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1
North Bristol NHS Trust
INTEGRATED PERFORMANCE REPORT
February 2018 (presenting January 2018 data)
2 2
CONTENTS
CQC Domain / Report Section Sponsor / s Page
Number
Performance Dashboard and Summaries
Director of Operations
5 Medical Director
Director of Nursing
Director of People and Transformation
Responsiveness Director of Operations 11
Safety and Effectiveness
Medical Director 25
Director of Nursing
Quality Experience Director of Nursing 39
Facilities Director of Facilities 45
Well Led
Director of People and Transformation 47
Medical Director
Finance Director of Finance 57
Regulatory View Chief Executive 62
3 3 Report Key
Target lines
Improvement trajectories
Performance improved
Performance maintained
Performance worsened
54
6
Unless noted on each graph, all data shown is for period up to,
and including, 31 January 2018.
All data included is correct at the time of publication.
Please note that subsequent validation by clinical teams can alter
scores retrospectively.
Abbreviation Glossary
ASCR Anaesthetics, Surgery, Critical Care and Renal
CCS Core Clinical Services
CEO Chief Executive
Clin Gov
GRR
Clinical Governance
Governance Risk Rating
HoN Head of Nursing
IM&T Information Management
Med Medicine
NMSK Neurosciences and Musculoskeletal
Non-Cons Non-Consultant
Ops Operations
RAP Remedial Action Plan
RCA Root Cause Analysis
WCH Women and Children's Health
NBT Quality Priorities 2017/18 QP1 Improving theatre safety
QP2 Reducing harm from pressure injury
QP3 Reduction of infections arising from indwelling
devices
QP4 Learning from deaths in hospital and improving
end of life care
QP5 Improving the care of patients whose condition
is at risk of deteriorating
QP6 Enhancing the way patient feedback is used to
influence care and service development
4 4 EXECUTIVE SUMMARY
January 2018
ACCESS
January’s position against the 4 hour standard was 75.11%, which although below trajectory, is an improved performance compared to December 2017
(70.26%). The majority of breach reasons were attributable to a wait for beds, with admissions higher than expected, not matched by discharge volumes. The
Trust continues to implement its emergency care improvement plan with a focus on reducing stranded patients and supporting the principle of ‘Home is Best’.
The Trust has not met the agreed recovery trajectory for Referral To Treatment (RTT) incomplete performance for January (86.30% vs trajectory of
87.77%). The waiting list backlog stands at 3758 vs a target of 3428. The Trust has experienced a decrease in patients waiting greater than 52 weeks from
Referral to Treatment (RTT) (55 in January vs 59 in December).
The Trust has achieved the national target (1.00%) for diagnostic performance with actual performance of 0.62% in January. This improvement from the
December position (2.06%) brings the Trust to the best reported performance since October 2015 and is reflective of the successful delivery of the DEXA Scan
remedial action plan.
The Trust has delivered 4 of the 7 national cancer targets in December. The 62 day standard was exceeded in December with performance at 85.71%
vs the 85.00% standard. Two Week Wait has achieved standard with performance of 94.50% confirming the successful delivery of the remedial action plan
and subsequent closure of the Contract Performance Notice.
SAFETY
Nursing staff levels continue to be monitored closely, but two wards triggered the Quality Effectiveness and Safety Trigger Tool (QuESTT) in January.
Recruitment to vacancies in these areas are underway and unfilled shifts are closely monitored to ensure safety is maintained.
Incidence of pressure ulcers in January were 15 reported Grade 2 pressure injuries, 4 reported Grade 3 and nil reported at Grade 4. The Trust remains
on target to achieve a 50% reduction of pressure injuries over the three year period, April 2015 - March 2018.
The Trust reported 1 Case of MRSA in January. This was a complex case colonised prior to admission. The Trust reported 2 cases of C. Difficile in
January.
PATIENT EXPERIENCE
The number of overdue complaints has risen in January to 39 from 27 in December. Friends and Family response rates have seen an increase in three
of the four areas with a decrease reported in inpatient response rates. NHS Choices ratings for both Southmead Hospital and Cossham Hospital are
both 4.5 stars.
WORKFORCE
The Trust vacancy factor increased from 6.8% in December to 7.00% in January. Agency expenditure increased in January to £700k and is above
NHSI target levels (£469k). The in-month sickness rate in December was 4.25%, remaining stable from November and remaining above the 4.05% target
submitted to NHSI for the month.
