COUNCIL OF GOVERNORS...Performance Report Council of Governors 17 February 2017 Page 3 of 24 Indicator Target Month Overall Oct 2016 Nov 2016 Dec 2016 For Q3 16/17 (previous Q) Number

Performance Report Council of Governors 17 February 2017 Page 1 of 24

COUNCIL OF GOVERNORS

Meeting date: 17 February 2017 Agenda item: 7.1 Public Title: PERFORMANCE REPORT Purpose: To update Council of Governors (CoG) on the performance of the Trust over the 2nd and 3rd Quarters of 2016/17. The Council of Governors approved a new style Performance Report at its April 2016 meeting and this is the third iteration of that new Report (the paper to April 2016 CoG is attached as Appendix 1 as a reminder). Feedback has been incorporated from the July and October 2016 meetings and the report will continue to be reviewed and revised to ensure it is fit for purpose. The CoG is reminded that its meetings are more closely aligned to the end of the most recent quarter in 2017 and this report covers two quarters to ensure more timely feedback to the CoG. This report seeks to provide a narrative overview of some of the key issues in Q2 and Q3 and some of the Board discussions relating to performance to provide assurance that performance is being adequately monitored and addressed where necessary. Key performance issues emerging in Q4 2016/17 will be highlighted during the presentation of this report particularly where this may impact on the Trust’s Licence. This report also contains community hospitals data from Q3, as presented to the Board of Directors at its January 2017 meeting. Please note this is community hospitals data, not community services data. The initial phase of reporting development for the Board has deliberately focussed upon inpatient activity within the hospitals. Work is in progress to develop the metrics in relation to community nursing services and it is anticipated these will report from April 2017. The community data is presented here as a separate section as per the reporting to the Board. NHS Improvement (NHSI) provide the Trust with a feedback letter on each Quarter’s performance. The letter for Q1 2015/16 is attached, the details of which were presented to CoG at its October 2016 meeting. At the time of writing the feedback letters from Q2 and Q3 had not been received. The Report also contains an update with progress against the Governor identified priorities for 2016/17 in the Quality Report 2015/16. Information in this report is taken from the Board’s Integrated Performance Reports, which are available on the Trust website along with all other Board papers and minutes: (http://www.rdehospital.nhs.uk/trust/board/boardpapers.html).

http://www.rdehospital.nhs.uk/trust/board/boardpapers.html


Key Issues: Overall performance against the Trust’s Licence in Q2 and Q3 2016/17

Risk Rating Q2 16/17 result

Annual Plan Forecast for

Q2

Q3 16/17 result

Annual Plan forecast

Financial Sustainability Risk Rating 3 2

Use of Resources 2 3

Governance Risk Rating Green Green Green Green

The Financial Sustainability Risk Rating / Use of Resources is intended to detect early signs of financial risk that could lead to financial failure and so threaten the continuity of services. There are four categories ranging from 1, the most serious risk, to 4, representing the least risk.

Patient Experience

Complaints and concerns

| Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 | Q1 | Q2 | Q3 | Q4 |

Latest

month

37

97.4%

Scale

120 ⁻

35 ₋

105% ⁻

80% ₋

Low

Medium

Risk for next

3 months

2014 - 2015 | 2015 - 2016 | 2016 - 2017Indicator

Complaints & Concerns

acknowledged within 3

days

100%

Number of Complaints and

Concerns

Target

line

<70

Indicator Target Month Overall

July 2016

August 2016

Sept 2016

For Q2 16/17

(previous Q)

Number of complaints and concerns received

<70 75 87 72 230

(214)

Complaints and Concerns acknowledged within 3 days

100% 100.0%

(75 out of 75)

98.9%

(86 out of 87)

97.2%

(70 out of 72)

98.7%

(98.6%)


Indicator Target Month Overall

Oct 2016

Nov 2016

Dec 2016

For Q3 16/17

(previous Q)

Number of complaints and concerns received

<70 62 69 37 168

(230)

Complaints and Concerns acknowledged within 3 days

100% 96.8%

(60 out of 62)

100%

(69 out of 69)

97.4%

(36 out of 37)

98.2%

(98.7%)

Compliments

There were 105 written compliments received in Q2 and 98 in Q3 (107 in Q1 2016/17). Demonstrating Difference examples can be found at Appendix 2. A deeper, more comprehensive report on complaints and compliments, including themes, is reported to the Patient Experience Committee, which has three Governor members.

Cases referred to the Parliamentary Health Service Ombudsman (PHSO) The PHSO requested one new case in Q2 and one in Q3. There were two final reports received in Q2. One was partially upheld in relation to how the complaint had been managed and one was not upheld. There was one final report received in Q3 which the PHSO upheld. This will be reported as part of the Quarter 3 Patient Experience Report to the Patient Experience Committee in February 2017. Care Quality Assessment Tool (CQAT) and Outpatient Quality Assessment Tool (OQAT) Details are reported to the PEC and will be reported to CoG via the PEC report where appropriate.


