\Board of Directors\Board Meetings\2018\6. 1st June 2018\Public\Draft AgendasPublic agenda 01Jun18 Final updated.docx\ Page 1 of 2 BOARD OF DIRECTORS MEETING Meeting in Public

$Page 1: \Board of Directors\Board Meetings\2018\6. 1st June 2018\Public\Draft AgendasPublic agenda 01Jun18 Final updated.docx\ Page 1 of 2 BOARD OF DIRECTORS MEETING Meeting in Public$
K:\Board of Directors\Board Meetings\2018\6. 1st June 2018\Public\Draft Agendas\Public agenda 01Jun18 Final updated.docx Page 1 of 2

BOARD OF DIRECTORS MEETING Meeting in Public

Friday 1st June 2018, 11:40-14:15

Dining Room, PGMC, Wexham Park Hospital A G E N D A

TIME AGENDA ITEM PAPER ACTION LEAD 11:40 1. Welcome and Apologies for Absence

Oral - Chairman

2.

Declarations of Interest Oral - Chairman

3. Minutes of the previous Board Meeting held in public on 4th May 2018

Attached

For Approval

Chairman

4. Action Log from previous Meeting

Attached For Action Chairman

QUALITY 11:45 5. Ward to Board – Orthopaedics & Plastics

Chief of Service – Col Peter Hill Clinical Matrons: Annmarie Lawson (FPH Wards F4, F5 and F6) and Fiona Mason (WPH WX1, WX2 and HWD W4 and Short Stay Unit)Head of Nursing: Alison Stevens

Attached/ Presentation

For Information

Director of Nursing & Quality

12:10 6. Chief Executive's Performance Report Attached For Assurance

Chief Executive & Executive Directors

12:30 7. Quality Improvement Plans Attached For Discussion

Medical Director/ Director of Nursing & Quality

FINANCE & PERFORMANCE 12:40 8. Finance Report - month 1 Attached

For Information

Director of Finance & IM&T

12:45 9. CIP Progress Report – month 1 Attached For information

Director of Finance & IM&T

12:50 10. Capital Investment Programme 2017/2018 – Outturn

Attached For Information

Director of HR and Corporate Services

13:00 11.

Capital Investment Programme 2018/2019

Attached For Information

Director of Finance & IM&T/Director of HR and Corporate Services

GOVERNANCE AND COMPLIANCE 13:10 12. Corporate Risk Assurance Framework Attached For

Assurance Chief Executive

AGENDA

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13:20 13. 13.1 13.2

Review Minutes and Recommendations of the Board Committees Audit Committee (Part 1) 24th May and Special Board to Consider 2017/2018 Annual Report, Quality Report and Accounts Audit Committee (Part 2) 24th May

Attached Attached

To Note To Note

Committee Chair/ Chairman Committee Chair

13:30 14. CNST Maternity Declaration

Attached For Approval

Director of Nursing & Quality

OTHER BUSINESS 13:35 15. Any Other Business

Oral - All

13:40 16. Review of the Meeting

Oral - All

13:45 17. Questions from Members of the Public

Oral - All

13:55 18. Date of Next Meeting Friday 6th July 2018 Board Room, Admin Block, Frimley Park Hospital

- - Chairman

NB: An ‘Acronym Buster’ has been included at the end of the Public Board papers pack.

AGENDA

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BOARD OF DIRECTORS MEETING IN PUBLIC Friday 4 May 2018, 11:40 to 14:30

Lecture Theatre, PGMC, Wexham Park Hospital

MINUTES OF MEETING

Present: Pradip Patel (PP) Chairman Neil Dardis (ND) Chief Executive Nigel Foster (NF) Director of Finance & IM&T Duncan Burton (DB) Director of Nursing & Quality Helen Coe (HC) Director of Operations FPH Lisa Glynn (LG) Director of Operations WPH Tim Ho (TH) Medical Director Mark Escolme (ME) Non-Executive Director Dawn Kenson (DK) Non-Executive Director Ray Long (RL) Non-Executive Director Mike O’Donovan (MOD) Non-Executive Director Rob Pike (RP) Non-Executive Director Thoreya Swage (TS) Non-Executive Director John Weaver (JW) Non-Executive Director Apologies: Janet King (JK) Director of HR & Corporate Services In Attendance: David Milwood (DW) Assistant to the Director of Operations, FPH Helen Paterson (item 5) (HP) Matron Vera Gill-Wakatama (item 5) (VGW) Matron Siobhan Whittaker (item 5) (SW) Matron Helen Oakes (item 5) (HO) Matron Zoe Fisher (item 5) (ZF) Matron Dee Carter (item 5) (DC) Matron Phillipa Rodwell (PR) Matron John Seymour (item 5) (JS) Chief of Service - Medicine Alan Steuer (item 5) (AS) Consultant Mena Vallance (item 5) (MV) Head of Nursing, Emergency &

Cardiovascular Medicine, FPH Michelle Youens (item 5) (MY) Head of Nursing, Medicine, WPH Phillipa Hooton (item 5) (PH) Head of Nursing , Medicine and Elderly FPH Kirstin Macdonald (item 5) (KM) AD Medicine and ED, WPH Susanne Nelson-Wehrmeyer (SNW) Company Secretary Kevin Jacob (KJ) Assistant Company Secretary (minutes) Eleanor Shingleton-Smith (items ) (ESS) Deputy Director Organisational

Development (HR) Jane Hogg (item ) (JH) Director of Transformation 1. Welcome, Introduction and Apologies for Absence a.

PP welcomed everyone to the meeting.

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Tab 3 Minutes of the Previous Public Board Meeting held on 4 May 2018



b.

Apologies for absence were received from Janet King.

2. Declarations of Interest a.

There were no declarations of interest.

3. Minutes of the Previous Meeting a. b.

The minutes of the previous Board meeting held in public on 6 April 2018 were approved as an accurate record subject to: • Correction of a number of minor typographical errors • Pg. 9 paragraph 6.i bullet 6 on maternity friends and family- points. Correction to

read ‘RP noted that the Friends and Family score for maternity at Wexham was 100% which as far as he could recall was higher than it had ever been. However the overall Trust score had fallen from a high of 98 to 95 which implied that the FPH score had gone in the other direction.’

KJ

4. Action Log from the Previous Meeting a. b. c. d.

1 September 2017 - 18.e Meeting Review PP to undertake a review of board papers and work with the EDs to make the papers fit for board. On-going into 2018 5 January 2018 – 18.e Meeting Review DB to reflect on the comments made in order to find the optimum format for consistency of Ward to Board reporting although this did not necessarily need to be implemented for the February meeting. Duncan Burton. DB asked to finalise the action. 6 April 2018 - 10.b Quarterly Board Objectives Q4 Communications team to look back at 2017-18 and create a story about what the Trust has achieved and share this with all staff to celebrate the significant achievements. Janet King & James Taylor. 1 June 2018. Action closed 6 April 2018 - 15.c National Staff Survey 2017 ND to write to the Top 10 departments with the best scores to congratulate them and JK to write to the ten lowest departments to review their results and produce an action plan to improve. Update 23/04/18: Letters to be dispatched by OD Department in next couple of weeks. Action closed.

5. Ward to Board – FHFT Medical Wards a.

The medical ward teams from Frimley Park and Wexham Park hospitals, presented to the board highlighting their achievements and challenges. The following staff attended:

• Chief of Service: Dr John Seymour • Consultant: Alan Steuer • Matrons: Vera Gill-Wakatama, Helen Paterson, Siobhan Whittaker, Helen Oakes,

Phillipa Rodwell, Dee Carter and Zoe Fisher • Kirstin Macdonald, AD Medicine and ED, WPH • David Millward, Assistant to the Director of Operations, FPH

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b. c. d. e. f. g.

• Mena Vallance, Head of Nursing, Emergency & Cardiovascular Medicine, FPH • Phillipa Hooton, Head of Nursing , Medicine and Elderly FPH • Michelle Youens, Head of Nursing, Medicine, WPH JS referred to the dashboard reports as circulated in the Agenda and highlighted the following: • G3 Stroke Rehab Ward, Frimley Park – it was recognised that there had been a

number of clostridium difficile infections. Action plans were in place, but hand hygiene was an issue requiring continuous vigilance and focus

• There had been a few challenges at Wexham Park around antibiotic microbial prescribing by new doctors. However, the direction of travel was positive.

Discussion and questions followed: MOD asked what the critical issue was that was preventing performance in respect of sepsis being the best it could be. JS responded that there was a need for greater awareness around the need to administer antibiotics to patients with sepsis very quickly. In addition, an audit had found that it was important for care to taken around the use of the term ‘sepsis’. Some infections were not actually sepsis but once it was recorded in patient’s notes then the infection would be deemed as sepsis from that point. There was a need to be very precise on this to get the right treatment in the right timeframe. MOD asked what would need to be different going forward, to improve this. JS responded that there was a continuing piece of work around education. This included training days and the Patient Safety Team undertook constant ward rounds around sepsis. Increased accessibility and visibility of the Sepsis Bundle would also help and he referred to the use of the ‘red tray’ system in the past and challenge around its use. PH added that she felt the bundle should be attached into dial on maps. RP commented that as a NED he had undertaken a number of medicine ward walkabouts and had been highly impressed with what he had seen. He referred to the patient experience performance dashboard included in the agenda and the response from patients to the questions around whether they had been involved as much as they might have wanted to be, in decisions around their care and treatment. This indicator had a red RAG rating in respect of a number of the wards. He asked whether the responses were a fair reflection of reality or a perception by the patient. PR responded that in her opinion the issue was largely linked to perception and included how staff dealt with relatives, so there was a need to clear about planning etc. Ward staff were speaking to patients at the bedside about their care, but the scores did not appear to be improving which was frustrating. RP asked whether there was anything else that needed to be reinforced. HO commented that it was about the question and the way it was asked, but maybe a question could be included to ask patients on what they felt the ward could have done better. A new questionnaire covering the entirety of admission to discharge was being introduced and this could include this question. TS asked how learning was shared across the wards and different sites and the process by which learning was embedded. JS responded that there had been changes to cross site communications at directorate level and every ward area now had a morbidity and mortality, (M&M) meeting and clinical governance huddles to look at complaints and

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h. i. j. k. l. m. n.

incidents. It was intended to try and get a standard output from these meetings through short easy to understand key messages, which would then be passed to directorate governance meetings. It was intended to look at implementing this approach at a local level first then roll out more widely amongst Frimley Health. At Wexham Park the approach had been embedded for longer and the local framework was stronger than at Frimley Park. RL asked the team to outline what they were most proud of and any challenges they faced. MY commented that her teams were amazing. In respect to Wexham Ward 6, matrons and staff had worked together through a very tough winter. They were a brand new team that had been together for a short period of time and had really turned the ward around following a previous incident. The environment within Ward 17, which had been flagged by the CQC, was being improved from its previous poor environment with new flooring. It was now a great place for patients and staff. The ward catered for patients waiting to leave hospital and for many of them it was felt to be a home from home. Hand hygiene was a challenge and the Wexham team was looking to get support from colleagues at Frimley to improve performance. There were more peer reviews taking place and these were felt to work really well with good relationships across departments and cross departmental learning. MV and PH commented that a highlight for them was the work of the renal team at Frimley Park who had done really well and outstripped the planned levels of activity for the new renal unit which had been originally estimated to be 2 patients per day, but was actually running at between 5-6 patients per day. One bed in the unit had been turned into a ‘hot bed’ where different patients could come down for dialysis sessions over the course of a day and it was a good example of multidisciplinary team working in practice. Another highlight was the work of the Frimley Stroke ward in respect of responding to clostridium difficile where a joined up action plans was in place and a more proactive approach to outcomes was being taken. HC added that the wards had taken on more stroke activity from Ashford St Peters than expected, (90% versus an expected level of 60%). This was a significant achievement. PH stated that she was proud of the work around the establishment of an acute frailty network. Good relationships had been built with the community teams to improve the pathways for frail patients in a way that had not been done previously. This had helped change the culture and environment in respect of F14 Elderly care ward, allowing patients to be up and mobile which had made a massive difference. In follow up to these remarks, RL asked if the theory around the need to prevent ‘pyjama paralysis’ was being borne out in practice. PH responded that she felt that this initiative had made a massive difference as patients felt more normalised and less institutionalised as a result of being in hospital. JS added that even for doctors, patients were perceived in a different way if they were wearing regular clothing rather than pyjamas. MY added there was to be a national launch in relation to combatting pyjama paralysis on the 17th April, but data was already being collected and this would provide evidence on the impact it has had. Other Trusts including Nottingham were also seeing positive results.

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o. p. q.

TH commented that the renal unit was the first of its kind in the county and that the establishment of the unit might be a true game changer. It had been a hugely complex project to set up and had carried some governance risk but had been the best thing for patients with real improvements for their care and experience through the removal of the need to transport patient’s off-site for dialysis. To set out such a specialised service within six months was a significant achievement and the need now was to look into the possibility of providing a similar provision on the Wexham site. MOD asked those present to identify one thing that the Trust board might help with and PP asked them to consider what it was in particular that made them get out of bed and come to work each day or what they were most proud of. Comments from the team included: • The quality of the staff working within the teams and the can do attitude which

allowed them to rise to the challenges they faced in going the extra mile for patients.

• Making a real difference to patient’s lives which underpinned a feeling of being proud to be a nurse and part of a group that delivered such care. Staff were passionate about their jobs.

• That the quality of leadership at Matron Level had helped staff deliver. • The renal unit at Frimley Park was a huge highlight with some 280 dialysis session

now completed. • Staff wanted to deliver the very best care they could and get good results and this

was demonstrated by their actions. • Being able to look back and see how care had changed for patients, was immensely

rewarding. In his summary, PP commented that the teams were operating at the serious end of medicine with some very sick patients. They had created opportunities for improvements to patient care and the fact that so many initiatives, such as the provision of the stroke services and the renal unit at Frimley, had been dealt with so quickly spoke for itself. At Wexham, ward 17 was looking after patients who were medically fit with nowhere to go and rheumatology was looking after patients in considerable pain. The difference in achieving the best outcomes for patients was down to the quality of leadership. His experience was that the quality of the leader was paramount and the leader got the team they deserved. So, if the team was good this was down to good leadership but if the team were not good, this was down to poor leadership. The Board were impressed with the leadership team that had come to do this presentation. PP thanked them for all their hard work and asked that those present take back the Board’s gratitude back to their own staff.

6. Chief Executive's Performance Report including Q1 Board Objectives 2018/2019 a.

ND presented the Chief Executive’s and the Quality and Performance Report for April 2018 and draft Quarter 1 Board Objective for 2018/2019 as set out in the Agenda. He commented that his report was framed around three themes, the external environment facing the Trust, key performance areas and the recognition of successes and accolades. • The ICS was now operating in shadow form and it was hoped to formalise its

arrangements soon. The Frimley ICS was gaining a good reputation as an ICS exemplar.

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b.

• The Trust continued to work with Ashford & St Peters NHS Foundation Trust with regard to vascular services

• Four hour wait target in Emergency Departments remained a challenge with significant variation in the performance of the two ED departments. Overall ED performance for April was 82.2%. There was a need to reflect on the current model and review best practice to develop a step change for patients and communities.

• Finance – there had been a successful end to the 2017/2018 year. The Trust had achieved its financial control total and generated a bonus of £2.5m which had offset the STF lost due to the failure to hit the required ED performance target in M12. The Trust's control total had reduced by £6m, following NHS Improvement’s decision to convert agreed capital-to-revenue funding into a control total adjustment. In addition to this a further STF bonus of £8m was earned.

• The Trust was reporting an outturn of £26.6m vs. £24m forecasted in Month 11, but it was recognised that were significant challenges ahead in 2018/2019.

• Recruitment and Retention – a number of recruitment fairs and events had taken place and these had been very successful.

• Learning – the Trust’s performance in respect to the number of serious incidents that had taken place in 2017/2018 was a cause for concern and continuing effort was being made to learn from the incidents. Some improvements had been made and the Trust also wanted to ensure it was working with external organisations

• Frimley Health had won the recent national `most improved flu fighter’ campaign. DB and TH were congratulated for this achievement.

Questions and discussion followed: • RL referred to the Trust performance in respect of operating theatre utilisation as

set out on Agenda page 31. There had not been any improvement in the percentage of utilisation over the last two years and he asked what needed to be done to improve on the 73%. ND responded that he agreed that theatre utilisation did need to improve significantly. HC added that it had been difficult to get engagement on this over the last year, but it had been possible to identify the reasons for poor utilisation and some solutions had been tried. There was still poor buy-in from anaesthetic doctors and consultants and this needed to be tackled. There was a need to achieve a CIP saving of £750,000 as a result of improved utilisation and a new Associate Director was in place. HC added that more work was needed to address this issue.

• RL asked what the barriers were to consultant buy-in on theatre utilisation. TH responded that there had been some push back about beds and movement of patients through the hospitals but this was only part of issue. There was also a need for consultants to work very differently through a team based approach, but many of them wanted to continue to work in their own way, which resulted in inefficiency. It would be necessary for consultants to work more collectively as a group and some governance was required around this. Traction in respect of the adoption of new practices was better in some areas than others. An example was endoscopy where a new mind-set had been adopted and extended day clinics introduced.

• RL asked what ‘good’ would look like in terms of theatre utilisation. TH responded that a national piece of work undertaken by Tim Briggs set out best practice by speciality. A ‘Getting it Right First Time’, (GRFT) project was being developed and the output from this would come to the Trust’s Hospital Executive Board. Change would need to be clinically lead and an issue was that most national benchmarks on utilisation were more liberal than the NHS ones. National direction would help in

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driving forward change as the Trust did not want to appear to be acting in a top down management style. TH indicated that he felt the benchmark should be over 80%.

• LG commented that the issue of theatre utilisation was quite complex and work was being undertaken to try and break down all the factors to see what would have the most impact on utilisation. There was more energy around the issue with a new team coming in, but the Board could help through the Trust’s Digital Strategy to drive efficiency. The systems at Wexham were old and fragile and this did not help.

• ND added there was a need to step back and review why previous initiatives to improve theatre utilisation had not worked fully. Early reflections were that the reasons related to different pre assessment models, different practices, different IT etc. This underpinned a lot of the inefficiencies throughout the Trust at present time and there was a need to do things differently.

• RP set out an analogy from the music industry where the culture had changed significantly overtime to one where there was now a strong focus on efficient studio utilisation including strong disincentives for poor timelines.

• HC added that if it was possible to achieve utilisation of 80%, there would effectively be no need to do waiting list initiatives and there was the potential to reduce costs significantly.

• DK asked what the operational impact of the electronic referrals system, (e-RS) for outpatients was on the Trust. LG responded that e-RS implementation process had been progressing for around nine months. During this time the number of e-referrals had gone from low to high numbers with some clinics at 100%. A number of staff welcomed and liked the system from an administrative perspective but from a clinical perspective some consultants felt it was a more burdensome process than before. DK asked if the system was now more efficient and whether it had been possible to reduce staff posts. LG responded this had not been possible to date as not all the systems were fully integrated. The system was becoming more efficient but there were still a few more elements required to complete this. For example, some of internal inefficiencies would have an impact, i.e. not updating consultant leave in a timely way which had an impact on patient choice.

• TS referred to delayed transfers of care. Her impression was that the wider ICS had been slow to date in tackling the issues. HC responded that the current situation in respect of delayed transfers of care from Frimley Park was better than it had ever been. In previous years there had been significant issues, but the current year had not seen such difficulties. There was an enhanced recovery service in place and joined up staff provision with Southern Health. There had not been significant delays from local authority social care services and detox delays were down to 4.7%. An area for improvement was in respect of availability of placements for EMI patients, but the situation was better than it was. LG commented that within the Wexham system conversations were needed with the South Bucks CCG to facilitate access to community and domiciliary care provision there.

• MOD commented that his impression was that the situation with South Bucks CCG had been going on for some time and asked what difficulties needed to be overcome. LG responded that she had recently attended a meeting that had brought director level staff of the key partners together in order to understand what was and was not working, so this could be factored into future planning. GPs present indicated that they wanted to refer patients to Wexham Park, but there were some frustrations and better alignment between the Trust and GPs around transitions of care was needed. A number of work streams had been agreed which would inform proposals to move away from a bed based model to more care in the

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c.

home. • PP referred to performance in respect of stroke patients and the target to admit

stroke patients directly to the stroke unit in four hours. He noted that there had been 17 breaches of the target and our performance was rated Red. He asked if the four hour target had any particular clinical impact on the final outcome for the patient. HC responded that it did not, as appropriate treatment was given on admission. There had been delays in getting beds in the Stroke Unit. A root cause analysis has been requested

• TH added that stroke patients who could not be admitted to the Stroke Unit were thrombolised and kept in the resuscitation area but the national standard was to require patients to go to a stroke unit and get the whole MDT care, as outcomes were significantly better once there. HC added that a deep dive was being undertaken, but the issue was that there were not enough beds in the right place with a higher number of such patients than anticipated.

Board Objectives Quarter 1 2018/2019 • RP commented that although there was a board objective around transforming

infrastructure there was nothing about transformation of processes or lean reviews that would improve efficiency. He felt that there should be objectives on this area. ND responded that the objectives had reflected a point in time, but the point was valid and the PRC could be asked to consider building in such objectives.

• RP referred to the objectives relating to managing staff turnover under part of the heading for developing staff and culture. He commented that he was used to seeing such an objective be split it two 2 categories, avoidable turnover and non-avoidable turnover. There could then be a better linkage with employee satisfaction scores. ND indicated he would feedback that point back to JK.

1) The Board noted the CEO and Quality and Performance reports 2) The Board agreed the Board Objectives for Quarter 1 2018/2019 subject to further

consideration by the PRC of objectives relating to the transformation of processes and refinement of the staff turnover objective.

JK/ DK

7. Quality Improvement Plan (QIP) a.

TH presented the report as set out in the Agenda and highlighted that: • A number of Filipino staff had now started with the Trust • In April the Trust had replaced its previous system (TempRe) used to book medical

bank and agency/locum staff with a new system (Allocate Locum OnDuty) which had previously been used within the Trust for nurses. This had operational and cost benefits.

• Work to improve hand over was continuing. The Directors of Operation and Deputy Medical Directors had recently undertaken an observational audit of clinical handover.

• For Do not Attempt Resuscitation, (DNAR) a new Trust wide position had been agreed in line with the national RESPECT position. The aim was for change to the work in the community, so conversations took place with patients and their relatives.

• Emergency Department pressure. Ambulatory care now accounted for 30% which had a positive impact on length of stay and on overall bed admissions.

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b. c. d.

In discussion the follow questions were asked: DK asked that the target completion dates be refreshed in the report as they all related to the 2017/2018 year. MOD asked whether it was intended to create a model for night time handover. TH responded that both sites were doing so and the aim was a true hospital at night where there were no individual teams. DB highlighted that the CQC were likely to take significant interest in mental health services in hospitals. The Board noted the report.

TH

8. Director of Infection Prevention and Control Annual Report 2017/2018 a. b. c.

As Director of Infection Prevention and Control, TH presented the annual summary of Trust healthcare-associated infection performance for 2017/18, and the feedback on agenda items presented at the Frimley Park Hospital and Heatherwood and Wexham Park infection control committees. He highlighted that: • An increase in Trust apportioned Clostridium Difficile infections, (CDI) to 45 against a

contractual objective of 31, with 13 of these due to lapses in care, although two of the cases have been redacted. Some of the lapses of care had been the result of stool samples not being sent off before the fourth day of admission. There was also a wider issue around community CDI infection which needed to be picked up by the Integrated Care System, (ICS).

• MRSA - Cases were apportioned to this Trust if the blood culture specimen date was on, or after, the third date of admission. There were three cases against a target of zero; two at FPH, one at WPH. The cases related to the use of devices in patients and screening.

• The earlier ward to board presentation by G3 ward staff had alluded to increased monitoring on G3 with a cluster of CDI cases. New processes had been put in place and equipment had been re-cleaned.

• In the future NHS Improvement would be promoting an Escherichia coli (E-Coli) metric which would also be an ICS issue. The key issues with E.Coli related to diagnosis, not using catheters and the use of particular antibiotics

• There was a need to maintain a strong focus on hand hygiene compliance JW referred to the lack of attendance of clinical leads at Hospital Infection Control Committee meetings. He queried why a target was not set if attendance was important and there was a need to improve. TH responded that the reason for clinical lead attendance was to set a tone, but actual delivery did not require them to be there. His preference was for clinical lead attendance, but if not he would expect chiefs of service or their deputy to attend. JW commented that there was a need for TH to decide what was necessary. TH agreed, but commented he would need to discuss it further with the Infection Prevention & Control Nurse Consultant. DK commented that she thought the report was of a high standard. With regard to derogations around requirements for bed spacing which were constrained within the Trust she asked if the expectations were unrealistic and were all hospitals in the same

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d. e. f. g.

position. TH responded that the Trust’s position was not unique and lots of Trusts used derogations due to the physical limitation of their wards. TH added that discussions were held with nursing staff about what was a reasonable area to work in. MOD referred to Agenda page which stated that Frimley Park Hospital had an automated ‘alert organism flag’ facility, but that Heatherwood and Wexham Park Hospital did not as there were two different IT systems in place. He asked what the safety implications of this might be. LG responded that the same ADT system was used on all three sites using Real Time for ADT and all three sites had been updated to the same software version and indicated she would follow this up. RL commented that he felt that the number of attendees for annual infection control training was still disappointingly low. He queried whether this might be because the Trust was waiting for experts to explain why they were not going for training. With regard to hand hygiene compliance as set out on Agenda page 126 he asked whether any formal action had been taken against staff that consistently disregarded the hand hygiene policy. TH responded that the Trust did take action and that staff also had a personal responsibility for this. Amongst medical staff the level of responsibility was very high as it was a requirement to revalidate their licence. Part of the issue was around staff capacity as the level of activity on the wards was very high. ND added that his observation was that the Infection and Prevention were a strong team and highlighted that they had attend 28 meetings. He suggested that there was potentially an opportunity to refocus on their team and there were also big changes coming with regard to e-prescribing and other factors. TH added that e-prescribing would help with regard to antimicrobial antibiotics as it would ‘lock in’ the drugs available. Issues around infection control and prescription were usually related to use of the wrong antibiotic, so the new system would provide a step change and allows audit of any use of any drug at any time, as opposed to have pharmacists physically checking. The Board approved: 1. The Frimley Health Annual Report 2017/18 2. The Integrated Frimley Health Infection Prevention and Control Annual Plan and

Audit Plan for 2018/19 (and is attached to the report as Appendix 1) 3. The outcome of the Frimley Health 2017/18 Annual Plan, Audit Plan and summary of

Audit and Surveillance Outcomes

9. Finance Report - month 12 a.

NF presented the Month 12 Finance Report to the board as set out in the Agenda. He highlighted the following: • The numbers in the report represented the expected year-end financial position ,

but were subject to confirmation by the Audit Committee and special Board meeting on 24 May prior to submission to parliament

• The report set out a mixed picture with positive and not so positive news. The 2017/18 outturn (excluding STF) was a £500,000 deficit which was £4.7m adverse to plan. However, the Trust’s control total was adjusted by £6m by NHSI instead of authorising the capital to revenue transfer we had asked for. This £6m more than covered the £4.7m adverse variance and meant that the Trust has achieved its control total and all financial targets as set by NHSI and was thus eligible for STF

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b.

payments of £16.7m subject to audit. In addition the Trust was eligible for an STF bonus of £10.5m making a total STF of £27.2m.

• These funds would remain on the balance sheet and could not be used for in year revenue expenditure although the money could be used for capital expenditure.

• A bottom line surplus including STF of £26.6 would be shown in the annual accounts subject to audit. However, once non recurrent sources of funding and the deficit support were taken out, the situation was different. The Trusts continued to overspend on its budgeted expenditure and rely on additional year end income gains due in part to a very difficult winter. Combined with the planned reliance on central support in year (deficit support of £16.6m plus a control total adjustment of £6m) meant that the Trust’s underlying deficit had not been reduced to planned levels. The Trust still had an underlying deficit position of £26m.

• Agency expenditure costs had picked up in M12 and were £400,000 higher than M11. The increase was consistent with the trend for the whole of South of England. The increase in agency costs were related to strict controls on using annual leave before the end of the financial year and this year the Easter period had fallen in M12.

• Capital spend in year had been £96.9m and was underspent by £36.6m due to continued slippage on Heatherwood Hospital redevelopment project, Wexham ED and estates maintenance. The knock on impact on the Trust’s cash position was to push the year end cash balance up to just over £113m.

PP indicated that CIP report was to be considered next followed by RP’s report as Chairman of the Finance Assurance Committee and then open up for any questions. The Board noted the report.

10. CIP Progress Report – Month 12 a. b.

HC presented the Month 12 report setting out the performance of Cost Improvement

Schemes, (CIP). Key points highlighted were: • The closing CIP position for the Trust was £28m against the plan of £30.5m, which

was an adverse variance of -£2.5m and a delivery of 91%. • The in-month CIP delivery was £2.4m (102.1%). • 91% delivery was due to significant under achievement on Medicine, Emergency

Departments and ward model adherence. The CIP performance of theatres, orthopaedics and IM&T had also been disappointing

• The combination of the YTD adverse variance (£2.5m) and the element of non-cash releasing CIP (£3.1m), helped to explain the impact of CIP delivery on the Trust’s income and expenditure position. This had resulted in £5.6m CIP issues for the 2018/2019 financial year.

Finance Assurance Committee (FAC) 27th April At the request of the Chairman, RP set out the key issues arising from the meeting of the FAC held on 27th April which had focussed in detail on the Trust’s year end Month 12 financial position: • It had been noted that although the Trust had held discussions with NHSI earlier in

the year for a capital to revenue transfer, NHS Improvement had instead decided to

3




c.

reduce the Trust’s control total by £6m. In the end this was considered to be a positive decision for the Trust. The change by NHS Improvement to the Trust’s control total was good news, but it was important to recognise this was a one off measure.

• Year-end resolution of Clinical Commissioning Group contracts had resulted in more CCG income than expected.

• Stock adjustment remained an option available going forward. The advantage of this measure was to increase the amount of cash on the Trust’s accounts, but it did little to improve the long term affordability of the Trust’s operations.

• Pay and non-pay budgets had been over spent and CIPs had under performed. In addition the STF bonus was welcomed, as was the cash position but these factors would not help balance the books going forward

• It was necessary for the CEO to carefully convey a message to staff and the wider public to reconcile the real cost challenges the Trust faced in the context of an apparently healthy £26m surplus.

• The Committee had also looked at a 5 year forward view on cash. The good news was that the Trust could afford its proposed major capital schemes and keep its cash balance above £50m, but under a middle or worst case scenarios if the Trust did not achieve its cash CIPs, it would not be possible to maintain a cash position above £50m and in the worst case would mean the Trust would be overdrawn.

• A discussion had taken place on the CIP program in terms of both cash releasing and non-cash releasing savings. There was a need for transformational and continuous improvement measures to bring benefits to patients.

• RP concluded that the financial position of the Trust was good at headline level and that the numbers could be signed off, but expressed a note of caution that the underlying position was not as comfortable as might be indicated from the figures at first glance. NF added that in 2015/2016 Frimley Park FT had acquired Wexham and Heatherwood Park FT, which at that time had a significant deficit. However, in 2015/2016 the Trust had received £33m extra for support, £25m in 2016/2017, £23m in 2017/2018 and £14m in 2018/2019. In spite of this, the deficit had not been addressed and as there would be no deficit support in 2019/2020, the Trust really had to demonstrate that it had turned this position around.

JW indicated that he wished to formally record his thanks to the entire Frimley Health team for the achievement of bringing home a good set of yearend financial numbers. He added that it was the end of his first year as a Non-Executive director and although he had never been naïve of how tough money was, he was now acutely aware of the underlying deficit. Windfalls and CIPs had not quite delivered and some CIPs were non-cash releasing and therefore the challenge over the current financial year would be so much greater. The Board noted the report.

11. People Strategy a. b.

ESS presented a paper requesting the approval for the implementation of a revised Trust wide People Strategy for 2018/2021. The strategy had been devised to support actions of the Trust to attract, recruit, develop, support, retain and reward staff and teams to meet the Trust’ future goals and aspirations. The following points were highlighted: • The draft Strategy had been previously considered by the PRC Committee for

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c. d. e. f. g. h. i.

feedback and comment. • The proposed Strategy had been developed from the previous version following a

SWOT analysis. • The ‘strategy on a page’ as set out on Agenda page 251 included nine ambitions. DB commented that the proposed strategy was good. He referred to the number of students the Trust employed and asked whether the Trust was leveraging its relationships with educational providers in the best way possible. He suggested that there might be an opportunity to think differently around the Trust’s strategic relationships with providers in the context of the value to them of the Frimley Health brand. ESS responded that this was a valid point and that it might be possible to elaborate and develop the point further as part of the implementation plan for the strategy. RP referred to the managing talent heading and the expectation that leaders would undertake appraisals for 85% of staff every year. He felt that that it was important to set a strong on-going expectation to leaders that 100% of staff should be apprised even if there was an understanding that given the challenges, the target might not be fully achieved. It was a question of nuance around wording, but an important one in setting the correct tone and giving the right steer. DK agreed that all staff had the right to expect an appraisal and that the language was important. MOD commended the plan on page. He referred to the target to reduce the percentage of the Trust’s overall workforce pay bill and queried the percentages quoted. It was agreed to check the figures outside of the meeting. NF added that the key message was that the Trust’s clear objective was to reduce the size of the workforce pay bill going forward. JW referred to the importance within the Strategy of supporting leaders and asked how the Trust might leverage this across the wider Integrated Care System. He suggested there might an opportunity for the Trust to act in concert with the wider system and facilitate the mixing of leaders from different partner organisations. RL commented that there was no specific reference to diversity within the ambitions for the Strategy. ESS responded that whilst the Strategy was not explicit around diversity it did make reference to the need for inclusive leaders and diversity was embedded with regard to career progression for different protected groups. She agreed that it could be made more explicit and PP supported this. MOD asked how progress in implementing the policy might be measured. ESS indicated that progress would be monitored by the Trust’s work force committee and an update report would also be considered by the PRC annually. ND stated that there was a need to move into implementation with a review of progress after six months and that there could be more within the policy around risk to implementation. The Board approved the People Strategy 2018-2021 for implementation.

ESS/ JK

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12. Corporate Risk Assurance Framework a.

PP indicated that the report had been discussed in detail as part of the previous private board meeting and therefore further discussion was not required on this occasion. The Board noted the high level risks included in the Trust wide Risk Assurance Framework.

13. Integrated Care System (ICS)– Committees in Common a. b. c. d. e. f. g.

SNW and JH presented the report and the power point presentation, explaining how committees in common would work in practice for the ICS, indicating the provenance of the delegated powers being sought which were consistent with the signed Memorandum of Association between the partner organisations. A key element of the committees in common concept was the principle of collaborative decision making and a worked example of how the structure might work in practice was outlined as part of the presentation. PP explained the context on the governance mechanism for both the ICS and the Trust. The Board needed to ensure it was comfortable with the recommendations set out in the report before approving them. Discussion and questions followed: DK referred to the need going forward for the Trust to be more mindful of the impact of its decisions on the system as whole. An example of this was the consideration of business cases for capital and other projects. NF commented that in the past the Trust would have approved a business case if it was thought the project could generate enough income from commissioners, but now if it would cause difficulty with commissioners, there will be a need to find out if a scheme was affordable within the ICS budget. RP added that the ICS relationship worked both ways in that how the CCGs made its decisions would affect the system control total and by implication Frimley Health. RP suggested that with NF, the Finance Assurance Committee, (FAC) might be a possible conduit for the flow of information between the ICS and the Trust and consequently it may need to meet more frequently. This might for example, include bringing a system wide finance report to the FAC in order to provide the Board with appropriate reassurance. TS commented that the decision around committees in common opened up a wider issue around how the Board was informed of the activities of the ICS. PP responded that the Chief Executive and Medical Director sat on the ICS board so the Board would get its information from them and be sighted through the Board’s Committees in Common ICS sub-committee. In addition the minutes of the ICS board could be shared with the Trust Board. There was a piece of work to be undertaken around putting in place possible further arrangements for the two way flow of information – e.g. finance information to be considered by FAC and QAC to consider system wider quality issue. The Board agreed to:

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1. Approve the move to a committees in common structure for the Frimley Health &

Care ICS under the terms set out in this paper; 2. Agree to create another board committee called the Frimley Health & Care’s

Integrated Care System Committees in Common; establish terms of reference for that committee and specify membership of the committee to include and be limited to the Chief Executive and the Medical Director with their respective nominated deputies to include the Director of Finance and the Director of Nursing;

3. Agree the delegations to the Chief Executive and Medical Director to include: i. Approving the final system control total by a date to be agreed with NHS

England/Improvement ii. Approving the annual system operating plan

iii. Approving in year changes to the system operating plan iv. Considering and approving transformation investment cases in line with the

system operating plan v. Escalation and resolution of any other issues which may impact on the system

14. Review Minutes and Recommendations of the Board Committees a. b. c.

14.1 Performance & Remuneration Committee - 11th April DK reported she had nothing to add to the written report included in the Agenda which was self-explanatory. 14.2 Finance Assurance Committee - 27th April It was noted that this had been covered under items 9 and 10. 14.3 Commercial Investment & Development Committee - 27th April ME summarised the update report as set out in the Agenda.