FINANCE
The Trust has planned a deficit of £18.7m for the year in line with the agreed control total with NHS Improvement. The financial position for the end of
January is £4.2m adverse to plan. The Trust is currently rated 3 by NHSI.
5
Target
92% 86.30% 87.77% 6 87.10% (Q2 2017/18) - 87.68% (Q3 2017/18) 53758 3428 6 3719 (Q2 2017/18) - 3461 (Q3 2017/18) 5
90% 75.11% 5 76.28% (Q2 2017/18) - 77.32% (Q3 2017/18) 512 Hour Trolley Waits 0 107 5 3 (Q2 2017/18) - 47 (Q3 2017/18) 6
Neurosurgery and Epilepsy 0 5 0 5 5 (Q2 2017/18) - 2 (Q3 2017/18) 5MSK 0 32 15 5Ortho-Spinal 0 8 0 4Other 0 10 N/A* 5 66 (Q2 2017/18) - 13 (Q3 2017/18) 5
1% 0.62% N/A* 5 4.83% (Q2 2017/18) - 2.38% (Q3 2017/18) 5Same day - non-clinical reasons 0.8% 1.73% 6 1.45% (Q2 2017/18) - 1.97% (Q3 2017/18) 628 day re-booking breach 0 12 6 6 3 (Q2 2017/18) - 5 (Q3 2017/18) 6
95% 101.52% 6 98.85% (Q2 2017/18) - 98.66% (Q3 2017/18) 56910 6 6816 (Q2 2017/18) - 6971 (Q3 2017/18) 6
2.50% 5.04% 6 4.86% (Q2 2017/18) - 4.04% (Q3 2017/18) 593% 94.50% 6 91.52% (Q2 2017/18) - 94.64% (Q3 2017/18) 593% 93.15% 6 94.95% (Q2 2017/18) - 96.90% (Q3 2017/18) 596% 96.12% 6 97.72% (Q2 2017/18) - 97.18% (Q3 2017/18) 694% 87.18% 5 95.92% (Q2 2017/18) - 85.67% (Q3 2017/18) 698% 100.00% 4 100.00% (Q2 2017/18) - 100.00% (Q3 2017/18) 485% 85.71% 86.60% 6 90.18% (Q2 2017/18) - 87.00% (Q3 2017/18) 690% 86.96% 5 97.14% (Q2 2017/18) - 88.17% (Q3 2017/18) 6
0 0 4 1 (Q2 2017/18) - 1 (Q3 2017/18) 497.34% 6 97.71% (Q2 2017/18) - 98.04% (Q3 2017/18) 5
95% 97.20% 5 95.83% (Q2 2017/18) - 95.70% (Q3 2017/18) 695% 94.00% 6 97.67% (Q2 2017/18) - 96.37% (Q3 2017/18) 6
Grade 2 QP2218
2017/1815 6 39 (Q2 2017/18) - 39 (Q3 2017/18) 4
Grade 3 QP20
2017/184 6 2 (Q2 2017/18) - 1 (Q3 2017/18) 5
Grade 4 QP20
2017/180 4 0 (Q2 2017/18) - 0 (Q3 2017/18) 4
0 1 6 1.21 (Q1 2017/18) - 1.83 (Q2 2017/18) 660
2017/186 6 22 (Q2 2017/18) - 41 (Q3 2017/18) 6
432017/18
2 5 10.92 (Q1 2017/18) - 11.00 (Q2 2017/18) 619
2017/183 6 7.28 (Q1 2017/18) - 9.17 (Q2 2017/18) 6
95% 95.30% 5 95.40% (Q2 2017/18) - 95.19% (Q3 2017/18) 6Emergency Department QP6 88.42% 5 84.49% (Q2 2017/18) - 87.08% (Q3 2017/18) 5Inpatient QP6 92.62% 5 91.62% (Q2 2017/18) - 90.88% (Q3 2017/18) 6Outpatient QP6 93.78% 6 93.38% (Q2 2017/18) - 93.81% (Q3 2017/18) 5Maternity (Birth) QP6 95.12% 5 92.81% (Q2 2017/18) - 90.44% (Q3 2017/18) 6% Overall Response Compliance 100.00% 5 65.30% (Q2 2017/18) - 74.18% (Q3 2017/18) 5Complaints acknowledged in <3 days 95% 70.00% 6Overdue <10 39 6 26 (Q2 2017/18) - 29 (Q3 2017/18) 6
£469 £700 6 £507 (Q2 2017/18) - £469 (Q3 2017/18) 53.80% 7.00% 6 8.20% (Q2 2017/18) - 6.50% (Q3 2017/18) 51.10% 1.20% 5 1.50% (Q2 2017/18) - 1.40% (Q3 2017/18) 54.05% 4.25% 4 4.07% (Q1 2017/18) - 4.37% (Q2 2017/18) 6
85.00% 84.48% 5 82.27% (Q2 2017/18) - 85.06% (Q3 2017/18) 590%
Nov. 201766.43% 6 46.86% (Q2 2017/18) - 66.03% (Q3 2017/18) 5
£18.7m2017/18 6
5
Description
C. Difficile
Bed Occupancy
Patients seen within 2 weeks of urgent GP referral
Patients with breast symptoms seen by specialist within 2 weeks
Trust Wide Referral to Treatment Backlog
Diagnostic DM01 - % waiting more than 6 weeks
Patients receiving first treatment within 31 days of cancer diagnosis
Patients waiting less than 31 days for subsequent surgery
E. Coli
Access Standard
Re
spo
nsi
ven