Safe Staffing On all wards the Ward Matron and Senior Nurses reviewed the acuity and dependency of patients and were satisfied having exercised professional judgement that the wards were safely staffed. Safety Summary Hospital-level Mortality Indicator (SHMI): SHMI was developed by NHS Digital (formerly known as the Health and Social Care Information Centre). It looks at the ratio of the number of in-hospital deaths and those within 30 days of discharge from hospital compared to the expected number of deaths given the patients clinically coded condition. Each Trust is given a banding of higher than expected, as expected or lower than expected when compared to the national baseline.

Safety concerns There were no safety concerns for the quarters. Never Events There were no Never Events during Q2. A Never Event occurred in December 2016 (Q3) and was reported to the Board at its January 2017 meeting as part of the Chief Executive Update. This is currently under investigation and will be reported through the Safety & Risk Committee and the Governance Committee on completion.


Clinical Effectiveness

The following areas of Red or persistent Amber performance are highlighted to the Council of Governors: Time to Surgery for Patients with a Fractured Neck of Femur In September 2016 (end Q2), 69.4% of Fractured Neck of Femur patients received surgery within 36 hours, which is 10 patients fewer than required to meet the 90% target. Trauma theatre capacity is an issue; therefore an additional Fractured Neck of Femur list on a Saturday was approved to commence from November 2016, as part of the winter plan. In December 2016 (end Q3) 84.4% of Fractured Neck of Femur patients received surgery within 36 hours, which is 3 patients fewer than required to meet the 90% target, an improved position from that at the end of Q2. The additional Saturday operating for patients with fractured neck of femur started in November 2016 was working well. Antimicrobial prescribing – compliance with duration and indication on the drug chart, and compliance with guidelines Trust wide figures for antimicrobial prescribing compliance in September 2016 (end Q2) were: 78.8% (238/302) for inclusion of a duration on the drug chart; 88.1% (266/302) for


inclusion of an indication on the drug chart; 92.4% (171/185) for guideline compliance. Trust wide figures for antimicrobial prescribing compliance in December 2016 (end Q3) were: 82.3% (255/310) for inclusion of a duration on the drug chart; 84.2% (261/310) for inclusion of an indication on the drug chart; and 90.1% (183/203) for guideline compliance. In response to the compliance rates, Adrian Harris, Executive Medical Director, wrote to all medical staff and ward management teams to reinforce the importance of achieving compliance with these best practice standards. In addition, the Trust’s Antimicrobial and Clinical Pharmacist is spending an hour per day working with ward teams to raise awareness and provide additional education. Ward pharmacists have also been empowered to challenge ward teams where any prescriptions are identified as incomplete, to request immediate resolution and provide real time feedback regarding practice.

Operational Effectiveness


The following areas of Red or persistent Amber performance are highlighted to the Council of Governors: A&E Maximum Waiting Time of Four Hours from Arrival to Admission, Transfer or Discharge (in Q2 including Walk In Centre activity; Q3 includes Honiton MIU but not the WICs) The position for Q2 was 91.42% against the target of 95%. Performance for Q3 was 92.40%. The Trust experienced significant issues with patient flow in December 2016, resulting in an increase in the number of breaches due to bed capacity. The number of delays attributable to the Emergency Department (ED) continued to reduce month on month from August 2016, indicating benefits of process optimisation, as well as benefits of front door streaming to other services being fully operational. An update on the key actions outlined in the ED recovery plan was provided in the Integrated Performance Report presented to the 25 January 2017 Board meeting. National performance against the 4 hour target continues to be extremely challenged with performance of 88.4% in November 2016 (the latest month for which nationally published performance data are available); however, the RD&E performed well compared to other A&E providers in the country ending the month at 21st out of 138 organisations, with only 11 achieving the 95% standard.