15. Senior Information Risk Owner (SIRO) Quarterly Report (to include Annual Report) a. b. c.

NF presented the quarterly and annual report detailing compliance with the Trust’s FOI and DPA requests and details for quarter 4 of the Information Governance work programme for 2017/2018. Preparations for the introduction of GDPR were also detailed. He highlighted the following: • Staff who had not completed Information Governance, (IG) training were followed

up and the Trust had hit its 95% compliance target. The achievement of the target was important as this fed into the IG toolkit to assess compliance on IG matters and fed into the Trust’s ability to be part of system wide projects

• GDPR - a lot of work was being undertaken behind scenes to be compliant with regulations coming into force on 25th May.

TS asked if IG training was included for bank and agency staff given that they may not have access to Trust systems. NF responded he would seek clarification and let TS know. DK asked whether the number of potential additional subject access requests had been estimated given that such requests could no longer be charged for and some were time consuming to respond to. NF responded that an increase was expected, but this would need to be reviewed in time.

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d.

PP commented that the IG team worked very hard and he asked that the Board’s thanks for their work and an excellent report be communicated to them. The Board noted the report.

16. NHSI Self-Certification a. b.

PP presented the self-certification tables which were required for the regulator and were to be published on the website. Each table was taken in turn by the Board as follows: 1. General Condition 6 and Continuity of Service Condition 7 of the NHS Provider

license – agreed subject to amendment of cash balance from £102m to £113m 2. FT4 Corporate Governance Statements-agreed 3. Certification on training of governors – agreed 4. The BOARD agreed to authorise ND and PP to sign the self-certifications on its

behalf.

17. Staff Appraisal Update (excluding medical staff appraisal) a. b. c. d. e.

ESS presented the report as set out in the Agenda which gave detail on the appraisal completion rate for non-medical staff. It was noted that regular updates were given to the Board on this issue, as the Board were concerned about the levels of achievement and wanted to monitor progress. RL commented that he had been struck by qualitative result which seemed worse than the previous report with less than a third of respondents feeling their appraisal had helped them and only a fraction responding that they felt it had made a difference. He queried whether this was disappointing. ESS responded that surprisingly, the results for the quality of appraisal at Frimley Health were in the best 20% of Trusts in the sector. Managers training for appraisals had recently changed and the emphasis now was to inspire managers to hold a more valuable conversation with their staff rather than the appraisal being regarded as a ‘tick box’ exercise. A lot of work had been undertaken on the issue and therefore it was expected that the qualitative results would improve. PP commented that he had attended a two hour training session on the subject and he was impressed with it. The whole appraisal training had been re-done and he agreed that it was moving away from a tick box approach to more of a quality discussion with changes to the paperwork to facilitate ease of completion. DK commented that it been consistently stated that appraisal compliance was actually higher than captured in the system because of the results of the staff survey questions on the issue. However, she was not on balance persuaded by this as a source of assurance, given staff appraisal had been on the risk register for six years. PP indicated that the new processes needed a window of time to be implemented, with appraisals for band 8 and above staff being undertaken by end of June and other staff by end of September. He agreed that the Trust should be aiming for a 100% compliance level and understood that the Board’s patience was running out on the issue. It was important to track the new system through and he asked that the results for band 8s and above be brought back to the Board, broken down by Directorate.

ESS/ JK

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f.

It was agreed that Directors and AD’s should make themselves aware of where appraisals were not taking place and/or recorded on the appraisal tracker and set timescales with relevant managers to complete/record these, (as set out in Appendix 1).

18. MAST Update a. b. c. d. e.

ESS presented the report setting out compliance with the targets for the mandatory or statutory training of staff, (MAST). • Overall MAST compliance was currently 80.71%. • Benchmark activity comparing the Trust with similar South East England regional

organisations suggested that it was broadly in line with other Trusts in terms of compliance reporting parameters.

• E-study and e-assessments have been launched via the MAST microsite with increasing activity improving compliance rates.

• Issues included: resource for some subjects matter experts such as resuscitation training (as a potential focus of forthcoming CQC visit).

PP commented that the results indicated a slightly improving picture, but there was still more to be done. In particular, level 2 and 3 paediatric resuscitation training requirements needed to improved urgently prior to the CQC inspection as this was an area flagged during the previous inspection. DB provided the board with assurance that significant work was being undertaken by the Resus team on this training. 40% had been already trained and training was also being taken out to the clinics. It was an absolute focus and DB indicated that he would be happy to report back to the Board when the training was completed. The Board agreed that 1. Executive Directors be asked to take action to understand their local compliance

rates and the specific issues for poor compliance within their Directorate and to take action to address these issues (informing Learning and Development Manager, Nikki Morgan, of issues which require L&D attention)

2. Executive Directors be asked to support their Associate Directors and Chiefs of

Service in ED, Paediatrics, Theatres, Critical Care and Anaesthetics to coordinate with the Resuscitation team (Karen Britton/ Nikki Morgan) urgent Resuscitation level 2 and 3 paediatric training ahead of CQC inspection. (appendix two provides details of staff names)

3. All staff should have email access provided in order to be able to take advantage of

e-learning/ assessments (as well as the wider benefits of receiving wider communications and information)

4. Equality, Diversity and Human Rights to be reinstated as face to face session at

Corporate Induction 5. Paediatric level 2 resuscitation to be included in Corporate Induction from June 2018

DB

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19. Any Other Business a.

No other business

20. Meeting Review a. b. c. d.

DK commented that that meeting had a heavy agenda. In discussion it was felt that whilst the ward to board presentation had been very good, it had included too many wards to be practical and that with the benefit of hindsight it might be an idea to split a large directorate such as medicine into several parts. DB indicated that every effort was being made to keep the number of presenters to a manageable number. ME indicated that he felt that potentially the same teams were now presenting and he was concerned that some areas might be missed. A short discussion took place and it was felt it would be useful for the Board to also hear from non-ward teams such as pharmacy and or teams undertaking therapies. MOD commented that he felt JS had kept his comments at the right level which was a credit to PP and DB for their briefing to him. PP thanked everyone.

DB

21. Questions from Members of the Public a. b. c. d.

Rod Broad referred to Agenda page 133 and the Annual Infection Control Report. He asked if it was correct that the programme of six monthly deep cleans had been reduced at Frimley and that there was no programme at Heatherwood and Wexham Park? HC responded that there used to be two deep cleans a year on the Frimley site which had then moved to annually on both sites. LG commented that this could be picked up as part of the housecleaning review. Sarah Peacy referred to the Board’s discussion about utilisation of operating theatres and questioned whether there would be an issue around continuity of care for patients if different clinicians were involved in their treatment. TH responded that the Trust was trying to move to a team based approach where patients would become more generic in their relationships with clinicians, but there would be a common standard across the piece and that each patient had a named accountable consultant for their overall care. Sarah Peacy asked how this could be managed with patients with lots of co-morbidities. TH responded that the key was consistent handover and good communication with patients and family. Jan Burnett asked what the response of the CCGs was to the Heatherwood project. NF responded that at the outline business case stage, the project had been positively received with letters of endorsement on the direction of travel. However, there was now a need to refresh those conversations as the project moved forward.

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20. Date of the Next Meeting

Friday 1 June 2018 Lecture Theatre, PGMC, Wexham Park Hospital

These minutes of the meeting were duly approved by the Board:

Name: Pradip Patel

Signature:

Date:

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BOARD OF DIRECTORS MEETING – PUBLIC

Friday 1 June 2018 ACTION LOG

AGREED ACTION LEAD END DATE

6 April 2018 - 10.b Quarterly Board Objectives Q4 Communications team to look back at 2017-18 and create a story about what the Trust has achieved and share this with all staff to celebrate the significant achievements.

Janet King & James Taylor

1 June 2018

6 April 2018 - 15.c National Staff Survey 2017 ND to write to the Top 10 departments with the best scores to congratulate them and JK to write to the ten lowest departments to review their results and produce an action plan to improve. Update 23/04/18: Letters to be dispatched by OD Department in next couple of weeks.

Neil Dardis & Janet King 4 May 2018

4 May 2018 – 3.b Minutes of the Previous Meeting KJ to make corrections to the April minutes

Kevin Jacob 14 May 2018

ACTIONS IN PROGRESS

1 September 2017 - 18.e Meeting Review PP to undertake a review of board papers and work with the EDs to make the papers fit for board

Pradip Patel On-going into 2018

5 January 2018 – 18.e Meeting Review DB to reflect on the comments made in order to find the optimum format for consistency of Ward to Board reporting although this did not necessarily need to be implemented for the February meeting. DB to finalise this action.

Duncan Burton On going

4 May 2018 6.c Chief Executive's Performance Report including Q1 Board Objectives 2018/2019

PRC to further consider board objectives relating to the transformation of processes and refinement of the staff turnover objective.

Janet King/ Dawn Kenson

15 June

4 May 2018 7.b Quality Improvement Plan Target completion dates to be refreshed to reflect the beginning of the new financial year

Tim Ho TBC

4 May 2018 11.e People Strategy Reflect on the Appraisal completion rates and more explicit reference to diversity within the ambitions for the strategy

Eleanor Shingleton-Smith /

Janet King TBC

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4 May 2018 17.f Staff Appraisal Staff appraisal completion rates for staff Band 8 and above, broken down by directorates, to be brought back to the Board when available.

Eleanor Shingleton-Smith /

Janet King September

4 May 2018 18.d Mast Update DB to report back on completion by Resus team of level 2 and 3 paediatric training

Duncan Burton TBC

4 May 2018 20.c Meeting Review DB to consider the possible inclusion of non-ward teams within the Ward to Board schedule

Duncan Burton TBC

ACTIONS OVERDUE

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Page 1 of 3

Report Title Ward to Board Report Frimley Health Orthopaedic Wards:

Meeting

Board of Directors – Public

Meeting Date

Friday, June 1st 2018

Agenda No.

5.

Report Type

Presentation

Prepared By

Executive Lead

D Burton

Executive Summary

The Health and Social Care Act 2008 (Code of Practice on the Prevention and Control of infections and related guidance July 2015) states that NHS provider organisations must demonstrate that infection prevention and cleanliness are an integral part of quality assurance. Please find the report to the Board by Chiefs of Service and Clinical Matrons for Frimley Health Orthopaedic Wards NB this report is presented in conjunction with the performance dashboard.

Background

Clinical Matrons: Annmarie Lawson (FPH Wards F4, F5 and F6) and Fiona Mason (WPH WX1, WX2 and HWD W4 and Short Stay Unit) Head of Nursing: Alison Stevens Chief of Service: Peter Hill

Issues/Actions

Areas of the Infection Control Section are RAG rated for information

Recommendation

Board members are asked to discuss and note this report

Appendices

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Page 2 of 3

Wards FPH F4 FPH F5 FPH F6 WX1 HWD 4 MRSA bacteraemia for year

0 0 0 0 0

Clostridium difficile Infection cases (Trust apportioned)

1 Oct 0 0 0 0

Clostridium difficile Infection cases with Lapse in care

0 NA NA NA NA

Antibiotic Audits obtained from Pharmacy Dept (Dec 2017):

Wards F4 F5 F6 WX1 HWD4 Was Stop/review date documented on the prescription? Was the correct Indication specified on chart? Did the prescribing Seem reasonable?

75% 83% 83%

80% 100% 100%

Wards F4 F5 F6 WX1

HWD4

Ward environmental audit

92% (Jun17)

96% (Oct17)

97% (Aug17)

80% (Jan 2018) 95% (Jan 2018)

Hand Hygiene Audit Scores – Matrons audits

92% 95% (March) No submission (April)

97% (May)

70% (Apr) 91% (May)

90% (March 18) 100% (March 18)

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Hand Hygiene Audit Scores IPCN

87% (Apr 2018)

92% (Jan 2018)

88% (Mar 2018)

100% ( Mar 2018)

100% (Jan - March 18)

Spot check audit of alcohol hand sanitizer availability

86% (Apr18)

100% (Apr18)

97% (Apr18)

88% (April 18)

100% (April 18)

Infection Control link rep attendance at quarterly forum

75% (3 of last 4 meetings)



25% 1 of last 4 meetings


Consultant Clinical Lead attendance at monthly HICC

75% 0%

Consultants attendance at annual infection control training

86% Consultants

60% Trust Doctors

50% Consultants

80% Trust Doctors

Bed Spacing (range and median) DH Estates & Facilities (2013) HBN 00-09 & 04-01: recommend clear bed space of at least 3.6m (width) by 3.7m (depth)

2.4m 2.5m 2.4m W1A,B C and MSU

2.5m

W2SAU

2.4m

2.4m

Number of single rooms (number with en suite toilet facilities)

2 (0 are en suite) 8 en-suite 4 (0 are en suite) Ward 1 8 (0 are en suite)

Ward 2 S 4 (0 are en suite)

4 (0 are en suite)

Cleanliness monitoring data obtained from Facilities Dept Wards F4 F5 F6 WX1 HWD 4 National Standards for Cleanliness score (March 2018)

HK = 95.9% Nursing 90.8%

HK 97.2% Nursing 93.9%




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Ward Performance ReportF4

F4

WARD CQUIN REQUIREMENTS Outurn Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTDTarget

2017/18

Dementia Assessment 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 90%

PATIENT EXPERIENCE Outurn Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 March YTDTarget

2017/18

Survey questions: (No. of questionnaires completed) 48 11 3 20 11 8 7 12 19 6 7 10 11 125

Overall, did you feel you were treated with respect and dignity while you were in this ward?

83% 100% 100% 100% 82% 100% 100% 100% 95% 100% 86% 100% 100% 97% 95%

Did you have confidence and trust in the doctors treating you? 95% 91% 67% 95% 100% 87% 100% 92% 95% 100% 86% 90% 91% 91% 95%

Were you involved as much as you wanted to be in decisions about your care and treatment?

New 73% 67% 90% 91% 100% 71% 75% 84% 83% 71% 80% 73% 80% 90%

Did nurses talk in front of you as if you weren’t there? New 73% 100% 85% 82% 100% 100% 100% 95% 100% 86% 100% 100% 93% 95%

Were you ever bothered by noise at night from other patients? (no response is counted as positive)

61% 100% 0% 70% 45% 37% 43% 67% 68% 100% 86% 80% 64% 63% 80%

Were you ever bothered by noise at night from hospital staff? (no response is counted as positive)

92% 50% 100% 95% 100% 75% 71% 75% 95% 100% 100% 90% 91% 87% 90%If you needed it, did you get enough help from staff with eating and drinking? 66% 100% 100% 100% 100% 100% 100% 60% 100% NA 75% N/A NA 93% 90%

Within the first couple of days of admission did a member of staff ask you about your home situation? (For example do you have help with the shopping and cooking? Do you use a stick or frame to walk etc.?)

82% 88% 100% 93% 90% 100% 83% 100% 93% 100% 57% 100% 91% 91% 80%

Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand?

New 80% 100% 100% 100% 67% 100% 100% 100% 100% 100% 100% 100% 96% 95%Have you and your family or carers been involved enough in discussing your discharge from hospital?

80% 71% 100% 94% 100% 80% 86% 100% 100% 100% 100% 100% 100% 94% 80%

Official FFT resultsWould you recommend FPH to family and friends?

98% 96% 96% 100% 100% 100% 100% 50% 100% 100% 100% 100% 0% 87% 90%

FFT Response Rate New 32% 30% 20% 34% 13% 16% 4% 11% 10% 2% 4% 0% 15% 40%

FFT Response - Number of extremely unlikely and unlikely responses 0 0 0 0 0

INFECTION CONTROL Outurn Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 March YTDTarget

2017/18C-Diff 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0

MRSA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NA

Hand hygiene 89% 88% 98% 98%, BBE 100% 98%

86%, BBE

95% 95% 98% 95% 94% 84% 91% 94%

F4

New

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PATIENT SAFETY PERFORMANCE Outurn Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 March YTDTarget

2017/18Hospital acquired pressure ulcer - Grade 2 8 1 2 1 1 1 0 0 0 1 1 1 9 NA

Hospital acquired pressure ulcer - Grade 3 1 0 0 0 0 0 0 0 0 0 0 0 0 NA


Safety Thermometer 92% NA 93% 93% 96% 93% 86% 82% 78% 93% NA 100% 100% 91% 95%

VTE Risk Assessment 99% 100% 100% 96% 100% 100% 100% 100% 100% 100% 97% 100% 100% 99% 95%

Complaints (by number) 4 0 0 0 1 0 0 0 0 0 1 0 1 3 NA

Compliments (by number) 0 0 NA

Total number of falls 67 4 1 5 6 5 4 2 3 2 5 1 4 42 NA

Total number of falls (with significant injury) 1 0 0 0 0 0 0 0 0 0 0 0 0 0 NA

Medication errors 24 2 4 2 0 1 3 2 4 5 1 2 0 26 NA

Medication errors with harm 0 0 0 0 0 0 0 0 0 0 0 0In

arrears0 NA

SIRI's 2 0 0 0 0 0 0 0 0 0 0 0 0 0 NA

Staffing incidents 5 0 2 0 1 0 0 1 2 1 0 0 1 8 NA

Emergency trolley compliance 99% 93% 97% 97% 100% 94% 97% 97% 97% 100% 94% 89% 100% 96%

Suction (quarterly) 86% 96% 94% 190%

F4

In arrears

COMMENTS

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F5


2017/18

Dementia Assessment 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 97% 100% 90%


2017/18



93% 100% 100% 100% 100% 100% 80% 93% 92% 100% 92% 100% 100% 96% 95%



New 75% 67% 100% 79% 100% 60% 79% 75% 100% 62% 73% 71% 78% 90%



51% NA 67% 68% 50% 100% 60% 67% 50% 100% 69% 64% 57% 68% 80%


92% 75% 67% 91% 86% 100% 80% 100% 92% 100% 85% 100% 100% 90% 90%If you needed it, did you get enough help from staff with eating and drinking? 86% 100% NA 100% 50% NA 0% 100% 50% NA 100% 100% 100% 78% 90%


81% 100% 100% 94% 85% 100% 100% 83% 100% 100% 100% 91% 86% 95% 80%


New 100% 100% 100% 100% 100% 100% 100% 100% NA 100% 100% 80% 98% 95%

Have you and your family or carers been involved enough in discussing your discharge from hospital?

85% 67% 100% 80% 100% 100% 100% 86% 80% 100% 75% 100% 67% 88% 80%


95% 100% 100% 96% 94% 91% 100% 94% 100% 100% 90% NA 0% 88% 90%

FFT Response Rate New 42% 10% 45% 71% 30% 13% 57% 8% 36% 21% NA 0% 30% 40%

FFT Response - Number of extremely unlikely and unlikely responses 0 1 NA 0 1


2017/18C-Diff 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0

MRSA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NA

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Hand hygiene 100% Nil Sub. 98%, BBE 100%

No Sub85%, BBE

100% 100% Nil Sub. Nil Sub 94% 95% 91% 95% 95% 95%

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2017/18Hospital acquired pressure ulcer - Grade 2 5 1 2 0 0 1 0 1 3 0 1 0 9 NA



Safety Thermometer 88% 96% 92% 96% 100% 96% 71% 88% 84% 100% NA 100% 83% 91% 95%



Compliments (by number) 0 0 NA





arrears0 NA

SIRI's 0 0 0 0 0 0 0 0 1 0 0 0 0 0 NA




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F6


2017/18

Dementia Assessment 99% NA 100% 100% 100% NA NA 100% 100% 100% NA 100% NA 100% 90%


2017/18



93% 100% 99% 99% 99% 99% 100% 99% 97% 100% 99% 97% 99% 99% 95%



New 99% 97% 97% 98% 99% 98% 98% 94% 99% 96% 97% 92% 97% 90%



51% 100% 91% 87% 82% 79% 67% 77% 75% 79% 69% 74% 65% 79% 80%


92% 85% 90% 88% 93% 88% 84% 88% 82% 89% 76% 82% 84% 86% 90%If you needed it, did you get enough help from staff with eating and drinking? 86% 100% 100% 93% 100% 94% 100% 98% 85% 98% 88% 91% 100% 96% 90%


81% 91% 78% 93% 96% 95% 98% 97% 93% 98% 93% 92% 91% 93% 80%


New 97% 98% 98% 97% 97% 99% 100% 95% 99% 97% 94% 99% 98% 95%


85% 91% 95% 93% 94% 95% 92% 100% 97% 97% 94% 92% 96% 95% 80%


95% 100% 99% 96% 97% 99% 100% 97% 100% 98% 95% 98% 98% 98% 90%

FFT Response Rate New 66% 38% 57% 74% 87% 42% 54% 46% 57% 53% 66% 45% 57% 40%

FFT Response - Number of extremely unlikely and unlikely responses 2 0 1 0 3


2017/18C-Diff 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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MRSA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NA

Hand hygiene 84% Nil Sub. 64%,BBE94%

Nil Sub. Nil Sub. 100% 100% 100% Nil Sub. Nil Sub. 91% 91% 100% 97%

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2017/18Hospital acquired pressure ulcer - Grade 2 3 0 0 0 1 0 0 0 0 0 0 0 1 NAHospital acquired pressure ulcer - Grade 3 0 0 0 0 0 0 1 0 0 0 0 0 1 NAHospital acquired pressure ulcer - Grade 4 0 0 0 0 0 0 0 0 0 0 0 0 0 NASafety Thermometer 99% 100% 86% 100% 100% 100% 100% 100% 96% 100% NA 100% 79% 96% 95%



Compliments (by number)(PALS) 1 0 NA





arrears0 NA

SIRI's 0 0 0 0 0 0 1 0 0 1 0 0 0 2 NA




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Ward Performance ReportF4

F4


2017/18

Dementia Assessment 100% 100% 100% 90%

PATIENT EXPERIENCE Outurn Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTDTarget

2017/18

Survey questions: (No. of questionnaires completed) 125 13 13


97% 92% 92% 95%

Did you have confidence and trust in the doctors treating you? 91% 92% 92% 95%


80% 69% 69% 90%

Did nurses talk in front of you as if you weren’t there? 93% 92% 92% 95%


63% 54% 54% 80%


87% 77% 77% 90%

If you needed it, did you get enough help from staff with eating and drinking?

93% 100% 100% 90%Within the first couple of days of admission did a member of staff ask you about your home situation? (For example do you have help with the shopping and cooking? Do you use a stick or frame to walk etc ?)

91% 100% 100% 80%


96% 100% 100% 95%


94% 78% 78% 80%


87% NA #DIV/0! 90%

FFT Response Rate 15% NA #DIV/0! 40%

FFT Response - Number of extremely unlikely and unlikely responses 0 NA 0

INFECTION CONTROL Outurn Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTDTarget

2017/18C-Diff 1 0 0 0

MRSA 0 0 0 NA

Hand hygiene 94% 92% 92%

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PATIENT SAFETY PERFORMANCE Outurn Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTDTarget

2017/18Hospital acquired pressure ulcer - Grade 2 9 NA

Hospital acquired pressure ulcer - Grade 3 0 NA


Safety Thermometer 91% 100% 100% 95%

VTE Risk Assessment 99% 100% 100% 95%

Complaints (by number) 3 0 0 NA

Compliments (by number) 0 0 0 NA

Total number of falls 42 7 7 NA

Total number of falls (with significant injury) 0 0 0 NA

Medication errors 26 2 2 NA

Medication errors with harm 0 In arrears 0 NA

SIRI's 0 0 0 NA

Staffing incidents 8 0 0 NA

Emergency trolley compliance 96% 93% 93%

Suction (quarterly) 190% #DIV/0!

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F5


2017/18

Dementia Assessment 100% 100% 90%


2017/18



96% 100% 100% 95%



78% 78% 78% 90%



68% 56% 56% 80%


90% 67% 67% 90%



95% 100% 100% 80%


98% 100% 100% 95%


88% 1 00% #DIV/0! 80%


88% NA #DIV/0! 90%

FFT Response Rate 30% NA #DIV/0! 40%

FFT Response - Number of extremely unlikely and unlikely responses 1 NA 0


2017/18C-Diff 0 0 0 0

MRSA 0 0 0 NA


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2017/18




Safety Thermometer 91% 96% 96% 95%



Compliments (by number) 0 0 0 NA





SIRI's 0 0 0 NA




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F6


2017/18

Dementia Assessment 100% 100% 100% 90%


2017/18



99% 99% 99% 95%



97% 91% 91% 90%



79% 63% 63% 80%


86% 85% 85% 90%



93% 88% 88% 80%


98% 96% 96% 95%


95% 89% 89% 80%


98% 99% 99% 90%

FFT Response Rate57% 48% 48% 40%

FFT Response - Number of extremely unlikely and unlikely responses3 0 0


2017/18C-Diff 0 0 0 0

MRSA 0 0 0 NA


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2017/18

Hospital acquired pressure ulcer - Grade 2 1 NAHospital acquired pressure ulcer - Grade 3 1 NAHospital acquired pressure ulcer - Grade 4 0 NASafety Thermometer 96% 100% 100% 95%



Compliments (by number)(PALS) 0 0 0 NA





SIRI's 2 0 0 NA




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Ward Performance ReportWard 1

WARD QUALITY REQUIREMENTSOuturn 16/17

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18Target

2017/18

Dementia Assessment 96% 94% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 90%

Home between 4pm & 7.59pm (number) 2 N/A N/A N/A N/A 1 N/A N/A 1 N/A N/A N/A N/A N/A

Percentage 50% N/A N/A N/A N/A 100% N/A N/A 50% N/A N/A N/A N/A N/A

Home 8pm & Later (number) 1 N/A 1 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Percentage 25% N/A 100% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

PATIENT EXPERIENCEOuturn 16/17


2017/18

Survey questions: (No. of questionnaires completed) 110 3 1 15 14 16 12 8 14 12 13 5Overall, did you feel you were treated with respect and dignity while you were in the hospital? 92% 100% 100% 93% 79% 100% 100% 100% 93% 75% 69% 95%

Did you have confidence and trust in the doctors treating you? 91% 100% 100% 93% 79% 88% 92% 100% 93% 75% 69% 95%Were you involved as much as you wanted to be in decisions about your care and treatment? N/A 100% 100% 80% 86% 69% 75% 88% 79% 75% 85% 90%

Did nurses talk in front of you as if you weren't there? N/A 100% 100% 100% 100% 94% 83% 100% 93% 67% 69% 95%

Were you bothered by noise at night from other patients? 64% 68% 100% 33% 50% 50% 75% 50% 50% 42% 31% 80%

Were you ever bothered by noise at night from hospital staff? 91% 100% 100% 87% 100% 69% 100% 75% 86% 67% 69% 90%Did you find a member of staff to talk to about your worries and fears? 69% 100% N/A 82% 50% 60% 50% 40% 67% 25% 75% 95%

Did you get enough help from staff to eat your meals? 95% 100% N/A N/A 100% 100% 0% N/A 100% 89% 100% 90%Within the first couple of days of admission did a member of staff ask you about your home situation? 80% 68% 100% 100% 92% 93% 73% 65% 83% 100% 55% 80%

Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? N/A N/A N/A 88% 90% 58% 89% 100% 63% 67% N/A 95%

Beforehand, were you told how you could expect to feel after you had the operation or procedure? N/A N/A N/A 56% 90% 42% 70% 33% 67% 83% N/A 95%

Before the operation or procedure, did the anaesthetist or another member of staff explain how he or she put you to sleep or control your pain in a way you could understand?

N/A N/A N/A N/A 100% 94% 100% 100% 89% 67% N/A 95%

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Have you and your family or carers been involved in discussing your discharge from hospital? 80% N/A N/A N/A 78% 83% 33% 100% 78% 80% 57% 80%Did you feel threatened during your stay in hospital by other patients or visitors? N/A 100% 100% 100% 100% 100% 100% 100% 93% 100% 76% 99%

FFT response rate 46% 47% 40% 41% 17% 35% 55% 54% 70% 35% 26% 44% 26% 40%

FFT % Would recommend 95% 98% 94% 98% 94% 88% 90% 90% 97% 90% 78% 91% 96% 90%

FFT no. extremely unlikely and unlikely responses 7 1 2 0 1 0 2 1 0 1 0 1 1 0

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INFECTION CONTROLOuturn 16/17


2017/18

MRSA 0 0 0 0 0 0 0 0 0 0 0 0 0 0

C-Diff 1 0 0 0 0 0 0 0 0 0 0 0 0 N/AWas the indication for antibiotics specified on the drug chart? (% Yes) N/A N/AWas a stop/review date for antibiotics documented on the prescription? (%Yes/Prophylaxis/Long term) N/A N/ADoes this antibiotic treatment meet the care bundle requirements? (% Yes) N/A N/A

Overall Cleaning % 98% NDA 99% 99% 98% 97% 98% 96% NDA NDA 99% 99% 99% 95%

Hand hygiene 83% NDA 90% 88% 95% 79% 90% 95% 90% 90% 95% 90% 90% 90%

Staff hand hygiene (IPCN Audits) N/A N/A 90% 90% NDA NDA NDA 100% NDA NDA NDA 100% 82%

Overall saving lives compliance N/A 82% 100% 100% N/A 100% 0% 87% 90% NDA 100% 100% 95%

PATIENT SAFETY PERFORMANCEOuturn 16/17


2017/18

Hospital acquired pressure ulcer - Grade 2 10 0 3 0 1 1 0 0 0 0 2 2 tbc N/AHospital acquired pressure ulcer - Grade 3 0 0 0 0 0 0 0 0 0 1 0 0 tbc N/AHospital acquired pressure ulcer - Grade 4 0 0 0 0 0 0 0 0 0 0 0 0 tbc N/AVTE Risk Assessment 96% 96% 97% 97% 98% 90% 95% 98% 96% 97% 97% 100% 99% 95%Complaints (by number) 9 0 1 2 1 0 0 0 3 1 0 N/ACompliments (by number) 67 10 10 12 12 15 15 21 20 26 20 0 0 N/ATotal number of falls 42 2 7 6 3 4 5 1 3 3 7 5 7 N/ATotal number of falls (with significant injury) 0 1 0 0 0 0 0 0 0 0 0 0 0 N/AMedication errors 11 2 1 1 0 0 0 2 0 2 0 0 1 N/AMedication errors with harm 0 0 0 0 0 0 0 0 0 0 0 tbc N/ASIRI's 3 1 0 0 0 0 0 0 0 1 0 0 0 N/AStaffing incidents 2 0 0 0 0 0 0 0 0 1 0 0 1 N/ANumber of Cardiac Arrest 5 0 0 0 0 0 0 1 1 0 1 0 0 N/ACrash trolley compliance 96% 95% 97% 97% 98% 100% 100% 98% 97% 100% 99% 100% 99% 100%Suction (quarterly) N/A N/A

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WORKFORCEOuturn 16/17


2017/18

Standard 1 - minimum x2 trained per shift 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Standard 2 - Total compliance against planned staffing 93% 97% 93% 93% 92% 94% 92% 98% 92% 90% 89% 90% 92%Standard 3 - Trained compliance against planned staffing 95% 100% 92% 92% 90% 92% 91% 95% 96% 91% 92% 89% 92%Trained Vacancies WTE N/A 11.54 11.54 10.54 10.54 10.54 10.54 11.26 12.26 12.26 12.26 12.6 13.6Untrained Vacancies WTE N/A 5.72 5.72 6.15 6.15 6.15 7.15 7.15 7.15 6.15 6.15 1.15 3.15Statutory Mandatory Rates - Annual N/A 86% 96% 93% 93% 94% 95 95 95% 95% 96% 95% 95Statutory Mandatory Rates - 3 yearly N/A 72% 89% 96% 96% 96% 96 96 96% 96% 97% 97% 95Appraisal Rates N/A 95% 97% 97% 97% 98% 98% 98% 97% 97% 96% 96% #####Sickness N/A 1.69% 1.60% 2.63% 3.93% 4.95% 4.95% 3.65% 1.79% 1.79% 1.86% 1.79% 1.79%Leavers from the organisation N/A 0.0 2.0 0.0 0.0 0.0 0.0 2.0 0.0 1.0 0.0 0.0 1.0Leavers from the ward N/A 1.0 3.0 0.0 1.0 1.0 0.0 3.0 0.0 0.0 0.0 1.0 1.0

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2018/19

Dementia Assessment 99% 90%

Home between 4pm & 7.59pm (number) N/A N/A N/A

Percentage N/A N/A N/A

Home 8pm & Later (number) N/A N/A N/A




2018/19

Survey questions: (No. of questionnaires completed) 108 5Overall, did you feel you were treated with respect and dignity while you were in the hospital? 91% 95%

Did you have confidence and trust in the doctors treating you? 89% 95%Were you involved as much as you wanted to be in decisions about your care and treatment? 84% 90%

Did nurses talk in front of you as if you weren't there? 91% 95%

Were you bothered by noise at night from other patients? 55% 80%

Were you ever bothered by noise at night from hospital staff? 85% 90%Did you find a member of staff to talk to about your worries and fears? 61% 95%

Did you get enough help from staff to eat your meals? 84% 90%Within the first couple of days of admission did a member of staff ask you about your home situation? 83% 80%

Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? 79% 95%

Beforehand, were you told how you could expect to feel after you had the operation or procedure? 63% 95%


92% 95%

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Have you and your family or carers been involved in discussing your discharge from hospital? 73% 80%Did you feel threatened during your stay in hospital by other patients or visitors? 97% 99%

FFT response rate 41% 3% 40%

FFT % Would recommend 92% 100% 90%

FFT no. extremely unlikely and unlikely responses 12 0 0

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2018/19

MRSA 0 0 0

C-Diff 0 0 N/AWas the indication for antibiotics specified on the drug chart? (% Yes) N/A N/A N/AWas a stop/review date for antibiotics documented on the prescription? (%Yes/Prophylaxis/Long term) N/A N/A N/ADoes this antibiotic treatment meet the care bundle requirements? (% Yes) N/A N/A N/A

Overall Cleaning % 98% 100% 95%


Staff hand hygiene (IPCN Audits) 92% 45

Overall saving lives compliance 85% 100%



2018/19

Hospital acquired pressure ulcer - Grade 2 6 1 N/AHospital acquired pressure ulcer - Grade 3 1 0 N/AHospital acquired pressure ulcer - Grade 4 0 0 N/AVTE Risk Assessment 97% 95%Complaints (by number) 8 1 N/ACompliments (by number) 161 N/ATotal number of falls 53 2 N/ATotal number of falls (with significant injury) 1 0 N/AMedication errors 9 2 N/AMedication errors with harm 0 0 N/ASIRI's 2 0 N/AStaffing incidents 2 1 N/ANumber of Cardiac Arrest 3 0 N/ACrash trolley compliance 98% 100% 100%Suction (quarterly) 85% N/A

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2018/19

Standard 1 - minimum x2 trained per shift 100% 100%Standard 2 - Total compliance against planned staffing 93% 91%Standard 3 - Trained compliance against planned staffing 93% 85%Trained Vacancies WTE N/AUntrained Vacancies WTE N/AStatutory Mandatory Rates - Annual N/AStatutory Mandatory Rates - 3 yearly N/AAppraisal Rates N/ASickness N/ALeavers from the organisation N/ALeavers from the ward N/A

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2017/18

Dementia Assessment 85% N/A 100% 80% 100% 100% 100% 100% 100% 100% 100% 100% 100% 90%

Home between 4pm & 7.59pm (number) 257 14 26 26 27 24 23 27 20 29 23 22 27 N/A

Percentage 40% 35% 32% 43% 50% 48% 46% 44% 63% 50% 43% 45% 39% N/A

Home 8pm & Later (number) 50 3 11 5 3 7 3 3 1 3 7 2 7 N/A

Percentage 8% 8% 14% 8% 6% 14% 6% 5% 3% 5% 13% 4% 10% N/A



2017/18

Survey questions: (No. of questionnaires completed) 1 1 3 4 22 10 12 10 15 6 1 0 21 5Overall, did you feel you were treated with respect and dignity while you were in the hospital? 92% 100% 100% 50% 77% 100% 75% 90% 87% 100% N/A N/A 100% 95%

Did you have confidence and trust in the doctors treating you? 82% 100% 33% 50% 46% 0% 92% 60% 60% 83% 100% N/A 86% 95%Were you involved as much as you wanted to be in decisions about your care and treatment? N/A 0% 67% 25% 52% 60% 58% 70% 47% 50% 100% N/A 86% 90%

Did nurses talk in front of you as if you weren't there? N/A 100% 67% 100% 91% 100% 83% 90% 80% 100% 100% N/A 91% 95%

Were you bothered by noise at night from other patients? 58% N/A 67% 75% 73% 70% 83% 80% 47% 60% 100% N/A 81% 80%

Were you ever bothered by noise at night from hospital staff? 95% 100% 100% 100% 91% 90% 75% 90% 80% 100% 100% N/A 95% 90%Did you find a member of staff to talk to about your worries and fears? 68% N/A 50% 100% 60% 67% 67% 0% 40% 67% N/A N/A 83% 95%

Did you get enough help from staff to eat your meals? 100% 100% N/A N/A 89% 100% 80% 50% 100% 0% N/A N/A 33% 90%Within the first couple of days of admission did a member of staff ask you about your home situation? 100% 100% 100% 50% 53% 78% 75% 100% 79% 60% 100% N/A 100% 80%

Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% N/A N/A 95%

Beforehand, were you told how you could expect to feel after you had the operation or procedure? N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% N/A N/A 95%


N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 100% N/A N/A 95%

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Have you and your family or carers been involved in discussing your discharge from hospital? 82% N/A N/A 67% 67% 100% 20% 50% 50% 0% N/A N/A 100% 80%Did you feel threatened during your stay in hospital by other patients or visitors? N/A 100% 100% 100% 96% 100% 100% 100% 100% 67% 100% N/A 100% 99%