ess
- C
ance
r (I
n a
rre
ars)
Cancelled Operations
ED 4 Hour Performance
Stranded Patients (LoS >7 days)
Delayed Transfers of Care (DToC)
Patients waiting less than 31 days for subsequent drug treatment
Patients receiving first treatment within 62 days of urgent GP referral
Patients treated within 62 days of screening
We
ll L
ed In Month Turnover
In Month Sickness Absence (In arrears)
Trust Mandatory Training Compliance
Non - Medical Annual Appraisal Compliance
Agency Expenditure ('000s)
Month End Vacancy Factor
Fin
ance Deficit (£m)
NHSI Trust Rating
Qu
alit
y P
atie
nt
Safe
ty a
nd
Eff
ect
ive
ne
ssQ
ual
ity
Exp
eri
en
ce
Pressure Injuries
FFT - % Would
recommend
Complaints
MSSA
Venous Thromboembolism Screening (In arrears)
Never Event Occurrence by Month
Safety Thermometer - Hospital Compliance
WHO Checklist Compliance QP1
Hand Hygiene Compliance
MRSA
Quarterly
performance
direction of travel
Re
sp
on
siv
en
es
s
Referral to Treatment - % incomplete pathways <18 weeks
Referral to Treatment
52 Week Waits
IPR
section
January 2018
Key Operational Standards Dashboard
Performance against
Target
Performance against
NBT Trajectory
Performance
direction of travel
from last month
Quarterly Performance
6 6 RESPONSIVENESS
SRO: Director of Operations
Overview Urgent Care
January’s position against the 4 hour standard was 75.11%, which although below trajectory, is an improvement to the reported performance of December
2017 (70.26%). The performance was directly attributable to the increase in emergency admissions experienced during the month with an inability to
discharge patients at the level required to meet the periods of surge. Occupancy therefore remained a significant impairment to supporting timely flow
through the hospital and resulted in a significant number of patients waiting over four hours for transfer into the admission unit. An emergency care
improvement plan is being revisited by the Trust and the System, focusing on reducing stranded patients through addressing unnecessary delays in a
patient’s pathway and also supporting the principle of ‘Home is Best’. This plan is expected to result in more effective flow through the hospital to support
sustained improvement against this target by Quarter 1 2018/19.
Referral to Treatment (RTT)
In month, the Trust has not achieved the Trust RTT trajectory of 87.77%, with actual performance at 86.30% which was impacted by the National directive
to cancel non-urgent operations as part of the winter resilience planning. The number of patients exceeding 52 week waits in January were 55 (the
majority of which (32) were due to capacity issues within MSK). The Trust is delivering against a remedial action plan specifically focusing on the
challenged sub-specialties within MSK.
Cancelled Operations
In month, there were twelve breaches of the 28 day re-booking target. Ten of these breaches were patients who were cancelled during December and
unable to be rebooked within 28-days.
Diagnostic Waiting Times
The Trust has achieved the 1.00% target for diagnostic performance for the first time this year in January with actual performance at 0.62%. This
improvement is the Trust’s best reported level since October 2015 and is reflective of the successful delivery of the DEXA Scan remedial action plan.