62 day wait for first treatment (all cancers) The Q2 position was 79.0% compared to a target of 85%. In Q3 the position was 80.41%. Delivery of the cancer targets continued to be challenging. During Q3 there was an issue in the Breast Care Unit (BCU), as well as further challenges of medical staffing within Urology. An issue relating to the environment in the BCU led to a decision to close the Unit to all activity pending further investigation. As per its business continuity plan, the service was relocated temporarily, which resulted in appointment delays beyond the two week target timescale for a significant number of patients. The BCU reopened to full capacity on 23rd January 2017. It was forecast that the backlog would be cleared and waiting times reduced to 14 days by end of February 2017. Whilst the teams are working hard to clear the backlog of patients, there is likely to be an impact to later stages of the pathway for some patients, resulting in potential 62-day treatment breaches during the next two months. The BCU team are closely monitoring patient pathways and have provided assurance that patients’ outcomes have not been adversely effected as a consequence of the additional 1-2 weeks waiting time. The business continuity plan would also be reviewed to ensure any learning was taken. The outcome of this review would be presented to the Safety & Risk Committee. One further issue for the Council to be aware of was the unexpected cessation of the Dermatology Service at Taunton from 1st November 2016. This is likely to add pressure to the RD&E service as patients will be referred further afield. Somerset CCG is working closely with providers in Somerset, Devon and Bristol in order to provide the required capacity and manage patients safely. The Trust is supporting the CCG by offering available capacity; however, this is limited and has to be balanced against local pressures. The possible increase in dermatology patients could place pressure on the delivery of the 2-week wait, 31-day and 62-day cancer targets if it were to occur in significant volumes. Maximum time of 6 weeks from referral to key diagnostics At the end of September 2016 (Q2) there were 134 patients (equivalent to 2.5% of the waiting list) waiting longer than 6 weeks for a key diagnostic test, against a target of no more than 1%. This is 34 patients in excess of the Trust’s recovery trajectory for September of 1.7%. Diagnostic performance was challenged particularly in Endoscopy, Cardiac MRI and Urodynamics (44, 47 and 30 patients respectively). After the promising performance in November 2016 of 1.4% against a trajectory of 1.5%, the Trust continued to make improvements across a number of modalities in December 2016, including full clearance of the Urodynamics backlog and improvements in the number of patients awaiting sleep study, endoscopy and cardiac MRI. Unfortunately however, due to a problem with non-cardiac MRI, there were 119 patients (equivalent to 2.07% of the waiting list) waiting longer than 6 weeks for a key diagnostic test at the end of Q3 (of which 45 were for non-cardiac MRI). This was 33 patients in excess of the Trust’s recovery trajectory for December of 1.5%. Median average number of patients reportable as a delayed transfer of care (DTOC)


The volume of recorded patients awaiting onward care has reduced from the peak of 92 in July down to a daily average of 69 during September 2016. The average for Q3 was 79. Whilst there is not a specific target for DTOCs, the impact of patients medically fit to be discharged who occupy inpatient beds underpins the achievement of a number of key performance indicators, most notably the A&E 4-hour target. Consequently, a great deal of management attention has been placed on working with partner organisations to reduce DTOCs and increase the system capacity for community and domiciliary care. Within the wider health and social care system, there are a number of challenges in both the personal care market (domiciliary care) and the care home market, including the closure of a residential home in Exeter, which resulted in the reduction in 16 local care home beds. 18 Weeks Referral to Treatment Incomplete Pathways (RTT) The Trust achieved a position of 92.0% against the 92.0% target in Q2; however it did not achieve the target in Q3, with 91.7% achieved. The greatest challenges are within the Orthopaedics, General Surgery, Cardiology and Urology specialities. A detailed, specialty level review of RTT performance, identifying key barriers and actions for improvement took place in November 2016. These actions are currently being delivered across the Trust and will provide a positive benefit to RTT achievement. Clearly there is a risk that improvements will be offset by cancellations during Quarter 4 caused by winter pressures; however managers and clinicians remain focused on maximising performance against the RTT standard.


Workforce

Staff Turnover (metric: 10-12%) The aggregate annual staff turnover rate fell in December 2016 to 12.4% (13.5% excluding Community Services). The predominant staff groups driving turnover performance continue to be registered nurses and midwives, unregistered nursing and unregistered Allied Health Professionals (AHP) staff. The data below provides detail by the three staff groups split by acute and community settings:

Staff Group Excluding Community Including Community

Registered nurses and midwives

16.6% 14.9%

Unregistered nursing 16.3% 16.5%

Unregistered AHP staff 16.3% 10.1%

Of note is that registered AHP turnover has further reduced to 11.7% in line with Trust targets and the lowest turnover in this staff group for more than 12 months. The work of the Task & Finish Group is continuing and an update was provided to the Board at its January 2017 meeting. In addition to the three staff groups identified above, the Administration & Clerical staff group have the fourth highest turnover at 11.7% Across all four staff groups there are a range of root causes driving individuals to leave. For registered and unregistered nursing the main turnover challenge lies within the Medicine Division with root causes including the continual demand of caring for patients with complex needs and a higher proportion of newly qualified registered nurses (including those with a first language other than English). For the Administration & Clerical staff group, the perceived lack of opportunity for career progression and support (at entry level) are contributing factors to turnover for all staff. The focus of the Task & Finish Group was moving to developing an action plan for


implementation from February 2017 which will focus on reducing staff turnover and be monitored by the Workforce Governance Committee and reported to the Governance Committee. Overall, c.89% of staff (against a target of 90%) employed by the Trust 12 months ago are still in post today. During the last year of 705 new starters, 152 (21.5%) left within the first 12 months. However this is an improvement from the average of 24% in 2013/14 and consistent with other trusts responding to our data request that are currently reporting between 15% and 25%. Sickness Absence (metric: <3.5%) Sickness absence performance (excluding Community Services) for December 2016 decreased from 4.09% to 3.86% with the 12 month rolling rate at 4.12%. As Community Services do not use ESR (Electronic Staff Record) self-service we are unable to report on sickness absence in the same way – work is underway to identify a solution for this. Approximately 67% of the total absence recorded in December 2016 span five reasons: Mental health related illness 22.42% Musculoskeletal problems 15.69% Gastrointestinal problems 13.20% Cold, Cough, Flu & Influenza 10.57% Injury/fracture 5.43% In addition to the divisional and support function plans to reduce sickness absence, the Health and Wellbeing Plan has been expanded and is now delivering a wide range of initiatives to support the wellbeing of our staff.