FFT response rate 87% 100% 43% 100% 71% 61% 66% 50% 52% 61% 63% 218% N/A 40%



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2017/18

MRSA 0 0 0 0 0 0 0 0 0 0 0 0 0 0

C-Diff N/A 0 0 0 0 0 0 0 0 0 0 0 0 N/AWas the indication for antibiotics specified on the drug chart? (% Yes) N/A N/AWas a stop/review date for antibiotics documented on the prescription? (%Yes/Prophylaxis/Long term) N/A N/ADoes this antibiotic treatment meet the care bundle requirements? (% Yes) N/A N/A

Overall Cleaning % 98% NDA NDA NDA 96% 98% 97% 98% 97% 97% 98% 97% 97% 95%

Hand hygiene 93% 95% 95% 95% 85% 75% 85% 85% 90% 95% 90% 90% 95% 90%

Staff hand hygiene (IPCN Audits) N/A NDA 95% 95% NDA NDA NDA 100% NDA NDA NDA 90% 82%

Overall saving lives compliance N/A 62% 100% NDA 67% 71% 95% 92% 100% 100% 82% NDA 100%



2017/18

Hospital acquired pressure ulcer - Grade 2 8 1 0 3 1 0 0 0 1 0 2 1 tbc N/AHospital acquired pressure ulcer - Grade 3 0 0 0 0 0 0 0 0 0 0 0 0 tbc N/AHospital acquired pressure ulcer - Grade 4 0 0 0 0 0 0 0 0 0 0 0 0 tbc N/AVTE Risk Assessment 79% 50% 86% 92% 91% 62% 79% 75% 94% 68% 95% 95% 100% 95%Complaints (by number) 3 0 0 0 0 0 1 0 0 0 0 N/ACompliments (by number) 39 11 9 3 6 4 4 6 11 8 10 14 8 N/ATotal number of falls 56 5 8 1 5 6 8 1 9 2 8 2 6 N/ATotal number of falls (with significant injury) 0 0 0 0 0 0 1 0 0 0 0 0 0 N/AMedication errors 9 1 1 1 1 0 1 1 2 0 1 0 0 N/AMedication errors with harm 0 0 0 0 0 0 0 0 0 0 0 0 tbc N/ASIRI's 0 0 0 0 0 0 1 0 0 1 0 0 0 N/AStaffing incidents 24 0 2 12 8 10 0 2 0 4 0 3 1 N/ANumber of Cardiac Arrest 5 0 0 0 1 0 0 0 1 0 1 2 0 N/AEmergency Crash trolley compliance 98% 83% 100% 100% 100% 100% 100% 100% 100% 97% 100% 100% 100% 100%Suction (quarterly) N/A N/A

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2017/18

Standard 1 - minimum x2 trained per shift 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Standard 2 - Total compliance against planned staffing 87% 92% 91% 87% 87% 87% 90% 94% 89% 104% 94% 92% 95%Standard 3 - Trained compliance against planned staffing 88% 86% 87% 91% 88% 87% 87% 90% 90% 95% 87% 88% 92%Trained Vacancies WTE N/A 7.22 7.22 7.22 7.22 7.83 6.83 6.83 6.83 6.83 6.83 4.75Untrained Vacancies WTE N/A 1.83 1.83 1.83 0.17 0.18Statutory Mandatory Rates - Annual N/A 0.37 0.48 0.66 0.66 0.70 0.70 0.83 0.87 0.87 0.95 0.95 0.95Statutory Mandatory Rates - 3 Yearly N/A 0.50 0.50 0.50 0.58 0.58 0.58 0.66 0.66 70.00 0.87 0.91 0.91Appraisal Rates N/A 84.00 84.00 75.00 89.60 89.60 83.00 83.00 96.00 93.00 93.00 0.93 0.88Sickness N/A 3.90 7.90 5.20 9.90 9.80 2.50 7.20 8.90 3.10 4.80Leavers from the organisation N/A 0.0 0.0 0.0 1.0 1.0 0.0 0.0 0.0 0.0 0Leavers from the hospital N/A 0.0 0.0 0.0 1.0 1.0 0.0 0.0 0.0 0.0 0.0

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LIC B





2018/19

Dementia Assessment 98% % 90%

Home between 4pm & 7.59pm (number) 288 0 N/A

Percentage 45% 0% N/A

Home 8pm & Later (number) 55 0 N/A

Percentage 8% 0% N/A



2018/19

Survey questions: (No. of questionnaires completed) 105 10 5Overall, did you feel you were treated with respect and dignity while you were in the hospital? 88% 100% 95%

Did you have confidence and trust in the doctors treating you? 64% 80% 95%Were you involved as much as you wanted to be in decisions about your care and treatment? 56% 90% 90%

Did nurses talk in front of you as if you weren't there? 91% 100% 95%

Were you bothered by noise at night from other patients? 74% 80% 80%

Were you ever bothered by noise at night from hospital staff? 93% 100% 90%Did you find a member of staff to talk to about your worries and fears? 59% 100% 95%

Did you get enough help from staff to eat your meals? 69% 67% 90%Within the first couple of days of admission did a member of staff ask you about your home situation? 81% 100% 80%

Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? N/A N/A 95%

Beforehand, were you told how you could expect to feel after you had the operation or procedure? N/A N/A 95%


N/A N/A 95%

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Have you and your family or carers been involved in discussing your discharge from hospital? 57% 100% 80%Did you feel threatened during your stay in hospital by other patients or visitors? 97% 100% 99%




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2018/19

MRSA 0 0 0

C-Diff 0 0 N/AWas the indication for antibiotics specified on the drug chart? (% Yes) N/A N/AWas a stop/review date for antibiotics documented on the prescription? (%Yes/Prophylaxis/Long term) N/A N/ADoes this antibiotic treatment meet the care bundle requirements? (% Yes) N/A N/A

Overall Cleaning % 97% 98% 95%


Staff hand hygiene (IPCN Audits) 92% 53%

Overall saving lives compliance 87% 83%



2018/19

Hospital acquired pressure ulcer - Grade 2 9 0 N/AHospital acquired pressure ulcer - Grade 3 0 0 N/AHospital acquired pressure ulcer - Grade 4 0 0 N/AVTE Risk Assessment 82% 95%Complaints (by number) 1 0 N/ACompliments (by number) 94 8 N/ATotal number of falls 61 3 N/ATotal number of falls (with significant injury) 1 0 N/AMedication errors 9 1 N/AMedication errors with harm 0 0 N/ASIRI's 2 1 N/AStaffing incidents 42 3 N/ANumber of Cardiac Arrest 5 0 N/AEmergency Crash trolley compliance 98% 100% 100%Suction (quarterly) 77% N/A

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2018/19

Standard 1 - minimum x2 trained per shift 100% 100%Standard 2 - Total compliance against planned staffing 92% 91%Standard 3 - Trained compliance against planned staffing 89% 85%Trained Vacancies WTE N/AUntrained Vacancies WTE N/AStatutory Mandatory Rates - Annual N/AStatutory Mandatory Rates - 3 Yearly N/AAppraisal Rates N/ASickness N/ALeavers from the organisation N/ALeavers from the hospital N/A

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Ward Performance ReportWard 4 HW



2017/18

Dementia Assessment 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 90%

Home between 4pm & 7.59pm (number) 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 N/A

Percentage 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 N/A

Home 8pm & Later (number) 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 N/A

Percentage 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 N/A



2017/18

Survey questions: (No. of questionnaires completed) 240 10 36 30 46 15 21 23 24 4 20 17 25 5Overall, did you feel you were treated with respect and dignity while you were in the hospital? 95% 100% 97% 100% 100% 100% 100% 100% 100% 100% 95% 100% 88% 95%

Did you have confidence and trust in the doctors treating you? 97% 100% 100% 97% 96% 100% 100% 91% 100% N/A 95% 94% 96% 95%Were you involved as much as you wanted to be in decisions about your care and treatment? N/A 100% 94% 97% 98% 93% 100% 91% 100% 100% 90% 88% 88% 90%

Did nurses talk in front of you as if you weren't there? N/A 100% 97% 97% 96% 100% 95% 96% 96% 100% 100% 94% 92% 95%

Were you bothered by noise at night from other patients? 78% 100% 86% 80% 76% 60% 100% 87% 75% 100% 80% 77% 68% 80%

Were you ever bothered by noise at night from hospital staff? 77% 100% 92% 83% 83% 73% 91% 88% 88% 100% 90% 88% 76% 90%Did you find a member of staff to talk to about your worries and fears? 86% 75% 79% 89% 88% 60% 67% 83% 86% 100% 88% 80% 83% 95%

Did you get enough help from staff to eat your meals? 73% N/A 50% 100% 100% 0% 100% N/A 100% N/A 100% 100% 90%Within the first couple of days of admission did a member of staff ask you about your home situation? 93% 75% 82% 87% 89% 87% 95% 100% 100% 100% 93% 100% 100% 80%

Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? N/A N/A 93% 100% 100% 100% 95% 95% 100% 100% 93% 100% 100% 95%

Beforehand, were you told how you could expect to feel after you had the operation or procedure? N/A N/A 100% 97% 98% 93% 91% 90% 100% 100% 100% 100% 100% 95%


N/A N/A 100% 100% 100% 100% 100% 95% 100% 100% 80% 100% 100% 95%

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Have you and your family or carers been involved in discussing your discharge from hospital? 79% 100% 85% 81% 86% 67% 100% 82% 83% 100% 100% N/A 75% 80%Did you feel threatened during your stay in hospital by other patients or visitors? N/A 100% 97% 97% 98% 100% 100% 100% 100% 100% 100% 100% 100% 99%




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2017/18

MRSA 0 0 0 0 0 0 0 0 0 0 0 0 0 0

C-Diff N/A 0 0 0 0 0 0 0 0 0 0 0 0 N/AWas the indication for antibiotics specified on the drug chart? (% Yes) N/A N/AWas a stop/review date for antibiotics documented on the prescription? (%Yes/Prophylaxis/Long term) N/A N/ADoes this antibiotic treatment meet the care bundle requirements? (% Yes) N/A N/A

Overall Cleaning % 99% NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA 95%

Hand hygiene 99% NDA 100% 95% 95% 100% 100% 100% 100% 100% 100% 100% 95% 90%

Staff hand hygiene (IPCN Audits) N/A NDA 77% 77% NDA NDA NDA 100% NDA NDA NDA 100% 100%

Overall saving lives compliance N/A N/A 100% 100% N/A 78% 94% NDA NDA 100% 100% 100% 100%



2017/18

Hospital acquired pressure ulcer - Grade 2 0 0 0 0 0 0 0 0 0 0 0 0 tbc N/AHospital acquired pressure ulcer - Grade 3 0 0 0 0 0 0 0 0 0 0 0 0 tbc N/AHospital acquired pressure ulcer - Grade 4 0 0 0 0 0 0 0 0 0 0 0 0 tbc N/AVTE Risk Assessment 99% 99% 99% 98% 100% 100% 98% 100% 100% 98% 100% 100% 100% 95%Complaints (by number) 0 0 0 2 0 0 0 0 1 0 0 0 0 N/ACompliments (by number) 0 30 25 32 30 30 35 35 40 0 0 0 0 N/ATotal number of falls 4 0 0 3 3 0 0 2 0 0 2 0 0 N/ATotal number of falls (with significant injury) 0 0 0 0 0 0 0 0 0 0 0 0 0 N/AMedication errors 3 0 0 0 0 0 0 1 0 0 1 0 0 N/AMedication errors with harm 0 0 0 0 0 0 0 0 0 0 0 0 tbc N/ASIRI's 0 0 0 0 0 0 0 0 0 0 0 0 0 N/AStaffing incidents 1 0 0 0 0 0 0 0 0 0 0 0 0 N/ANumber of Cardiac Arrest 0 0 0 0 0 0 0 0 0 0 0 0 0 N/AEmergency Crash trolley compliance 100% 100% 100% 100% 100% 100% 100% 97% 97% 100% 100% NDA NDA 100%Suction (quarterly) N/A N/A

N/A

N/A

N/A

N/A

N/A

War

d 4

HW

tbcN/AN/A100%

N/A

N/A

N/A

N/A

N/A

N/A

N/A

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2017/18

Standard 1 - minimum x2 trained per shift 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Standard 2 - Total compliance against planned staffing 95% 86% 94% 84% 85% 89% 82% 89% 88% 93% 94% 83% 83%Standard 3 - Trained compliance against planned staffing 96% 85% 94% 83% 83% 86% 83% 87% 92% 83% 92% 83% 82%Trained Vacancies WTE N/A 4.03 4.03 5.03 5.03 5.03 5.03 5.03 5.03 5.03 5.03 5.03 4.03Untrained Vacancies WTE N/A 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34 0.34Statutory Mandatory Rates - Annual N/A 45% 50% 45% 60% 60% 65% 70% 70% 80% 90% 90% 90%Statutory Mandatory Rates - 3 Yearly N/A 53% 53% 53% 50% 55% 60% 65% 65% 70% 70% 80% 80%Appraisal Rates N/A 100% 100% 100% 100% 100% 100% 75% 60% 80% 90% 95% 100%Sickness N/A 3.59% 4.24% 1.36% 2.64% 1.44% 4.29% 1.25% 6.73% 5.85% 5.68% 7.53% 5.35%Leavers from the organisation 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/ALeavers from the ward N/A 0.0 0.0 1.0 0.0 0 0.0 0.0 1.00 1 0.0 0.00 0COMMENTS

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Ward Performance ReportHEATHERWOOD - SHORT STAY SURGICAL UNIT



2017/18

Dementia Assessment 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 90%

Home between 4pm & 7.59pm (number) N/A N/A

Percentage N/A N/A

Home 8pm & Later (number) N/A N/A

Percentage N/A N/A



2017/18

Survey questions: (No. of questionnaires completed) 92 7 13 20 11 7 7 10 4 15 17 10 5Overall, did you feel you were treated with respect and dignity while you were in the hospital? 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 95%

Did you have confidence and trust in the doctors treating you? 98% 100% 100% 100% 100% 100% 100% 90% N/A 93% 100% 80% 95%Were you involved as much as you wanted to be in decisions about your care and treatment? N/A 100% 100% 100% 91% 100% 100% 90% N/A 100% 100% 90% 90%

Did nurses talk in front of you as if you weren't there? N/A 100% 100% 100% 100% 100% 100% 100% N/A 100% 100% 100% 95%

Were you bothered by noise at night from other patients? 77% 86% 92% 95% 91% 100% 100% 70% N/A 73% 100% 90% 80%

Were you ever bothered by noise at night from hospital staff? 90% 71% 85% 90% 82% 86% 100% 70% N/A 100% 100% 100% 90%Did you find a member of staff to talk to about your worries and fears? 91% 100% 100% 100% 80% 100% 100% 67% N/A 100% 100% 100% 95%

Did you get enough help from staff to eat your meals? 67% N/A N/A 100% 100% 0% N/A N/A N/A 100% 100% 50% 90%Within the first couple of days of admission did a member of staff ask you about your home situation? 89% 71% 85% 85% 82% 83% 100% 88% N/A 100% 100% 100% 80%

Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? N/A 100% 100% 100% 100% 100% 100% 90% N/A 100% 100% 100% 95%

Beforehand, were you told how you could expect to feel after you had the operation or procedure? N/A 86% 100% 100% 82% 100% 100% 100% N/A 100% 100% 83% 95%


N/A 100% 100% 100% 100% 100% 100% 100% N/A 88% 100% 100% 95%

Have you and your family or carers been involved in discussing your discharge from hospital? 75% 67% 67% 68% 91% 100% 100% 90% N/A 69% 88% 70% 80%Did you feel threatened during your stay in hospital by other patients or visitors? N/A 100% 100% 100% 100% 100% 100% 100% N/A 93.3.% 86% 100% 99%




HW S

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2017/18

MRSA 0 0 0 0 0 0 0 0 0 0 0 0 0 0

C-Diff N/A 0 0 0 0 0 0 0 0 0 0 0 0 N/A

Antibiotics Score - complaince with local guidelines N/A N/A

Documentation of Indication % N/A N/A

Documentation of Duration % N/A N/A

Overall Cleaning % 99% NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA NDA 95%

Hand hygiene 90% 95% 95% 95% 90% 95% 85% 90% 95% 100% 95% 100% 100% 90%

Staff hand hygiene (IPCN Audits) N/A N/A 100% 100% NDA NDA NDA 100% NDA NDA NDA 100% 100%

Overall saving lives compliance N/A N/A 100% 100% NDA 100% 100% NDA NDA 100% NDA NDA 100%



2017/18

Hospital acquired pressure ulcer - Grade 2 0 0 0 0 0 0 0 0 0 0 1 0 N/AHospital acquired pressure ulcer - Grade 3 0 0 0 0 0 0 0 0 0 0 0 0 N/AHospital acquired pressure ulcer - Grade 4 0 0 0 0 0 0 0 0 0 0 0 0 N/AVTE Risk Assessment 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 95%Complaints (by number) 9 0 0 0 1 0 0 0 0 0 0 NACompliments (by number) 71 2 5 10 5 5 7 8 4 6 4 3 5 NATotal number of falls 4 0 0 0 0 0 0 1 1 0 1 4 1 NATotal number of falls (with significant injury) 0 0 0 0 0 0 0 0 0 0 0 0 0 NAMedication errors 2 0 0 1 0 1 0 0 0 0 1 1 0 NAMedication errors with harm 1 0 0 0 0 0 0 0 0 0 0 0 NASIRI's 0 0 0 0 0 0 0 0 0 0 0 0 0 NAStaffing incidents 0 0 0 0 0 0 0 0 0 0 2 0 0 NANumber of Cardiac Arrest 0 0 0 0 0 0 0 0 0 0 0 0 0 NAEmergency Crash trolley compliance 79% 100% 100% 100% 100% 97% 100% 100% 100% 94% 94% N/A N/A 100%Suction (quarterly) N/A N/A100% N/A N/A

HW S

SSU

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

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2017/18

Standard 1 - minimum x2 trained per shift N/A 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Standard 2 - Total compliance against planned staffing N/A 68% 73%Standard 3 - Trained compliance against planned staffing N/A 67% 81%Trained Vacancies WTE N/A 5 4.66 4.66 4.66 4.66 4.66 4.66 4.66 4.66 4.66 4.66 4.66Untrained Vacancies WTE N/A 2.23 1 1 1 1 1 1 1 1 1 1 1Statutory Mandatory Rates - Annual N/A 75% 55% 95% 95% 90% 90% 95% 95% 95% 100% 100% 100%Statutory Mandatory Rates - 3 yearly N/A 100% 100% 100% 90% 95% 100% 100% 100% 100% 100% 95% 95%Appraisal Rates N/A 100% 100% 89% 60% 100% 100% 100% 90% 89% 68% 68% 74%Sickness N/A 9.46% 9.12% 6.90% 8.23% 3% 5.80% 8.16% 7.83% 7.71% 11.20% 8% 5.36%Leavers from the organisation N/A 0 0 0 0 0 0 0 0 0 0 0 0Leavers from the ward N/A 0 0 0 0 0 0 0 0 0 1 0 0

HW S

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Ward Performance ReportHEATHERWOOD - SHORT STAY SURGICAL UNIT



2018/19

Dementia Assessment N/A N/A 90%

Home between 4pm & 7.59pm (number) N/A N/A N/A


Home 8pm & Later (number) N/A N/A N/A




2018/19

Survey questions: (No. of questionnaires completed) 121 N/A 5Overall, did you feel you were treated with respect and dignity while you were in the hospital? 100% N/A 95%

Did you have confidence and trust in the doctors treating you? 96% N/A 95%Were you involved as much as you wanted to be in decisions about your care and treatment? 97% N/A 90%

Did nurses talk in front of you as if you weren't there? 100% N/A 95%

Were you bothered by noise at night from other patients? 90% N/A 80%

Were you ever bothered by noise at night from hospital staff? 88% N/A 90%Did you find a member of staff to talk to about your worries and fears? 95% N/A 95%

Did you get enough help from staff to eat your meals? 75% N/A 90%Within the first couple of days of admission did a member of staff ask you about your home situation? 89% N/A 80%

Beforehand, did a member of staff explain the risks and benefits of the operation or procedure in a way you could understand? 99% N/A 95%

Beforehand, were you told how you could expect to feel after you had the operation or procedure? 95% N/A 95%


99% N/A 95%

Have you and your family or carers been involved in discussing your discharge from hospital? 81% N/A 80%Did you feel threatened during your stay in hospital by other patients or visitors? 98% N/A 99%




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2018/19

MRSA 0 0 0

C-Diff N/A 0 N/A

Antibiotics Score - complaince with local guidelines N/A N/A N/A

Documentation of Indication % N/A N/A N/A

Documentation of Duration % N/A N/A N/A

Overall Cleaning % NDA NDA 95%


Staff hand hygiene (IPCN Audits) 100% NDA

Overall saving lives compliance 100% NDA



2018/19

Hospital acquired pressure ulcer - Grade 2 1 0 N/AHospital acquired pressure ulcer - Grade 3 0 0 N/AHospital acquired pressure ulcer - Grade 4 0 0 N/AVTE Risk Assessment 100% 95%Complaints (by number) 1 0 NACompliments (by number) 64 NATotal number of falls 8 0 NATotal number of falls (with significant injury) 0 0 NAMedication errors 4 0 NAMedication errors with harm 0 NASIRI's 0 0 NAStaffing incidents 2 0 NANumber of Cardiac Arrest 0 0 NAEmergency Crash trolley compliance 99% NDA 100%Suction (quarterly) N/A N/A

HW S

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2018/19

Standard 1 - minimum x2 trained per shift 100% 100%Standard 2 - Total compliance against planned staffing 71% 91%Standard 3 - Trained compliance against planned staffing 74% 85%Trained Vacancies WTE N/AUntrained Vacancies WTE N/AStatutory Mandatory Rates - Annual N/AStatutory Mandatory Rates - 3 yearly N/AAppraisal Rates N/ASickness N/ALeavers from the organisation N/ALeavers from the ward N/A

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Site Cost Centre SpecialityAnnual

Budget

Annual

SpendVariance

1220 F4 Ortho £1,914,684 £2,050,324 £135,640

1221 F5 Ortho £1,575,596 £1,556,627 -£18,969

1222 F6 Ortho £1,637,188 £1,665,776 £28,588

7305 Ward 1 Wx Ortho £2,332,633 £2,411,281 £78,648

7307 Ward 4 Hwd Ortho £1,078,681 £1,089,511 £10,830

7315 Ward 1SS Ortho £681,632 £627,252 -£54,380

2017/18

FPH

WPH

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Page | 1

Report Title

Chief Executive’s Report

Meeting

Board of Directors - Public

Meeting Date

Friday 1st June 2018

Agenda No.

6.

Report Type

To note

Prepared By

Daryl Gasson, Director of Business Strategy & Performance and James Taylor Head of Communications

Executive Lead

Neil Dardis, Chief Executive Officer

Introduction

This report aims to highlight to Board members those areas of strategic or national significance as well as areas that will benefit from focused discussion in today’s meeting. It also outlines the developments and achievements of the Trust since we last met. Many of the challenges from the end of last year in relation to finance and ED performance remain for the month, as outlined below. Some of these challenges will require systematic changes to address with support from partners. However, from the hundreds of staff that I have met so far, their commitment, professionalism and enthusiasm leaves me optimistic that we can successfully meet those challenges. From next month’s Board we are developing a dashboard to complement this report giving Board members more assurance on the improvement trajectory.

Strategy and partnership working

NHSI/E NHSI and NHSE have set out how they will align to provide more joined up effective leadership to the NHS and how NHSI will be shifting focus from regulating trusts to supporting improvement.

Board Away Day Event

• The Board away day focused on quality with involvement of the clinical and managerial leaders in the organisation. Day 1 of the two day event included a self-assessment against the CQC Well-Led criteria by each of the directorates. Five areas were identified for immediate focus.

• Day 2 included time with Nick Mulholland, an experienced CQC inspector, who advised the organisation on the best approach to self-assessment. The event was very useful and provided good opportunities for learning and development.

6

Tab 6 Chief Executive's Performance Report


Page | 2

Integration and collaboration

Earlier this month an Integrated Care System (ICS) event brought together clinical colleagues from primary and secondary care to discuss how clinical professionals would work together in future to improve experience and outcomes for patients with better integration and systematic organisation. Speakers, including Medical Director of NHS England Prof Stephen Powis, also emphasised that we have an opportunity to shape change in local systems ourselves rather than being led centrally.

A new brand has been launched for the Frimley Health and Care System, along with refined key messages, which we hope will help to engage the public in the many changes underway. The brand is not NHS specific since the ICS includes many other organisations such as local authorities and other social care providers.

We expect to hear by early June that the Frimley Health and Care system will be confirmed as a fully operational ICS.

HSJ I attended the HSJ’s 2018 top 50 chief executives’ debate last week where we held very productive discussions around the different approaches to leadership between provider and community CEOs and what CEOs could do to maintain staff morale during tough times.

Performance overview

Key indicators The Trust continues to perform well in relation to standards for the RTT (referral to treatment), cancer and diagnostics in spite of the challenges. The most significant challenge remains the 4-hour ED target across the Trust. While there have been times in April where the ED performance was good, performance overall stood at 87.6% for the month. This placed the Trust 44th out of 138 providers of major (type1) A&E services. Our teams are reviewing our processes and practices against best performance to redesign our system to enable our patients to receive timely care consistently. Same sex accommodation Following agreement with NHSI and NHSE, Trusts across the South East region have been asked to review their application of the 2010 national guidance for delivering same sex accommodation. This includes removal of all previous local agreements with commissioners on application of the guidance. FHFT has reviewed this alongside our patient experience survey results to establish where application of the guidance needs to be reset. The inevitable result has been a significant increase in breaches of same sex standard, with 267 reported for April. Our Director of Nursing has an improvement plan in place to ensure actions are taken to reduce breaches as quickly as possible. Patient safety One never event was reported in April along with 14 Serious Incidents Requiring Investigation (SIRIs). A common theme was inappropriate use of confidential information being sent on non-secure email, although no information was lost. Work is ongoing to ensure that lessons are learnt and cascaded through the organisation.

Finance

The Trusts’ operational deficit (before exceptional items and STF) was £4.9m in month

which was £1.8m worse than plan. This is a significant adverse variation at month 01

and means achievement of plan is already under significant pressure. The exit run rate

from March has continued into April but the plan assumes significant cost reduction

which has not materialised. The PSF of £1.3m for the month has been accrued on the

assumption that the Trust will reverse the overspends and deliver to original plan over

time.

6



Page | 3

The key challenges lie around pay pressures and underdelivery of the cost

improvement plan. We were due to meet this week to review our position and take

action to rectify this position.

Developments and achievements

Managing deteriorating patients

• The Trust has welcomed two new specialist nurses who are to be key members of the Deteriorating Patient and Resuscitation Team on each of our acute sites. They will be part of the team focusing on identifying and managing deteriorating patients on the wards. They will also help identify learning points that can be used in wider staff training.

Honours at Association of Respiratory Nurse Specialists (ARSN) conference

The event held in Reading in early May saw the Trust’s Jo King awarded Respiratory Nurse Leader 2018. This was judged by an independent panel and presented by the ARNS founder. Jo is part of the adult integrated respiratory team launched in 2016 – a joint service based at KE VII Hospital. She became a consultant nurse specialist in 2016.

There were also honours for respiratory nurse consultant Iain Wheatley for his poster presentation and Nursing Times Award winners Emma Bushell and Rosie Reading (CNSs in paediatric asthma) presented their work with the paediatric asthma bus – another collaboration with commissioners and community services.

100 day plan

Thank you to everyone who has made me feel welcome as I meet them as part of my first 100 days programme. I continue to be impressed by what I have seen and heard from them and have been grateful for the honest discussions which will help us formulate the best approach for the Trust in future. To date I have seen about 1,500 staff and have shadowed teams from facilities to theatres. In addition I am currently meeting with cross sections of staff from each directorate to gain deeper insights into their issues.

One recurring theme is around workforce. This week we started some roadshows on what the Trust is doing in relation to recruitment and retention where we will also be gathering feedback from staff. We are also formulating a number of ideas around recognising and rewarding staff appropriately and we will be announcing some of these initiatives soon.

I am especially looking forward to the staff awards later this month at the Royal Berkshire Hotel where we will be celebrating some of the stars of Frimley Health.

Recommendation

The Board is asked to note the report.

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Quality and performance report April 2018

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Quality and performance report – April 2018 Frimley Health NHS Foundation Trust – Board of Directors Page 2

Contents

Safe Effective Caring Responsive Efficiency / Finance Well-led Activity

This report covers the period from April 2017 to allow comparison with historic performance.

However, the targets relate to April 2018 for the financial year 2018/19

Page Page

Contents 2 Appendix A 31

Chief executive’s overview 3 Methodologies for calculating the measures 32

CQC rating and single oversight framework 6 Glossary 34

Key messages by exception 7

Domains

Safe 13

Effective 15

Caring 18

Responsive 20

Well-led (workforce) 23

Well-led (efficiency) 25

Well-led (finance) 26

Benchmarking RAG key

Benchmarking 27 Achieving target

Activity Between target and threshold (where applicable)

Activity 29 Worse than target or threshold (where applicable)

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Chief executive’s overview (1)


Introduction

This report aims to highlight to Board members those areas of strategic or national significance as well as areas that will benefit from focused

discussion in today’s meeting. It also outlines the developments and achievements of the Trust since we last met.

Many of the challenges from the end of last year in relation to finance and ED performance remain for the month, as outlined below. Some of

these challenges will require systematic changes to address with support from partners. However, from the hundreds of staff that I have met so

far, their commitment, professionalism and enthusiasm leaves me optimistic that we can successfully meet those challenges.

From next month’s Board we are developing a dashboard to complement this report giving Board members more assurance on the

improvement trajectory.

Strategy and partnership working

NHSI/E

NHSI and NHSE have set out how they will align to provide more joined up effective leadership to the NHS and how NHSI will be shifting focus

from regulating trusts to supporting improvement.

Board Away Day Event

The Board away day focused on quality with involvement of the clinical and managerial leaders in the organisation. Day 1 of the two day event

included a self-assessment against the CQC Well-Led criteria by each of the directorates. Five areas were identified for immediate focus.

Day 2 included time with Nick Mulholland, an experienced CQC inspector, who advised the organisation on the best approach to self-

assessment. The event was very useful and provided good opportunities for learning and development.

Integration and collaboration

Earlier this month an Integrated Care System (ICS) event brought together clinical colleagues from primary and secondary care to discuss how

clinical professionals would work together in future to improve experience and outcomes for patients with better integration and systematic

organisation. Speakers, including Medical Director of NHS England Prof Stephen Powis, also emphasised that we have an opportunity to

shape change in local systems ourselves rather than being led centrally.

A new brand has been launched for the Frimley Health and Care System, along with refined key messages, which we hope will help to engage

the public in the many changes underway. The brand is not NHS specific since the ICS includes many other organisations such as local

authorities and other social care providers.

We expect to hear by early June that the Frimley Health and Care system will be confirmed as a fully operational ICS.

HSJ I attended the HSJ’s 2018 top 50 chief executives’ debate last week where we held very productive discussions around the different

approaches to leadership between provider and community CEOs and what CEOs could do to maintain staff morale during tough times.

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Performance overview

Key indicators

The Trust continues to perform well in relation to standards for the RTT (referral to treatment), cancer and diagnostics in spite of the

challenges. The most significant challenge remains the 4-hour ED target across the Trust. While there have been times in April where

the ED performance was good, performance overall stood at 87.6% for the month. This placed the Trust 44th out of 138 providers of

major (type1) A&E services. Our teams are reviewing our processes and practices against best performance to redesign our system to

enable our patients to receive timely care consistently.

Same sex accommodation

Following agreement with NHSI and NHSE, Trusts across the South East region have been asked to review their application of the

2010 national guidance for delivering same sex accommodation. This includes removal of all previous local agreements with

commissioners on application of the guidance. FHFT has reviewed this alongside our patient experience survey results to establish

where application of the guidance needs to be reset. The inevitable result has been a significant increase in breaches of same sex

standard, with 267 reported for April. Our Director of Nursing has an improvement plan in place to ensure actions are taken to reduce

breaches as quickly as possible.

Patient safety

One never event was reported in April along with 14 Serious Incidents Requiring Investigation (SIRIs). A common theme was

inappropriate use of confidential information being sent on non-secure email, although no information was lost. Work is ongoing to

ensure that lessons are learnt and cascaded through the organisation.

Financial performance

The Trusts’ operational deficit (before exceptional items and STF) was £4.9m in month which was £1.8m worse than plan. This is a

significant adverse variation at month 01 and means achievement of plan is already under significant pressure. The exit run rate from

March has continued into April but the plan assumes significant cost reduction which has not materialised. The PSF of £1.3m for the

month has been accrued on the assumption that the Trust will reverse the overspends and deliver to original plan over time.

The key challenges lie around pay pressures and under delivery of the cost improvement plan. We were due to meet this week to

review our position and take action to rectify this position.

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Developments and achievements

Managing deteriorating patients

The Trust has welcomed two new specialist nurses who are to be key members of the Deteriorating Patient and Resuscitation Team on

each of our acute sites. They will be part of the team focusing on identifying and managing deteriorating patients on the wards. They

will also help identify learning points that can be used in wider staff training.

Honours at Association of Respiratory Nurse Specialists (ARSN) conference

The event held in Reading in early May saw the Trust’s Jo King awarded Respiratory Nurse Leader 2018. This was judged by an

independent panel and presented by the ARNS founder. Jo is part of the adult integrated respiratory team launched in 2016 – a joint

service based at KE VII Hospital. She became a consultant nurse specialist in 2016.

There were also honours for respiratory nurse consultant Iain Wheatley for his poster presentation and Nursing Times Award winners

Emma Bushell and Rosie Reading (CNSs in paediatric asthma) presented their work with the paediatric asthma bus – another

collaboration with commissioners and community services.

100 day plan

Thank you to everyone who has made me feel welcome as I meet them as part of my first 100 days programme. I continue to be

impressed by what I have seen and heard from them and have been grateful for the honest discussions which will help us formulate the

best approach for the Trust in future. To date I have seen about 1,500 staff and have shadowed teams from facilities to theatres. In

addition I am currently meeting with cross sections of staff from each directorate to gain deeper insights into their issues.

One recurring theme is around workforce. This week we started some roadshows on what the Trust is doing in relation to recruitment

and retention where we will also be gathering feedback from staff. We are also formulating a number of ideas around recognising and

rewarding staff appropriately and we will be announcing some of these initiatives soon.

I am especially looking forward to the staff awards later this month at the Royal Berkshire Hotel where we will be celebrating some of

the stars of Frimley Health.

Recommendation

The Board is asked to note the report.

