ Executive

Director of Finance. 7.3 Papers to be issued one week in advance of the meeting via BoardPad or email.

8. Frequency of Meetings 8.1 There will be a minimum of five meetings a year.

9. Quorum 9.1 The Committee shall be quorate when two Non-executive Director members are

present.

10. Self assessment 10.1 An annual self-assessment will be completed each year by the Committee. 10.2 An annual report monitoring the effectiveness of the Committee will then be

prepared by the Committee Chair and Executive Lead for discussion each year. The agreed report will then be submitted to the Board of Directors for assurance. The annual report will include: consideration of all the main duties of the Committee;

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accountability, including reporting arrangements; input from sub groups; confirmation of completion of the work of the Committee as set out in its annual business cycle; membership and attendance; quoracy and frequency of meetings.

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ANNEX A: Duties Integrated Governance, Risk Management and Internal Control Review establishment and maintenance of effective system of integrated governance, risk management and internal control. Review the Trust’s internal financial controls and seek assurance on their effectiveness. Receive Risk and Board Assurance Framework reports as well as the Board, strengthening links with the internal audit plan for each year Internal Audit

Ensure that there is an effective Internal Audit system in place. Monitor and review effectiveness of the Trust’s internal audit function on an annual basis, taking into consideration relevant UK professional and regulatory requirements. Review and approve an annual Internal Audit Plan which meets the needs of the Trust and its objectives underpinned by the Board Assurance Framework. Consider major findings of the auditors work and ensure coordination between internal and external auditors is made to optimise the use of audit resources. External Audit Review and monitor external auditor’s independence and objectivity and effectiveness of audit process, taking into consideration relevant UK professional and regulatory requirements. Develop and implement policy on engagement of external auditor to supply non-audit services, taking into account relevant ethical external guidance regarding the provision of non-audit services by the external audit firm. Support the council of governors to develop criteria for appointing, reappointing and removing auditors. Ensure and explain in the Annual Report, where the auditor provides non-audit services, how auditor objectivity and independence are safeguarded. Undertake an annual review of the work and fees of the auditor to support recommendation to the Council of Governors on appointment of the auditor. Counter Fraud Review and approve an annual Counter Fraud Plan which meets the Trusts objectives which are underpinned by the Board Assurance Framework.

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Ensure that effective arrangements are in place to enable staff to raise, in confidence, concerns about possible improprieties, in financial, clinical or safety matters for independent investigation if required. Other Assurance Functions Obtain assurance from other Board Committees on key risks and issues concerning the control environment. In reviewing the clinical governance and risk arrangements the Committee should seek assurance from the clinical audit functions. Audit and Assurance Committee to undertake periodic deep dives into governance and compliance issues. Disclosures The Committee shall review the annual report and financial statements before submission to the Board. The Committee should also receive a programme of assurance statements and satisfy themselves on the robustness of the information. Financial Reporting Monitor integrity of financial statements of the Trust and any formal announcements relating to Trust’s financial performance, reviewing significant financial reporting judgments they contain.