Finance

Quarter 2 2016/17

Actual Planned

Net deficit -£0.9m -£4.1m

EBITDA (Earnings before interest, tax, depreciation and amortization)

£8.6m £5.4m

16/17 Cost Improvement Programme (CIP) achieved (YTD)

£5.1m £3.9m

Cash & cash equivalents £5.8m £6.4m

Financial sustainability risk rating 3 2

Governance risk rating Green

Quarter 3 2016/17

Actual Planned

Net deficit -£0.8m -£6.5m

EBITDA (Earnings before interest, tax, depreciation and amortization)

£13.4m £7.8m

16/17 Cost Improvement Programme (CIP) achieved (YTD)

£9.1m £7.7m

Cash & cash equivalents £15.3m £6.4m

Use of Resources 2 3

Governance risk rating Green

At Q2 the Trust incurred a deficit of £0.9m compared to a planned deficit of £4.1m. EBITDA at Q2 was £8.6m versus a plan of £5.4m. The year to date deficit was better than plan due to the actual profiling of reserves. Cash balances of £5.8m were £0.6m lower than originally planned. CIP at the end of September 2016 had over achieved the current year to date plan by £1.2m. £8.0m of savings have been achieved in the year against the target of £12.2m, of which £4.5m of these savings have been achieved on a recurrent basis against the target for the year of £12.2m. At quarter 3 the Trust incurred a deficit of £0.8m compared to a planned deficit of £6.5m. EBITDA at quarter 3 was £13.4m versus a plan of £7.8m. The year to date deficit was better than plan due to Income and Expenditure (I&E) reserves not being required in line with plan. The deficit is forecast to deteriorate in the final quarter of the financial year and is forecast to be similar to the planned deficit. This is mainly due to greater expenditure forecast to be incurred to meet planned activity. At the end of December the Trust achieved £9.1m CIP and is £1.4m overachieved against the year to date plan of £7.7m. The forecast CIP achievement is £14.6m


compared to the planned achievement of £11.5m. There has been a change in the forecast current year achievement due to the addition of the £2.4m Success Regime target relating to bed based care and planned care.

Single Oversight Framework (SOF) – Finance and Use of Resources NHS Improvement (NHSI) introduced a Single Oversight Framework (SOF), effective from 1st October 2016. The purpose of this framework is to provide one framework for overseeing providers, irrespective of their legal form; it should help identify potential support requirements; allows NHSI to tailor support packages to the specific needs of providers and is based upon the principle of earned autonomy. Finance and use of resources is one of the five themes included within the SOF. The finance and use of resources score is calculated using a series of financial metrics, with scores of 1 being rated the best and scores of 4 rated the poorest. The providers’ scores are averaged across all the metrics. Where providers have a score of 4 or 3 in the financial and use of resources theme, this will identify a potential support need under this theme. Capital Expenditure 2016/17 Year to date capital expenditure to December 2016 was £3.5m, in comparison to £7.6m per the plan submitted. Capital expenditure was therefore £4.1m (55%) lower than the budget. This was mainly due to a delay in procurement of X-Ray equipment (£1.9m) and delays in the estates infrastructure plans (£900k). Forecast capital expenditure for the year is £7.5m, compared to £12.4m per the plan, a reduction of £4.9m. The decrease in forecast expenditure relates to £5.7m of 2016/17 schemes that have been deferred to 2017/18 including £1.5m relating to the Catheter Lab and £3.3m of equipment schemes that are to be acquired with either a lease or loan funding. These have been deferred due to procurement lead times as a decision is still awaited on the loan application. This is partially offset by schemes slipped from 2015/16, and new charitable / grant funded schemes, totalling £767k, including £340k of expenditure for the 100K Genomes scheme. Leadership and Governance NHS Improvement (NHSI) On the basis of performance across Quarter 2, two NHSI targets were not achieved for the quarter:

Maximum Waiting Time of Four Hours from Arrival in A&E to Admission, Transfer or Discharge. The position for Q2 was 91.42% compared to a target of 95%.

62 day wait from GP Urgent Referral to Treatment. The Q2 position was 79.58% compared to a target of 85%.

Within NHS Improvement’s Risk Assessment Framework (in place until 30


September 2016), these two targets carried an aggregate weighting of 2.0 points. Both targets remain as key operational performance metrics within the Single Oversight Framework, which replaced the Risk Assessment Framework from October 2016. On the basis of performance across Quarter 3, four NSHI targets were not achieved for the quarter:

Maximum Waiting Time of Four Hours from Arrival in A&E to Admission, Transfer or Discharge. Performance including the Honiton Minor Injuries Unit of 92.4% in Q3, compared to a target of 95%.