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CQC overall rating & NHSI single oversight framework

Safe Effective Caring Responsive Efficiency / Finance

Care Quality Commission (CQC) overall rating

Frimley Park Hospital September 2014 Outstanding

Wexham Park Hospital February 2016 Good

Heatherwood Hospital May 2014 Good

Well-led Activity

16/17 17/18 Apr-17 May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4 Apr-18 YTD Target Threshold

NHS Improvement (NHSI) – overall segment score

Segment score* 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2

Operational performance (SOF)

A&E > 4 hours 91.6% 89.0% 92.3% 90.2% 91.3% 91.2% 91.5% 90.4% 90.7% 90.9% 94.2% 91.4% 84.3% 89.9% 83.6% 85.0% 83.1% 86.4% 87.6% 87.6% >=95% >=90%

RTT incomplete < 18 weeks 92.6% 92.2% 92.2% 93.2% 92.8% 92.8% 92.9% 92.3% 92.0% 92.4% 92.2% 92.5% 91.3% 92.0% 92.4% 92.7% 92.4% 92.4% 92.4% 92.4% >=92% None

Cancer 62 day standard 89.9% 92.3% 90.2% 92.6% 92.8% 91.9% 95.7% 94.5% 93.2% 94.2% 94.0% 94.1% 93.0% 93.6% 89.2% 89.1% 94.1% 91.0% in arrears >=85% >=80%

Cancer 62 day screening to

treatment 98.2% 100% 97.0% 97.1% 97.8% 94.2% 100% 98.1% 97.5% 100% 100% 100% 100% 96.2% 100% 97.6% 97.4% in arrears >=90% >=85%

Diagnostics < 6 weeks 0.4% 0.4% 0.7% 0.4% 0.4% 0.5% 0.4% 0.4% 0.3% 0.4% 0.3% 0.2% 0.4% 0.3% 0.4% 0.4% 0.4% 0.4% 0.4% 0.4% <=1.0% <=1.5%

* Segment score definitions: 1 = maximum autonomy; 2 = targeted support; 3 = mandated support; 4 = special measures

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Key messages – by exception (1)

Domain Key points Action taken

Safe

Never events

One Never Event reported in April for the FPH site

Never events

This is currently under investigation. A thematic review of all Never

Events for 2017/18 will be included in the Annual Patient Safety report

Serious Incidents Requiring Investigation

14 serious incidents were reported for FHFT

Five serious incidents were reported for HWP including two

falls and two diagnostic incidents

Nine serious incidents were reported for FPH including

three falls, two IG breaches as per the IG toolkit and a

Never Event

Serious Incidents Requiring Investigation

All serious incidents care reviewed via an RCA framework

A thematic analysis of all serious incidents reported in 2017/18 is

currently being undertaken and will be included in the Annual Patient

Safety report

Pressure ulcer incidence – grade 2

There continues to be an increase in the number of hospital

acquired pressure ulcers

In 2017/18 there was an increase in the number of grade 3

hospital acquired pressure ulcers

Pressure ulcer incidence – grade 2

A pressure ulcer summit has been scheduled to ensure a robust

improvement plan is implemented

Improvement plan to be monitored via patient safety and quality forums

Safe staffing – registered nurse day

Registered Nurse (RN) Day Hours fill rate overall in April

2018 was 1% below the Trust’s 90% minimum target at 89%

Previous month Trust average 87%, 2% improvement this

month

Site breakdown:

FPH RN average Day Hours % fill rate: 88.6%

WP RN average Day Hours % fill rate: 90.1%

HH RN average Day Hours % fill rate: 85.6%

Registered Nurse Trust average RN Night hours % fill rate

was 96%

Safe staffing – registered nurse day

Good Rostering practice and monitoring of ward/directorate KPIs

against roster policy and monitoring hours (net and carried forward) to

support fill rates

Partnership working with HR is ensuring recruitment and retention of

N&M staff is seen as a priority. Initiatives are underway to aid

recruitment and retention of permanent staff, including using an external

agency to assist with overseas and UK recruitment, and a cross site

N&M and AHP careers open morning

Recruitment and retention strategies and plans are being shared at

internal road-shows run by the Chief Executive and the Directors of

Nursing and HR

Piloting Bank fortnightly assessment centres for RN Band 5’s on both

FPH & WPH sites to aid the recruitment of temporary staff

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Effective

Stroke – 4 hour target

There has been a dip in the 4 hour performance, but the trust is

still performing better than the national average

Sentinel Stroke National Audit Programme (SSNAP) improvement

plan has now been agreed by stroke MDT and co-dependencies

Since the plan has been agreed, Catheterisation Laboratory

escalation beds have been utilised for overnight stays, premium

and super premium discharges have been achieved, and use of

FPH transport has increased. Patients have been stepped down

in a more timely manner, stroke outliers have been better

managed and the process of handing back non-stroke patients to

ED has been agreed

This has all helped with patient flow and freeing up the stroke

coordinators’ and consultants’ time to manage stroke patients

Stroke – 4 hour target

The SSNAP improvement plan will be reviewed monthly at the

Stroke Clinical Governance meeting

Improvement plan includes a number of actions for improving the 4

hour admission performance, which is part of Domain 2: Stroke

Unit

Obstetrics – C section rate (planned, unscheduled and

emergency)

The Caesarean section rate for April was 28%, the emergency

rate was 15.4%

Obstetrics – C section rate (planned, unscheduled and

emergency)

The rate continues to be monitored on a monthly basis

The Chief of Service has asked for an audit of emergency C

Sections to be undertaken

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Caring

Noise at night from other patients

Noise at night from other patients continues to be reported as

an issue

Noise at night from other patients

Meetings have taken place with senior nurses across site, and patients

are cohorted where appropriate

Eye masks and ear plugs are offered to all patients

Mixed sex accommodation breaches

Following agreement with NHSI and NHSE, Trusts across the

South East Region have been asked to review their application

of the 2010 National Guidance for delivering same sex

accommodation, this includes removal of all local agreements

within Trust policies that have been in place previously

FHFT has reviewed this in conjunction with our patient

experience survey results and has subsequently identified

areas where application of the guidance has needed to be

reset

The increase in breaches had been anticipated following the

removal of local agreements and our Director of Nursing has

been in contact with NHSI and the Directors of Nursing at the

CCGs during this process


The Trust has an improvement plan in place and are working closely

with the NHSI team to review areas where the Guidance is challenging

to interpret and we welcome their support in this improvement project.

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Responsive

Cancelled operations (on the day and percentage admitted

within 28 days)

The non-clinical hospital cancellations were predominantly

due to a significant number of emergency admissions which

placed the hospitals under additional pressures. Elective

surgical lists were reviewed and prioritised to ensure that all

patients received safe care

Cancelled operations (on the day and percentage admitted within

28 days)

An escalation policy and dashboard continue development for both

sites and are already providing good information to the business

managers for rebooking. Also a group meeting led by the

Transformation Project Manager is now held fortnightly to

accelerate the processes

28 day breaches are still being validated by the operational

managers and any breaches are being booked as a priority

Emergency Department – 4 hour target

At HWP site achieving the 4 hour performance remains an

on-going challenge. Consistent issues are lack of flow out of

the ED for patients requiring admission due to the number of

discharges not matching the admission numbers and volume

of patients to manage in the evening/overnight in ED

At FPH, the four hour performance remains an on going

challenge and it is pleasing to see the significant

improvement in April

Emergency Department – 4 hour target

A continued focus on recruitment and retention

Ongoing work of a new flow model to support rapid flow out of ED

for medical patients

Initiative with senior GPs planned to inform the appropriate primary

care offering in ED with the aim of reducing volume of patients

managed by the ED clinical teams

At FPH, recruitment and retention remain the top priority to enable

effective rotas to map activity of attendances

Trust engagement on achieving effective premium discharges to

support flow

Consistent implementation of the ED manager role to support

quality and safety within the department

Delayed transfers of care

DTOCs at Frimley have increased from 4.8% to 5.6%


A discharge to assess (D2A) pilot is starting for Hampshire patients.

These patients will be discharged to either a care home or home

with a Package of care and the Continuing Health care

assessments will be carried out in the community

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Well-led

(Workforce)

Turnover rate (total and nursing)

Turnover has increased this month and is higher than the

target for total staffing and nursing, although the total

turnover figure is lower than Apr 2017. During the last

year 46.9% of employees (39.3% of nurses) left FHFT with

less than two years’ service (excluding Junior Doctors).

The main reasons for leaving FHFT were Relocation and

Work Life Balance and the most common destinations on

leaving were No employment and NHS Organisation.

55.8% of Nurses that left FHFT were band 5 Nurses

Turnover rate (total and nursing)

Time to recruit

Time to recruit has increased this month from 46.7 to 50.4

(lower than reported figure in April 2017 50.5)

Time to recruit

Work is ongoing to identify areas of improvement and

streamlining in the recruitment process. Standardised

assessment centres for nursing posts will remove some of

delays between the interview and offer stages

Agency spend

Agency spend has decreased this month from 6.40% to

5.60% , however, remains above the new KPI of 4%. This

KPI has been readjusted to allow for the new agency

target of £15.6m for this financial year

Agency spend

Appraisal rate (non medical)

The appraisal rate has improved this month from 62.2% to

64.1% but remains below target

Appraisal rate (non medical)

A new appraisal scheme has been introduced

Well-led

(Efficiency) No exceptions to report

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Domain Key points Risks

Well-led

(Finance)

The Trust’s operational deficit (before exceptional items and STF) was £4.9m in month which was £1.8m worse than plan. This is a

significant adverse variation at month 01 and means achievement of plan is already under significant pressure. The exit run rate from

March has continued into April but the plan assumes significant cost reduction which has not materialised. Pay and non pay costs are

not reducing which is driven by continued capacity pressures unabated from the end of last year

Income

Clinical income in month was broadly on plan which had been set at

outturn from last year. Activity is higher than this period last year but

contracting rules and the ICS system risk share mean that this will not

readily translate into increased income

Income is less relevant in 2018/19. It may point to

where system deficits should sit organisationally

but do not represent a means to cover costs

Expenditure

Agency and substantive pay costs have not reduced in line with CIP

expectations due to continued capacity pressures. This has meant a

significant adverse variance in Month 01 of £1.9m. Bank costs are similar

to the exit run rate £3.2m

Underlying costs significantly higher than plan

CIP mitigation plans require immediate attention

Net surplus/deficit

The Trust is behind plan year-to-date (ytd) by £1.8m. PSF of £1.3m ytd

has been accrued on the basis that the Trust will recover the cost overruns

by end of Q1 and then for the rest of the year will remain within budget

Although early, forecasting to the year end without corrective action would

suggest a significant adverse variance to plan

Urgent immediate corrective action required to pull

back CIP slippage and to reduce run rate to plan

levels

CIPs

In month £1.7m delivery which is 68% due mainly to early slippage on

agency reduction schemes

Unidentified CIP is at £5m (ignoring non-cash

releasing items)

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Safe – Key measures (1)


16/17 17/18 Apr-17 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr-18 YTD Target Threshold

Infection control

Clostridium difficile due to lapses in care 4 10 0 0 1 0 4 2 0 0 3 0 0 0 0 0 <=30 None

Clostridium difficile – total numbers (SOF) 33 45 3 1 5 4 6 3 6 3 6 5 2 1 2 2 <=30 None

Clostridium difficile - infection rate per 100,000 bed days (SOF) 7.5 7.3 7.9 8.1 8.8 8.8 9.0 8.6 9.4 9.6 9.6 9.5 9.2 9.2 <=7.60 >10.40

MRSA bacteraemia – total numbers 2 3 0 0 1 0 1 0 0 0 0 0 1 0 0 0 0 None

MRSA bacteraemia – infection rate per 100,000 bed days (SOF) 0.4 0.4 0.6 0.4 0.6 0.6 0.6 0.6 0.6 0.6 0.8 0.6 0.6 0.6

MSSA bacteraemia – total numbers New 38 7 1 3 3 5 2 3 5 1 1 1 6 1 1 TBC TBC

MSSA – infection rate per 100,000 bed days (SOF) 8.5 8.1 7.7 7.5 7.1 7.3 7.7 7.7 7.7 7.3 7.1 8.0 6.7 6.7

E coli bloodstream infection (BSI) New 131 9 14 12 15 9 8 15 15 11 8 6 10 9 9 TBC TBC

E coli – infection rate per 100,000 bed days (SOF) 20.7 22.2 23.2 24.2 25.3 25.4 25.8 27.7 27.9 28.4 36.0 27.7 27.7 27.7

Hand hygiene compliance 85% 90% 91% 96% 93% in arrears >=90% <75%

Medication errors resulting in harm

Low 22 15 2 0 2 2 1 0 1 2 2 1 0 2 in arrears None

Moderate 8 4 1 1 0 0 0 1 0 0 1 0 0 0 in arrears <=8 None

Severe 0 0 0 0 0 0 0 0 0 0 0 0 0 0 in arrears 0 None

Pressure ulcer incidence

Hospital acquired - grade 2 169 222 20 18 21 17 14 14 10 22 19 25 21 21 in arrears <=216 None

Hospital acquired - grade 3 5 10 0 2 0 1 0 1 0 1 3 1 1 0 in arrears <=12 None

Hospital acquired - grade 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 in arrears 0 None

Community Services- lapses in care 3 1 0 0 1 0 1 1 0 0 0 0 0 in arrears TBC TBC

Incident reporting

Never events (SOF) 4 13 1 0 1 1 1 1 0 2 1 1 2 2 1 1 0 None

Serious incidents (SIRI) - total trust including Fleet * 70 120 4 11 12 7 14 14 10 10 11 8 8 15 14 14 <=105 >111

Fleet community services SIRIs 4 1 0 0 1 0 1 1 0 0 0 0 0 1 1 TBC TBC

NHSI/NHSE Patient Safety Alerts outstanding (SOF) 0 1 0 0 0 1 0 0 0 0 0 0 0 0 in arrears 0 None

Incidents triggering a duty of candour response 96 148 10 13 8 13 13 13 15 12 16 9 11 18 in arrears TBC TBC

Failure to notify suspected / actual reportable patient SIs (SOF) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 in arrears 0 None

Falls resulting in significant injury

Number of falls 20 23 1 3 3 2 1 3 1 3 0 0 3 3 5 5 <=37 None

Number of falls per 1000 bed days 0.04 0.05 0.03 0.07 0.08 0.05 0.03 0.07 0.02 0.08 0.00 0.00 0.08 0.07 0.13 0.13 TBC

Safe staffing - hours filled as planned

Registered nurse day 92% 90% 88% 91% 90% 90% 88% 89% 91% 94% 91% 90% 89% 87% 89% 89% >=90% None

Unregistered care staff day 96% 96% 95% 98% 98% 98% 95% 96% 95% 95% 93% 93% 95% 95% 100% 100% >=90% None

Registered nurse night 96% 95% 94% 96% 96% 96% 94% 95% 95% 96% 96% 97% 95% 95% 96% 96% >=90% None

Unregistered care staff night 100% 99% 96% 99% 99% 99% 98% 99% 97% 99% 98% 99% 100% 99% 95% 95% >=90% None

* Fleet community services were transferred under FHFT from January 2017

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Safe – Key measures (2)



VTE (venous thromboembolism) risk assessment

Admitted adults risk assessed for VTE (SOF) 97% 98% 98% 98% 97% 98% 97% 97% 97% 98% 98% 98% 97% 97% in arrears >=95% None

Delivering a 7-day service

Emergency admissions reviewed by a

consultant within 14 hours of admission 87% Bi-annual audit >=90% >=87%

Sepsis CQUIN - Timely identification of Sepsis in emergency department (ED) and acute inpatient settings

% of patients screened for sepsis in ED 94% 96% 88% 100% 100% 100% 96% 100% 100% 100% 100% 100% 100% in arrears >=90% <50%

% of acute inpatients screened for sepsis 61% 42% 42% 34% 28% 30% 44% 66% 64% 68% 68% 60% 68% in arrears >=90% <50%

Sepsis CQUIN – Timely treatment of Sepsis in emergency department (ED) and acute inpatient settings

The percentage of patients who met criteria

were administered intravenous antibiotics

within 1 hour of arrival in ED

83% 38% 85% 75% 85% 71% 73% 79% 83% 70% 61% 58% 75% in arrears >=90% <50%

The percentage of patients who met criteria

were administered intravenous antibiotics

within 1 hour of arrival on the ward

68% 63% 43% 57% 63% 50% 63% 56% 89% 71% 50% 93% 89% in arrears >=90% <50%

Sepsis CQUIN – Antibiotic Review

% of antibiotic prescriptions for patients

diagnosed with sepsis that were documented

and reviewed by a clinician within 72 hours

82% 88% 96% 91% in arrears

Q1 >=25%

Q2 >=50%

Q3 >=75%

Q4 >=90%

Reduction in antibiotic consumption per

1,000 admissions

4828

baseline in arrears in arrears

4575

baseline in arrears TBC

* Audit data to be treated with caution due to loose national definitions and the use of questions that were open to interpretation

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Effective – Mortality and morbidity


In-hospital mortality and summary hospital-level mortality indicator (SHMI) (SOF)

KEY: Higher than expected Within expected range : 90 - 110 (overall and non-elective)

70 - 130 (elective) Lower than expected

Range (confidence intervals) Deaths

Well-led Activity

As a result of issues with NHS Digital’s external data supplier, we have been informed that they are unable to provide us with ONS

data in time for this month’s dissemination. This means that the monthly SHMI, mortality outcomes and VTE PE deaths after discharge

indicators will not be updated this month

16/17 17/18 Apr-17 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar-18 YTD

Number of inpatient deaths 209 217 206 185 201 192 219 204 217 306 221 243

Total deaths screened (including <30 day post discharge) New 252 309 292 259 243 242 280 264 304 417 320 328

Deeper reviews completed New 65 69 70 49 41 52 64 43 35 62 21 7

Total number of deaths judged > 50% likely to be due to problems

with care New 4 2 2 5 2 1 3 2 1 in arrears

Number of deaths of patients with a Learning Disability 1 1 3 1 1 2 3 5 2 2 in arrears

Total number of deaths of patients with LD judged > 50% likely to be

due to problems with care 0 0 0 0 0 0 0 1 0 in arrears

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Effective – CRAB morbidity – key measures & key messages


Medical

practice

trigger

trends *

Surgical

complications *

Area Key messages

Mortality Case Record

Review

Learning from case record review has included falls prevention and response to a fall. End of life decision

making, ceilings of care and discussion of aggressive interventions in the frail elderly. Communication of

difficult decisions. Response to deterioration, VTE risk assessment and opiate use in renal failure.

CRAB data

There has ben a winter rise in all triggers trust wide. AKI and shock/hypotension on the ward has risen again

on the Wexham site particularly. Hospital acquired pneumonia has risen at Frimley Park. AKI is under

investigation. All the rises correlate with the increased activity over the winter months. Surgical complications

are as expected. Mortality is lower than would be expected.

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Effective – Clinical performance measures



Stroke *

% of patients admitted directly to the

stroke unit in 4 hours 72% 72% 83% 76% 78% 81% 77% 70% 84% 70% 52% 60% 67% 57% 64% 64% >=80% <72%

% of patients scanned within 1 hour of

arrival 64% 64% 67% 76% 65% 55% 58% 66% 62% 57% 60% 64% 70% 69% 69% 69% >=50% <45%

% of patients receiving a swallow screen

<= 4 hours of arrival 81% 81% 81% 80% 81% 77% 84% 80% 79% 74% 62% 85% 96% 86% 83% 83% >=90% <80%

Cardiology

% of eligible patients receive treatment;

call to balloon within 150 minutes 92% 89% 96% 95% 100% 94% 84% 96% 96% 81% 88% 71% 81% 88% in arrears >=85% <80%

Trauma and orthopaedics

% #NOF patients meeting best practice

criteria 83% 67% 52% 75% 69% 75% 66% 66% 62% 56% 69% 75% 71% 73% in arrears >=65% <55%

% #NOF patients going to theatre < 36

hours 80% 71% 83% 82% 80% 80% 89% 73% 75% 80% 81% 83% 82% in arrears >=90% <80%

Critical care

Critical care non-clinical transfers out of

the trust 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 None

Theatres

Compliance with the WHO surgical safety

checklist 99% 99% 98% 98% 99% 99% 99% 100% 99% 99% 100% 99% 99% 99% 99% 99% >=95% <90%

Obstetrics

C section rate (planned & unscheduled) 26.9% 28% 27% 29% 30% 27% 26% 27% 29% 29% 27% 27% 30% 30% 28% 28% <=25% >27%

Emergency C-section rate (SOF) 14% 14.5% 13.4% 14.7% 15.2% 14.2% 13.5% 13.8% 13.5% 14.3% 14.3% 14.2% 16.7% 16.3% 15.4% 15.4% <=14.0% >15.0%

Still births over 24 weeks 41 27 4 1 3 2 3 1 4 3 4 1 0 1 3 3 None None

Emergency readmissions

Emergency re-admissions within 30 days

following an elective or emergency spell 6.9% 6.8% 7.1% 7.2% 6.9% 6.9% 7.0% 7.2% 6.2% 6.2% 7.5% 6.5% 6.5% 6.6% in arrears <=6.8% None

* Stroke data is for FPH only as the unit at Wexham Park was decommissioned during 2016/17

6

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erformance R

eport

87 of 181P

UB

LIC B



Caring – Key measures (1)



Local Surveys

1. Overall did you feel you were treated with respect and dignity

while you were in this ward? 96% 97% 97% 97% 98% 96% 97% 97% 96% 96% 97% 97% 96% 97% 97% 97% >=95% <90%

2. Do you have confidence and trust in the doctors treating you? 93% 93% 93% 93% 95% 92% 94% 91% 92% 94% 93% 91% 92% 93% 95% 95% >=95% <90%

3. Were you bothered by noise at night from hospital staff?

(percentage of patients saying no) 87% 87% 85% 88% 87% 89% 88% 88% 86% 87% 87% 86% 88% 87% 86% 86% >=90% <80%

4. Were you ever bothered by noise at night from other patients?

(percentage of patients saying no) 66% 69% 77% 70% 73% 72% 67% 69% 69% 68% 68% 68% 68% 67% 69% 69% >=80% <70%

5. If you needed it, did you get enough help from staff with eating

and drinking? 90% 91% 92% 90% 95% 90% 95% 91% 85% 88% 91% 92% 93% 91% 92% 92% >=90% <80%

6. Have you and your family or carers been involved enough in

discussing your discharge from hospital? 82% 85% 84% 85% 88% 84% 84% 82% 83% 86% 86% 86% 86% 86% 88% 88% >=80% <70%

7. Were you involved as much as you wanted to be in decisions

about your care and treatment? 92% 86% 86% 87% 90% 84% 88% 83% 83% 85% 87% 85% 86% 87% 88% 88% >=90% <80%

8. Within the first couple of days of admission did a member of

staff ask you about your home situation? 83% 88% 84% 87% 86% 88% 88% 89% 86% 89% 91% 90% 90% 90% 91% 91% >=80% <70%

9. Did nurses talk in front of you as if you weren’t there?

(percentage of patients saying no) New 93% 89% 92% 94% 92% 95% 93% 92% 93% 94% 94% 93% 92% 96% 96% >=95% <85%

10. Beforehand, did a member of staff explain the risks and

benefits of the operation or procedure in a way you could

understand? New 92% 86% 94% 93% 98% 95% 88% 90% 90% 88% 87% 96% 94% 92% 92% >=95% <90%

Complaints

Number of complaints received * 920 952 63 70 80 75 93 88 78 80 55 96 87 88 71 71 <=924 >1056

Number of complaints per 100 patient contacts (SOF) 1.72 2.22 0.06 0.06 0.07 0.07 0.09 0.08 0.07 0.07 0.06 0.08 0.09 0.08 0.07 0.07 <=0.07 >0.09

Number of complaints with 25 day timescales New New New measure in arrears

Number of complaints answered within 25 working days 340 387 26 45 44 36 39 41 31 24 17 37 27 20 in arrears

Number of complaints with extended agreed timescale New New New measure in arrears

Number of complaints answered within extended timescale New New New measure in arrears

Number of complaints re-opened 97 111 2 12 11 11 13 12 9 11 7 8 7 8 10 10 <=96 >108

* provisional data for the reporting month

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UB

LIC B



Caring – Key measures (2)



Patient Friends and Family Scores - What % would recommend this trust to friends and family if they needed similar care or treatment?

Emergency department - % positive (SOF) 91.1% 93.4% 94.2% 94.5% 94.0% 91.3% 92.3% 92.9% 94.2% 93.5% 93.9% 94.1% 93.8% 90.1% 91.3% 91.3% >=94.4% <89.1%

Outpatients - % positive 95.9% 96.6% 95.6% 96.2% 97.1% 96.5% 96.1% 97.0% 96.9% 97.0% 97.0% 96.2% 97.3% 96.4% 96.7% 96.7% >=96.8% <94.6%

Inpatients - % positive (SOF) 97.4% 97.6% 98.0% 97.7% 97.5% 97.3% 97.9% 97.3% 97.6% 98.0% 97.3% 97.4% 97.4% 98.1% 97.4% 97.4% >=97.7% <96.4%

Maternity - % positive (of those giving birth

here) (SOF) 96.7% 96.6% 97.5% 95.4% 98.4% 97.5% 94.3% 95.4% 96.3% 93.6% 98.7% 97.6% 95.4% 98.9% 98.0% 98.0% >=99.0% <97.9%

Community - % positive (SOF) 97.6% 98.8% 98.6% 100% 100% 90.9% 100% 93.9% 100% 100% 99.6% 98.8% 100% 93.2% 93.2% >=98.3% <97.0%


Mixed sex accommodation breaches (SOF) 6 27 0 0 0 0 6 7 5 0 5 4 0 0 267 267 0 None

Dementia care - % of all admitted patients (75+) who : (SOF)

Have been screened for Dementia

(within 72 hours) 100% 99% 99% 100% 99% 100% 99% 99% 99% 100% 100% 100% 100% in arrears >=90% None

Dementia positives - dementia diagnostic

assessment (within 72 hours) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% in arrears >=90% None

Received a dementia diagnostic

assessment with a “positive‟ or

“inconclusive‟ outcome that were then

referred for further diagnostic advice/follow

up (within 72 hours)

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% in arrears >=90% None

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LIC B



Responsive – Key measures



Diagnostics

Diagnostics waiting 6 weeks and over 49 76 40 40 44 48 29 32 26 36 37 45 47 48 None None

% waiting 6 weeks and over for a

diagnostic procedure 0.4% 0.4% 0.7% 0.4% 0.4% 0.4% 0.4% 0.3% 0.3% 0.2% 0.4% 0.4% 0.4% 0.4% 0.4% 0.4% <=1.0% None

Referral to treatment (RTT)

Total Incompletes waiting 36093 35728 36097 36694 36772 36587 37031 37315 36780 34912 34585 34691 34290 35728 35568 35568

% waiting within 18 weeks 92.6% 92.3% 92.2% 93.2% 92.8% 92.9% 92.3% 92.0% 92.2% 92.5% 91.3% 92.4% 92.7% 92.3% 92.4% 92.4% >=92.0% None

Waiting >= 18 weeks (backlog) 2715 2722 2812 2489 2729 2692 2833 2985 2855 2608 2998 2649 2510 2722 2710

Waiting 35 weeks and over 149 156 136 136 156 141 124 126 148 121 140 135 129 156 159

Waiting 52 weeks and over 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 None

Cancelled operations

On day cancelled operations (Non-Clinical)

(% of electives) 0.9% 1.2% 0.8% 0.8% 0.9% 1.2% 0.8% 1.0% 1.0% 1.2% 1.4% 1.5% 2.0% 1.3% in arrears <=0.8% >1.2%

% of cancelled patients admitted within 28

days 93.3% 92.5% 100% 95.0% 88.9% 91.0% 96.2% 98.4% 98.5% 92.3% 88.4% 90.5% 91.9% 88.0% in arrears 100% <90%


% of bed days lost due to delays 4.4% 5.1% 4.8% 3.9% 4.7% 5.5% 6.5% 5.7% 6.3% 5.6% 5.2% 4.2% 3.9% 5.4% 5.1% 5.1% <=3.5% >4.0%

Number of patients delayed at the end of

each month 395 839 55 53 66 64 74 89 84 62 75 76 61 80 76

Emergency department

A&E Delivery Board (includes Type-3

activity) 91.2% 94.2% 92.6% 88.1% 89.0% 87.9% 89.9%

Q1=91.3%

Q2=94.3%

Q3=92.7%

Mar 2019=95%

None

A&E > 4 hours (SOF) 91.6% 89.0% 92.3% 90.2% 91.3% 91.5% 90.4% 90.7% 94.2% 91.4% 84.3% 83.6% 85.0% 83.1% 87.6% 87.6% >=95% >=90%

Patients >12 hours from DTA 4 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 None

% of all ambulance handovers

> 60 mins? 1.2% 0.6% 0.1% 0.5% 0.2% 0.5% 0.4% 0.4% 0.1% 0.3% 1.1% 1.4% 1.0% 1.3% in arrears <=1.0% >2.0%

6

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90 of 181P

UB

LIC B



Responsive – Cancer – Key measures


Apr-17 May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec-17 Q3 Jan Feb Mar Q4 Apr-18 Target

Cancer

2 week waits – urgent GP

referrals 95.6% 96.4% 96.4% 96.2% 96.8% 95.6% 95.5% 96.0% 96.5% 97.1% 95.9% 96.5% 96.2% 97.2% 96.9% 96.8% in arrears >=93%

2 week waits - Breast

symptomatic referrals 95.8% 96.2% 95.7% 95.9% 97.5% 95.1% 96.9% 96.5% 94.7% 95.0% 96.0% 95.2% 95.6% 95.6% 96.7% 96.0% in arrears >=93%

31 day wait for first

treatment 98.9% 99.2% 97.8% 98.6% 99.6% 100% 100% 99.9% 99.3% 98.9% 100% 99.4% 99.3% 99.5% 100% 99.7% in arrears >=96%

31 day wait

for second

or

subsequent

treatment

Surgery 100% 100% 96.9% 98.8% 100% 100% 100% 100% 96.6% 100% 100% 98.5% 100% 100% 100% 100% in arrears >=94%

Anti-cancer

drugs 100% 100% 100% 100% 100% 100% 98.2% 99.3% 100% 100% 100% 100% 100% 100% 100% 100% in arrears >=98%

62 day wait for first

treatment (SOF) 90.2% 92.6% 92.8% 91.9% 95.7% 94.5% 93.2% 93.3% 94.0% 94.1% 93.0% 93.6% 89.2% 89.1% 94.1% 91.0% in arrears >=85%

62 day wait for screening

patients (SOF) 100% 97.0% 97.1% 97.8% 94.2% 100% 98.1% 97.5% 100% 100% 100% 100% 96.2% 100% 97.6% 97.4% in arrears >=90%

Well-led Activity

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LIC B



Responsive – Cancer 62-day waits standard by tumour group


Apr-17 May Jun Q1 Jul Aug Sep Q2 Oct Nov Dec Q3 Jan Feb Mar Q4 Apr-18 Target

Brain/CNS NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

in arrears >=85%

Breast 94.1% 100% 89.4% 94.7%

(62.5/66) 100% 100% 100%

100%

(78/78) 100% 100% 96.1%

98.7%

(76/77) 100% 100% 100%

100%

(53/53)

Childrens NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Gynaecological 77.8% 88.9% 100% 86.4%

(9.5/11) 75.0% 100% 100%

89.3%

(12.5/14) 87.5% 84.6% 92.9%

88.4%

(19/21.5) 88.9% 91.7% 100%

92.0%

(11.5/12.5)

Haematological 90.9% 100% 100% 96.6%

(28.5/29.5) 100% 75.0% 100%

92.3%

(12/13) 85.7% 100% 83.3%

88.9%

(12/13.5) 90.0% 57.1% 80.0%

81.1%

(15/18.5)

Head & Neck 100% 75.0% 100% 93.3%

(7/7.5) 100% 60.0% 77.8%

81.0%

(8.5/10.5) 80.0% 36.4% 100%

59.1%

(6.5/11) 77.8% 100% 50.0%

80.0%

(6/7.5)

Lower GI 90.9% 84.6% 100% 92.1%

(35/38) 93.3% 93.3% 90.0%

92.0%

(34.5/37.5) 90% 100% 78.3%

90.3%

(32.5/36) 80.0% 88.9% 88.9%

85.7%

(36/42)

Lung 75.0% 86.7% 86.7% 84.2%

(16/19) 88.9% 100% 76.5%

86.5%

(16/18.5) 100% 93.3% 84.6%

93.5%

(21.5/23) 62.5% 81.8% 83.3%

72.7%

(12/16.5)

Sarcomas 100% NA 100% 100%

(1.5/1.5) 100% 100% NA

100%

(1/1) 100% 0.0% NA

50.0%

(0.5/1) 100% 50.0% NA

66.7%

(1/1.5)

Skin 100% 92.3% 100% 96.9%

(63.5/65.5) 100% 97.6% 100%

99.0%

(97.5/98.5) 95.7% 96.8% 100%

97.6%

(80/82) 100% 100% 100%

100%

(74/74)

Upper GI 66.7% 81.8% 90.9% 80.7%

(23/28.5) 85.7% 80.0% 100%

86.0%

(18.5/21.5) 92.3% 100% 100%

97.1%

(16.5/17) 84.2% 66.7% 100%

84.2%

(16/19)

Urological 88.0% 94.7% 87.5% 90.5%

(86/95) 96.6% 94.7% 87.1%

92.4%

(73/79) 92.5% 96.2% 94.5%

94.3%

(108/114.5) 91.5% 80.0% 92.4%

90.1%

(77.5/86)

Other 100% NA 0.0% 66.7%

(1/1.5) 100% 0.0% NA

25.0%

(0.5/2) 50% 100% 50.0%

57.1%

(2/3.5) 0.0% NA NA

00.0%

(0/1.5)

Total 90.2% 92.6% 92.8% 91.9%

(332/361.5) 95.7% 94.5% 93.2%

94.2%

(351/372.5) 94% 94.1% 93.0%

93.6%

(374/399) 89.2% 89.1% 94.1%

91.0%

(301/330.5)

Cancer – 62-day referral to treatment standard – over 104 day waiters

Number of patients

waiting over 104 days 3 3 2 2 3 2 4 2 3 0 2 4 2

% of patients waiting

over 104 days 0.2% 0.2% 0.1% 0.1% 0.2% 0.1% 0.3% 0.1% 0.2% 0.0% 0.1% 0.3% 0.1%

Half numbers are where a patient has been referred here for treatment from another provider or vice versa; the patient is shared between providers

The additional figures provided for the quarters are the number of patients treated within the 62-day standard out of the total number of patients treated for that tumour group

Well-led Activity

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LIC B



Well-led – Workforce Key measures (1)

Safe Effective Caring Responsive Well-led Efficiency / Finance Activity

16/17 17/18 Apr-17 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr-18 YTD Target* Threshold*

Staff numbers

Staff in post FTE 8011 N/A 8062 8081 8066 8038 8079 8121 8113 8138 8160 8170 8238 8184 8167 N/A None

Vacancy FTE 649 N/A 706 779 867 819 922 983 934 904 981 998 1051 1029 1064 N/A None

Starters FTE 1564 1139 118 87 71 115 85 129 111 101 46 90 107 79 63 63 None

Leavers FTE 1197 1170 102 80 101 111 102 102 116 75 108 79 67 127 89 89 None

Turnover

Turnover rate % (SOF) 14.6% N/A 15.1% 15.7% 15.1% 14.9% 14.8% 15.0% 15.0% 15.1% 15.2% 15.0% 14.9% 15.0% 15.0% <=13.0% >14.5%

Nursing turnover rate % 14.6% N/A 14.6% 15.1% 15.0% 14.9% 14.8% 15.0% 14.1% 13.9% 14.5% 14.4% 14.2% 14.5% 14.6% <=13.0% >14.5%

Executive team turnover

(definition TBC) 0 3 1 0 0 1 0 0 0 0 0 0 1 1 0 None

Time to recruit

From date vacancy created to

unconditional offer (days) 53.9 50.5 53.4 55.5 52.7 48.7 52.2 58.4 51.3 54.4 58.9 52.4 46.7 50.4 <=40 >50

Vacancy

Vacancy rate - total % 10.2% 8.5% 9.3% 10.2% 9.7% 10.8% 11.4% 10.9% 10.5% 11.3% 11.5% 11.1% 11.8% <=10.5% >12.0%

Vacancy rate – doctors % ** New 3.5% 2.1% 3.1% 2.0% <=5.0% >5.5%

Vacancy rate – nurses % 15.4% 14.0% 15.7% 17.1% 18.0% 17.7% 17.7% 15.5% 15.0% 15.3% 15.6% 15.4% 16.4% <=14.0% >15.5%

Agency spend (SOF)

Agency spend as % of pay bill 7.7% 5.6% 5.7% 5.9% 6.0% 5.3% 6.0% 5.2% 4.8% 4.3% 5.0% 5.2% 6.4% 5.6% <=4.0% >5.0%

Agency spend – total (£000s) *** 30473 1886 1917 2036 2012 1789 2042 1764 1658 1461 1724 1801 2218 1980 1980 1300 1625

Agency - doctors (£000s) **** 12656 911 794 1018 958 792 1068 836 778 617 757 823 1108 819 819 None

Agency - nurses (£000s) 8490 604 465 406 485 492 550 524 452 446 539 504 561 493 493 None Agency - other (£000s) 9327 371 658 612 569 505 424 404 428 398 428 474 549 668 668 None Sickness

Sickness absence rate % (SOF) 2.9% 2.9% 3.0% 2.9% 2.8% 2.9% 3.1% 3.1% 3.1% 3.1% 3.1% 3.1% 3.2% 3.2% <=2.9% >3.2%

* Targets and thresholds for Workforce have been amended for 2018-19. RAG ratings for 2017-18 remain as at the targets/thresholds for last year

** On-going reviews with finance are being undertaken to ensure the establishments reflect the actual position trust-wide; data will be available as soon as possible

*** The agency spend total is a control target based on an annual total target of £23m or £1.917m per month

**** Agency spend for doctors – the target is based on an overall reduction in spend of £1.88m for 2017/18

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UB

LIC B



Well-led – Workforce Key measures (2)


Appraisal rates

Appraisal (non-medical) % N/A N/A 54.8% 56.2% 56.9% 58.2% 61.8% 60.7% 61.6% 60.6% 61.9% 62.3% 62.7% 62.2% 64.1% N/A >=80.0% <70.0%

Appraisal (medical) % N/A N/A 98.6% 98.1% 97.2% 97.2% 98.1% 98.4% 96.9% 95.6% 94.6% 96.5% N/A >=95.0% <85.0%

Training

Statutory and mandatory training % ** N/A N/A 66.7% 68.2% 68.9% 73.7% 72.8% 73.3% 76.5% 77.7% 78.4% 78.6% 79.8% 80.7% 81.3% N/A >=85.0% <60.0%

Friends & family test for staff

% recommending here as a place to

work N/A N/A 73% 69% 66% 72%

Q1, 2, 4 >=70%

Q3 >= 66%

Q1, 2, 4 <62%

Q3 <62%

% recommending here as a place for

care (SOF) N/A N/A 89% 88% 79% 88%

Q1, 2, 4 >=86%

Q3 >=76%

Q1, 2, 4 <79%

Q3 <70%

NHS staff survey

NHS staff survey - engagement score

(definition TBC) 3.91 3.89 >=3.87 <3.79

* Work continues to standardise the electronic staff record (ESR) trust-wide from which this data is taken

** Friends and family test (FFT) replaced by National Staff Survey in Q3; the question is worded slightly differently “If a friend or relative needed treatment, I would be happy with the

standard of care provided by this organisation”. Note the target and threshold for Q3 is based on the National Staff Survey results; Q1, 2 and 4 are based on FFT results

Safe Effective Caring Responsive Well-led Efficiency / Finance Activity

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UB

LIC B



Well-led – Efficiency Key measures



Outpatients

Did not attend (DNA) rate 6.8% 7.0% 6.5% 6.7% 7.2% 7.3% 7.3% 7.3% 6.8% 6.9% 7.1% 6.8% 6.8% 7.0% 6.7% 6.7% <=8.2% >11.3%