Cancer
Cancer performance in December has achieved four of the seven standards. The Trust has met and exceeded the 62 day standard at 85.71% (Target
85.00%). Two Week Wait urgent GP referrals standard has been met at 94.50%, Commissioners have closed the Contract Performance Notice in relation
to this standard. Two Week Wait Breast has exceeded standard in December with performance of 93.15%. The three standards that have missed the
national targets in December 2017 are: 31 days from diagnosis to first treatment; 31 day subsequent treatment (Surgery); and 62 day screening.
Areas of Concern
The system continues to monitor the effectiveness of all actions being undertaken, with daily and weekly reviews. The main risks identified to the Urgent
Care Recovery Plan (UCRP) are as follows:
• UCRP Risk: Lack of community capacity and/or pathway delays fail to meet bed savings plans as per the bed model.
• UCRP Risk: Length of Stay reductions and bed occupancy targets in the bed model are not met leading to performance issues.
7 7
QUALITY PATIENT SAFETY AND EFFECTIVENESS
SRO: Medical Director and Director of Nursing
Overview
Improvements
The positive increase in incident reporting following the implementation of Datix is continuing with a decrease in serious incidents and an increase in
incidents resulting in minor or no harm.
Areas of Concern
There was an increase in hospital acquired pressure ulcers in January with an increase in grade 2 pressure ulcers and four grade 3 pressure ulcers
affecting three patients. This has reduced the harm free care rating for the trust.
Hand hygiene has fallen below the Trust standard (94% vs 95% requirement) for the first time in a year which may reflect the pressures on ward care during
January.
8 8 QUALITY EXPERIENCE
SRO: Director of Nursing
Overview
Improvements and Actions:
Overdue complaints remain of concern, work continues to bring the residual number overdue to ten or less. Additional resource is in place to support ASCR
and to address areas with high volumes of patients to ensure complaint responses are more timely. There is a new Director of Midwifery in post who is
already addressing their overdue complaints and working on a patient experience improvement plan.
A programme of work is underway to address poor performance in percentage that recommend. Our strategic aim is to achieve 95% would recommend and
some improvement is noted already for January’s data.
9 9 WELL LED
SRO: Director of People and Transformation
Overview Resourcing
Nurse / HCA Recruitment
Work continues between NBT and Cohesion on a proactive recruitment campaign for HCA and nurse vacancies. Since the start of the campaign the Trust
has offered and had accepted 193 HCA candidates’ and 26 registered nurse candidates.
Our prioritised activity is now focused on Band 5 experienced qualified nurses in terms of both recruitment and retention.
Sickness
Short term sickness due to “Anxiety/stress/depression/other psychiatric reason” saw a 24% reduction in reason for absence. It remains the top reason for
long term sickness with a slight increase in December. Our staff health and well being initiatives are in place to specifically support management of anxiety
and stress.
Agency Spend
Month three of the neutral vendor contract to supply nursing agency staff remains challenging and this remains under review to identify changes to improve
performance. The bank team continue to work closely with DePoel (neutral vendor) and have met with suppliers to work together to improve the fill rates.
Trends
Trust compliance in mandatory and statutory training remains on target during the period of postponed face to face training to support winter pressures.
In month turnover decreased in January 2018 compared with December, however the rolling 12 month position increased with the Trust seeing an increase in
voluntary turnover from 12.5% to 12.74%.
Areas of Concern
Worked WTE and pay expenditure increased in January. The largest increase was in bank usage which increased by 16.7% in terms of worked WTE and
14.3% in terms of expenditure. The biggest increase was in Medicine with an additional 50 WTE used in January. This represents over half of the Trust’s
increase for December. The additional usage is linked to the escalation areas currently open within Medicine. Our experienced Band 5 nurse workforce is an
area of concern.
10 10 FINANCE
SRO: Director of Finance
Overview
The Trust has a planned deficit of £18.7m for the year in line with the control total agreed with NHS Improvement.
• At the end of January, the Trust is reporting a deficit of £21.1m compared with a planned deficit of £16.9m, £4.2m adverse to plan.
• The adverse variance is wholly driven by loss of Sustainability and Transformation Funding (STF) of £2.7m related to non-delivery of A&E performance
trajectories. This does not preclude the Trust from receiving the element of STF dependent on financial performance as NHS Improvement measure
delivery of control total on the position excluding STF. However, this month the pre-STF position has deteriorated to £1.4m adverse to plan. The control
total excluding STF needs to be achieved.