62 day wait from GP Urgent Referral to Treatment. In Q3 80.41% of patients were treated within 62 days, compared to a target of 85%.

Patients waiting no more than 6 weeks for a key diagnostic test. In Q3 97.86% of patients waited no more than 6 weeks, compared to a target of 99%.

Maximum time of 18 weeks from point of referral to treatment in aggregate (Incomplete Pathways). Performance was 91.7% compared to the target of 92%.

Further detail is supplied in the Operational Effectiveness section of this report. Care Quality Commission (CQC) The CQC issued the Trust with a new Certificate of Registration to reflect the new services which the Trust now provides following the transfer of community services on 1st October 2016. Contract The total penalty risk for month 6 was £0k. The total penalty risk for month 9 was £13k, bringing the total penalty position for the year to date to £43k. The overall figure is much lower than in 2015/16 because some penalties no longer apply since the introduction of the Sustainability and Transformation Fund (STF). Achievement of the £10m STF for the Trust is dependent upon achieving performance and financial targets. An appeal to exempt the Trust from the loss of STF income linked with the achievement of performance targets for the A&E 4-hour wait and the 62-day cancer waiting times target has been successful in respect of cancer waiting times. A further appeal will be submitted in relation to performance in Q3 due to increases in referrals and demand for services beyond the organisation’s control. Duty of Candour There were 25 incidents involving patients graded with an actual impact of moderate, major or catastrophic closed between 1st April 2016 and the 30th June 2016. All incidents met the Duty of Candour requirements. Duty of Candour is reported to the Board of Directors quarterly in arrears. Of the 25 incidents, 21 were moderate, 2 were major and 2 were catastrophic.


Community Services Division As mentioned on page 1 of this Report, the Board of Directors was presented with Q3 data for the community hospitals at its January 2017 meeting. This is replicated for the Council below in relation to the areas of performance outlined earlier in this report. Patient Experience

Complaints & Concerns There were two complaints and concerns received during December 2016 in relation to community services which was a decrease from November 2016 (six). Both were acknowledged within 3 working days, maintaining the high level of performance from both October and November 2016. Cases referred to the Parliamentary Health Service Ombudsman (PHSO) No cases were opened for review by the PHSO in relation to community services in December 2016. It has been agreed that any cases open at the time of transfer will be responded to by Northern Devon Healthcare NHS Trust. Clinical Effectiveness

VTE Risk Assessment and Proportion of Appropriate Patients receiving Thromboprophylaxis In December, 97.9% of inpatients in community hospitals were risk assessed for VTE. Of these patients, 87.6% who required thromboprophylaxis to be administered were documented as having received it. Operational Effectiveness Due to nationally mandated reporting requirements, the position reported within the main fabric of this report represents a full Trust wide position in respect of the key performance metrics. The following metrics reflect key occupancy and length of stay indicators for the community hospitals. Length of stay for patients occupying community hospital beds has been omitted for October 2016. This is due to the recorded hospital spell length being artificially lowered as a consequence of patients transferring onto the


RD&E Patient Administration System (PAS) on the 1 October 2016.

Workforce Sickness Absence As Community Services do not yet use ESR self-service we are unable to report on sickness absence in the same way as for staff working in the acute services. Work is underway to identify a solution for this.


Board focus during Q2 and Q3 2016/17 This section provides an overview of some of the performance issues that were discussed by the Board during the second and third quarters of 2016/17. The Board looked in detail at the Trust’s performance during the Quarter both in the discussions around the Integrated Performance Reports but also in relation to other items on the Board’s agenda.

Throughout both quarters the Board discussed the Success Regime and the Devon Wide Sustainability and Transformation Plan (STP). This include sessions at both its July and August 2016 meeting

The Board focussed on the Eastern Community Services transfer in Q2, receiving regular updates and approving the transfer at its August 2016 meeting.

The Board received a detailed presentation on Delayed Transfers of Care (DTOC) at its August 2016 meeting.

A review of the Trust’s Corporate Strategy began in Q2, with the Board receiving regular updates, including a session at September 2016 Board. Its development day in October 2016 focussed on the corporate strategy before the both the Council of Governors and Board received an update at the joint Development Day on 5 December 2016, with the Council then discussing it further in its own afternoon session.

In conjunction with the Corporate Strategy refresh, a review of the Trust’s Clinical Services Strategy began in September 2016, with an update provided to the Board at its September 2016 meeting and the December 2016 Development Day.

As the host Trust, the Board approved the Annual Report 2015/16 and Annual plan 2016/17 for the NIHR Clinical Research Network (CRN): South West Peninsula at its July 2016 meeting.