Outpatient new to follow-up ratios 2.03 2.00 2.01 2.04 2.05 1.94 1.98 2.04 1.95 1.97 2.00 2.10 2.03 2.00 1.98 1.98 <=2.48 >3.85

Average length of stay

Elective LOS 2.53 2.71 2.69 2.96 2.56 2.67 3.11 2.85 2.62 2.43 2.58 2.64 2.51 2.89 2.62 2.62 <=2.77 >3.53

Non-elective LOS 4.05 4.05 4.26 4.13 4.16 4.00 3.98 4.03 4.06 3.85 3.93 4.17 4.27 3.98 4.03 4.03 <=3.13 >4.98

Day case rate

% day cases of all electives 81% 82% 81% 82% 82% 82% 82% 82% 83% 83% 82% 84% 82% 81% 83% 83% >=81% <71%

Theatre utilisation

Intra-session theatre utilisation rate 73% 73% 74% 73% 74% 73% 71% 74% 74% 74% 73% 72% 71% 74% 70% 70% >=85% <70%

* Targets and thresholds for Workforce have been amended for 2018-19. RAG ratings for 2017-18 remain as at the targets/thresholds for last year

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95 of 181P

UB

LIC B



Well-led – Finance Key measures


Year to Date (Month 01) Forecast Outturn

Plan £m Actual £m Variance £m Plan £m Actual £m Variance £m

Income 53.7 53.8 0.1 667.7 667.7 0.0

Expenditure (50.5) (52.6) (2.1) (603.3) (603.3) 0.0

EBITDA (income less expenditure) (SOF) 3.2 1.2 (2.0) 64.4 64.4 0.0

Financing costs (3.9) (3.7) 0.2 (47.1) (47.1) 0.0

Net / surplus deficit (0.7) (2.5) (1.8) 17.3 17.3 0.0

CIPs 2.5 1.7 (0.8) 31.0 22.0 (9.0)

Cash balance 109.2 100.0 (9.2) 113.0 113.0 0.0

Capital expenditure 6.4 6.1 (0.3) 86.1 86.1 0.0

Figures in brackets indicate an adverse position

* Cash balance - threshold is cumulative at £0.5m per month , given material variances are correlated to STF payments

** Capital expenditure – timing differences / slippage in-month can mean the month threshold is lower than for the forecast

Well-led Activity

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eport

96 of 181P

UB

LIC B



Benchmarking – selected measures (1)

Safe Effective Caring Responsive Efficiency / Finance Activity

Safe Effective

Caring

NOTE – for each graph, the position furthest to the left is the best performing trust

Data periods: VTE = Q3 2017/18; SHMI = data not available this month; ED FFT, Inpatient FFT, Maternity

FFT (friends & family test) = Mar 2018; Dementia = Q3 2017/18

Well-led

As a result of issues with NHS Digital’s external

data supplier, we have been informed that they

are unable to provide us with ONS data in time for

this month’s dissemination. This means that the

monthly SHMI benchmarking will not be updated

this month

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erformance R

eport

97 of 181P

UB

LIC B



Benchmarking – selected measures (2)

Responsive

Workforce

NOTE – for each graph, the position furthest to the left is the best performing trust

Data periods: A&E (4 hour target) = Apr 2018; RTT (incomplete pathways) = Mar 2018; Diagnostic test waits = Mar 2018; Cancer = Q4 2017/18; Staff FFT

(friends & family test) = Q3 2017/18 – taken from National Staff Survey results; Staff turnover = Feb 2018


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UB

LIC B



Activity


16/17 17/18 Apr-17 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr-18 YTD YTD %

change

GP and general dental practitioner referrals to all outpatients

Total GP/GDP referrals 184988 181328 13627 15955 16079 15753 15512 15276 15785 15336 12309 15350 14863 15483 14275 14275 5%

% change on previous year -14% 4% -1% 7% 1% -3% 3% -3% -8% 0% 3% -10% 5%

Outpatient attendances

New attendances 276653 292722 22138 25808 25854 25131 24453 24032 26226 26996 21095 25632 22366 22991 23009 23009 4%

Follow-up attendances 598902 587617 44390 52644 52912 48643 48462 48981 51112 53157 42182 53822 45317 45995 45599 45599 3%

Total OP attendances 875555 880339 66528 78452 78766 73774 72915 73013 77338 80153 63277 79454 67683 68986 68608 68608 3%

% change on previous year -8% 7% 3% 4% -3% -7% 4% 0% -5% 6% -2% -15% 3%

Elective admissions

Daycase 64340 67492 4895 5973 5647 5537 5386 5393 5899 6294 5054 6089 5579 5746 5511 5511 13%

Overnight 15567 14456 1144 1290 1231 1193 1161 1147 1198 1265 1104 1186 1205 1332 1126 1126 -2%

Regular day attenders 15820 16655 1321 1525 1514 1422 1434 1312 1375 1421 1225 1486 1240 1380 1227 1227 -7%

Total elective admissions 95727 98603 7360 8788 8392 8152 7981 7852 8472 8980 7383 8761 8024 8458 7864 7864 7%

% change on previous year -10% 11% 2% 1% -1% -9% 2% -1% 0% 4% 2% -6% 7%

Emergency department (ED)

attendances

ED attendances (total) 237509 238438 19209 21147 20339 20686 19251 19468 20149 19811 20198 20059 17941 20180 19437 19437 1%

% change on previous year 2% 2% 2% -4% -1% -3% -1% 0% 2% 3% 3% -1% 1%

Non-elective admissions

Non-elective admissions (total) 104023 109368 8487 9257 8827 9169 8688 9059 9202 9452 9516 9488 8526 9697 9218 9218 9%

% change on previous year -2% 0% -4% -3% 0% -2% -2% 0% 1% 5% 6% 4% 9%

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Activity – CCG breakdown

16/17 17/18 Apr-17 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr-18 YTD YTD %

change

GP and general dental practitioner (GDP) referrals to all outpatients by CCG

NHS NE Hants and Farnham 40519 2970 3591 3791 3527 3447 3331 3559 3523 2752 3500 3224 3304 3270 3270 10%

NHS East Berkshire 94428 7121 8283 8221 8299 8154 8110 8244 7901 6409 7861 7730 8095 7032 7032 -1%

NHS Surrey Heath 15717 1203 1437 1428 1408 1413 1339 1365 1292 991 1300 1271 1270 1313 1313 9%

NHS Buckinghamshire 14603 1120 1264 1204 1239 1242 1262 1253 1282 1058 1235 1222 1222 1079 1079 -4%

Other CCG's 16061 1213 1380 1435 1280 1256 1234 1364 1338 1099 1454 1416 1592 1581 1581 30%

Total GP/GDP referrals * 184988 181328 13627 15955 16079 15753 15512 15276 15785 15336 12309 15350 14863 15483 14275 14275 5%

% change on previous year -14% 4% -1% 7% 1% -3% 3% -3% -8% 0% 3% -10% 5%

Emergency department (ED)

attendances

NHS NE Hants and Farnham 78179 81903 6568 7172 6884 7146 6579 6777 6777 6853 7019 6979 6238 6911 6826 6826 4%

NHS East Berkshire 94453 100564 8002 8917 8497 8420 7762 8158 8756 8426 8343 8686 7655 8942 8288 8288 4%

NHS Surrey Heath 25399 25479 2069 2258 2228 2204 2137 2136 2097 2118 2213 2096 1856 2067 1984 1984 -4%

NHS Buckinghamshire 287 313 33 23 36 40 31 26 21 26 21 16 17 23 34 34 3%

Other CCG's 29467 30179 2537 2777 2694 2876 2742 2371 2498 2388 2602 2282 2175 2237 2305 2305 -9%

Total * 237509 238438 19209 21147 20339 20686 19251 19468 20149 19811 20198 20059 17941 20180 19437 19437 1%

% change on previous year 2% 2% 2% -4% -1% -3% -1% 0% 2% 3% 3% -1% 1%

Emergency Admissions

NHS NE Hants and Farnham 18269 18012 1323 1465 1522 1596 1465 1468 1523 1520 1597 1602 1393 1538 1547 1547 17%

NHS East Berkshire 35879 38490 2937 3353 3037 3099 2922 3126 3279 3426 3363 3356 3046 3546 3352 3352 14%

NHS Surrey Heath 8738 8485 686 717 711 730 685 732 669 708 731 720 706 690 729 729 6%

NHS Buckinghamshire 10776 12477 978 1004 913 961 984 1016 949 1102 1207 1156 1021 1186 1091 1091 12%

Other CCG's 9152 9589 731 821 776 853 823 759 828 809 880 773 703 833 735 735 1%

Total * 86115 87053 6655 7360 6959 7239 6879 7101 7248 7565 7778 7607 6869 7793 7454 7454 12%

% change on previous year -1% 3% -3% -3% 3% -2% -3% 0% 3% 4% 9% 5% 12%

* Totals for 2017/18 include data from NHS Chiltern CCG which is now part of NHS Buckinghamshire CCG and NHS Bracknell & Ascot CCG, NHS Slough CCG and

NHS Windsor, Ascot & Maidenhead CCG which together now form East Berkshire CCG

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Appendix A – Methodologies & glossary

Appendix A


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Appendix A – Methodologies for calculating the measures

Measure name Numerator Denominator

Length of stay Total number of bed days occupied

Excludes private patients

Excludes daycases

Based on admission method, split

between elective (from a waiting

list) and non-elective admissions

(includes emergencies and

obstetrics)

Total number of discharges in the

period

Expressed as a proportion

Measure is consistent with

that reported on HED

(benchmarking service)

Readmissions Emergency readmissions to any

specialty following an elective or

non-elective spell

Readmission length of stay must be

at least 1 day ie an overnight stay

Readmission occurs within 30 days

of previous discharge

Total number of discharges

(completed spells) in the period prior

to the last 30 days


that used by CQC

Daycase % Total number of admitted spells

where the intended management

was daycase, they were admitted

electively (off a waiting list) and

their spell length of stay was 0 days

Total number of elective spells

(admitted off a waiting list) Expressed as a percentage


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Appendix A – Methodologies for calculating the measures

Measure name Numerator Denominator

Outpatient new

to follow-up

ratio

Number of follow-up outpatient

attendances for all referrals and all

appointment types (consultant and

non-consultant led). Includes ward

attenders and private patients

Number of new outpatient

attendances

Expressed as a ratio where

one new attendance results

in “n” follow-up attendances




Outpatient

DNA rates

Number of outpatient appointments

where the patient did not attend.

Includes all referrals and all

appointment types (consultant and

non-consultant led). Includes

private patients

Number of outpatient attendances

plus the number of appointments

where the patient did not attend

Expressed as a percentage




Falls resulting

in significant

injury (rate per

1000 beddays)

Falls recorded on Datix resulting in

moderate or severe harm or death

Total number of occupied beddays

(including daycases)

Divided by 1000

Expressed as a rate


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Appendix A – Glossary

Term Meaning

CCG Clinical Commissioning Group

CIP Cost Improvement Plan or Programme

CoSRR

Continuity of Services Risk Rating As from 1st October 2013 Monitor‟s new Risk Assessment Framework replaced the old Compliance Framework. Part of

the change saw the Financial Risk Rating (FRR) being replace by the Continuity of Services Risk Rating. This measure is

designed to describe the risk of a provider failing to carry on as a going concern. The scale is rated from 1 to 4 with 4

being „No evident concerns‟ and 1 being „Significant Risk‟

CQUIN Commissioning for quality and innovation

CRAB CRAB (Copeland’s Risk Adjusted Barometer) is based on the POSSUM scoring system

EBITDA Earnings before interest, tax, depreciation and amortization

FHFT Frimley Health NHS Foundation Trust

FPH Frimley Park Hospital

HW Heatherwood Hospital

HWP Heatherwood and Wexham Park Hospitals

POSSUM Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity

WX Wexham Park Hospital

SOF Single Oversight Framework

YTD Year-to-date


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[Copyright information needs to go here]

Xxxxxxxxxxxxxxxxxxxxx

150315-230733-KN-UK

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Page | 1

Report Title

Frimley Health NHS Foundation Trust Quality Improvement Plan as at May 2018

Meeting

Board of Directors (Public)

Meeting Date

Friday, 1st June 2018

Agenda No.

7.

Report Type

To advise the Board of Directors on the progress against the Frimley Health NHS Foundation Quality Improvement Plan

Prepared By

Debbie Barrow Governance Manager

Executive Lead

Dr Timothy Ho Medical Director

Executive Summary

Attached is the Frimley Health Quality Improvement Plan which was reviewed and agreed at the meeting of the Trustwide Quality Committee in April 2018 The Quality Improvement Plan describes the key quality and patient safety risks identified for Frimley Health and the actions that are being taken to mitigate those risks, current work streams in progress and further work required. Progress against the Improvement Plan is monitored on a monthly basis by the Frimley Health Quality Committee.

Background

The Trust Quality Committee coordinates and monitors the implementation of the responsive actions being taken by the organisation in relation to quality and provides assurance to the Board that the quality agenda is being embedded in line with the quality strategy, and that performance is measured and monitored.

Issues / Actions

The Trust has is holding monthly CQC meetings where the Chiefs of Service, Associate Directors and members of the nursing teams were asked to consider the the key strengths and risks/weaknesses for the organisation against the 5 CQC domains (safe, effective, caring, responsive & well-led).

The risks/weaknesses identified are to be reviewed against the Trust Quality Improvement Plan to ensure that these have been recognised and appropriate actions being taken

3 new risks have been identified: o Pressure ulcers o Mixed Sex Accommodation o Infection Control – E-coli

Recommendation

The Board of Directors is asked to review the progress against the action plan, to agree the priority areas of concern and trajectories for achieving compliance

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Appendices

Quality Improvement Plan May 2018

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Tab 7 Quality Improvement Plan


Page 1

FRIMLEY HEALTH NHS FOUNDATION TRUST

Quality Improvement Plan as at May 2018

Ragging Key:

Achieved/on target/progress made

In progress but some challenges

Significant difficulty, poor

progress

Action achieved, closed

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SiteRecommendation & Current Risk Rating Actions

Target Completion Date

Director Lead(s) Manager

Monitoring Committee Actions / Current Status

Frimley Health

Recruitment & RetentionContinue to improve staffing recruitment and retention

The Trust has put in place a robust recruitment plan and this is monitored regularly by Directors and reported monthly to the Board. National undersupply of qualified clinical staff is resulting in high vacancy rates and over reliance on agency staff. Specific risks in the following occupations:*Band 5 Staff Nurses (General)*Theatre nurses & ODP's*Paediatric Nurses*Sonographers*RadiographersMedical Roles:1. Paediatrics – middle grade 2. Anaesthetics – middle grade 3. Trauma and orthopaedics – junior and middle grade 4. Acute medicine – junior, middle grade and consultant 5. Care of the Elderly – junior, middle grade and consultant 6. Respiratory Consultant 7. Urology Consultant 8. Dermatology Consultant 8. ED - junior and middle grade

Q4 17/18 Director of HR &

Corporate Services /

Director of Nursing

Deputy Director of

Nursing (WPH) /Assistant

Director of Resourcing

Workforce Committee

May update (Nursing):• During the first three months of 2018 the Trust has recruited 81 new nurses compared to 52 during the same period last year, which represents an increase of 29 (55%). • Steady flow of Philippine candidates starting with the Trust. • Recruitment campaign in India took place at the end of February. 93 offers made with 12 to start within next 6-8 months. * Over the last six months we have recruited to 69 non-training medical positions. These appointments include 32 consultants (20 at FP and 12 at WP). There has been a focus in recent months to appointment to positions currently being filled by high cost locums in specialties such as Gastroenterology and Dermatology in order to reduce agency spend and to have a more substantive medical workforce. • In April the Trust will be replacing the current system (TempRe) used to book Medical Bank and Agency/Locum staff with new system (Allocate Locum OnDuty) which we currently use for nurses. There will be many benefits to this, not least of which will be substantial annual savings (approximately £350k for Trust) as well providing users with a more intuitive, responsive and user friendly system when compared to TempRE. Retention Strategy is out for consultation June 2018

Quality Committee Quality Improvement Planas at May 2018

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Frimley Health

Medical Staffing Out of Hours / Use of AgencyTo ensure early identification of potential gaps in medical staffing cover out of hours and minimise the use of agency staff

Each speciality to review medical staffing model and make recommendations to mitigate forthcoming expected gaps in junior doctor rota

Q4 17/18 Medical Director

Deputy Medical

Directors FPH & WPH

HCAs and non clinical support staff being used in surgeryNew Temporary Workforce approval process for all medical bank & agency staff developed by HR/Deputy Medical Directors/Directors of Operations. Introduced at beginning of October, email from CEO to all AD's & CoS to launch new processLocum agency bookings are now centralised at FPH apart from ED and anaesthetics. From 1st May 2018 here is a new software system (Allocate) for temporary staff bookings and it is anticipated that a centralised system to cover all of FPH and WPH bookings will follow shortly after. * There are plans to form a shared doctor bank with Ashford and St Peters, Chertsey and the Royal Surrey County Hospital, Guildford and to extend this to cover the North of the FHFT patch – this is being reviewed in light of the new software system.

Frimley Health

Deteriorating Patient:To ensure all clinical staff have the right skills & tools to recognise & deliver timely treatment to the deteriorating patient

Learning from SIs and M&M Reviews to be incoporated into training programmes

Ongoing Medical Director

Lead Nurse for

Deteriorating Patient

Resuscitation Committee Continued improvement in compliance in Resus training stats,

Adult Level 1 79.84% against target of 85% as at 25/5/182 x Band 7 posts appointed to, one for each site.Resus team undertaking targetted sessions in Paediatric resus training with aim of moving compliance to amber by mid April* Additional training sessions being provided in clinical areas* Electronic observations system tender documents under development, to be released to framework May 18 with implementation planned end Q3 beginning Q4. April update: E – Observations work stream planned and initial meetings have happened. Workshop for staff in June agreed. Deteriorating patient improvement plan with GANT chart for compliance with Resus MAST. Targeted sessions continue.Deteriorating Patient Improvement Plan monitored at Resuscitation CommitteeDeteriorating Patient Summit planned for June 18 with all stakeholders

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Observational review of compliance with Hospital at Night arrangements to be undertaken regarding implementation and effectiveness of night-time handover

Q4 17/18 T Ho W Jewsbury Quality Committee

March update: Deputy Medical Director and Chief of Serivce for Medicine currently to undertake an Observational auditMedical & Deputy Medical Directors to attend clinical handover to observe compliance and agree further actions. To feedback to Quality Committee June 18

Frimley Health

SepsisTo implement the new NICE guidelines for recognition and Management of Sepsis (NG51)

Monitor compliance of the Sepsis Screening Tool through quarterly audits

Ongoing Medical Director

Head of Patient Safety

Sepsis Committee

Inpatient screening & antibiotics within 1 hour of trigger time remains a challenge2 band 7’s appointed and in post, one for each site.Q3 audit results improved with 68% antibiotics within 1 hour, 100% O2 administration & 96% blood cultures taken for FPH and 90% oxygen administration & 70% blood cultures for HWPH * Patient information leaflet approved and to be implemented. * Sepsis clinician lead from WPH leaving the trust, one clinical lead for FHFT appointed to aid alignment. * Electronic observations system tender documents under development, to be released to framework May 18 with implementation planned end Q3 beginning Q4Q4 audit results continued improvement, compliance with screening 100% in ED with 65% antibiotics within 1 hour. Inpatient compliance with screening 65% compared with 39% in Q1 and antibiotics within 1 hour 89%

Frimley Health

Do Not Attempt ResuscitationTo ensure there is evidence that DNAR decisions have been appropriately discussed & and are displayed in the medical records (at the front)

To review new national guidance (ReSPECT)

Q4 17/18 Medical Director

Lead Nurse for

Deteriorating Patient

Resuscitation Committee

January update: Proposed new Escalation and DNACPR form for FHFT for consultation in January. DNACPR audit Q4.Adult Level 1 73.58% against target of 85%Being addressed through different forum. April update:NEW FHFT DNACPR and Escalation form ratified at the Resuscitation committee 7th March following an extensive consultation period. Awaiting the 2017/18 DNACPR audit of 50 patients cross site. Will present findings when available. Looking at new patient/relative form, mainly pictures with narrative for FHFT. Audit findings presented at Quality Committee, aligned approach implementing best practice to be adopted across Frimley Health

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Frimley Park

Emergency PressureTo ensure quality of patient care through patient flow

To reduce avoidable admissions through Ambulatory Care pathways and review the threshold for admission by implementing a dynamic response from primary care, social care and community services to support pts at home.

Ongoing Director of Operations

AD for Medicine

Unscheduled Care

April update: ambulatory care now has 30% zero LOS admissions and has impacted on overall bed admissions. ESI streaming continues. Two paediatric mental health liaison nurses provide rapid assessment to young ED attenders 6 days a week and have significantly reduced the delay for them being seen. We are achieving 95% handover of ambulances on target and highest performing of SECAmb acute trusts. ED Improvement Plans developed May update: ESI reception nurse continues to stream patients to ambulatory care, GP, eye clinic or specialities when appropriate. The ED ward model has requested that this role is extended to 0200 to manage the daily second peak in activity. ED paediatric consultant continues to work in collaboration with paediatrics to improve direct referral to PAU. ED medical staffing continues to support three seniors overnight to enable early senior decision making in ED A&E Improvement Plan for both sites being developed by Directors of Operations.

Frimley Health

Discharge PlanningTo ensure there is a robust discharge planning process in place to reduce patients’ length of stay, pressure on hospital beds and patient readmission

Discharge planning is a Transformation Workstream supported by the Project Management Office (PMO), currently developing prioritised action plan with ‘quick’ wins and long term actions to be taken

Q4 17/18 Director of Nursing /

Director of Operations

Transformation Group

Heads of Nursing

Clinically fit list utilised daily to enable community teams to 'pull' patients from hospital to homeADT & implementation of ECFD & EDD relaunched Dec 17, current uptake average of 85%Delayed transfer of care down to 3.9% for February, best performance in financial yearTo develop dashboard to monitor up-take of ADTMilitary to provide Welfare officer on FPH site to support dischargeWork ongoing to fully embed SAFER care bundleA&E Board to agree actions to reduce DeToC July 18To prioritise achieving premium patients and review of stranded patients via Safer Discharge Group

To review the management of private funding for nursing home care and support families who are privately funded

Q4 17/18 Director of Operations

Matron - Patient Access

Urgent Care Board

December update: JD Currently being banded Trusted assessor meeting to held 30/11 to review current process and feedback from all involved.May update: Appointed to Private Funder post

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Frimley Health

Clinical HandoverTo ensure consistency in both medical handover arrangements & ownership

Review weekend handover plans/documents to identify consistent approach

Q4 17/18 Su2S Matron Quality Committee

February update: Chief of Service Medicine has agreed standard form should be used. Current forms to be accumulated for review. March update: Chief of service currently collecting weekend plan docuents used with medical directorate cross site for review and standardised format to be designed.May update: Awaiting Chief of Service for Medicine to provide current weekend plan forms for review or identify doctor to lead on standardisation with the support of the sign up to safety team. June 18

Frimley Health

Consent / Local Safety Standards for Interventional ProceduresTo ensure appropriate checking processes are in place for patients undergoing invasive procedures undertaken outside of Theatres

Review consent documentation and procedures & implement new process

Q4 17/18 Consent Policy & Implementation Group

April update: Frimley data collected for consent audit, Wexham data collection in progress. Joint consent committee chaired by Deputy Medical Director scheduled for 26/04/18 at Heatherwood. ENT consent forms have been approved by Endoscopy User Group, Cystoscopy form approved by Urology Governance team. First draft of Uro/Gynae form created. Feedback continues to come in on Orthopaedic forms. May update: New cross-site Consent Leadership Group established. To implement best practices identified at Addenbrookes

Review current patient information with particular focus on risks and benefits to support the consent process for high priority procedures

Q4 17/18 Consent & Implementation Group

February update: Endoscopy PIL to be reviewed alongside the production of 5 new specific consent forms. March update: The trust wide Patient Information Policy will be revised and reviewed in conjunction with the new consent policy. April update: Endoscopy PIL have been amended and returned to the speciality for ratification.

Frimley Health

Management of Patients with Mental Health Issues & Learning DisabilitiesTo review with mental health colleagues the increase in number and complexity of patients with with mental health needs

The Trust should ensure that staff haveclarity around accountability and Dutyof Care when managing patientssectioned under the MHA including theuse of restraint

Q4 17/18 Director of Nursing

Deputy Director of

Nursing FPH

Acute Mental Health Group

February update: Video now complete, final editing underway. Bid for additional training for security team : managing patients with challenging behaviour. 2 CAHMS liaison nurses, one in ED & one F1 working well and providing training. ED Consultant at WPH and Psychs in discussion with SIM team re: simulation trainign for staff. Lead Dementia Nurse Specialist launching 'Forget Me Not' (dementia awareness). May Update: All security staff across all 3 sites have had advances restraint training together with Head of Nursing for Mental Health. Training to be maintained on an ongoing basis

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The Trust should ensure that any patient detained under section 2 of the MHA with a high risk of absconding, self-harm and previous suicidal attempts must be escalated and addressed by the senior nursing staff if a RMN or a 1:1 specialist cannot be provided. All patients requiring 1:1 supervision should receive a daily assessment of their requirement and priority for 1:1care


Assoc Director for

Site Management


All patients sectioned under the Mental Health Act are now highlighted & discussed at the Bed Management MeetingsPolicy approved at Nursing & Midwifery Board, now at implementation stage2 x Band 7's on FPH site for CAMHS one based in ED, one in F1 working wellBerkshire Healthcare to recruit Liaison posts for Wexham siteMeeting with Commissioners held wk beginning 19/3, Draft SLA received for comment. Funding agreed with Commissioners for LD Nurse on the Wexham site, delayed while they agree model of provisionExtra training for junior nurses around escalation of concerns re: challenging patientsDebriefing teams after significant incidents or managing challenging patients for extended time.Developing guidance for supporting wards with extremely challenging patients to ensure staff are supportedDeveloping draft TNA reviewing training needs for all groups of staff in relation to mental health issues (June 18)Continuing to participate in joint training with BroadmoorAudit of 1:1 supervision guidance July 18

To ensure parity of esteem for vulnerable patients including those with mental health disabilities, learning disabilities and autism where patients receive specialist care within the acute hospital setting


Deputy Director of

Nursing FPH


* Extensive mental health improvement plan* Audit of awarness of specialist resources and advice for patients with specialist needs demonstrated generally good awareness, targetted training and awareness for hot spots* Specialist consideration to ensure appropriate consent processes for vulnerable patients using IMCAs and other patient advocates* Accessing more specialist training to manage particularly

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Frimley Health

Maternity CNST StandardsTo ensure the Trust meets the 10 new Maternity CNST criteria, ensuring safe management of obstetric patients and potentially delivering a reduction in annual premium in excess of £1m

To evidence the Trust's progress against 10 safety actions:* the trust is using the National Perinatal Mortality Review Tool* the Trust is submitting data to the Maternity Services Data Set (MSDS)*that the Trust has transitional care facilities in place* the Trust has an effrective system of medical workforce planning* the Trust has an effective system of midwifery workforce planning* the Trust is compliant with all 4 elements of Savid Babies' Lives care bundle* the Trust has a feedback mechanism for maternity services such as Maternity Voices* the Trust can evidence that 90% of each maternity unit staff group have attended 'in house' multidisciplinary maternity emergencies training within the last year* the Trust can demonstrate that the Trust safety champions (obstetrician & midwife) are meeting bi-monthly with Board level champions to escalate locally identified issues* the trust has reported 100% of qualifying 2017/18 incidents under NHS Resolution's Early Notification scheme?

Jun-18 Medical Director & Director of

Nursing

Head of Midwifery

Quality Committee

March Update:Self assessment of Trust position against 10 safety actions undertaken. One red action in evidencing 90% of each maternity unit staff group having attended an 'in-house' multi-professional maternity emergencies training session within the last training year. This is due to amount of training that is required and difficulties in reeleasing staff to attend. Existing mandatory training does fulfil the learning requirements but most sessions do not include all disciplines. April update: Evidence is being prepared for submission to board for sign off in June 2018 May update: A paper is being prepared for the top team of progress and discussion on 14th May ahead of going to June board for sign off,

Frimley Health

Infection ControlHigh incidence of E-coli compared with national average, target is to reduce by a minimum of 20% in next 12 months

Raising awareness & education re: E-coli, hand hygiene & personal hygiene compliance Q4 17/18

Medical Director

Head of Nursing

Infection Control

HICC

* Senior team briefing at Perforamnce re: E-coli, incident & contributory factors* Clear care plan for management of urinary catheters* Educating patients and carers in management of catheters

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Frimley Health

Pressure UlcersIncrease in avoidable harm due to hospital acquired pressure sores in the last 12 months

To reduce avoidable harm due to pressure ulcers by a minimum of 10% across all sites

Q4 17/18Director of

Nursing

Deputy Director of

Nursing (WPH)

Quality Committee

* Participate in NHSI Improvement workstream for pressure ulcers* Thematic review of 17/18 Pressure ulcers* RCA all grade 2 PU by Ward Managers & Clinical Matrons* Roadshows on each site* Stop the Pressure Day* Reinforce use of patient information leaflet to engage patients in their own care* Pressure Ulcer summit to get stakeholder views

Frimley Health

Mixed Sex AccommodationRisk to patients' privacy & dignity due to high incidence of mixed sex accommodation breaches

To reduce incidence of mixed sex accommodation breach.To fully implement national guidance

Timeline currently being scoped

Director of Nursing

Deputy Director of Nursing FPH & WPH

Patient Experience Group

*Developed and updated new Mixed Sex Accommodation Policy in line with national guidance (June 18)* Task & Finish Group chaired by Director of Nursing* Prepared briefing for Execs & prioritised issues to be addressed including infrastructure at Heatherwood and new design for Day Unit at FPH* Reporting of mixed sex breaches, claifying justified & unjustified breaches* Education of staff in reporting requirements

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Page | 1

Report Title

Month 01 Finance Report to The Board of Directors

Date of Meeting


Agenda Number

8.

Report type

To receive assurance on the current and forecast financial position of the Trust

Prepared by

Edward John (Director of Operational Finance) / Hugh Cronshey (Assoc. Dir of Finance)

Executive Lead

Nigel Foster (Director of Finance)

Executive Summary

The Trusts’ operational deficit (before exceptional items and PSF) was £4.9m in month which was £1.8m worse plan. This is as measured against the internal issued budgets. This is a significant adverse variation at month 01 and means achievement of plan is already under significant pressure. The exit run rate from March has continued into April but the plan assumes significant cost reduction which has not materialised. Pay and non pay costs are not reducing (£1.3m and £0.4m above plan respectively) which is driven by continued capacity pressures unabated form the end of last year. The PSF of £1.3m for the month has been accrued on the assumption that the Trust will reverse the overspends and deliver to original plan over time. For reporting against NHSI plan the income has been phased more evenly and so shows a lower adverse variance £0.2m. This is expected to correct itself over the year to align with the true ledger position. CIP was £1.7m (68%) in month which is £0.7m lower than plan largely on agency and bank reduction schemes. Capital spend for the year is set at £81.6m. In month 01 actual spend was £6.1m, a minor slippage of £0.3m, for which there is an expectation to recover by the year end. Cash is still healthy at £100m.

Background

The Trust had set a budget of £33.3m surplus for 2018/19 against which this report is monitored. This surplus plan includes £26.1m of PSF; £13.8m of DH and assumes delivery of £31m of cost reduction CIP. The plan is to generate a surplus of £7.1m before PSF.

Issues and Options

Risks to the delivery of the Trusts forecast outturn are considered significant:

Gap of c.£5m on current cash releasing CIP target (£26m vs £31m requirement)

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Slippage on CIP at month 01 requires additional measures to recover the position

Cost run rate is following exit run rate and needs to be at 5% below current level

Income is broadly to expectations but unlike previous years cannot be relied on to cover cost overruns

Recommendation

This report is for assurance only

Appendices

Finance and Commercial Board Report: Note – all variance are reported against budgets and not original NHSI Plan.

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Finance Board Report Financial Performance April 2018

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2

M01 Dashboard

Key points: Income is broadly to expectations but unlike previous years cannot be relied on to cover cost overruns Pay and non pay costs are not reducing (£1.3m and £0.4m above plan respectively) Gap of c.£5m on current cash releasing CIP target (£26m vs £31m requirement) Slippage on CIP at month 01 requires additional measures to recover the forecasted £22m position Capital spend for the year is set at £81.6m. In month 01 actual spend was £6.1m, a small slippage of £0.3m, for which there is an expectation to

recover by the year end. Cash is still healthy at £100m.

Summary: The Trusts’ operational deficit (before exceptional items and PSF) was £4.9m in month which was £1.8m worse than plan. This significant adverse variation means delivery of plan is under significant pressure. The exit run rate from March has continued into April but the plan assumes significant cost reduction which has not materialised. Pay and non pay costs are not reducing which is driven by continued capacity pressures unabated from the end of last year.

Plan £m Actual £mVariance

£m RAG Plan £m Actual £mVariance

£m RAG Plan £m Actual £mVariance

£m RAG

Income 53.7 53.8 0.1 53.7 53.8 0.1 667.7 667.7 0.0Expenditure (50.5) (52.6) (2.1) (50.5) (52.6) (2.1) (603.3) (603.3) 0.0

EBITDA (Income less expenditure) 3.2 1.2 (2.0) 3.2 1.2 (2.0) 64.4 64.4 0.0Financing costs (3.9) (3.7) 0.2 (3.9) (3.7) 0.2 (47.1) (47.1) 0.0Net / Surplus Deficit (0.7) (2.5) (1.8) (0.7) (2.5) (1.8) 17.3 17.3 0.0CIPs 2.5 1.7 (0.8) 2.5 1.7 (0.8) 31.0 22.0 (9.0)Cash Balance 109.2 100.0 (9.2) 109.2 100.0 (9.2) 113.0 113.0 0.0Capital Expenditure 6.4 6.1 (0.3) 6.4 6.1 (0.3) 86.1 86.1 0.0

Use of resources score (1-4) 1 2 1 2 1 1

Year to Date (Month 01) Full Year OutturnMonth 01

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Plan Actual Variance Plan Actual Variance Plan Forecast Variance£m £m £m £m £m £m £m £m £m

Income 51.1 51.1 (0.0) 51.1 51.1 (0.0) 626.2 626.2 (0.0)Expenditure (50.4) (52.3) (1.9) (50.4) (52.3) (1.9) (601.8) (601.8) (0.0)Trust Financing (3.9) (3.7) 0.2 (3.9) (3.7) 0.2 (47.1) (47.1) (0.0)Net Revenue Surplus / (Deficit) (3.2) (4.9) (1.8) (3.2) (4.9) (1.8) (22.7) (22.7) (0.0)

Exceptional Items 1.2 1.2 0.0 1.2 1.2 0.0 13.8 13.8 (0.0)Net Position (2.0) (3.8) (1.8) (2.0) (3.8) (1.8) (8.9) (8.9) (0.0)

STF Funding 1.3 1.3 (0.0) 1.3 1.3 (0.0) 26.2 26.2 (0.0)Integration Funding 0.1 0.3 0.2 0.1 0.3 0.2 1.5 1.5 (0.0)Integration Costs (0.1) (0.3) (0.2) (0.1) (0.3) (0.2) (1.5) (1.5) (0.0)Net Revenue Surplus / (Deficit) after one-off items

(0.7) (2.5) (1.8) (0.7) (2.5) (1.8) 17.3 17.3 (0.0)

Frimley HealthCurrent Month Year to Date Full Year Out-turn

Income & Expenditure - Month 1 and Year to Date – Summary

3

Key messages: The presentation above shows performance against the NHSI plan, with an adjustment to the income to reflect a revised phasing. From M02, the report will revert back to monitoring against the internal plan. PSF: The trust failed to meet the financial control total for M01, however since the forecast is to recover the position by the end of Q1, the full PSF has been accrued in. Operating Income: Income delivered to plan. Operating Expenditure: Pay costs remain high and similar to the exit run-rate

when adjusted for a 1% pay award. The adverse variance reflects CIP performance (£0.8m) and sustained pressure on pay experienced in the final quarter of 17/18 (£0.7m) and continued pressure on non-pay. Exceptional Items: Deficit support has been moved from Income into the Exceptional Items row, in order to better present the Trust's underlying position. Forecast: The trust forecast has been held to plan, although the current performance and challenge of delivering the CIPs, both identified and unidentified, would suggest that this is at significant risk.

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Income & Expenditure - ‘Worse Case’ Forecast

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Plan Forecast Variance£m £m £m

Income 626.2 626.2 (0.0)Expenditure (601.8) (621.8) (20.0)Trust Financing (47.1) (47.1) (0.0)Net Revenue Surplus / (Deficit) (22.7) (42.7) (20.0)

Exceptional Items 13.8 18.8 5.0Net Position (8.9) (23.9) (15.0)

STF Funding 26.2 9.2 (17.0)Integration Funding 1.5 1.5 (0.0)Integration Costs (1.5) (1.5) (0.0)Net Revenue Surplus / (Deficit) after one-off items

17.3 (14.7) (32.0)

Frimley HealthFull Year Out-turn Key Message:

The trust is facing a challenging financial year and

this table presents a worse case scenario for the financial outturn.

Under this scenario, this could lead to a £32m adverse variance against the NHSI plan for 18/19.