• Non-pay (excluding finance costs) was £2.1m favourable, whilst pay is £5.5m adverse to plan and income excluding donations is £0.1m adverse to
plan..
• Savings delivery was £6m less than required in the year to date. The planned increase in savings each month has now been achieved but needs to be
sustained.
• The main areas of concern relates to the level of elective activity income against planned levels as well as savings delivery which is behind plan. This
is despite the fact that the overall financial plan profile reflected a savings profile that is lower in the first half of the year.
• The Trust has ended the month with £12.8m cash after receipt of £2.8m loan financing from the Department of Health to support the ongoing deficit.
• Capital expenditure was £10.4m for the year to date against a plan of £13.3m.
• The Trust is rated 3 by NHS Improvement (NHSI).
Key areas of concern:
• Continued focus on delivering the full savings required as well as full delivery of planned activity and income for the remainder of the year will be
crucial to ensure delivery of the Trust’s control total. Ongoing operational pressures continue to challenge the delivery of financial targets.
11 11
RESPONSIVENESS
Board Sponsor: Director of Operations
Kate Hannam
12
Responsiveness - Board Sponsor: Director of Operations
Overview of Urgent Care
Although overall ED attendances in
January were in line with the previous
three months, acuity remained high with
majors patients equating to 60% of all
ED attendances vs. an average of 54%
year to date.
Admissions for Medicine were higher
than predicted in January which
resulted in occupancy levels at above
100% for the majority of the month.
The inability to match discharges to the
surges in flow resulted in 25% of
patients waiting more than four hours in
ED and the challenges for timely
transfer from the ED to the wards
continued to be a major contributor to
the reasons patients were waiting in
excess of the four hours.
13
Responsiveness - Board Sponsor: Director of Operations
Majors / Minors
The number of minors patients
treated within the four hour target in
January returned to above 95% at
97.09%, despite the overall pressure
on the department.
Majors performance for January was
61.14% and was directly attributable
to the surges in demand and the
inability to pull patients out of the
department in a timely way.
4 Hour Breaches
The primary cause of delays
continues to be waiting for transfer to
the admission unit. This is directly
linked to the lack of flexibility to meet
surges in demand due to operating at
100%+ occupancy within the main
admission wards.
14
Responsiveness - Board Sponsor: Director of Operations
12 Hour Trolley Waits
There were 107, 12 hour trolley
breaches in January. All breaches
have had the initial 24hr clinical
review with a follow up review at two
weeks to establish the harm levels.
The Trust’s governance process will
report on any findings. One of the
breaches in month was associated
with a wait for a specialist mental
health bed.
Ambulance Handovers
Ambulance attendances at NBT are
up 6.67% year to date when
compared to 2016/17. In month
surges in attendances has resulted in
delays against the 15 minute
handover target. There were no 60
minute breaches in month despite on-
going winter pressures.
15
Responsiveness - Board Sponsor: Director of Operations
Attendances and Admissions
Attendances and admissions into the
Trust continue to rise when
compared to previous years. ED had
an additional 10 attendances per
day in January 2018 compared with
numbers seen in January 2017. In
spite of this, the conversion rate has
fallen in January in comparison to
last winter.
Monthly emergency admissions
remain above 2016/17 levels.
The number of patients who are
managed within our short stay
medical and surgical admission units
continues to meet National best
practice for the number of patients
treated in less than 48 hours.
16
Responsiveness - Board Sponsor: Director of Operations
Occupancy, DToCs and North
Bristol Operational Standards
High occupancy levels (102.04%) in
the Trust remains the prime reason
for ineffective flow through the
hospital and remains the main area
targeted for improvements - both
from an internal and a system
perspective.
The number of patients recorded as
formal delays (DToCs) remains
above target levels (5.04%) with
particular pressure experienced for
Bristol patients.
Extra capacity in terms of D2A
pathway two beds and pathway one
support at home is planned for
February, but demand continues to
outstrip supply and further work is
needed across BNSSG to mitigate
against this position.
Opportunities to reduce internal
delays and therefore bed days (up to
2000 bed days Trust wide) are the
focus of patient flow improvement
plans.
17
Responsiveness - Board Sponsor: Director of Operations
Referral to Treatment (RTT)
The Trust has failed to achieve the
RTT trajectory in month with
performance of 86.30% against
trajectory of 87.77%. The Trust did not
meet the RTT backlog trajectory,
reporting 3758 against trajectory of
3428.