At its July 2016 meeting, the Board approved the Infection Prevention and Control Annual Report 2015/16 and the Infection Prevention and Control Programme for 2016/17. In addition the Board discussed ensuring the Trust promotes its achievements in this area.

The Board approved the Research & Development Annual Report 2015/16 at its September 2016 meeting. The report informed the Board of the activity and achievements of research and development during 2015/16, including the impact of research at international and regional level as well as translation into patient care within the Trust

Implementation of NHS Productivity and Efficiency (Lord Carter) Procurement recommendations (also known as the Carter Review) – the Board discussed these recommendations at its September and October 2016 meetings. One of the Carter Review requirements was the creation of a Procurement Transformation Plan (PTP) for each acute Trust, to be submitted to NHS


Improvement (NHSI) by the end of October 2016. The Board reviewed and approved the Trust’s PTP at its September 2016 meeting. At its October meeting it received an update on progress against all the recommendations in the Carter Review.

The Board received a report at its October 2016 meeting on the Trust’s self-assessment of compliance with the NHS England Core Standards for Emergency Preparedness, Resilience and Response. The Board endorsed the self-assessment ahead of its submission to the NEW Devon Clinical Commissioning Group by 31 October 2016.

Throughout the period the Board received and discussed the monthly Integrated Performance Reports, the quarterly Ward to Board report and the routine reports from the Audit and Governance Committees.

The Board heard at its October 2016 meeting that the Trust had been successful in its bid to be a pilot site for Nurse Associate roles. The Trust had bid through NHS Education England and was one of only 11 successful sites.

The Board met as the Corporate Trustee in November 2016 to receive and approve the Annual Report and Accounts 2015/16 of the RD&E Charity.

The Board received, discussed and endorsed the 2016/17 Operational Capacity and Resilience Plan. It was appraised of the changes in approach to bed capacity in the plan and assured that robust plans were in place to manage anticipated demand for inpatient beds. The Council of Governors also received a presentation on the Plan at the 5 December 2016 Development Day.

Update on the Governor Quality priorities for 2016/17 At the time of writing, an update on mental health services (focussing on children and young people) was planned for the afternoon session of the 17 February 2017 meeting.


NHS Improvement (NHSI) Dashboard The following table provides a summary of the service performance indicators that NHSI examines as part of its Single Oversight Framework, which was in place from 1 October 2016. The table focuses on performance against target for Q2 and Q3 2016/17 (July to December 2016) and the risk inherent against the target for the quarter as declared at the start of the quarter.

Please also note that the Trust is now required to report monthly on the targets below rather than quarterly.

NHSI Indicators Position at end of Q3 2016/17 Dec 2016

Previous Position at end of Q2 2016/17 Sept 2016

Target for the year 2016/17

Risk for quarter

A&E 4hr waiting (includes Walk in

Centre in Q2 and the Honiton MIU in Q3)

92.4% (2033 of 26761)

91.4% (2601 of 30321)

95% High

Referral to Treatment Incomplete Pathways

91.7% (6070 of 73191)

92.0% (5447 of 68415)

Minimum 92% in 18

weeks High

62 day 1st treatment (all cancers) GP urgent referral

80.41% (95 of 485)

79.00% (96.5 of 459.5)

85% High

62 day 1st treatment (all cancers) Consultant Screening Service Referral

90.91% (5.5 of 60.5)

92.2% (5.5 of 70.5)

90% Medium

Maximum time of 6 weeks from point of referral to key diagnostic test

97.86% (367 of 17162)

97.31% (430 of 15963)

99% High

Although not a mandated NHSI performance metric, Governors had previously requested Cancelled Operations Data and this is below.

Position at end of Q3 2016/17 December 2016

Previous Position at end of Q2 2016/17 Sept 2016

Target Risk for Quarter

Cancelled Operations*

0.6% (114 of 18497)

0.2% (40 of 19025)

1.5%

*Total of same day cancellations as a proportion of all elective admissions. As not a NHSI target no risk rating is assigned.


Appendix 1 COUNCIL OF GOVERNORS PAPER Meeting date: 22 April 2016

Agenda item: 8.1, Public

Title: PROPOSED AMENDMENTS TO THE PERFORMANCE REPORT AND TIMING OF COG MEETINGS

Purpose: To make a proposal to amend the timing and contents of the Governors’ Performance Report.

Background: The Effectiveness Working Group has reviewed the timing and content of the Governor Performance report to ensure it is fit for purpose as it is a key resource for Governors in undertaking their role of holding the NEDs to account for the effective performance of the Trust Board.

Key Issues: Review of CoG Performance Report (PR) Timing of the PR The timing of the report has always been problematical because it is four months old by the time it is presented to CoG, due mainly to the time it takes Monitor to issue its formal response to the Trust’s performance over that Quarter. For example, the January 2016 PR referred to Quarter 2 (July to September) 2015. The Trust has always tried to ensure that the presentation of the report reflects the latest position on key issues. The CoG Effectiveness Group believe that the timing of future CoG meetings needs to change to align them closer to the end of each respective Quarter and a proposal is set out in the table below. The PR Review sub-group felt that the absence of a Monitor feedback response for the Quarter in question was not essential for CoG to take a view on the performance of the Board because it does not normally add anything further to the information included within the PR. The exception would be if Monitor decided to take regulatory action, but again, this would be flagged in the PR. The Monitor dashboard traffic light section should remain.