Below is a summary of the main assumptions: Income has been set to plan, reflecting the limited

opportunity for income over-performance and constraints of working within a system control budget.

Expenditure has been forecasted based on the current run-rate and therefore assumes no delivery of incremental CIPs nor mitigation for current under-delivery.

Exceptional items include the re-introduction of stock that was delayed from 17/18.

As a result of the above assumptions, meeting the control total would be unachievable, but the model assumes delivery of Q1 & Q2, in full.

A straight line extrapolation from month 01 adjusted for CIP phasing means the

Trust does not achieve the control total. This then triggers a reduction in PSF

leading to a significant adverse variance

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Expenditure Trend – Excluding Integration

5

Pay: Pay costs have risen in M01, although this increase is largely due to the 1% pay award that has been accrued pending the formal award. However, the continued pay expenditure is £1.3m above the NHSI plan. As mentioned above and set out in more detail in the following slide, this adverse variance is caused by a combination of CIP non-delivery and the growth in pay in the final quarter of 17/18

Non-Pay: Non-pay is also above plan in M01 (£0.4m) and also above the trend of the final quarter. Due to the additional ‘noise’ generated by year-end, it is difficult to get a precise picture of the issues and further analysis will be done before M02 reporting.

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Exploded View of the Exit Run-Rate and drivers of the M01 Variance

Key Message: The graph above shows the growth in pay

costs in the final quarter, which added almost £0.8m onto the Q3 run rate.

The NHSI plan was initially based on the M09 forecast, prior to that cost growth. The trust absorbed that cost pressure, through the high levels of non-recurrent income.

The final submitted plan increased in pay, however, the constraints of both income and the control total, limited the opportunity.

Although there has been some reported delivery of CIPS, the undelivered schemes have put an additional pressure on the trusts finances.

Recovery of the position will be extremely challenging as the currently unidentified CIPS are phased to deliver from M04 and there will need to be a considered effort to identify genuine cash releasing cost reductions.

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Total Trust Bank Expenditure (Excl. Integration funded spend)

Bank Costs are at a similar level to the exist run-rate

Bank cost have remained high in M01, with modest improvements in some areas, although growth in others. More analysis is required to understand the reduction in Ancillary staff costs on the WPH site.

7

Hospital Agency M10 M11 M122017/18 Q4

Ave ra g e M01FPH Medical 416,527 545,846 484,280 482,218 528,385

Nursing 453,579 555,576 612,892 540,682 500,728Prof Tech & Scientific 100,502 131,969 110,102 114,191 128,220AHP 24,079 31,420 23,258 26,252 29,932Ancillary 435,169 516,556 532,461 494,729 467,784Admin 98,962 125,303 92,792 105,685 93,044

FPH 1,528,817 1,906,671 1,855,785 1,763,757 1,748,094WPH Medical 462,363 453,321 422,853 446,179 478,054

Nursing 561,214 609,200 542,643 571,019 673,485Prof Tech & Scientific 18,539 26,800 29,883 25,074 23,468AHP -32,167 35,531 50,066 17,810 44,667Ancillary 282,218 322,403 429,417 344,679 182,021Admin 55,936 68,937 42,692 55,855 63,620

WPH 1,348,105 1,516,192 1,517,553 1,460,617 1,465,313

Total 2,876,922 3,422,863 3,373,338 3,224,374 3,213,407

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Total Trust Agency Expenditure (Excl. Integration funded spend)

Agency Costs are close to the M10 levels, showing a modest improvement from the Q4 average.

Although there has been a modest improvement in the agency spend compared to the levels experienced in M11 & M12, the NHSI plan and CIP programme demands a significant and immediate reduction.

8

Hospital Agency M10 M11 M122017/18 Q4

Ave ra g e M01FPH Medical 184,912 183,295 312,617 226,941 204,097

Nursing 178,337 131,647 145,029 151,671 159,448Prof Tech & Scientific 56,003 65,273 99,408 73,561 108,773AHP 86,181 102,614 105,853 98,216 66,909Ancillary 7,580 4,244 7,114 6,313 5,887Admin 29,572 11,924 52,558 31,351 10,441

FPH 542,585 498,998 722,579 588,054 555,555WPH Medical 572,351 640,171 795,391 669,304 615,251

Nursing 361,244 371,769 416,894 383,302 333,506Prof Tech & Scientific 139,011 134,720 94,693 122,808 164,300AHP 59,735 89,972 41,991 63,899 88,504Ancillary 1,054 1,561 -4,645 -677 0Admin 24,241 63,718 136,940 74,966 42,265

WPH 1,157,636 1,301,910 1,481,263 1,313,603 1,243,826

Total 1,700,221 1,800,908 2,203,842 1,901,657 1,799,381

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Trust Overview – 2018/19 Total Savings Programme

All values in £000 9

The Annual plan of £31m includes £2.3m of unidentified schemes needed to balance the Trust’s budget against the control total. April recorded a £744k under delivery on the identified CIP programme and £44k against the unidentified CIP. Pay savings have proved particularly challenging in month 01. The current forecast out-turn is a finance based view looking at risk and month 1 performance.

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Balance Sheet M1

Frimley Health total assets employed at 30th April 2018 are £458m. Items to note: • The combined assets across all 3 sites increased by £3m to £554m, £4m above plan. • Non-current assets of £367m increased by £4m in month in line with plan • Net current assets decreased by £5m to £94m as per the in month plan. • Current assets remained at £187m, above plan by £3m, as although the cash balance fell by £13m this was offset by in increase in trade and other receivables • A slight increase seen in trade and other payables and deferred income resulted in current liabilities finished at £93m, £4m above plan • Equity and reserves finished on plan for the month at £458m, the only movement seen within the I&E reserve as this fall by £2m as forecast

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Page | 1

Report Title

2018/19 CIP Summary – Month 1

Meeting

Trust Board (Public)

Meeting Date


Agenda No.

9.

Report Type

Note

Prepared By

Hugh Cronshey, Associate Director of Finance

Executive Lead

Helen Coe, Director of Operations, FPH Lisa Glynn, Director of Operations, HWPH

Executive Summary

Performance of CIP schemes are given in the attached paper.

1. CIP Programme Performance Month 1

• At the close of month 1, the Trust delivered £1.7m against the plan of £2.5m, which is an adverse variance of £0.8m and a delivery of 68%.

• Pay related CIPs performed the worse, reflecting the pressures reported in the trust’s financial position. Pay schemes were showing an adverse variance of £0.6m

• The main areas of underperformance were in Theatres utilisation and the medical and nursing related CIPs particularly in the Medical/ED directorates on both sites.

• Cash releasing CIPS made up £0.7m on the £0.8m adverse variance.

Background

Annual Savings Programme

• The trust has set a challenging CIP target to deliver £31m cash releasing CIPs. Directorates have identified £26m of schemes that fall into that category, leaving a gap of £5m.

• The current plan, which the trust is being monitored against includes:

Cash releasing CIPS £26m Non-Cash releasing CIPS £2.7m Unidentified CIPS £2.3m Total £31m

9

Tab 9 CIP Progress Report – Month 1


Page | 2

Issues / Actions

• The monthly CIP Board will focus on the top ten worse performing CIPs each month and identify actions to support improvement of those schemes or seek to find alternative mitigations.

• The Executive team will continue to discuss options and opportunities to identify new schemes to close the £5m cash releasing gap, this includes exploring ways of delivering clinical and corporate support service functions.

Recommendation

The Board is asked to note the content of this report, progress made, and continued focus on delivery of existing schemes.

Appendices

2018/19 CIP Summary Report – Month 1

9

Tab 9 CIP Progress Report – Month 1


2018/19 CIP Report M01 April 2018

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Trust Overview – 2018/19 Total Savings Programme

All values in £000 2

The Annual plan includes £26m of identified cash releasing schemes, £5m short of the £31m required to deliver the Trust’s financial control total. April recorded a £744k under delivery on the identified CIP programme and £42k against the unidentified CIP. Pay savings have proved particularly challenging in month 01. The current forecast out-turn is a finance based view looking at risk and month 1 performance.

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CIP Type Annual PlanYTD Plan YTD Actual Var %

Pay 16,749 1,131 578 (553) 51%Non-Pay 11,536 806 651 (155) 81%Income 2,715 521 444 (77) 85%Total 31,000 2,458 1,673 (786) 68%

Values

CIP Themes Total (£k) YTD Plan YTD Actual YTD Var FOT FOT VarAdmin/Back Office Staff 2,896 182 159 (22) 2,520 (376) Agency & Locum 2,510 213 128 (85) 1,731 (778) Estates & Facilities Staffing 860 65 36 (29) 860 0 Medical Staffing 2,725 143 38 (104) 1,678 (1,047) Nursing Staffing 2,146 193 69 (124) 1,085 (1,061) Other Clinical Staffing 1,605 148 141 (7) 1,568 (37) Clinical Supplies & Services 3,553 293 275 (18) 3,429 (124) Corporate Non-Pay 771 43 29 (14) 783 12 Estates & Facilities Non-Pay 1,505 107 28 (79) 1,385 (120) Other Non-Pay 938 31 13 (19) 808 (130) Pathology 887 66 66 - 887 -Pharmacy 608 12 12 - 158 (450) Procurement 2,790 216 216 (0) 2,690 (100) WLI 670 56 16 (40) 150 (520) Theatre Utilisation 1,500 125 0 (125) 0 (1,500) Other Income 1,895 454 384 (70) 1,606 (288) Private Income 384 32 37 5 334 (50) Clinical Income 461 38 27 (12) 361 (100) GAP 2,296 42 0 (42) 0 (2,296) Grand Total 31,000 2,458 1,673 (786) 22,034 (8,965)

Key Messages:

Planned Cash releasing schemes are £5m below the required target of £31m and are £0.7m behind plan year-to-date.

Pay related schemes are only reporting delivery of 51%

Considerable focus is required in order to improve the current forecasted delivery.

CIP Performance by Category: Cash Releasing Annual Plan

YTD Plan YTD Actual Var %

Not Specified 2,333 45 0 (45) 0%Yes 25,985 2,228 1,497 (730) 67%No 2,682 186 175 (11) 94%Total 31,000 2,458 1,673 (786) 68%

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Top 10 Worse Performing CIPs Values

Ref Scheme Name Directorate Curr Mth

Plan Curr Mth

Act Curr Mth

Var YTD

Actual YTD Plan YTD VarAnnual

Plan Latest FOT FOT Var

14.12 Theatre Utilisation Theatres Crit Care & Anaes 125.00 0.00 (125.00) 0.00 125.00 (125.00) 1,500.00 0 (1,500.00)

4.07 Nursing Seasonal Medicine Wexham 50.00 0.00 (50.00) 0.00 50.00 (50.00) 300.00 150 (150.00)

25.01 Unidentified GAP GAP 41.67 0.00 (41.67) 0.00 41.67 (41.67) 2,296.00 0 (2,296.00)

3.16 Ward Model Adherance ED Medicine Frimley 36.67 0.00 (36.67) 0.00 36.67 (36.67) 440.06 0 (440.06)

3.11 Ward Model Adherance Medicine Medicine Frimley 33.84 0.00 (33.84) 0.00 33.84 (33.84) 406.12 0 (406.12)

3.06 Medical ED Savings Medicine Frimley 33.33 0.00 (33.33) 0.00 33.33 (33.33) 400.00 0 (400.00)

14.11 Stock Control- All Theatre Items Theatres Crit Care & Anaes 90.18 62.00 (28.18) 62.00 90.18 (28.18) 1,082.17 744 (338.17)

8.02 Medical Agency Savings Orthopaedics & Plastics 33.17 6.31 (26.86) 6.31 33.17 (26.86) 398.00 100 (298.00)

4.05 Medicine Medics Agency Medicine Wexham 26.67 0.00 (26.67) 0.00 26.67 (26.67) 320.00 160 (160.00)

7.01 Decommission HW Med Rec library Outpatients WPH 25.00 1.44 (23.56) 1.44 25.00 (23.56) 300.00 50 (250.00)

Grand Total 495.53 69.75 (425.78) 69.75 495.53 (425.78) 7,442.35 1,204 (6,238.35)

Key Messages:

The above schemes represent the top 10 worse performing schemes and total 54% of the YTD variance of all schemes.

The FOT of these 10 schemes make up 70% of the total forecasted underdelivery The schemes are dominated by pay type schemes, along with the currently unidentified CIP gap.

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Scheme Exec lead SRO Supporting resources

CIP potential

Risk rated value Actions

Aligning ratios within medicine (£6.4m of opportunity identified)

HC/LG DB AS CHine £1m £0.5m

Discussions with nursing re ward areas and detailed analysis of cardiology/gastro/respiratory

FP10s LG DL £0.075m £0.075m Detailed analysis reduced scheme to £75k

Housekeeping JK CM £1m £0.75m PID developed – financial modelling needed.

Total £2.075m £1.325m

5

Additional Opportunities Being Actively Explored:

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Page | 1

Report Title Capital Programme Report – 2017/18 Outturn

Meeting Board

Meeting Date Friday June 2018

Agenda No. 10.

Report Type Receive Assurance

Prepared By Stephen Holmes, Associate Director of Capital, Capital Projects

Executive Lead Janet King, Director of HR & Corporate Services

Executive Summary

The purpose of this report is to update the Trust on the outturn expenditure for the 2017/18 capital programme. The budget approved for capital projects (excluding equipment and IT) across all three sites in 2017/18 was £65.5m. Actual expenditure at year end (month 12) was £48.6m, which is approximately £16.9m below the capital budget available, but is in line with the Trust’s annual plan. The majority of the projects to which the slippage relates are either on site or are in detailed design and hence the £16.9m has been carried forward into 2018/19.

Background

The attached spreadsheet shows the total budget available for each project in 2017/18; actual expenditure as at month 12; and the level of any in year underspend, or overspend. A brief narrative explaining progress with each scheme is recorded in the comments column. Further explanation is given in respect of the larger capital projects below. In the main, delays in expenditure have been caused by changes to the brief and planning issues (e.g. Heatherwood where planning approval took a lot longer than anticipated); operational demands requiring works to be postponed (e.g. F9 ward upgrade); technical design matters which have taken longer to resolve than expected (e.g. drainage – getting access into the mains sewer), site logistics (e.g. EAC – issues with neighbouring land owners (L&Q)); and savings (Women’s Services, Paediatrics).

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Tab 10 Capital Investment Programme 2017/2018 – Outturn


Page | 2

Issues / Actions

Heatherwood Redevelopment Work to fully define and agree the brief has taken longer than anticipated, and planning permission was delayed. The GMP is now anticipated in summer 2018. EAC - Wexham Park

The main contract works began in April 2017 and are due to complete, on programme, in December 2018. In year cash flow is one month behind original forecast. Maternity - Wexham Park

Kier commenced the main project in late October 2016. Completion was achieved in December 2018. A saving of around £500k is recorded.. CHP – Wexham park

Provision of Combined Heat and Power plant currently in design for installation by December 2018. Paragon Suite – Wexham Park

Works to the lobby / reception commenced in January 2017, with the bedrooms following on in May 2017. Works completed in December 2018. Final account is within budget. Car Park – Wexham Park

Works on the Pinewood’s Nursery site completed in June 2017. Public use of the car park is to commence in summer 2018. Corridors – Wexham Park

A rolling programme of corridor refurbishment work is on site. New, and emergency, lighting has been installed along the main corridors, along with new flooring, double glazed windows and hand rails.

• HV/LV Infrastructure – Wexham Park Five new LV generators, providing 100% resilience across the site have / are being installed. Additional costs are being incurred due to the poor condition of the existing infrastructure.

• Drainage – Wexham Park The main drain from Women’s Services to the street is being enlarged. Approval to close Church Lane to connect into the mains sewer ha now ben granted.

• Fire doors / compartmentation – Wexham Park A rolling programme of fire door replacement, and fire stopping within ceiling voids and the under croft, is complete. CT Scanner – Wexham Park

Installation of a new CT scanner was completed in May 2017. Capitalisation of Salaries

Staff costs related to capital projects have been charged to capital. Revenue to capital – both sites

A number of minor works projects have been recharged from revenue to capital. Roofing – Wexham Park

Phase 4 of the roof replacement programme completed in January 2018. The majority of the flat roofs to the north of the site have now been replaced. Energy Centre – Wexham park

Enabling works for the CHP scheme to ensure that low temperature hot water is provided to new EAC this summer. On site. Maternity – Wexham Park

Rolling programme of works to refurbish the remaining maternity wards excluded from Women’s Services scheme. First floor to complete Autumn 2018. Theatres – Wexham Park

Air handling units to theatres 1 and 2 replaced. Theatre 3 on site. Paediatrics – Wexham Park

Works to refurbish and address backlog maintenance issues within paediatric out-

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Page | 3

patients and Ward 24 Completed in June 2017. Final account below budget. Diagnostic and Investigation Unit - Frimley Park

An options appraisal for the development of a 3 storey building to accommodate new MRI facilities, breast cancer services and a generic ward, was considered early in 2017 and outline design proposals are being advanced. A full business case is expected to be considered in winter0 2018.

• Parkside – Frimley Park Works to upgrade bedrooms within Parkside were completed in December 2017. ED Minors – Frimley Park

Phase 1 works to improve facilities within ED Minors completed February 2017. Phase 2 began in April 2017 and completed in June 2017.

• Ward F9 – Frimley park Two of the three unrefurbished bay were upgraded by December 2017. The remaining bay put on hold due to bed pressures.

• Ward F1 – Frimley Park Works to expand the paediatric ward F1 completed in March 2017, whilst alterations to the internal accommodation continued until June 2017. Renal – Frimley Park

Works to provide a dedicated renal beds in ward G8 completed in December 2017. Roof Structural Remedial Works

Works to address the structural problems with the roof beams at Frimley Park are on-going and will continue throughout 2017/18 and 2018/19. First floor street refurbishment completed December 2017. Ground floor streets on site. Completion November 2018.

Recommendation The Board is asked to note the report.

Appendices 2017/18 Capital Plan

10



Proposed capital programme

1

2

3

4

5

6

7

8

9

10

11

1213

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

A M O P AA AB AC

Heatherwood2017 - 18 budget

(£'000)

2017 -18 Spend

to Date Mth 12

2017-18 under /

(over) spendProgram Budget Comments

Heatherwood Heatherwood

New Build FBC 5,380 1,425 3,955 6 5 Planning approval achieved. Kier appointed. In design. FBC summer 2018.

Backlog Maintenance 500 580 80- 5 5 On-going maintenance of existing facilities.

CT Scanner - 5 5 Complete

Office conversion - Block 40 718 1,496 778- 6 5 Start on site Dec 2017. Completion August 2018

Heatherwood Mobile Scanner - 5 5

Heatherwood Nursery 13- 13 5 5 Conversion to offices for Finance. Complete

Heatherwood Bevan House (F16 Decant) 100 62 38 5 5 Conversion to offices for HR / Procurement. Complete

Heatherwood Site Decommissioning 2,400 16 2,384 5 5 Series of service diversions underqay and demolition being consdered.

Other - Lithotripsy 78 220 142- 5 6 Creation of Lithotripsy service in existing building. Complete.

sub-total 9,176 3,786 5,390

Wexham Park 2017 - 18 budget

(£'000)

2017 -18 Spend

to Date Mth 12

2017-18 under /


Wexham Park Wexham Park

Infrastructure / Service Improvements Infrastructure / Service Improvements

EAC - FBC 12,481 10,703 1,778 5 5 On site - completion anticipated Dec 2018

Assessment Redevlopment (ED Upper Floors) 12,481 10,703 1,778 5 5 On site - completion anticipated Dec 2018

Women's Services - FBC 5,784 5,649 135 5 5 Start on site Oct 2016. Completed Nov 2017. £378k charged to Ophthalmology

Women's Services - Backlog contribution 500 - 500 5 5 Start on site Oct 2016. Completed Nov 2017. Saving anticipated.

Linac - 6 5 RBH to Fund. On hold.

CHP 500 322 178 5 5 Possible invest to save scheme. Currently in design / manufacture

Cath Lab (12 recovery beds) c/fwds - 5 5 Complete and retention paid in 2016/17.

Theatre Admissions Lounge (and minor ops room) c/fwds 50 - 50 5 5 Main scheme complete. Minor works project being considered.

Paediatric HDU 16 15 1 5 5 All works complete

Pre-assessment relocation 25 22 3 5 5 Main works complete. Car park pay machine installed.

Paragon Room Upgrades 747 714 33 5 5 New reception, out patient rooms and rolling programme of bedroom upgrades complete.

Drs Mess (relocation) - - 5 5 on hold

Ops Room (relocation) - - 5 5 on hold

Eden Day Ward (Chemo expansion) 20 25 5- 5 6 Complete. Further minor works being considered.

Car parking 84- 84 5 5 Complete. Final account now agreed. Landscaping outstanding.

Overflow car park - 5 5 Temporary works complete.

Corridors (6 facet survey) 900 661 239 5 5 Rolling programme of upgrades on site.

Cardiology Simulation Facility (Legacy funded) - - 6 5 Cardiology reviewing priorities for funding. Deferred.

Ward Refurbishment (£400k per ward + backlog + quality) - - 5 5 To commence once EAC complete.

Wayfinding 96 45 51 5 5 External wayfinding complete. Further works post completion of EAC.

Project Feasabilities / Estates overheads 33 30 3 5 5

Cardiology (£570k legacy funded) - - 5 5 Feasibility being considered for expansion of CIU and CCU (£1.97m for CIU)

Pharmacy Consultation Room 4 - 4 5 5 complete.

Dental X-Ray 4 - 4 5 5 complete.

Pinewood Car Park - Fees + Temp Surface 1,384 1,308 76 5 5 Car park complete. S278 works for crossing complete. Wayfinding required.

HV Infrastructure - generators / ring 1,411 1,494 83- 5 6 Part of HV ring replaced for EAC scheme. LV transformers on site.

Hot and Cold Water Services 200 - 200 5 5 Not included in condition survey. Out to tender.

Oxygen ring 250 32 218 5 5 Not included in condition survey. BOC on site installing second VIE.

Drainage 900 487 413 5 5 Works on site.

Disabled Access (incl changing places) 87 35 52 5 5 Toilet improvements complete. Future priorities bring reviewed.

\\wexham2\users\StHolmes\My Documents\Capital Programme\Reports\2017-18 programme Month 12 outturn

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47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

6768

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

A M O P AA AB AC

Security 201 163 38 5 5 Works being progressed in co-ordination with facilities team. CCTV and barriers

Alarms & Detection Systems 250 2 248 5 5 Plant room security to be improved

Fire Doors / Compartmentation 220 169 51 5 5 High and medium risk works complete. Undercroft on-site.

CT Scanner 1,306 1,079 227 5 5 Complete. MEB budget funded + £200k from backlog.

X-ray 1,300 106 1,194 5 5 X-ray replacement and waiting area refurb tender let. Master plan produced for next phases.

RVS Café 11 - 11 5 5 Complete.

Ophthalmology 22 - 22 5 5 temporary Out-patient clinic created for Maternity. Complete. Now used by Plastics. No further works planned.

Bed Store 117 83 34 5 5 works complete

Wph Rev To Cap 300 1,092 792- 5 5 Minor works

Capitalisation of salaries 600 668 68- 5 5 Predominantly capital team staff.

Cippenham Community Centre - 5 5 Site works for breast scanner. Complete

Landscaping and pathways 5 5 outstanding planning requirement from car park project.

Theatre Chillers 5 5 to be funded from Block 62 Backlog budget

Autoclaves 5 5 Budget to be approved.

Heating pipes - flushing 5 5 To assist CHP project. Budget to be approved

Front Entrance 5 5 To remodel and upgrade retail offer. Budget to be approved.

Sub-station 5 5 To improve resilience. Budget to be approved.

Cold water main / tanks 5 5 To meet compliance issues. Budget to be approved.

Bore Hole 5 5 To reduce water costs. Budget to be approved.

Other (med Sec's offfice) 1 - 1 5 5 Minor works funded.

sub-total 42,201 35,523 6,678

Wexham Park (Backlog split over 10 years)2017 - 18 budget

(£'000)

2017 -18 Spend

to Date Mth 12

2017-18 under /



2) Planned Maintenance - block by block, spread over 10 years 2) Planned Maintenance - block by block, spread over 10 years

Roof Phase 2 5 5 complete

Roof Phase 3 200 130 70 5 5 Main works complete Dec 2016. Roof over pharmacy ran on into 2017/18. Complete

Roof Phase 4 890 811 79 5 5 Works to complete Feb 2018. future programme from 2019/20

Emergency Lighting100 - 100 5 5 Funds taken from block budgets as cross site project. Works being progressed.

Fire alarm system400 134 266 5 5 Funds taken from block budgets as cross site project. Tenders back. Works being prioritised.

BMS

50 20 30 5 5

Funds taken from block budgets as cross site project. Local connections for women's services complete. Tenders bing sought

for other areas.

Energy Centre cont'b from backlog for ditribution and exchangers560 637 77-

5 5 Funds taken from block budgets as cross site project. LTHW provison to wards 1 to 3 and to EAC

Wards 1 - 3 - 21- 21 5 5 Nurse call upgraded in 2016/17. hot water recirculation in design. Remaining funds for refurb once ward vacated.

Wards 4 - 6 77 5- 82 5 5 Nurse call upgraded. Remaining funds for refurb once ward vacated.

Wards 7 - 8 50 - 50 5 5 £25k per ward to address emergency issues. Remaining funds for refurb once ward vacated.

Ward 9 31 - 31 5 5 Nurse call ugraded. Remaining funds for refurb once ward vacated.

Block 10 - Sterile services 159 191 32- 5 5 Chiller replacement. Complete.

Block 11 - Heating Systems - 5 5 Separated from Restaurant budget. Complete.

Block 11 - Restaurant 601 81 520 5 5 £500k b/f from 18/19 to allow for fit out in Feb 2017. complete. Kitchen refurb in 18/19 in design.

Block 12 - Pharmacy / mortuary 100 9 91 5 5 Mortuary proposals in feasibility stage - OBC to go to CDIC in summer 2018

Block 13 - Radiology 100 - 100 5 5 £100k contribution to x-ray scheme to address backlog issues. Remainder for phase 3 and 4 of refurb.

Block 14 - Tower 62 70 8- 5 5 Emergency repairs only 16-17. Minor works in 17/18. OBC being produced for future of building.

Block 15 - Out-patients - 5 5 Refurbishment to be considred once ED moves into EAC - providing decant facility.

Block 16 - Estates 50 8 42 5 5 Immediate roof repairs reqired. In design. Remainder for CHP scheme.

Block 22 - Day Surgery / Wards 10 - 11 40 29 11 5 5 Patient kitchen refurbished. Other works to be progressed once decant available.

Block 23 - Training Centre (school of nursing) 45 72 27- 5 5 Lecture theatre fit out complete. Meeting room upgraded. Futre works on hold pending decision about future.


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140 of 181P

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93

94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127128

129

130

131

132

133

134

135

136

137

138

139

140

A M O P AA AB AC

Block 27 - Histopathology 26 5 21 5 5 Works as part of new analyser installation (funded by Dept). Further works to be determined.

Block 28 - Maternity 622 272 350 5 5 Refurb post completion of WS scheme. Works to first floor started on site in February 2018.

Block 29 - Stores / Medical Records 26 - 26 5 5 Emergency repairs only so far.

Block 30 - Eden, Stroke, Paragon 51 7 44 5 5 Emergency repairs only so far. Refurbishment once decant space can be provided.

Block 31 - Paediatrics 1,258 767 491 5 5 Refurbishment works complete. Further improvements to be identified.

Block 32 - Coronary Investigation Unit (CIU) - 5 5 On hold. Remodelling of department planned. Funds to be identified.

Block 34 - Switch room - 5 5 Roof repairs charged to roof budget.

Block 35 - Rehab / Physio 20 - 20 5 5 Feasibility produced. On hold, pending potential relocation of MIDU from small gym.

Block 36 - GIU - - 5 5 Very limited budget. Emergency repairs only

Block 39 - Capital Hut - - 5 5 Demolition once IT move to heatherwwod

Block 40 - Streets - - 5 5 Immediate needs being addressed via corridor budget. Green and Orange corridors in future years.

Block 41 - South Lodge - 5 5 Fit out for Capital Team occupation. Complete.

Block 42 - PGMC 40 - 40 5 5 Lighting and ventillation works being considered.

Block 45 - Nursery 98 94 4 5 5 Essential repairs complete.

Block 47 - ED / EDDU A&E 2 7 5- 5 6 Essential repairs only. Further works post relocation to EAC

Block 49 - ITU - 5 5 Possible expansion being considered.

Block 51 - The Shed 32 11 21 5 5 Roof repairs and redecoration complete. Future demolition?

Block 53 - Pre-assessment 16 - 16 5 5 Roof repairs and redecoration complete. £51k transferred to roof budget

Block 54 - CCU - 5 5 Very limited budget. Emergency repairs only

Block 57 - Discharge Lounge - 5 5 Very limited budget. Emergency repairs only

Block 58 - OHPAT - 5 5 Very limited budget. Emergency repairs only. OHPAT now relocated to Rehab.

Block 60 - Ward 17 - 5 5 Very limited budget. Emergency repairs only

Block 62 - Theatres 380 351 29 5 5 Theatre suite doors replaced. 2 AHUs replaced summer 2017. 1 AHU replaced Spring 2018. Chillers in design.

Block 63 - MRI - 5 5 Very limited budget. Emergency repairs only

Block 64 - Angio 13 13- 5 6 Structural cracks underpinned. Further works dependent on proposals to expand the facilitiy

Contingency 231 - 231 5 5 Contingency

sub-total 6,317 3,693 2,624

3) On-Going Maintenance 5 5 3) On-going Maintenance

3)Statutory Compliance Work 151 46 105 5 5 Emergency repairs only

3) Toilets (6 facet survey) 18 3- 21 5 5 Crossroads, DSU, Wards 1 and 7 toilets complete. Rehab wcs on site.

3) Pathology Flammable Store 2 - 2 5 5 complete

3) Pneumatic Tube Replacement 25 17 8 5 5 Start on site in January 2017. Budget increased to £200k. Connection to EAC outstanding.

3) Other 400 117 283 5 5 Retentions and outstanding fees on 2015/16 programme. Plus contingency.

sub-total 596 177 419

TOTAL WEXHAM PARK ESTATE 49,114 39,393 9,721

Frimley Park2017 - 18 budget

(£'000)

2017 -18 Spend

to Date Mth 12

2017-18 under /


Frimley Park Frimley Park

Strategic Projects: Strategic Projects:

MRI Building / Diagnostic and In-patient building 1,003 174 829 6 5 Steering Group established. Design only 2017-18. FBC due autumn 2018. start on site Jan 2019.

Breast Cancer Unit 100 - 100 6 5 as above

Parkside Windows & Kitchen Refurbishment 35 13 22 5 5 Windows complete. Savings utilised in scheme below.

Parkside Bedroom Refurbishment 486 470 16 6 5 rolling programme of bedroom upgrades complete (bar five rooms).

F9 Ward refub 651 357 294 5 5 4 of 5 bays refurbished. 5th bay on hold due to bed pressures.

ED Minors Suite 415 350 65 5 5 Phase 1 - completed Feb 2017. Phase 2 - £360k completed August 2017. Final account outstanding.

Ward F10 Refurbishment - - 5 5

Ward F11 / F15 Gynae Move 1 1- 5 5 complete - included works on F15

F14 Ward Refurb 100 22 78 5 5 Works complete - charged to charity budget.


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141

142

143

144

145

146

147

148

149

150

151

152

153

154

155

156

157

158

159

160

161

162

163

164

165

166

167

168

169

170

171

172

173

174

175

176

177

178

179

180

181200

201

202

203

204

205

206

A M O P AA AB AC

Ward G5 Refurbishment - 5 5 Refurbishment of washrooms plus additional storage. Budget to be approved.

Ward F5 Refurbishment - 5 5 Budget to be approved.

Day Surgery Ward upgrade for Overnight stay (phase 2) - 1 1- 5 5 Works to make compliant for in-patients in design.

Medical Records - - 5 5 Works complete.

Car Park Expansion - - 5 5 Car park and footpath complete. Resurfacing of top deck required.

New Ward - G6 13 19- 32 5 5 Complete.

New Ward (enabling work in Med Records for G6) - 5 5 Works complete.

Ward F1 Teenage/Assesment Unit 475 487 12- 5 6 Completed June 2017.

Ward F2 Refurbishment - 5 5 Scope of works to be determined. Limited budget.

Physiotherapy Department - - 5 5 Works to be identified. Defered until 21/22

Create Ward F16 30 2 28 5 5 Minor expenditure on early design fees. Project now on hold.

Fracture Clinic Refurbishment - 5 5 Scope of works to be determined. Limited budget.



Maternity Ward - 5 5 Scope of works to be determined. Limited budget.

Central Delivery Suite Upgrade - - 6 5

ENT Day Unit Refurbishment - 5 5 Scope of works to be determined. Limited budget.

G3 Stroke 80 27 53 5 5 Charity funded scheme in design - to be funded 50:50 trust:charity.

Renal 1,000 828 172 5 5 Complete. Scope of works in G9 reduced. Potential saving.

Ambulatory Care - 17 17- 5 6 Complete.

ED Paediatrics (2 additional beds) 5 5 Two additional beds required

Cystic Fibrosis - expansion 5 5 Additional beds required. Feasibility complete. Possible charity funding.

Critical Care (2 additional beds) 5 5 Two additional beds required

Infrastructure Projects: - 5 5 Infrastructure Projects:

Essential Maintenance (Property maintenance) / Backlog 700 595 105 5 5 Rolling programme of works

Roof/Structural Works (Property maintenance) 869 859 10 5 5 First floor complete. Ground floor on site. Outstanding roofs to be prioritised.

Wayfinding 100 29 71 5 5 In manufacture

Portacabin 100 133 33- 5 5 Replacement of damaged portacabin. Need to remove once HW offices complete.

Roof finish Recovering/insulation - 5 5 Covered by structural budget.

Generator/Substation (plant and equip other) 300 70 230 5 5 Spec for replacement generator being progressed.

Carbon Management Plan (property maintenance) 100 133 33- 5 5 Environmental Officer progressing various projects.

Minor Projects 228 364 136- 5 5 Minor Projects - rolling programme.

First floor toilets (Blue Street) 6 - 6 5 5 complete

General Contingency and New Projects 123 - 123 5 5 £300k transferred to roof/structural works. £372k transferred to minor works. Other priorities to be determined.

Fph Rev To Cap 200 466 266- 5 5 rev to cap transfer

Woodlands Nursery 5 5 refurbishment out to tender.

Demolition of Residences 5 5 Consultants appointed.

Kitchen refurbishment 5 5 £250k taken from essential maintenance. Fire supression non-compliant. Temproary decant being considered.

Other 50 1 49 5 5

TOTAL FRIMLEY PARK ESTATE 7,164 5,380 1,784

2017 - 18 budget

(£'000)

2017 -18 Spend

to Date Mth 12

2017-18 under /

(over) spend

Heatherwood 9,176 3,786 5,390 Heatherwood

Wexham Park 47,808 38,314 9,494 Wexham Park

CT Scanner - from MEB budget 1,306 1,079 227 CT Scanner - from MEB budget

Frimley Park 7,164 5,380 1,784 Frimley Park

Total 65,454 48,559 16,895 Total


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Page | 1

Report Title

2018/19 Capital Programme

Meeting Board of Directors

Meeting Date


Agenda Number

11.

Report type

For noting

Prepared by

Nick Reynolds, Head of Capital and Treasury Stephen Holmes, Associate Director of Capital Projects

Executive Lead

Nigel Foster, Director of Finance and IM&T Janet King, Director of HR & Corporate Services

Executive Summary

Capital expenditure across all three sites is forecast to be in the region of £81.6 million in 2018/19 and £274 million over the next five years to 2022/23. Of the £81.6 million in 2018/19; £68.1 million relates to the Trust’s estate, £8.3 million to medical equipment purchases, and £5.2 million on IM&T and the digital services strategy. This paper highlights the key projects that make up this programme alongside detail provided for the estates programme in the attached spreadsheet that sets this in the context of the next five years. In line with current SFIs (subject to internal review) business cases for individual schemes with a value in excess of £500k will be brought to CDIC for approval, in due course. Schemes with a value above £1.5m will go to CDIC and then Board.

Background

The proposed capital programme for 2018/19 amounts to £81.6m and forms part of a £274m capital outlay over the next five years to 2022/23.