Remedial action plans are in place for
Divisions where performance is an
issue - of particular concern is
Respiratory Medicine where
performance has not been delivered
at trajectory level since April 2017,
this is due to an ongoing demand and
capacity imbalance.
Plastic Surgery has failed to deliver
the national standard of 92% with
January performance of 87.09%. This
is mainly due to underperformance at
a sub-specialty level in Breast and
Hands resulting from staffing issues.
Return to standard in March 2018 is
now at risk, as it is dependent on
these staffing issues being resolved.
Urology has also failed to deliver the
national standard in January with
performance of 89.92%. This is the
first time in 2017/18 that the standard
has not been met. Reasons for
underperformance are multifactorial,
but in the main relate to the impact of
staff shortages, which are being
addressed. A return to standard is
anticipated in June 2018.
18
Responsiveness - Board Sponsor: Director of Operations
Cancellations
The same day non-clinical cancellation
rate in January was 1.73% against the
national target of 0.8%. This is a 1.3%
improvement in the rate of
cancellations when compared to
December 2017, 2.79%.
There were twelve operations that
could not be rebooked within 28 days of
cancellation in January 2018. RCAs
have been completed for each of these
cases to understand the reasoning and
to ensure that there was no patient
harm. Patients were unable to be
rebooked within 28 days mostly due to
winter pressures and cancellation of all
non-urgent elective work throughout
January.
In month there were two urgent
operations cancelled for a subsequent
time. These were due to theatre list
overrun owing to a complex case and
incorrect anaesthesia requested at the
time of booking. RCAs are being
completed for these breaches.
The Theatres Board is overseeing the
monthly performance for the Trust
cancelled operations with an aim to
further reduce cancellations and is also
overseeing a delivery plan to improve
theatres productivity and to introduce
changes to scheduling.
19
Responsiveness - Board Sponsor: Director of Operations
Referral to Treatment 52 Week
Waits
The Trust has reported a total of 55
breaches in January 2018. These
patients were within the following
specialties:
2 Neurosurgery;
3 Epilepsy;
8 Orthopaedic Spinal;
32 MSK;
10 Others, which include a small
number of patient choice (4).
Root Cause Analyses (RCAs) have
been completed for all patients, with
dates for patients’ operations being
agreed at the earliest opportunity and
in line with the patient’s choice.
A remedial action plan is in place for
MSK 52 week wait performance and
an improvement in performance has
been noted with a trajectory for
clearance at the end of Quarter 4.
The Trust has classed patient choice
as any patient choosing to wait
beyond 52 weeks when two
reasonable offers with three weeks
advance notice have been made prior
to week 28 in their pathway The
patient will have been clinically
reviewed as per best practice
guidance that the most appropriate
course of action is for them to
continue to wait as per their choice.
N.B. MSK 52ww performance is managed against the RAP agreed with the CCG
N.B. Epilepsy and Neurosurgery 52ww performance is managed against the RAP agreed with NHSE Specialised Commissioning
20
Responsiveness - Board Sponsor: Director of Operations
Diagnostic Waiting Times
The Trust has achieved the 1.00%
target for diagnostic performance in
January with actual performance at
0.62%, a 1.44% improvement to
December’s reported position of
2.06%. This improvement in
performance brings the Trust to the
best reported diagnostic performance
level since October 2015.
Endoscopy diagnostic tests continue to
be delivered in line with the recovery
trajectory. DEXA has achieved the six
week standard sooner than anticipated
with performance reported at 0.75%.
Plans remain in place to ensure this
improvement is continued in to the next
financial year.
There is an in month
underperformance in Colonoscopy and
Urodynamics.
Although the largest underperforming
diagnostic test type, Urodynamics is
also the most improved in month. At
4.03%, Urodynamics has improved
1.71% from the December reported
position of 5.74%.
The largest number of breaches was
reported for non-obstetric ultrasound
(20), which is 16 breaches under the
36 breach tolerance threshold for that
test type.
21
Responsiveness - Board Sponsor: Director of Operations
Clinic Letter Typing
Four of the five Clinical Divisions’
average typing turnaround time
continues to report within the
contractual obligation of ten days.
ASCR have had an average increase
of eight working days to their typing
turnaround time. Taking an average of
89 days, Urology has the longest typing
turnaround time of the four
underperforming ASCR specialties.
The outsourcing of typing pilot has
commenced in General Surgery and
Urology has secured additional staffing.