Current CoG Date and Quarter under review

Proposed new CoG Date and Quarter under review

October Q1 November Q2

January Q2 February Q3

April Q3 June Q4

July Q4 August Q1

The Group acknowledge that the proposed August meeting date is a time when some senior staff/Executives take annual leave but September is a time when many Governors take holidays and is also a very busy month with appraisals and preparation for the AMM/Members Say event. Content of the PR The PR is an amalgam and summary of the three, separate, Integrated Performance Reports (IPR) reported to the Board during the Quarter period in question. A sub-group of


the Effectiveness Group has reviewed the information presented to the Board and tried to assess how much of it is really relevant or needed by the CoG, bearing in mind its role is to monitor the Board’s performance rather than to supervise the Board’s efforts. We have sought to ensure that the information presented to CoG is readily available from the Trust and that no further resources are needed to provide additional information. Each of the topics, listed in the Board IPR, was assessed in turn to decide what aspects of each, if any, were likely to be of interest to CoG. The results of this are listed below.

Main Heading Topic Aspects of interest to CoG over the Quarter with Board response where relevant

Patient Experience

Complaints Number of complaints and compliments; Number reported to Ombudsman. CQUAT/OQUAT numbers to be reported on by governor members of the PEC where appropriate. Retain the “spark” chart

Safety & Safe Staffing

Safe Staffing Levels

Confirmation that “safe staffing” levels are maintained or details of breaches.

Mortality Indicator

Rolling 12 month SHMI – Any “red” items to be flagged

Safety Concerns

Report concerns only

Never Events No. for Quarter, if any

Clinical Effectiveness

Monitor Dashboard

With reference to the Traffic-light chart, highlight any red or persistent amber areas with narrative

Anti-microbial Stewardship

Departures from compliance only

Operational Effectiveness

Traffic Light Headings

With reference to the Traffic-light chart, highlight any red or persistent amber areas with appropriate narrative

Workforce Staff Turnover Rates & generic reasons behind them

Sickness Long term sickness rate

Finance Summary Table As per the current CoG finance report

Capital Report at start of year identifying principal capital schemes and quarterly report identifying those projects being delayed.

Leadership & Governance

Regulatory & Contract Position

Retain Monitor traffic-light charts plus concerns narrative List quarterly & YTD penalties

CQC Any CQC interventions/reports

Duty of Candour

No. of incidents & narrative explanation

Hindsight What could have been done better

Governor Priorities

Current Topics Regular report to CoG on actual progress rather than a reiteration of the priorities.

Any confidential issues may need to be reported during the confidential part of the CoG agenda, especially where they may include litigation or references to the ombudsman which could prejudice the outcome of such referrals. The review group recommend that the changes to the content of the PR suggested


above should be adopted as soon as possible if they are agreed by CoG; initially as a trial to see how they work in practice, and that they are kept under review to ensure they remain relevant to the needs of CoG. The changes to timings of meetings would take effect from the beginning of 2017 so that the meetings already booked for the rest of this year remain in place.

Recommendation: That the Council of Governors approves the proposed amendments to the timing of CoG meetings and the content of the Performance Report.

Presented by: Richard May, Lead Governor


Appendix 2 Examples of ‘Demonstrating Difference’ taken from the Board of Directors Integrated Performance Reports in Q2 and Q3 2016/17. The following are examples of where patient feedback has led to a service development or change. These changes may have been prompted either from an individual patient complaint or concern, a patient story, or from an identified theme within patient feedback. Medical Services Dermatology has developed local services run by GPs with special interest to deliver skin cancer clinics. These are run in the local community and provide integrated care for patients. Those who require more complex care are referred to RD&E for surgery or on-going treatment. The initiative has been nominated for a General Practice award and Dr Noel Lawn and team have been shortlisted. Medical Services (Tiverton) Following feedback from relatives about a lack of facilities to support interaction with patients with dementia, a number of changes have been implemented, including refurnishing the day room with new furniture, books, games and puzzles etc. The local team have also arranged visits to the museum and Morrison’s café, as well as arranged visits by the school choir, local band, and craft sessions. The work has been responded to positively by patients and relatives and the community services will consider how this can be rolled out following transfer. Specialist Services Diagnostics Following feedback from patients who displaced valuable items during assessment, e.g. hearing aids, the medical imaging team have reviewed its practices in relation to personal possessions to ensure notes are kept when patients have to remove these items for their diagnostic procedure. Neonatal A concern was raised by the parents regarding availability of vegetarian formula, for a baby whose mother was unable to express milk. A discussion was held with the family and the NNU senior nurse, matron and the infant feeding co-ordinator. The care plans and guidance have been reviewed to ensure that information for vegetarians and other cultural and dietary considerations are included. Surgical Services Division Head & Neck Clinical Nurse Specialist (CNS) Team The team have worked with FORCE and Macmillan who have provided funding for the service to set up an ‘Aquather Service’ for patients across the UK enabling laryngectomy patients with an altered airway to be able to swim. Fourteen patients have been trained to swim using a snorkel and a mouthpiece which enables them to swim above and under the water. The National Association of Laryngectomy Clubs (NALC) which acts as an umbrella organisation for all laryngectomy clubs throughout