11

Tab 11 Capital Investment Programme 2018/2019


Page | 2

The £81.6 m has been allocated against the estate, medical equipment and IM&T Estate The proposed capital programme for 2018/19 amounts to £68.1m. To put this in context, the 2017/18 outturn was £48.6m that in itself was the highest level of in year expenditure seen by the Trust. Of the £68.1m, £40.0m relates to Heatherwood (£16.3m) and the Emergency Assessment Centre at WP (£23.7m), the latter of which is on site and due to complete in December 2018. Heatherwood remains subject to full business case approval; hence there is a relatively high risk of slippage on this scheme. The remaining £28.1m is made up of a number of smaller value projects split across the Wexham Park and Frimley Park sites. These comprise a mix of projects including those that commenced on site in 2017/18 (e.g. corridor refurbishment at both Wexham Park and Frimley Park, Maternity upgrade at Wexham Park), new schemes recently commenced on site (e.g. New Combined Heat and Power (CHP) plant, and x-ray refurbishment at Wexham Park) and projects still in design (e.g. new Diagnostic and In-Patient Building at Frimley Park). Of this around £15m of spend, including the CHP plant, in 2018/19 will be on works which address infrastructure failings and backlog maintenance items. This will reduce the risk of service failure and improve the life of our assets, combined with the investment in major projects that will significantly improve the patient experience in terms of the quality of accommodation in which they are being treated. Future year plans being progressed in year include the development control plans for the Frimley and Wexham sites, the future of the Tower block, and the potential for the sale of land at Wexham that could generate additional funding to contribute towards the capital programme. Medical Equipment The medical expenditure plan for 2018/19 comprises of £4.3m allocation to the Heatherwood and Wexham Park sites and £4m to the Frimley Park site. Significant purchases approved for the year ahead include in excess of £3m for four new CT scanners; two replacement items for the Frimley site, one for the new Emergency Assessment Centre at Wexham Park and one replacement for Aldershot Centre for Health. Other equipment purchases planned include Radiology equipment for the new Emergency Assessment Centre at Wexham Park (£850k) and the second phase of replacement anaesthetic machines at Frimley Park

11



Page | 3

(£650k), as well as the on-going replacement programme for expiring and below standard equipment across all sites. It is hoped that this investment will eliminate the number of category D items currently in circulation within the Trust although this will remain a rolling programme in future years as further equipment comes to end of life. IM&T The IM&T capital expenditure plan for 2018/19 is £5.2m across the Trust and although this has been shown separately as Frimley, HWP and Integration budget lines this is due to the source of funding following the transaction agreement but in reality the scope of works are largely applicable across all sites. Much of the expenditure and focus for the year is on the IM&T Enablers to help delivery of the Digital Services Strategy and objectives of improving information sharing and efficiency amongst the workforce and achieving Trust integration, with key areas including the Cloud, Cyber Security, WiFi and Unified Communications projects. Significant projects planned to be completed in year having been approved and initiated in prior years include the PACS/RIS and Pharmacy systems for the Wexham site, NHSMail2, and the Inventory Management System. In addition to the benefits identified in the digital services strategy, both cyber security and PACS/RIS at Wexham are on the corporate risk register therefore these works will seek to mitigate and eliminate the risks identified. Further spend will be seen on upgrading essential infrastructure to enable full integration with BSPS partners.

Issues and Options

The table below summarises the trust’s capital programme over the next five years, and identifies the source of funding.

Year

Ending Year

Ending Year

Ending Year

Ending Year

Ending

Capital 5 Year Plan 31/03/2

019 31/03/2

020 31/03/2

021 31/03/2

022 31/03/2

023 5 Year

£'000 £'000 £'000 £'000 £'000

Heatherwood redevelopment 11,686 25,500 32,900 19,497

89,583

Heatherwood backlog maintenance 525 500 500

1,525

Hwd Block 40 4,122

4,122

WP EDAR (Trust Funded) 18,459

18,459

WP EDAR (PDC Funded) 5,197

5,197

WP Backlog (PDC Funded) 16,306

16,306

11



Page | 4

WP Backlog (Trust Funded) 2,232 12,184 5,540 10,930 6,712 37,598

FP Diagnostic Unit 3,329 17,297 11,900

32,526

FP Estate 6,268 3,866 1,847 7,450 6,250 25,681

WP IT (PDC Funded) 2,478 0 0 0 0 2,478

WP IT (Trust Funded) 0 2,867 2,500 1,500 1,500 8,367

IT Integration (PDC Funded) 2,000 0 0 0 0 2,000

FPH IT 654 2,467 2,500 1,500 1,500 8,621

WP Equip (PDC Funded) 4,311 0 0 0 0 4,311

WP Equip (Trust Funded) 0 2,715 1,500 1,500 1,500 7,215

FPH Equip 4,000 1,500 1,500 1,500 1,500 10,000

TOTAL 81,567 68,896 60,687 43,877 18,962 273,989

Year Ending

Year Ending

Year Ending

Year Ending

Year Ending

Source of Funding 31/03/2

019 31/03/2

020 31/03/2

021 31/03/2

022 31/03/2

023 5 Year

£'000 £'000 £'000 £'000 £'000

Cash Resrves 44,149 41,826 39,950 36,513 11,598 174,037 IFTT Loans (Inc short term £28m loan)

28,000 31,000

59,000

Salix Loans 4,653

4,653

Loan repayments -465 -930 -10,263 -10,263 -10,263 -32,185

Land Sales 2,938

17,627 17,627 38,192

DH - PDC 30,292 0 0 0 0 30,292

TOTAL 81,567 68,896 60,687 43,877 18,962 273,989

The attached spreadsheet gives more detail as to the individual estates projects identified within the 2018/19 programme, alongside future projects proposed between 2019/20 and 2022/23. If there is slippage within the 2018/19 programme it may be possible to bring forward some of the future year’s projects.

Issues and Options Planning and design delays, both internal and external, have the potential to materially impact the delivery of projects and profile of expenditure across all schemes.

Recommendation

The Board are asked to note the contents of this report, and request that there support be provided to aid project teams in achieving this expansive programme.

Appendices

2018/19, and future years, Estate Capital Programme

11




1

2

3

4

5

6

7

8

9

10

11

12

1314

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

A R S T U V Y AC

Heatherwood2018-19 budget

£'000

19 - 20 budget

£'000

20 - 21

budget £'000

21 - 22 budget

£'000

22 - 23

budget

£'000

Total 2015 - 16 to 24 -

25 (£'000)Comments

Heatherwood Heatherwood

New Build FBC 11,686 25,500 32,900 19,497 94,167 Planning approval achieved. Kier appointed. In design.

Backlog Maintenance 500 500 500 2,446 On-going maintenance of existing facilities.

CT Scanner 2

Office conversion - Block 40 4,122 5,900 Start on site Dec 2017. Completion August 2018

Heatherwood Mobile Scanner - -

Heatherwood Nursery 205 Conversion to offices for Finance. Completer

Heatherwood Bevan House (F16 Decant) 62

Heatherwood Site Decommissioning - - 841 Series of service diversions underqay and demolition being consdered.

CQC Works 25 25

Other - Lithotripsy 632 Creation of Lithotripsy service in existing building

sub-total 16,333 26,000 33,400 19,497 - 104,280

Wexham Park 2018-19 budget

£'000

19 - 20 budget

£'000

20 - 21

budget £'000

21 - 22 budget

£'000

22 - 23

budget

£'000

Total 2015 - 16 to 24 -

25 (£'000)Comments


Infrastructure / Service Improvements Infrastructure / Service Improvements

ED - FBC 12,675 25,297 On site - completion anticipated Dec 2018

Assessment Redevlopment (ED Upper Floors) 10,981 23,603 On site - completion anticipated Dec 2018

Women's Services - FBC 135 9,557 Start on site Oct 2016. Completed Nov 2017. £378k charged to Ophthalmology

Women's Services - Backlog contribution 600 Start on site Oct 2016. Completed Nov 2017

Linac - RBH to Fund. On hold.

CHP 5,678 6,000 Possible invest to save scheme. Currently in design

Cath Lab (12 recovery beds) c/fwds 1,051 Complete and retention paid in 2016/17.

Theatre Admissions Lounge (and minor ops room) c/fwds 50 402 Main scheme complete. Minor works project being considered.

Paediatric HDU 1,199 All works complete

Pre-assessment relocation 131 Main works complete. Car park pay machine installed.

Paragon Room Upgrades 967 New reception, out patient rooms and rolling programme of bedroom upgrades complete.

Drs Mess (relocation) 50 50 on hold

Ops Room (relocation) 50 50 on hold

Eden Day Ward (Chemo expansion) - 45 440 Complete.

Car parking 84 2,514 Complete. Final account now agreed.

Overflow car park 175 Temporary works complete.

Corridors (6 facet survey) 609 30 34 - 1,847 Rolling programme of upgrades on site. £250k brought forward from 18/19

Cardiology Simulation Facility (Legacy funded) 180 186 Cardiology reviewing priorities for funding. Deferred.

Ward Refurbishment (£400k per ward + backlog + quality) - 400 400 400 2,000 To commence once ED complete. Funds deferred.

Wayfinding 51 225 External wayfinding complete. Further works post completion of EAC.

Project Feasabilities / Estates overheads 23 50

Cardiology (£570k legacy funded) - 20 1,950 2,006 Feasibility being considered for expansion of CIU and CCU (£1.97m for CIU)

Pharmacy Consultation Room 10 96 complete.

Dental X-Ray 33 complete.

Pinewood Car Park - Fees + Temp Surface 76 1,840 Car park complete. S278 works for crossing complete.

HV Infrastructure - generators / ring 637 - - 2,620 Part of HV ring replaced for ED scheme. LV transformers on site.

Hot and Cold Water Services 250 200 450 Not included in condition survey. Out to tender.

Oxygen ring 218 200 450 Not included in condition survey. BOC on site installing second VIE.

Drainage 513 600 1,603 Works on site.

Disabled Access (incl changing places) 52 100 200 Toilet improvements complete. Future priorities bring reviewed.

Security 138 100 425 Works being progressed in co-ordination with facilities team. CCTV and barriers

Alarms & Detection Systems 248 266 Plant room security to be improved

Fire Doors / Compartmentation 51 114 400 1,000 High and medium risk works complete. Undercroft on-site.

\\wexham2\users\StHolmes\My Documents\Capital Programme\Programme\2018-19 programme and future years v2

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51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

6970

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

100

A R S T U V Y AC

CT Scanner 1,523 Complete. MEB budget funded + £200k from backlog.

X-ray 1,394 1,000 500 3,000 X-ray replacement and waiting area refurb tender let. Master plan produced for next phases.

RVS Café 206 Complete.

Ophthalmology 600 978 temporary Out-patient clinic created for Maternity. Complete. Now used by Plastics. No further works planned.

Bed Store 116 works complete

Wph Rev To Cap 500 300 2,837

Capitalisation of salaries 800 600 600 600 3,268

Cippenham Community Centre 26 Site works for breast scanner. Complete

Landscaping and pathways 150 100 250 outstanding planning requirement from car park project.

Theatre Chillers 250 250 to be funded from Block 62 Backlog budget

Autoclaves 100 100 Budget to be identified

Heating pipes - flushing 250 250 Budget to be identified

Front Entrance 500 500 Budget to be identified

Sub-station 250 250 Budget to be identified

Cold water main / tanks 250 250 500 Budget to be identified

Bore Hole 250 250 Budget to be identified

CQC Works 50

Other (med Sec's offfice) 1 Minor works funded.

sub-total 36,713 3,680 1,903 4,350 400 101,638

Wexham Park (Backlog split over 10 years)2018-19 budget

£'000

19 - 20 budget

£'000

20 - 21

budget £'000

21 - 22 budget

£'000

22 - 23

budget

£'000

Total 2015 - 16 to 24 -

25 (£'000)Comments


2) Planned Maintenance - block by block, spread over 10 years 2) Planned Maintenance - block by block, spread over 10 years

Roof Phase 2 281 complete

Roof Phase 3 - - 1,271 Main works complete Dec 2016. Roof over pharmacy ran on into 2017/18

Roof Phase 4 29 620 1,000 1,285 1,000 4,745 Works to complete Feb 2018. future programme from 2019/20

Emergency Lighting160 500 660

Funds taken from block budgets as cross site project. Spec being developed.

Fire alarm system266 - 20 420

Funds taken from block budgets as cross site project. Tenders back. Works being prioritised.

BMS

180 103 303

Funds taken from block budgets as cross site project. Local connections for women's services complete. Tenders bing sought

for other areas.

Energy Centre cont'b from backlog for ditribution and exchangers323 317 1,277

Funds taken from block budgets as cross site project. LTHW provison to wards 1 to 3 and to EAC

Wards 1 - 3 121 41 1,189 Nurse call upgraded in 2016/17. hot water recirculation in design. Remaining funds for refurb once ward vacated.

Wards 4 - 6 57 100 - 737 1,012 Nurse call upgraded. Remaining funds for refurb once ward vacated.

Wards 7 - 8 100 493 - 593 £25k per ward to address emergency issues. Remaining funds for refurb once ward vacated.

Ward 9 41 10 10 228 338 Nurse call ugraded. Remaining funds for refurb once ward vacated.

Block 10 - Sterile services - 191 Chiller replacement. Complete.

Block 11 - Heating Systems 4 Separated from Restaurant budget. Complete.

Block 11 - Restaurant 542 - 400 1,396 £500k b/f from 18/19 to allow for fit out in Feb 2017. complete. Kitchen refurb in 18/19 in design.

Block 12 - Pharmacy / mortuary 91 900 1,000 Mortuary proposals in feasibility stage - OBC to go to CDIC in Feb 2018

Block 13 - Radiology 100 580 680 £100k contribution to x-ray scheme to address backlog issues. Remainder for phase 3 and 4 of refurb.

Block 14 - Tower 42 50 50 598 1,000 1,821 Emergency repairs only 16-17. Minor works in 17/18. SOC being produced for future of building.

Block 15 - Out-patients 33 1,100 595 1,728 Refurbishment to be considred once ED moves into EAC - providing decant facility.

Block 16 - Estates 292 - 706 1,006 Immediate roof repairs reqired. In design. Remainder for CHP scheme.

Block 22 - Day Surgery / Wards 10 - 11 111 10 40 542 772 Patient kitchen refurbished. Other works to be progressed once decant available.

Block 23 - Training Centre (school of nursing) - 13 - 317 Lecture theatre fit out complete. Meeting room upgraded. Futre works on hold pending decision about future.

Block 27 - Histopathology 21 - 60 790 880 Works as part of new analyser installation (funded by Dept). Further works to be determined.

Block 28 - Maternity 1,430 1,638 - - 3,418 Refurb post completion of WS scheme. Works to first floor starting on site in February 2018.

Block 29 - Stores / Medical Records 26 - 60 422 Emergency repairs only so far.

Block 30 - Eden, Stroke, Paragon 69 25 100 630 1,466 Emergency repairs only so far. Refurbishment once decant space can be provided.

Block 31 - Paediatrics 33 458 1,894 Refurbishment works complete.

Block 32 - Coronary Investigation Unit (CIU) 31 31 On hold. Remodelling of department planned. Funds to be identified.


11

Tab 11 C

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rogramm

e 2018/2019

148 of 181P

UB

LIC B



101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127

128

129130

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

150

151

152

A R S T U V Y AC

Block 34 - Switch room 58 58 Minor works to form new wc in design.

Block 35 - Rehab / Physio 20 - 40 373 444 Feasibility produced. On hold, pending potential relocation of MIDU from small gym.

Block 36 - GIU 14 - 14 Very limited budget. Emergency repairs only

Block 39 - Capital Hut - Demolition once IT move to heatherwwod

Block 40 - Streets 500 600 54 1,154 Immediate needs being addressed via corridor budget. Green and Orange corridors in future years.

Block 41 - South Lodge 45 Fit out for Capital Team occupation. Complete.

Block 42 - PGMC 40 - 40 204 284 Lighting and ventillation works being considered.

Block 45 - Nursery 96 Essential repairs complete.

Block 47 - ED / EDDU A&E - 15 123 148 Essential repairs only. Further works post relocation to EAC

Block 49 - ITU 293 293 Possible expansion being considered.

Block 51 - The Shed 21 100 Roof repairs and redecoration complete.

Block 53 - Pre-assessment 16 40 48 104 Roof repairs and redecoration complete. £51k transferred to roof budget

Block 54 - CCU 26 26 Very limited budget. Emergency repairs only

Block 57 - Discharge Lounge 13 13 Very limited budget. Emergency repairs only

Block 58 - OHPAT 11 11 Very limited budget. Emergency repairs only. OHPAT now relocated to Rehab.

Block 60 - Ward 17 - Very limited budget. Emergency repairs only

Block 62 - Theatres 199 196 199 1,119 Theatre suite doors replaced. 2 AHUs replacemed summer 2017. 1 AHU to be replaced Spring 2018. plus chillers.

Block 63 - MRI - 9 9 Very limited budget. Emergency repairs only

Block 64 - Angio - 95 Structural cracks underpinned. Further works dependent on proposals to expand the facilitiy

Contingency 279 250 197 - 3,534 5,262 Contingency

sub-total 4,656 7,904 2,867 6,580 6,312 38,390

3) On-Going Maintenance - 3) On-going Maintenance

3)Statutory Compliance Work 305 200 1,577 Emergency repairs only

3) Toilets (6 facet survey) 21 - 100 300 Crossroads, DSU, Wards 1 and 7 toilets complete. Rehab wcs in design

3) Pathology Flammable Store 23 complete

3) Pneumatic Tube Replacement 187 Start on site in January 2017. Budget increased to £200k. Complete.

3) Other 189 400 670 1,837 Retentions and outstanding fees on 2015/16 programme. Plus contingency.

sub-total 825 600 770 - - 3,924

TOTAL WEXHAM PARK ESTATE 42,194 12,184 5,540 10,930 6,712 143,952

Frimley Park2018-19 budget

£'000

19 - 20 budget

£'000

20 - 21

budget £'000

21 - 22 budget

£'000

22 - 23

budget

£'000

Total 2015 - 16 to 24 -

25 (£'000)Comments

Frimley Park Frimley Park

Strategic Projects: Strategic Projects:

MRI Building / Diagnostic and In-patient building 3,329 16,097 11,300 31,000 Steering Group established. Design and enabling works only 2017-18

Breast Cancer Unit - 1,200 600 1,800 as above

Parkside Windows & Kitchen Refurbishment 228 Windows complete. Savings utilised in scheme below.

Parkside Bedroom Refurbishment 484 rolling programme of bedroom upgrades complete (bar five rooms).

F9 Ward refub 294 772 4 of 5 bays refurbished. 5th bay on hold due to bed pressures.

ED Minors Suite 65 660 Phase 1 - completed Feb 2017. Phase 2 - £360k completed August 2017.

Ward F10 Refurbishment 650 650

Ward F11 / F15 Gynae Move 147 complete - included works on F15

F14 Ward Refurb 22 Works complete - charged to charity budget.

Ward G5 Refurbishment 175 175 Budget to be identified

Ward F5 Refurbishment 250 250 Budget to be identified

Day Surgery Ward upgrade for Overnight stay (phase 2) 300 550 - 851 Works to make compliant for in-patients in design.

Medical Records 26 868 Works complete.

Car Park Expansion 18 2,100 Car park and footpath complete.

New Ward - G6 20 1,618 Complete.

New Ward (enabling work in Med Records for G6) 592 Works complete.

Ward F1 Teenage/Assesment Unit 1,862 Completed June 2017.


Physiotherapy Department 200 200 Works to be identified. Defered until 21/22


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153

154

155

156

157

158

159

160

161

162

163

164

165

166

167

168

169

170

171

172

173

174

175

176

177

178

179

180

181

182

183

184203

204

205

206

207

208

209

A R S T U V Y AC

Create Ward F16 2 Expenditure on early design fees. Project now on hold.

Fracture Clinic Refurbishment - 100 100 Scope of works to be determined. Limited budget.

Ward F3 Refurbishment 250 250 Scope of works to be determined. Limited budget.

Ward F4 Refurbishment 100 100 Scope of works to be determined. Limited budget.

Maternity Ward 100 100 Scope of works to be determined. Limited budget.

Central Delivery Suite Upgrade - -

ENT Day Unit Refurbishment 250 250 Scope of works to be determined. Limited budget.

G3 Stroke 413 229 669 Charity funded scheme in design - to be funded 50:50 trust:charity.

Renal 259 1,150 Complete. Scope of works in G9 reduce. Potential saving.

Ambulatory Care 1,021 Complete.

ED Paediatrics (2 additional beds) 250

Cystic Fibrosis - expansion 100 400

Critical Care (2 additional beds) 500 500

Infrastructure Projects: - Infrastructure Projects:

Essential Maintenance (Property maintenance) / Backlog 605 500 2,688 Rolling programme of works

Roof/Structural Works (Property maintenance) 1,010 300 3,491 First floor complete. Ground floor to follow next year. £300k taken from contingency

Wayfinding 71 100 Tenders back. CPC to decide Feb 2018.

Portacabin 107 240 Replacement of damaged portacabin. Need to remove once HW offices complete.

Roof finish Recovering/insulation - -

Generator/Substation (plant and equip other) 180 450 300 500 1,500 Spec for replacement generator being progressed.

Carbon Management Plan (property maintenance) 67 100 75 400 Environmental Officer progressing

Minor Projects 386 250 250 250 250 2,372 Minor Projects - rolling programme.

First floor toilets (Blue Street) 65 complete

General Contingency and New Projects 226 87 758 5,850 6,000 13,204 £300k transferred to roof/structural works. £372k transferred to minor owrks. Other priorities to be determined.

Fph Rev To Cap 200 1,052 rev to cap transfer

Woodlands Nursery 85 85

Demolition of Residences 200 200

Kitchen refurbishment 500 500 £250k taken from essential maintenance

CQC 25 25

Other - 91

TOTAL FRIMLEY PARK ESTATE 9,597 21,163 13,747 7,450 6,250 74,034

2018-19 budget

£'000

19 - 20 budget

£'000

20 - 21

budget £'000

21 - 22 budget

£'000

22 - 23

budget

£'000

Heatherwood 16,333 26,000 33,400 19,497 0 Heatherwood

Wexham Park 42,194 12,184 5,540 10,930 6,712 Wexham Park

CT Scanner - from MEB budget 0 0 0 0 0 CT Scanner - from MEB budget

Frimley Park 9,597 21,163 13,747 7,450 6,250 Frimley Park

Total 68,124 59,347 52,687 37,877 12,962 Total


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Report Title

Corporate Risk Assurance Framework – May 2018

Meeting

Board of Directors (Public)

Meeting Date


Agenda No.

12.

Report Type

To present Frimley Health NHS Foundation Trust’s high level risks to the Board of Directors

Prepared By

Debbie Barrow Governance Manager

Executive Lead

Neil Dardis Chief Executive

Executive Summary

The Frimley Health Risk Assurance Framework (RAF) is the primary mechanism for high level risk management within the organisation. This report summarises the discussions regarding ‘high level’ risks facing Frimley Health NHS Foundation Trust at the May 2018 meeting of the Corporate Governance Group.

Background

Frimley Health NHS Foundation Trust is dedicated to establishing an organisational philosophy that ensures risk management is an integral part of corporate objectives, business plans and management systems. Compliance with legislative requirements is only a minimum standard. The specific function of risk management is to identify and manage risks that threaten the ability of the Trust to meet its objectives.

Issues / Actions

In this version of the RAF, There are 4 ‘extremely high’ graded and 14 ‘high’ graded identified and these are summarised in the attached paper. One risk was regraded and no new risks were identified

Recommendation

The Board of Directors is asked to note the high level risks included in the Trustwide Risk Assurance Framework

Appendices

Corporate Risk Assurance Framework – May 2018

12

Tab 12 Corporate Risk Assurance Framework


Page | 2

Risk Assurance Framework - Risk Scoring Guide

Risks included in the Risk Assurance Framework (RAF) are assessed as extremely high, high, medium and low based on a Impact/Consequence x Likelihood matrix. Impact/Consequence- The descriptors below are used to score the impact/ consequence of the risk occurring. If the risk covers more than one column, the highest scoring column is used to grade the risk.

Level Descriptor Risk Type

Injury/Harm Service Delivery Financial Reputation/Publicity

1 Negligible No injuries or injury requiring no treatment or intervention

Service Disruption that does not affect patient care

Less than £10,000 Rumours

2 Minor

Minor injury or illness requiring minor intervention.

Short disruption to services affecting patient care or intermittent breach of key target

Loss of between £10,000 and £100,000

Local media coverage

< 3 days off work if staff

3 Moderate

Moderate injury requiring professional intervention

Sustained period of disruption to services/sustained breach of key target

Loss of between £101,000 and £500,000

Local media coverage with reduction in public confidence RIDDOR reportable

incident

4 Major

Major injury leading to long term incapacity requiring significant increased length of stay.

Intermittent failures in a critical service Loss of

between £501,000 and £5M

National media coverage and increased level of political/public scrutiny Total loss of public confidence

Significant underperformance of a range of key targets

5 Extreme

Incident leading to death Permanent closure/loss of a service Loss of >£5M

Long term or repeated adverse national publicity

Serious incident involving a large number of patients

Removal of Chair/CEO or exec team

High Risk Tracking Matrix

Likelihood

Consequence

Insignificant Minor Moderate Major Catastrophic

Rare

Unlikely

Possible FGKOP

Likely ABCDHIJLMN0 EOQR

Almost Certain

12

Tab 12 Corporate Risk Assurance Framework


Page | 3

High Risk Summary May 2018

Chart Ref Risk Name Source

Current Score

Target Score

Score Trend

Date Risk Added C L R

Previous Month

3 months ago

6 months ago

Corporate Objective 1: Pursuing the highest level of quality, patient experience and clinical outcomes

A Staff Retention FPH/WPH 4 4 16 4 Nov-14

B Bed Capacity FPH/WPH 4 4 16 4 Jul-15

C Recognition of Deteriorating Patient FPH/WPH 4 4 16 6 Apr-15

D Critical Care Capacity FPH/WPH 4 4 16 6 Jun-15

E A&E 4-hour target FH 4 5 20 8 Sep-12

F Medical Staffing Capacity FH 5 3 15 8 Nov-12

G Management of Patients with Mental Health issues & LD FH 5 3 15 4 Oct-16

H Cardiology WPH 4 4 16 4 Jul-17

I Delays in Discharge FH 4 4 16 8 Jun-16

J Access to MRI OOH for Cauda Equina Patients WPH 5 3 15 4 Sep-17

K Specialist Commissioning FH 4 4 16 8 Nov-17

L Sepsis FH 4 4 16 6 Dec-17

M Nurse Staffing Capacity FH 4 4 16 8 Nov-14

Corporate Objective 2: Transforming our infrastructure

N WPH New Emergency Department Cladding WPH 5 3 15 8 Apr-18

O Heatherwood Affordability HW 4 5 20 6 Apr-18

Corporate Objective 3: Developing our Staff and our Culture

P Participation in Mandatory Training & Appraisals HWP/FPH 4 4 16 6 Jan-12

Corporate Objective 4: Breaking through traditional healthcare boundaries

Corporate Objective 5: Keeping Control of Resources & Delivery Key Standards

Q Failure to achieve Medium Term Financial Sustainability 18/19 FH 4 5 20 8 Mar-18

R Delivering the Financial Plan both both FH & the ICS for 18/19 FH 4 5 20 8 Mar-18

Corporate Objective 6: Developing sustainable clinical services

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Risk Name Current Risk

Rating

Actions Assurance

Failure to Achieve Financial Sustainability 18/19 In 2018/19 the Trust plans to deliver a further £31m of savings, which after national CIP and in year cost pressures, will reduce the underlying deficit to c£9m. There is a significant risk that the Trust will not be able to deliver this level of recurrent cost savings

1. Project Initiation Documents to be produced for all remaining savings schemes. 2. Quality Impact assessments to be completed for all remaining schemes. 3. PMO to ensure that all schemes are tracked and remedial actions developed where necessary. 4. Medium-term transformation projects to be developed, informed by cross site and national benchmarking (Model Hospital and GIRFT) 5. EY supporting development of additional CIP schemes 6. ICS financial plan focusing system savings on cost reduction rather than price reduction. Improve system costing and demand/capacity modelling 7. New governance arrangements - CIP Delivery Board once a month cusing Performance Meeting around CIP delivery

• Reported to Board through Financial Assurance Committee.

Delivering the financial plan for both FH and the ICS for 18/19 For 2018/19 the Trust is part of a shared “System Control Total” to deliver a combined I&E surplus of £6.7m (before Provider Transformation Funding) If this is not achieved, there is a risk that £27.4m of system PTF is not received (of which £26.1m relates to FHFT

1. Summary of ICS financial position to be included in Board finance report 2. ICS Programme Delivery Board overseeing pan-ICS workstreams to deliver financial balance and service changes and greater scale and pace than could be delivered by organisations individually. Further system-wide schemes to be developed 3. ICS financial plan focusing system savings on cost reduction rather than price reduction. Improve system costing and demand/capacity modelling 4. Continue to develop trust and relationships across ICS geographies and ‘new ways of working’ 5. Work with NHSE and NHSI to secure best possible funding / control total arrangements for ICS 6. Ensure potential stranded costs are identified and funded within system-wide business cases

• Reported to Board through Financial Assurance Committee.

A&E 4-Hour Target Risk to Monitor governance rating due to failure to deliver A&E 4 hour target as per trajectory reaching 95% in March 18, potential 12-hour breaches, and pressures on bed capacity and patient flow with potential to impact ability to deliver routine and critical services, delay in patient treatment, quality of care, and patient safety..

1. Establisihing GP streaming at Wexham. Alternative ESI model at FPH, awaiting sign off 2. Potential better staffing with Middle Grades (recruitment in Qatar) 3. Joint A&E Delivery Board established with STP delivery plan. North/South delivery plan in draft to support STP plan 4. 90% admitted or discharged within 4 hours achieved YTD (end January 18), aganst target 95% 5. Triggers document in draft with action cards 6. Managing flow in Paeds/Minors a challenge on both sites 7. At WPH ED, focused work with system wide partners has reduced the number of medically stable patients in acute beds Next Key Action • A&E Delivery Plan to be developed with trajectories for improvement by end of May 18 • A&E ALAMAC to be developed & signed off by A&E Delivery Board to reflect Delivery Plan

by end of June 18

• Weekly performance meetings. • Daily monitoring of breaches of A&E 4 hour target. • Daily alerts to CEO. • Performance on standard reported directly to the Board. • Reviewed by Hospital Executive Board and Quality Assurance

Committee on behalf of the Board.

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Heatherwood Affordability 1. Revise demand / capacity modelling May 2018 2. Assess indicative financial impacts May 2018 3. Discuss at Steering Group May 2018 4. Top team discussion on next steps will be required on whether FBC needs to reframed toward non-financial benefits and whether Hwd Hospital strategy requires a review 5. ICS Partners will need to be engaged and continual dialogue and impacts signed

• Heatherwood Steering Group • CDIC

WPH New Emergency Department Cladding

1. Alternative cladding being considered 2. Implications in respect of cost and programme being reviewed

•

Participation in Mandatory Training & Appraisals

1. Hot spots and priorities identified and presented at Quality Committee, targetting shortfalls that may impact on patient safety 2. To evaluate e-learning to assess impact on training requirements 3. Monthly report with compliance and RAG status sent to all SME’s MAST group now established to include SME’s and review training on a regular basis 5. All level 1 stat man training live on micro site Next Key Action • April 18 currently at 81.43% FH, further push to achieve 85% by end May 18 * Continued focused improvement actions for April 18 for Resus training in Paeds & Adults * Email from acting CEO to all senior managers including CoS, ADs & HofN to achieve ambition of 85% by end May 18

• Board will be updated via the Trust Corporate Governance Group

• Workforce Group established which monitors management of risk, reporting into Hospital Executive Board

Bed Capacity Risk to patient experience due to potential for lack of sufficient bed capacity to meet demand during Winter months 15/16

1. Submitted bed capacity to NHSI to achieve 88% capacity for winter 2. Schemes being looked at to bridge gap including reducing LOS in ortho, ambulatory care position at 'front door' in an effort to keep conversion rate down 3. Total bed occupancy currently at 100% 4. Hale Ward at Farnham Hospital closed 5. Ambulatory Care on Wexham site providing 7-day service Next Key Action • To undertake bed modelling (underway) by end of June 18 • To ensure Commissioners deliver a reduction in numbers of DToC from 5% to 3% by Q4 • Establish a Transformation Group Q2 • To ensure all specialities within FH meet upper quartile performance in length of stay (LOS)

• 6-monthly updates presented to BOD

Critical Care Capacity Risk of poor outcome through failure to provide sufficient flow out of ICU and to generate increased level 2 capacity outside of Critical Care, potentially impacing on flow out of A&E

1. Business case to Commissioners regarding additional level 3 critical care capacity 2. New cross-site Critical Care Lead appointed for Critical Care services to lead on development on new Critical Care strategy & vision for future 3. Capacity reviewed on FPH site and recommendation for 4 level 2 beds Next Key Action • To evaluate effectiveness of new MADU on the Wexham site Q3 • To review capacity on the Frimley site • Business case & option appraisal to be submitted to Top Team by Q2

• Work of Trustwide M&M Committees monitored through Quality Committee and reported to Board verbally by Medical Director

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Medical Staffing Capacity Risk of inadequate, appropriately trained staff, particularly in Middle and Junior Grades in A&E and Middle Grade Surgeons and difficulty in recruiting, with potential to impact on, and cause delays to, patient diagnosis and treatment, and lead to clinic cancellations, gaps in the on-call rota, lack of immediate urgent specialty support and compromise patient care.

1. Trust-wide workforce planning exercise commencing in September 2017 – the results are being reviewed and actioned at the Medical Workforce Committee. 2. There are currently rolling adverts on NHS jobs for both ED and general medicine doctors of Specialty Doctor level and Junior Doctor grade. 3. Overseas recruitment continues for junior /middle grade positions. Some visas (approx. 6) have been refused for specialties not on the shortage list; hopefully the cap will be lifted at the start of April and the limit reviewed by the Home Office. 4. Medicine 15% more doctors in post compared with last year 5. Recruitment trajectory has been set at 3% vacancy rate for WPH as there are more vacancies that need to be recruited to. 6. Hard to recruit posts and recruitment update produced every two months. Recruitment is focused on these hard to recruit posts. Next Key Actions: * Locum agency bookings are now centralised at FPH apart from ED and anaesthetics. From 1st May 2018 here is a new software system (Allocate) for temporary staff bookings and it is anticipated that a centralised system to cover all of FPH and WPH bookings will follow shortly after. * There are plans to form a shared doctor bank with Ashford and St Peters, Chertsey and the Royal Surrey County Hospital, Guildford and to extend this to cover the North of the FHFT patch – this is being reviewed in light of the new software system.

• Board will receive assurance via the Quality Assurance Committee.

• A Workforce Group established to monitor management of risk, reporting into the Hospital Executive Board.

Recognition of the Deteriorating Patient Risk of poor outcome through failure to recognise a patient with a deteriorating condition. To ensure that all clinical staff have the right skills, knowledge and tools to recognise & deliver timely treatment to the deteriorating patient.

1. Introduction of Adult Deteriorating patient study day with assessment called ESCALATE (october 2017) 2. Deteriorating Patient Improvement Plan in place 3. New plan for improving compliance with mandatory training for resucitation being developed 4. Resus team now part of Patient Safety team 5. Continued improvement in compliance in Resus training stats, Adult Level 1 76.86% against target of 85% as at 27/3/18 6. 2 x Band 7 posts appointed to, one for each site Next Key Action * Resus team undertaking targetted sessions in Paediatric resus training with aim of moving compliance to amber by mid April * Additional training sessions being provided in clinical areas * Electronic observations system tender documents under development, to be released to framework May 18 with implementation planned end Q3 beginning Q4

• Work of Trustwide M&M Committees monitored through Quality Committee and reported to Board verbally by Medical Director

Cardiology Interventional Service Potential risk to patient safety and patient experience due to staffing difficulties in maintaining continuity in pPCI 24/7

1. Spike in SIs from Cardiology 2. Lookback exercise of pPCI cases since 24/7 service started, Deputy Medical Director (FPH) reviewing on behalf of Medical Director 3. Temporary staffing changes leading to reduced numbers on pPCI rota 4. External case reviewer appointed 5. Extraordinary SI Panel Meeting held 18th October with Commissioners & NHS England 6. 75 patient case lookback undertaken, report finalised, not highlighted any further concerns following case review

• Mortality Surveillance Group

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7. 4 additional Cardiologists appointed 8. FPH senior Cardiologist appointed as Cardiology lead cross-site Next Key Action * To review effectiveness of Clinical Governance & Morbidity & Mortality in speciality * To develop common patient pathways & strategy for Cardiology * To introduce Human Factors training for Cardiology

Management of Patients with Mental Health issues & Learning Disabilities Potential risk to safe management of both adults & children with mental health needs or learning disabilities, to review with mental health colleagues the increase in number and complexity of these patients

1. 'Managing Challenging Behaviour' incidents roles & responsibilities in-house awareness video being developed. On-line roll out anticipated end Q3 2. Mental Health post financing through STP - awaiting confirmation 3. Learning Disabilities Specialist Nurse appointment for Wexham site to be confirmed - business case to CCG for post in February 18 4. Current significant issues with CAMHS service on FPH site with long term young patients with behavioural issues but no acute clinical problems and no suitable placements in the community 5. Positive proposal from Berkshire CCG around CAMHS 6. Liaison Service at Wexham to be fully recruited to by February 18 7. Funding for security staff for additional training around restraint approved and training completed 8. 2 x Band 7's on FPH site for CAMHS one based in ED, one in F1 working well Next Key Action * Berkshire Healthcare to recruit Liaison posts for Wexham site * Meeting with Commissioners held wk beginning 19/3, awaiting written SLA * To strengthen support for wards when dealing with very challenging patients & relatives (May 18)

• Annual Report to Board of Directors

Delays in Discharge Potential risk to patients becoming unwell with hospital acquired infections, i.e. UTI, pneumonia due to delays in discharge

1. IRIS launched on WPH site 11th December 2017 2. FPH delays escalated to CCGs & Social services for assistance 3. 4.2% of bed occupancy lost due to delays in transfer of care as at January 18 against target of 3.5% 4. Clinically fit list utilised daily to enable community teams to 'pull' patients from hospital to home 5. ADT & implementation of ECFD & EDD relaunched Dec 17, current uptake average of 82% 6. Delayed transfer of care down to 3.9% for February, best performance in financial year Next Key Action * To develop dashboard to monitor up-take of ADT * Military to provide Welfare officer on FPH site to support discharge

• Joint Urgent Care Delivery Board (Whole System) to HEB • Trust Monthly Performance Report to Board of Directors • Quarterly report to Trust Quality Assurance Committee

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Sepsis Risk of poor outcome through failure to recognise a patient with potential sepsis

1. All clinical leaders aware of need to improve recognition, escalation and timely treatment of sepsis 2. Inpatient screening & antibiotics within 1 hour of trigger time remains a challenge 3. 2 band 7’s appointed and in post, one for each site. 4. Q3 audit results improved with 68% antibiotics within 1 hour, 100% O2 administration & 96% blood cultures taken for FPH and 90% oxygen administration & 70% blood cultures for HWPH Next Key Action: * Patient information leaflet approved and to be implemented. * Sepsis clinician lead from WPH leaving the trust, one clinical lead for FHFT appointed to aid alignment. * Electronic observations system tender documents under development, to be released to framework May 18 with implementation planned end Q3 beginning Q4

• 1. Sepsis Group in place on both sites • 2. Monitoring compliance with Sepsis Screening Tool

through quarterly audits

Access to MRI OOH for Cauda Equina Patients Currently patients are going to Oxford as per pathway for scanning & treatment. However, there are some challenges for patients leading to potential poor patient experience

1. Current process is for patients to go to St Georges although there is no contract for MRI and then returned to WPH and then on to Oxford for treatment. Services at WPH vulnerable to not haeing access to MRI from 8 p.m. to 8 a.m. Pathway to be drawn up by Chief of Service. Chief of Service and Radiology determining how out of hours MRI to be provided 2. Chief of Service pursuing St Georges solution as an interim Next Key Action * Associate Director for Contracts & Business Development to initiate contract discussions wk beginning 31/3 in an effort to secure contract in Q1 18/19

• Process in place for patients to go to St Georges for Out of Hours MRI. Last MRI in Radiology at WPH is 8.00 p.m.