Both of these actions should ensure
backlog clearance by the end of March
2018.
Medicine have the largest improvement
in month with a further two day
reduction in turnaround time from the
eight days reported in December.
Discharge Summaries
In January, 78.20% of discharge
summaries were available on ICE
within 24 hours.
January’s performance is a 2.30%
decrease to December’s reported
position of 80.50%, although year to
date performance remains improved
from 2016/17 at an average of 7.09%
more discharge summaries available
on ICE within 24 hours.
*Where data is unavailable, an average of the previous fortnight’s performance is calculated for chart purposes.
22 22
Cancer
The Cancer Waiting Times
Performance for December 2017
shows that the Trust achieved five of
the seven national standards.
The Trust continued to pass the TWW
standard with a performance of
94.50%.The Trust received 1,601
TWW referrals in December and there
were 84 breaches. The three
specialities with the highest number of
breaches were in ASCR. There were
18 Colorectal breaches, 29 in Breast
and 13 in Skin. All breaches were
either a result of capacity issues or
patients being unable to attend the
appointments offered.
The Trust has continued performance
against the Breast Non-Symptomatic
TWW standard with a performance of
93.15% against the 93% target. There
were five breaches against this
standard; Three due to capacity
issues and two due to patients not
being available to attend the
appointment offered.
The Trust continues to pass the 31
day first treatment standard with a
performance of 96.12% against the
96% target. There were nine breaches
against this standard, all in Urology.
Of these nine breaches; seven were
due to insufficient elective capacity,
one was a medical delay and one was
cancelled on the day due to consultant
sickness. All capacity related
breaches were patients who required
robotic surgery.
Responsiveness - Cancer - Board Sponsor: Director of Operations
23 23 Cancer
The Trust passed the 62 day national
standard for December 2017 with a
performance of 87.00% against target
of 85%. The Trust is now being
measured against the new national
breach reallocation policy; However
official monitoring of this will not
commence until April 2018. The Trust
reported a performance of 85.71%
against the new rules.
The Trust continues to meet the 62
There were 27 patients that breached
in November, 16 of which started their
pathway at NBT. Of these 16 patients,
15 had their first appointment at NBT
after day seven.
Delays in radiology contributed to four
of these breaches and delays in
pathology contributed to four others.
Eight Urology patients were
transferred in to the Trust from other
providers for treatment in November
beyond day 38 of their pathway. The
Urology department managed to treat
one of these patients within 24 days of
transfer, enabling the Trust to
reallocate a half breach back to the
referring providers. Capacity issues in
Oncology and Theatres continue to
limit the ability to treat these patients
within 24 days of referral.
The Trust transferred six patients to
treating providers later than day 38
which created the negative impact on
performance when applying the new
guidance for December.
NB: The charts show the breakdown of breach reasons for both
whole and shared 62 day breaches for the month. Breakdown of
breach reason may not match total published performance due to
time of which data was captured. Data is extracted from a live
system.
Responsiveness - Cancer - Board Sponsor: Director of Operations
December
Brain 0.5 0.5 0 100.00%
Breast 17.5 17.5 0 100.00%
Colorectal 9 8 1 88.88%
CUP 0 0 0 0.00%
Gynaecology 2.5 1.5 1 60.00%
Haematology 6 6 0 100.00%
Head and Neck 0 0 0 0.00%
Lung 7 4.5 2.5 64.27%
Sarcoma 1 1 0 100.00%
Skin 33 31.5 1.5 95.45%
Upper GI 1.5 1.5 0 100.00%
Urology 51.5 39 12.5 75.73%
Total 129.5 111 18.5 85.71%
New National
Policy Applied
62 Day (Urgent GP) - Target 85 %
Total
treated
Total
treated in
target
Breaches% meeting
target
24 24
Cancer
The Trust failed the 31 day
subsequent treatment target in
December 2017 for patients requiring
surgery with a performance of
87.18% against the 94% standard.
This is an improvement on November
2017.
Of the ten breaches, one was in
Sarcoma, two were in Urology and
seven were in Skin. All ten breaches
were due to capacity in theatres.
The Trust also failed the 62 day
screening target with a performance
of 86.96% against the target of 90%.
There were three breaches in total, all
in Breast. Of the three breaches; two
were due to medically appropriate
delay and one was patient initiated
delay due to being on holiday.
The Trust passed the 31 day
subsequent treatment for patients
receiving anti-cancer drugs with a
performance of 100%.