the UK has endorsed this service, and following discussions with Club President Malcolm Babb, will act as a source of referral for any enquiries they receive The Aquather Service is open to all residents in the UK and specialist nurses and speech therapists across the UK have been very supportive of this service and have assisted patients in becoming competent in tube self-insertion prior to receiving training by the CNS team. Feedback so far has been extremely positive with stories of swimming with grandchildren for the first time, increased health benefits, improved quality of life and momentous holidays. Princess Elizabeth Orthopaedic Centre (PEOC) Previously an increase in demand for appointments and complexity of cases meant that clinics often over ran resulting in patients waiting for long periods of time. There were also a large number of patients awaiting routine review due to capacity issues. The service introduced virtual clinics conducted by a nurse practitioner to enable some patients to be reviewed more quickly. In addition patients are able to be seen by their local hospital for x-ray appointments at which time they complete an assessment form which is later reviewed by a Surgical Care Practitioner; the results are then sent to the patient and their GP. These changes have improved the overall service and resulted in reduced waiting times for patients. Consideration is now being given to expanding these innovations to other services. Community Services Division Demonstrating Difference As part of the embedding of the Divisional Performance Review Process, the Division will be invited to share examples of where feedback from service users has led to a service improvement or change, at their Performance Review meetings each month. The inaugural meeting took place in December 2016, and a meeting schedule has been established running throughout 2017 and beyond. Examples of “Demonstrating Difference” will be routinely incorporated within the Board’s Integrated Performance Report and therefore to the Council.

31 August 2016 Mrs Suzanne Tracey Acting Chief Executive Royal Devon and Exeter NHS Foundation Trust Barrack Road Wonford Exeter EX2 5DW

Dear Mrs Tracey Q1 2016/17 monitoring of NHS foundation trusts Our analysis of your Q1 submissions is now complete. Based on this work, the trust’s current ratings are:

Financial sustainability risk rating: 3

Governance rating: Green These ratings will be published on NHS Improvement’s website in September.

NHS Improvement is the operational name for the organisation which brings together Monitor and the NHS Trust Development Authority. In this letter, “NHS Improvement” means Monitor exercising functions under chapter 3 of Part 3 of the Health and Social Care Act 2012 (licensing), unless otherwise indicated. The trust has failed to meet the A&E four-hour wait performance target for the last three

quarters that has triggered consideration for further regulatory action.

NHS Improvement uses the above target (amongst others) as indicators to assess the

quality of governance at foundation trusts. A failure by a foundation trust to achieve the

targets applicable to it could indicate that the trust is providing health care services in

breach of its licence, which could lead to consideration of enforcement action1.

We expect the trust to address the issues leading to the target failure and achieve

sustainable compliance with the target promptly, and in line with its submitted improvement

trajectory.

NHS Improvement has decided not to open an investigation to assess whether the trust could be in breach of its licence at this stage. The trust’s governance rating has been

1 Under the Health and Social Care Act 2012, taking into account, as appropriate, our published guidance on

the licence and enforcement action including our Enforcement Guidance (www.monitor-nhsft.gov.uk/node/2622) and the Risk Assessment Framework (www.monitor.gov.uk/raf).

Wellington House 133-155 Waterloo Road London SE1 8UG T: 020 3747 0000 E: [email protected] W: improvement.nhs.uk

http://www.monitor-nhsft.gov.uk/node/2622

http://www.monitor.gov.uk/raf

reflected as ‘Green’. Should any other relevant circumstances arise, NHS Improvement will consider what, if any, further action may be appropriate. A report on the aggregate performance of all NHS providers (Foundation and NHS trusts) from Q1 2016/17 is available on our website (in the Resources section), which I hope you will find of interest. For your information, we have issued a press release setting out a summary of the report’s key findings. If you have any queries relating to the above, please contact me by telephone on 02037470192 or by email ([email protected]). Yours sincerely

Justin Collings Senior Regional Manager cc: Mr James Brent, Chair,

Mr Paul Southard, Acting Director of Finance

Documents

COUNCIL OF GOVERNORS...Performance Report Council of Governors 17 February 2017 Page 3 of 24 Indicator Target Month Overall Oct 2016 Nov 2016 Dec 2016 For Q3 16/17 (previous Q) Number