Specialist Commissioning Specialist Commissioning don’t recognise some of our established services. If this happens, the CCGs willnot be able to finance service

Series of meetings to be held with CCG to align Next Key Action List of services not recognised and value drawn up To review criteria and satisfy ourselves that Trust is compliant

•

Nursing Staffing Capacity Risk of insufficient, appropriately trained Nursing staff, with potential to impact on patient care and support, breach of safe staffing levels, impact on diagnosis and treatment, and reliance on temporary staffing.Particular risk at Wexham site

1. Highly successful recruitment of newly qualified nurses & midwives on both sites 2. FPH no maternity vacancies, WPH 16 (lowest in the last year) 3. 11 nurses arrived from Phillippines, currently being boot camped 4. Recruitment campaign in India at end of February 18 with 93 offers made, 12 to commence in next 6-8 months Next Key Action * Skype interviews with Australia/New Zealand & Canada * Recruitment trip to Phillippines in May 2018 * Review to be undertaken of skill mix * Associate Nurse roles to be developed, Band 4, 50 across both sites, April to September 18

1. HR Monitoring reports on Recruitment, Retention & numbers of vacancies 2. Staff levels Trust-wide reviewed daily by Senior Duty Nurse; short-staffed wards allocated support from better staffed areas. 3. Daily Safe Staffing report details planned staffing level for nursing shifts. 4. Retrospective Safe Staffing report actual staffing for all nursing shifts. 5. Recruitment & Retention group in place. 6. Rota management and shifts out to agency. 7. Standard nurse:patient ratios agreed max guidance, 1:10 & 1:8 8. Principles for the use of agency and 1:1 specials developed 9. Matrons working clinically in ward areas at time of short staffing

12

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orporate Risk A

ssurance Fram

ework

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Report Title Summary minutes of Special Audit Committee and Special Board Meeting on 24 May 2018

Meeting

Board of Directors

Meeting Date

Friday 1 June 2018

Agenda No.

13.1

Report Type

For Information

Prepared By

Dawn Kenson, Chair of Audit Committee Kevin Jacob, Assistant Company Secretary

Executive Lead

Nigel Foster, Director of Finance and IM&T

Executive Summary

This report briefs the Board on the main items discussed at the 24 May 2018 Audit Committee (part 1) and special Board Meeting to approve the Frimley Health Annual Report and Accounts.

Background

The Audit Committee met on 24 May 2018 to consider;

i. the ISA 260 Report; ii. the 2017-18 Annual Report for the twelve month period ended 31

March 2018 including, the Directors’ report & management commentary, Remuneration report, the statement of the accounting officer , and Annual Governance statement (‘Annual Report’);

iii. the financial statements and notes to the accounts for the Trust for the twelve month period ended 31 March 2018 (‘Annual Accounts’);

iv. the Quality Report for the Trust for the twelve month period ended 31 March 2018 (‘Quality Report’);

v. the Letters of Representation to KPMG: a. on the audit of the Annual Accounts; b. On the limited assurance for the Quality Report.

The external Auditors ISA 260 report confirmed an unqualified opinion on the accounts. The Audit Committee AGREED to recommend that the Board approve the Annual report, Quality account & report and accounts for the year ended 31

13.1

Tab 13.1 Audit Committee Part and Board 24th May


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March 2018 and that the associated documentation was fair, balanced and understandable in terms of its content and format. On recommendation from the Audit Committee the Board went on to APPROVE the Annual Report, Quality account and report and accounts for 2017-18.

Issues/Actions

NA

Recommendation

This Board is asked to note the report.

Appendices

NA

13.1

Tab 13.1 Audit Committee Part and Board 24th May


Page | 1

Report Title

Update Summary from the Audit Committee

Meeting

Public Board of Directors Meeting

Meeting Date


Agenda No.

13.2

Report Type

For Information

Prepared By

Dawn Kenson, Chair of Audit Committee Kevin Jacob, Assistant Company Secretary

Executive Lead

Nigel Foster, Director of Finance and IM&T

Executive Summary

This report briefs the Board on the main items discussed at the 24th May Audit Committee.

Background

1. Medical Equipment Assurance Report The Committee considered a report and detailed appendix which set out information in respect of the maintenance of the Trust’s medical devices, (either directly by the Trust or via third parties) and training given to clinical staff in the use of medical devices. It was noted that the report had been requested for assurance purposes following a serious incident relating to a mobile incubator used and maintained by another Trust. The Committee supported the harmonisation of processes and procedures across the Trust’s sites for the removal of equipment from the equipment libraries and the establishment of a Hospital Equipment Group on the Frimley site. 2. Payroll – Overtime Policy and Payments The Committee considered a report on overtime use and compliance with the Trust’s policy on overtime. This followed the previous meeting whereby the Committee had considered an internal audit report in respect of the Trust’s payroll systems and had asked for additional information. The Committee supported a change to the overtime policy to allow overtime to be used at certain times as this would be more cost effective than agency or bank, but with tighter controls over the sign off for its use, improved reviews of its use and stronger controls and actions over non-compliance.

3. Internal Audit Progress Report

13.2

Tab 13.2 Audit Committee Part 2 24th May


Page | 2

The Committee considered internal audit reports in respect of the following areas:

Safety Alerts – Reasonable Assurance

Information Governance Toolkit – Reasonable Assurance

GDPR – (evaluation not applicable)

Temporary Staffing (other staff groups) – Limited Assurance

Consultant Job Planning – Limited Assurance

Mortality Review Process – Reasonable Assurance

Sharing of Learning from Never Events - Reasonable Assurance

Electronic Medical Records Projects – Reasonable Assurance

Patient Experience Embedding Learning – Reasonable Assurance. In discussing each of the audit reports, the Committee focussed on the audits with a limited assurance evaluation and explored a number of detailed points and sought assurance that actions plans addressed the right areas and were sufficiently specific and robust in term of outcomes. The Committee noted the report. 4. Internal Audit Strategic Plan 2018/2019 The Committee considered a draft internal audit plan for 2018/2019 compiled by the Trust’s new internal auditors BDO. It was noted that the plan had been drafted by BDO in consultation with the Trust’s officers so as to reflect key corporate governance requirements and the Trust’s own corporate priorities and risks and also to be as flexible as possible in order to adapt to new issues that arose during the course of the year In discussion the Committee felt it was important that the Quality Assurance Committee, (QAC) also be given the opportunity to comment on the priorities set out within the draft plan, particularly in terms of the scope of in audits with a link to quality of care to patients. It was noted final approval of the plan would be made via E-Governance rather than waiting until the next meeting. 5. Risk Assurance Framework The Committee considered a report which set out the corporate risks faced by the Trust as reviewed by the April meeting of the Corporate Governance Group, (CGC) and as previously considered by the Board at the 5th May meeting. The Committee noted the report. 6. Local Counter Fraud Service Annual Report The Committee considered the annual report from RSM, the Trust’s outgoing local counter fraud specialist. The Committee queried and noted the arrangements being put in place for the handover between RSM and the Trust’s new LCFS provider Grant Thornton to ensure continuity and quality of provision particularly with respect of on-going investigations.

The Committee noted the report. 7. Losses and Write Offs – Quarter 4 2017/2018 The Committee considered a report setting out losses and write offs for the period January to March 2018.

13.2



Page | 3

The Committee noted and approved the report and details of losses and write offs. 8. Combined Costs Collection Submission 2017/2018 The Committee considered a paper which provided assurance that: (a) NHS Improvement’s Approved Costing Guidance has been used to prepare the

return (b) information, data and systems underpinning the national cost collection return

are reliable and accurate;

(c) there were proper internal controls over the collection and reporting of the information included in the national cost collection, and these controls are subject to review to confirm that they are working effectively in practice

The Committee noted the position in relation to the collection and submission of the 2017/2018 national cost collection. 9. Audit Committee – Self Evaluation 2017/2018 The Committee considered the preparations for the annual review of its effectiveness and decided to trial a revised self-evaluation questionnaire based upon a best practice example produced by the HFMA NHS Audit Committee Handbook. 10. Policy Integration Update

The Committee received a progress report on the project to update and integrate the Trust’s policies and noted that a total of 95 policies had now been completed. The Committee noted the progress made

Recommendation

This Board is asked to note the issues highlighted in the report.

13.2



1

Report Title

Clinical Negligence Scheme for Trusts (CNST) incentive scheme maternity safety actions

Meeting

Board of Directors

Meeting Date

1st June 2018

Agenda No.

14.

Report Type

Decision

Prepared By

Emma Luhr Head of Midwifery

Executive Lead

Duncan Burton Director of Nursing

Executive Summary

The Clinical Negligence Scheme for Trusts (CNST) have put in place a Maternity Safety Incentive Scheme from 18/19. Maternity related claims represent the scheme’s biggest area of spend, in 2016/17, obstetric claims represented 10% of the volume and 50% of the value. Trusts have therefore been incentivised to comply with 10 safety actions. If Trusts demonstrate compliance with the requirements by 29th June 2018, 10% of the 2018/19 CNST maternity payment will be reimbursed. The Board is required to confirm compliance with the requirements by 29th June 2018. The Trust is not required to submit evidence of compliance at this stage as this is a self-certification process. The attached report provides the evidence of its compliance with the 10 safety actions set out by CNST, these being; 1). Are we using the National Perinatal Mortality Review Tool (NPMRT) to review perinatal deaths?

2). Are we submitting data to the Maternity Services Data Set (MSDS) to the required standard?

3). Can we demonstrate that you have transitional care facilities that are in place and operational to support the implementation of the ATAIN Programme? 14

Tab 14 CNST Maternity Declaration


2

4). Can we demonstrate an effective system of medical workforce planning?

5). Can ye demonstrate an effective system of midwifery workforce planning?

6). Can we demonstrate compliance with all 4 elements of the Saving Babies' Lives (SBL) care bundle?

7). Can we demonstrate that you have a patient feedback mechanism for maternity services, such as the Maternity Voices Partnership Forum, and that you regularly act on feedback?

8). Can we evidence that 90% of each maternity unit staff group have attended an 'in-house' multi-professional maternity emergencies training session within the last training year?

9). Can we demonstrate that the trust safety champions (obstetrician and midwife) are meeting bi-monthly with Board level champions to escalate locally identified issues?

10). Have we reported 100% of qualifying 2017/18 incidents under NHS Resolution's Early Notification scheme?

Evidence for all 10 maternity safety actions has been reviewed by the Quality Committee on 16th May 2018, with further follow up by Executive Directors to ensure evidence of full compliance. The Trust is able to declare full compliance with the 10 requirements. To note this is subject to the completion of planned training of 14 obstetric staff by 29th June 2018, in order to meet requirement 8. This training has been further updated for 2018/19 to ensure on-going compliance and the addition of a wider definition of MDT as outlined by NHS Resolution.

Recommendation

The Board of Directors are asked to agree sign off for submission to NHS Resolution on 29th June 2019.

Appendices

Board report on Frimley Health NHS Foundation Trust progress against the CNST incentive scheme maternity safety actions

14

Tab 14 CNST Maternity Declaration


3

Board report on Frimley Health NHS Foundation Trust progress against the Clinical Negligence

Scheme for Trusts (CNST) incentive scheme maternity safety actions

Date: May 2018 (for Top Team meeting prior to Trust Board approval in June 2018 – further evidence to be added when available)

SECTION A: Evidence of Trust’s progress against 10 safety actions:

Please note that trusts with multiple sites will need to provide evidence of each individual site’s performance against the required

standard.

Safety action –

please see the

guidance for the

detail required

for each action

Evidence of Trust’s progress Action met?

(Y/N)

1). Are you

using the

National

Perinatal

Mortality Review

Tool (NPMRT) to

review perinatal

deaths?

Please refer/ append all relevant evidence to demonstrate the Trust’s progress against this action

as per the guidance document.

NHS Resolution will also use data from MBRRACE to verify the Trust’s progress against this

action.

The Perinatal Mortality Review Tool (NPMRT) was released in February 2018.

Both sites have key users registered to complete the tool for perinatal deaths

The original requirement is to use the tool for all deaths between Jan 2018 and April 2018. As the

tool was only released in February the department is focusing initially on term deaths as

recommended by MBRRACE. The requirement has been adjusted and states the need to

demonstrate use of the tool.

Yes compliant

on both sites

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The first tool at FPH has been commenced and was used on 9.5.18 in a serious incident review.

The plan is to aim for completion of:

Deaths over 36 weeks gestation by end of June 2018

Deaths over 34 weeks gestation by end of June 2018

Deaths over 30 weeks gestation by end of July 2018

Deaths over 27 weeks gestation by end of July 2018

Deaths over 22 weeks gestation by end of August 2018.

By end of August 2018 all the retrospective deaths will be completed using the new tool, going

forward the tool will be used when cases are reviewed as part of the department process.

Term perinatal deaths are being prioritised and then early deaths will be analysed using the tool.

Parents’ views should be sought during the investigation.

Multidisciplinary meetings are required for using the tool and external representation is

recommended. The final report is to be shared with the parents.

2). Are you

submitting data

to the Maternity

Services Data

Set (MSDS) to

the required

standard?



NHS Resolution will also use data from NHS Digital to verify the Trust’s progress against this

action.

Frimley Health is fully compliant with reporting to the National Maternity Services Data Set for all 10

elements for both Frimley and Wexham sites.

Confirmation of this was received via email on 9th April 2018 in the document ‘Maternity Services

Yes compliant

on both sites

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5

Data Set information for CNST incentive scheme’.

3). Can you

demonstrate

that you have

transitional care

facilities that are

in place and

operational to

support the

implementation

of the ATAIN

Programme?



NHS Resolution will cross-check trusts’ self-reporting with Neonatal Operational Delivery Networks

to verify the Trust’s progress against this action.

Transitional care facilities are open and operational on both Frimley Park and Wexham Park sites.

There is a cross site action plan for the ATAIN programme that is submitted quarterly to the

Neonatal network.

There is an audit process in place and an e-mail has been received from the Network Manager, South East Coast Neonatal Operational Delivery Network anticipating that the trust should be compliant with 2018/19 requirements when published, as an audit process is in place for the rate of admissions.

Yes compliant

on both sites

4). Can you

demonstrate an

effective system

of medical

workforce

planning?


as per the guidance document. This should include reference to the Royal College of Obstetricians

and Gynaecologists (RCOG) workforce monitoring tool template

The RCOG workforce monitoring template has been forwarded to the labour ward lead

obstetricians on both sites by the Chief of Service.

Frimley site and Wexham site data has been completed and demonstrates compliance. Submitted

to RCOG

Yes compliant

on both sites

5). Can you

demonstrate an

effective system

of midwifery


as per the guidance slides.

Trust Board supports the funding of a Birth ratio 1 midwife to 30 women [1:30], with a 90/10 split of

Yes compliant

on both sites

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6

workforce

planning?

midwife and maternity support worker in place, this is supported by Birth Rate Plus.

Detailed report updated in April 2018, outlines how clinical workforce is deployed across the

service, this includes nursing and medical neonatal workforce for both sites.

Establishment reviews undertaken on both sites monthly with HOM, Deputy HOM and matrons.

Reports are presented on a quarterly basis to the trust Quality Committee on midwifery staffing.

Safer Staffing monthly data submission from both sites for maternity and neonatal units based on

agreed establishments.

Neonatal unit staffing on both sites supports 24 hour nursing and medical cover,

2017 – 8A structure reviewed cross site which included;

Cross site Antenatal and Newborn Screening post substantive.

Development of a cross site midwifery education lead midwife to support the practice

development tem and support the head of midwifery in workforce planning and training for

the future.

Transferring a vacant consultant midwife to the Frimley Park site, so there is one WTE

consultant midwife on both sites

16th April 2018 a new Band 7 restructure was put in place, following a consultation to align needs of

service and service development on both sites.

This saw an increase in;

Perinatal mental health specialist midwife

Diabetes specialist midwife

Infant feeding specialist midwife

Lead midwife for the Maternity Assessment Centre/Triage

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In addition new posts created;

IT midwife for Wexham Park site

Pregnancy Loss Midwife for both sites.

The Trust Executive Team has supported the supernumerary role of the Labour Ward

Coordinators. This will be implemented by backfilling 5.4 WTE with Band 5 midwives on each site

(10.8 WTE in total). This will come into place on 1st May 2018

6). Can you

demonstrate

compliance with

all 4 elements of

the Saving

Babies' Lives

(SBL) care

bundle?



NHS Resolution will cross-check trusts’ self-reporting with NHS England.

1. Reducing smoking in pregnancy

CO monitoring in pregnancy is well established on both sites. It is offered to all women at booking

and then during pregnancy if indicated.

There is information about smoking and CO monitoring in the hand held notes issued to all women.

Women who smoke are offered written information about the risk of smoking for themselves and

their unborn baby and referral to the smoking cessation service.

Women are asked if anyone else in the household smokes and whether other household members

would like help to stop smoking.

Nicotine replacement products are available in the community and to hospital inpatients.

Smoking status is checked at delivery.

Yes compliant

on both sites

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Information on prevention of cot death and co-sleeping includes the importance of a smoke-free

environment for the baby and siblings.

Health promotion prompts on Facebook.

2. Risk assessment and surveillance for fetal growth restriction

The GAP/GROW protocol from the Perinatal Institute has been implemented for low risk women.

High risk women have an individualised plan from their consultant. The protocol will be followed for

all women once there are sufficient resources for the additional scans required.

All midwifery and obstetric staff have been required to complete face-to-face and e-learning

packages and to complete an assessment of competency in use of the GAP protocol. Training has

been offered to GPs.

Individual feedback is given when deviation from the protocol is identified.

The units participate in the Perinatal Institute’s ‘missed cases audit’ of babies with a birth weight

centile below 10 to identify whether there was an opportunity to intervene earlier.

Staff have the opportunity to attend study days run by the Perinatal Institute.

3. Raising awareness of reduced fetal movements (RFM)

A new cross site guideline was launched in December 2016 based on national guidance. This was

supported by themed newsletters in December 2016 and January 2017 summarising the main

changes in advice to be given to women.

A checklist for staff to use to identify the appropriate action to take was included in the guideline

and is used for each woman who reports reduced fetal movements.

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Information for women has been added to the hand held notes so that all women have access.

Posters have been designed and displayed in outpatient areas for women and their families to raise

awareness.

MAMA Academy envelopes to hold the pregnancy hand held record are being used cross site and

have information about reduced fetal movements printed on the envelope.

4. Effective fetal monitoring during labour

Current unit guidance is based on NICE recommendations but the unit is considering whether to

change to FIGO classification in line with many other units. Work on the guideline is in progress.

In April 2017 a themed newsletter on interpretation of antenatal CTGs was produced to share

learning from local incidents during induction of labour.

All staff are required to complete annual CTG training. Midwives are required to complete the CTG

e-learning package and attend a CTG and labour management session on mandatory training.

Obstetricians are required to complete e-learning and face- to-face sessions.

Two external study days were organised with a nationally recognised speaker in 2016 and 2017.

We submit a quarterly update to NHS England, last report in April 2018.

7). Can you

demonstrate

that you have a

patient feedback

mechanism for

maternity

services, such



A ‘Maternity Voices’ group was launched on 27th October 2013 on the Frimley site and meets

quarterly at different venues across the community. Sessions are advertised within the unit, in GP

practices and on Facebook.

A ‘Maternity Voices’ group has been established on the Wexham site and also meets quarterly at

Yes compliant

on both sites

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10

as the Maternity

Voices

Partnership

Forum, and that

you regularly

act on

feedback?

different venues across the community. Sessions are advertised within the unit, in GP surgeries

and on Facebook.

On the Frimley site the ‘Goldfish Bowl’ initiative was held on 30th May 2017 where a group of staff

listen to feedback from users and then action plan to address the issues on which they have heard

the feedback. This was a pilot for the trust and is to be repeated. Lessons have been shared in

mandatory training.

Facebook has been used to send out surveys and to seek user views, e.g. on partners staying

overnight. Feedback from Facebook reviews is shared with staff regularly.

A ‘Good News’ newsletter is circulated each December to celebrate and share good practice and

positive feedback.

Sharing learning from feedback include ‘Message of the Week’ e.g.

Woman’s experience in theatre during a postpartum haemorrhage

Telephone advice when a woman goes home during induction of labour

As part of the Local Maternity system a Maternity Voices Partnership has been set up cross site

funded by the LMS with terms of reference in line with National Maternity Voices. The groups will

be used to seek out harder to reach populations and proactively seek user input on changes to the

service in line with ‘Better Births’.

8). Can you

evidence that

90% of each

maternity unit

staff group have


as per the guidance document. This should include completion of a local training record form.

Training records for Multidisciplinary Team from April 2017 – April 2018 demonstrate 93%

compliance for midwives and 41% compliance for obstetric staff (as documented on MAST, this is

being cross referenced with local records). With additional training taking place of 14 obstetric staff

Yes compliant

on both sites

(*subject to

completion of

further training

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attended an 'in-

house' multi-

professional

maternity

emergencies

training session

within the last

training year?

by 29th June 2018 the Trust will be above the 90% required threshold for training. Review of

provision with job plans to participate in delivery of training will be undertaken.

MDT during this year consisted of midwives of all grades working in all settings both clinical and

managerial, obstetricians including all grades working in all settings.

From April 2018 both sites have implemented a new MDT training which will be progressed

throughout the financial year ending in March 2019 for the following disciplines;

Midwives of all grades working in all settings both clinical and managerial, obstetricians working in

all settings, maternity care assistants in hospital and community settings, maternity support

workers, obstetric anaesthetic staff, maternity theatre and critical care staff.

The programme is based on PROMPT training methods.

Training records from January 2018 using the local training from are attached.

New programme launched from April 2018 will include multidisciplinary training using PROMPT

methods. Training to be extended to include theatre staff, anaesthetists and maternity support

workers.

Strategy for implementation of Practical Obstetric Multi-professional Training (PROMPT) and

Simulation.

Cross site teams consisting of midwives, obstetricians and anaesthetists were identified and

have commenced Train the trainer courses for PROMPT from February 2018 last team to

attend September 2018.

Identifying key staff from all Health professional groups to form course faculty – trainer the

trainers to provide instruction to faculty on concept of course including team working,

communication, roles and responsibilities when responding to obstetric emergencies.

by 29th June

2018)

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Course content also to be informed by local risk issues, audit findings and use of proformas.

Full implementation by October 2018 with ongoing review, evaluation and recording and

reporting of attendance of all staff groups.

Liaise with Obstetric theatres and Critical care to identify key staff to participate in MDT

training and aim to join as part of faculty.

Further development and implementation of Obstetric Emergency Simulation days to be

accessed by all staff cross site. Currently two days scheduled per year on Wexham site

which include obstetricians/anaesthetists/midwives and ODPs. Explore means for

attendance by key midwifery staff such as Labour Ward coordinators.

9). Can you

demonstrate

that the trust

safety

champions

(obstetrician

and midwife) are

meeting bi-

monthly with

Board level

champions to

escalate locally

identified

issues?



A plan is in place for the local safety champions (chief of service and head of midwifery) will meet

with the Board level maternity safety champions (Medical Director and Director of Nursing) bi-

monthly from May 2018 prior to the Hospital Executive Board meeting. The meetings will be

minuted and are scheduled for July, September, November 2018, January and March 2019.

Further meetings will be scheduled if concerns need to be escalated to the trust board level

champions.

In addition the head of midwifery attends the monthly Quality Committee and presents the

maternity dashboard. The maternity service provides quarterly patient safety reports to the

committee and twice a year there is a deep dice in to maternity which the chief of service presents.

Any concerns that require escalating to the committee would be included in minutes and circulated

to all committee representatives.

Yes compliant

on both sites

10). Have you

reported 100%

Please refer/ append all relevant evidence to demonstrate the Trust’s progress against this action Yes compliant

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13

of qualifying

2017/18

incidents under

NHS

Resolution's

Early

Notification

scheme?


NHS Resolution will also use data from the National Neonatal Research Database to verify the

Trust’s progress against this action.

Frimley site has now reported all relevant cases and has cross checked with the neonatal unit to

ensure all cases have been identified. One case was identified through the final cross check and

has now been reported to litigation.

A report has been obtained from the neonatal unit at Wexham and is being cross checked by the

maternity patient safety midwife at Wexham.

on both sites

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SECTION B: Further action required:

If the Trust is unable to demonstrate the required progress against any of the 10 actions, please use this section to set out a detailed plan for

how the Trust intends to achieve the required progress and over what time period. Where possible, please also include an estimate of the

additional costs of delivering this.

The National Maternity Safety Champions and Steering group will review these details and NHS Resolution, at its absolute discretion, will agree

whether any reimbursement of CNST contributions is to be made to the Trust. Any such payments would be at a much lower level than for those

trusts able to demonstrate the required progress against the 10 actions and the 10% of the maternity contribution used to create the fund. If

made, any such reimbursement must be used by the Trust for making progress against one or more of the 10 actions.

SECTION C: Sign-off

………………………………………………………………………..

For and on behalf of the Board of Frimley Health NHS Foundation trust confirming that:

The Board are satisfied that the evidence provided to demonstrate compliance with/achievement of the maternity safety actions meets the

required standards and that the self-certification is accurate.

The content of this report has been shared with the commissioner(s) of the Trust’s maternity services

If applicable, the Board agrees that any reimbursement of CNST funds will be used to deliver the action(s) referred to in Section B

Position: ………………………….

Date: ………………………….

We expect trust Boards to self-certify the Trust’s declarations following consideration of the evidence provided. Where subsequent verification

checks demonstrate an incorrect declaration has been made, this may indicate a failure of board governance which the Steering group escalate to

the appropriate arm’s length body/NHS System leader.

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Page 1 of 4

ACRONYMS BUSTER

A A&E - Accident and Emergency ACS - Accountable Care System ACO - Accountable Care Organisation AD - Associate Director ADT - Admission, Discharge and Transfer AfC - Agenda for Change AGM - Annual General Meeting / Annual Governance Meeting AHP - Advanced Health Professional AKI - Acute Kidney Injury AMM - Annual Members Meeting AMR - Antimicrobial Resistance AMU - Acute Medical Unit AOS - Acute Oncology Service ANP - Advanced Nurse Practitioner AR - Annual Report ASPH - Ashford and St. Peter’s Hospital

B BAU - Business As Usual BBE - Bare Below Elbow BME - Black and Minority Ethnic BCF - Better Care Fund BMA - British Medical Association BMI - Body Mass Index BoD - Board of Directors

C CAMHS - Child and Adolescent Mental Health Services CAS - Central Alert System CAU - Clinical Assessment Unit CCG - Clinical Commissioning Group CCU - Coronary Care Unit CDI - Clostridium Difficile Infection CDIC - Commercial Development and Investment Committee Cdif /C.Diff - Clostridium Difficile CEA - Clinical Excellence Awards CEO - Chief Executive Officer CFO - Chief Finance Officer CHC - Continuing Health Care CHD - Coronary Heart Disease

CIO - Chief Information Officer CIP - Continuous Improvement Plan CoG - Council of Governors CoS - Chief of Service CoSec - Company Secretary CoSRR - Continuity of Service Risk Rating CPA - Care Programme Approach CQC - Care Quality Commission CQUIN - Commissioning for Quality and Innovation CRAB - Copeland’s Risk Adjusted Barometer C.Section - Caesarean Section CSU - Commissioning Support Unit CT - Computerised Tomography CTG - Cardiotocography CVC - Central Venous Catheter

D DBS - Disclosure Barring Service DGH - District General Hospital DH / DoH - Department of Health DIPC - Director of Infection Prevention and Control DNA - Did Not Attend DNACPR - Do Not Attempt Cardiopulmonary Resuscitation DNAR - Do Not Attempt Resuscitation DNR - Do Not Resuscitate DoLS - Deprivation of Liberty Safeguards DoN - Director of Nursing DoO - Director of Operations DPA - Data Protection Act DSU - Day Surgery Unit DVT - Deep Vein Thrombosis

E E&D - Equality and Diversity EAU - Emergency Assessment Unit EBITDA - Earnings Before Interest, Taxes, Depreciation and Amortization ECG - Electrocardiogram ECIST - Emergency Care Intensive Support Team ED - Emergency Department EDD - Estimated Date of Discharge EDMS - Electronic Document Management System EEA - European Economic Area EEG- Electroencephalogram

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EHR - Electronic Health Record EHRC - Equality and Human Rights Commission EIA - Equality Impact Assessment ELSCS - Elective Caesarean Section EM - Emergency Medicine EMLSCS - Emergency Caesarean Section ENT - Ear, Nose and Throat EOLC - End of Life Care EOLCA - End of Life Care Audit EPR - Electronic Patient Record EPRR - Emergency Preparedness, Resilience and Response ERS - e-Referral System (electronic) ESD - Early Supported Discharge ESR - Electronic Staff Record ETP - Electronic Transmission of Prescriptions

F FAC - Finance Assurance Committee FBC - Full Business Case FFT - Friends and Family Test FH - Frimley Health FHFT - Frimley Health NHS Foundation Trust FOI - Freedom of Information FPH - Frimley Park Hospital FRR - Financial Risk Rating FT - Foundation Trust FTE - Full Time Equivalent FYE - Financial Year End

G GI - Gastrointestinal GMC - General Medical Council GMS - General Medical Services GP - General Practitioner GRE - Glycopeptide Resistant Enterococci

H HAI - Hospital Acquired Infection HASU - Hyper Acute Stroke Unit HCA - Health Care Assistant HCAI - Healthcare-Associated Infection HDU - High Dependency Unit HEB - Hospital Executive Board HED - Healthcare Evaluation Data

HEKSS - Health Education Kent, Surrey and Sussex HETV - Health Education Thames Valley HH - Heatherwood Hospital HICC - Hospital Infection Control Committee HoN - Head of Nursing HR - Human Resources HSE - Health and Safety Executive HSMR - Hospital Standardised Mortality Ratio HTC - Hospital Transfusion Committee HWB - Health and Wellbeing Board HWD - Heatherwood HWP - Heatherwood and Wexham Park HWPH / H&WPH - Heatherwood and Wexham Park Hospitals

I I&E - Income and Equity IC - Information Commissioner ICM - Integrated Case Management ICP - Integrated Care Pathway ICS - Integrated Care System ICU - Intensive Care Unit IG - Information Governance IGT / IGTK - Information Governance Toolkit IM&T - Information Management and Technology IPCN - Infection Prevention and Control Nurse IPCT - Infection Prevention and Control Team IPR - Individual Performance Review ITU - Intensive Therapy Unit / Critical Care Unit IV - Intravenous

J JAG - Joint Advisory Group

K KPI - Key Performance Indicator

L LA - Local Authority LCFS - Local Counter Fraud Specialist LD - Learning Disability LHRP - Local Health Resilience Partnership LiA - Listening into Action

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LINAC - Linear Accelerator LOS / LoS - Length of Stay LUCADA - Lung Cancer Audit Data

M M&M - Morbidity and Mortality MAU - Medical Assessment Unit MDT - Multi-Disciplinary Team MHPS - Maintaining High Professional Standards MIDU - Medical Investigations Day Unit MIG - Medical Interoperability Gateway MIU - Minor Injuries Unit MRI - Magnetic Resonance Imaging MRSA - Methicillin-Resistant Staphylococcus Aureus

N NBOCAP - National Bowel Cancer Audit Programme NCASP - National Clinical Audit Support Programme NED - Non-Executive Director NEHF / NEH&F - North East Hants and Farnham NHS - National Health Service NHS FT - NHS Foundation Trust NHSE - NHS England NHSI - NHS Improvements (formerly Monitor) NHSLA - NHS Litigation Authority NHSP - NHS Professional NICE - National Institute for Health and Care Excellence NICU - Neonatal Intensive Care Unit NMC - Nursing and Midwifery Council NNU - Neonatal Unit NOGCA - National Oesophago-Gastric Cancer Audit NRLS - National Reporting and Learning System / Service

O O&G - Obstetrics and Gynaecology OBC - Outline Business Case ODP - Operating Department Practitioner OHD - Occupational Health Department OLM - Oracle Learning Management OOH - Out of Hours OP - Outpatient OPD - Outpatient Department OSCE - Observed Structured Clinical Exam OT - Occupational Therapist/Therapy

P PACS - Picture Archiving and Communications System PACU - Post-Anaesthetic Care Unit PALS - Patient Advice and Liaison Service PAS - Patient Administration System PAU - Paediatric Assessment Unit PbR - Payment by Results PCI - Percutaneous Coronary Intervention PD - Practice Development PDC - Public Dividend Capital PDD - Predicted Date of Discharge PE - Pulmonary Embolism PEAT - Patient Environment Action Team PFI - Private Finance Initiative PHE - Public Health England PICC - Peripherally Inserted Central Catheters PID - Patient / Person Identifiable Data PILS - Patient Information Leaflets PID - Project Initiation Document PLACE - Patient-Led Assessments of the Care Environment PMS - Personal Medical Services PMO - Programme Management Office POD - Pre-Operative Department POSSUM - Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity PPE - Personal Protective Equipment PPI - Patient and Public Involvement PSED - Public Sector Equality Duty

Q QA - Quality Assurance QAC - Quality Assurance Committee QI - Quality Indicator QIP - Quality Improvement Plan QIPP - Quality, Innovation, Productivity and Prevention QIA - Quality Impact Assessment QOF - Quality and Outcomes Framework

R RAF - Risk Assurance Framework RAG - Red Amber Green RBH - Royal Berkshire Hospital RCA - Root Cause Analysis RCN - Royal College of Nursing

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RCP - Royal College of Physicians RCS - Royal College of Surgeons RIDDOR - Reporting of Injuries, Diseases and Dangerous Occurrences Regulations RN - Registered Nurse RSCH - Royal Surrey County Hospital RTT - Referral to Treatment

S SADU - Surgical Day Unit SAU - Surgical Assessment Unit (FPH) / Surgical Assessment Unit (WPH) SCAS / SCAmb - South Central Ambulance Service SCT - System Control Total SDIP - Service Development and Improvement Plan SECAMB - South East Coast Ambulance Service SH - Surrey Heath SHMI - Summary Hospital-level Mortality Indicator SHO - Senior House Officer SI - Serious Incident SIRI - Serious Incident Requiring Investigation SIRO - Senior Information Risk Owner SID - Senior Independent Director SLA - Service Level Agreement SLR - Service-Line Reporting SLT / SaLT - Speech and Language Therapy SME - Subject Matter Expert SMR - Standardised Mortality Ratio SoS - Secretary of State SPS - Surrey Pathology Service SSI(S) - Surgical Site Infections (Surveillance) SSNAP - Sentinel Stroke National Audit Programme SSS - Short Stay Surgical Unity STF - Sustainability and Transformation Funding STP - Sustainability and Transformation Plan/Partnership SUI - Serious Untoward Incident

T TACC - Theatres and Critical Care directorate TIA - Transient Ischaemic Attack TLC - Turn off, Lights out, Close doors TMG - Theatre Management Group TNA - Training Needs Analysis TPN - Total Parenteral Nutrition TTA - To Take Away TTO - To Take Out

TUPE - Transfer of Undertakings (Protection of Employment) Regulations 1981

U UCB - Urgent Care Board UI - Untoward Incident UGI - Upper Gastrointestinal UTI - Urinary Tract Infection

V VfM - Value for Money VSM - Very Senior Manager VTE - Venous Thromboembolism

W WAM - Windsor and Maidenhead WHO - World Health Organization WLI - Waiting List Initiative WPH - Wexham Park Hospital WTE - Whole Time Equivalent

Y YTD - Year to Date

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