The Trust also passed the 62 day
consultant upgrade target with a
performance of 90.70%, however this
standard is only monitored internally
and not nationally reported.
Responsiveness - Cancer - Board Sponsor: Director of Operations
25 25
Safety and Effectiveness
Board Sponsors: Medical Director and Director of Nursing
Chris Burton and Sue Jones
26 26
Safe Staffing - Board Sponsor: Director of Nursing
QuESTT
The areas not submitted have been
individually reviewed by the Head of
Nursing for each Division to ensure
that any triggers are reviewed.
Two wards have triggered for action in
January.
Gate 34b- Recruitment to vacancies &
unfilled shifts monitored closely to
ensure safety maintained. HR
investigations have now concluded..
Gate 34a- Recruitment to vacancies is
underway, the ward transferred to
Medicine in January 2018 and
received an increase in establishment
to reflect enhanced care requirements.
Unfilled shifts monitored closely to
ensure safety maintained.
Safe Care Live
(Electronic Acuity tool)
The acuity of patients is measured
three times daily and reviewed at the
twice daily safe staffing meetings .
Staff are moved between Divisions to
ensure safety is maintained where a
significant shortfall in required hours is
identified. Rostered hours were above
in all Divisions than required in
January and reflected the additional
staffing required for escalation areas. .
Professional judgement is also utilised
to maintain safe staffing levels. It has
been recognised that staff require on
going education to complete and data
validation is continuing to ensure
consistency of patient assessments.
More detailed work on implementation
and full utilisation of the SafeCare tool
is being planned in order that the tool
can be used to its maximum benefit.
27 27 Nursing Workforce
January saw a sustained increase in
the over establishment of both RNs and
HCAs due to volume of new starters in
January requiring supernumerary time
and the staffing of additional escalation
areas and enhanced care.
NMSK
Increases in HCA requirements to
cover enhanced care in Neuro and
increased requirements for acuity of
care for medical patients in MSK.
Medicine
Significant escalation areas in January
required additional staffing with both
RN’s and HCA’s. Increased
requirement for HCAs and RMNs to
provide enhanced care above plan due
to higher acuity and occupancy on
wards.
ASCR
Increased HCA for enhanced care
across Surgical wards where there has
been an increase in Medical patients.
Escalation areas requiring additional
staffing of both RNs and HCAs in
January.
Women and Children’s
Increase due to staffing additional
capacity beds on Cotswold and
covering maternity leave.
Actions in place: HCAs in the pipeline
due to start over the next two months to
support shortfall. Cross Trust working
to support areas where vacancies are
increased. The agency expenditure in
January increased to 4% due to
increased requirement for escalation
areas and higher use of Non framework
high cost agency use to ensure patient
safety.
Safe Staffing - Board Sponsor: Director of Nursing
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18
Agency 28.44 31.65 34.69 40 51 45 41 31 32 45
Bank 165.31 168.61 167.4 165 166 167 172 179 146 198
Substantive 1959.7 1958.3 1929.2 1924 1918 1945 1995 2025 1988 1974
Total 2153.4 2158.5 2131.3 2129 2136 2158 2208 2235 2166 2217 0 0
Agency 0 0 0 0 0 0 0 0 0 0
Bank 234.34 240.83 251.61 266 269 243 241 242 231 259
Substantive 881.41 894.09 889.58 891 889 867 881 913 916 938
Total 1115.8 1134.9 1141.2 1157 1158 1110 1122 1155 1147 1197 0 0
Worked WTEs
N&M
HCA
28 28 Southmead Nursing Fill Rate and CHPPD
RN fill rates are up this month in line with the skill mix
review and the winter planned staffing for increased
escalation. Care assistant (CA) fill rates for January have
fallen slightly as some ward have now been adjusted to the
planned number from the skill mix review. This should
continue as the new levels are absorbed fully into the
planned numbers within the roster build.
CHPPD has increased again this month by 0.2 to 8.6
despite an increase of over 2399 patients within the
midnight census however this is reflective of the increased
RN fill rates.
Wards below 80% fill rate are:
Mendip: The reduced number of Midwives on both day and
night on Mendip ward occurred again this month due to
continued high acuity on CDS.
NICU: Reduced fill for CA day and night; NICU continues to
work to a reduced cot base where possible and staffing is
closely monitored each shift. In order to maintain safety,
practice development staff and the Clinical Matron have
supported the unit. The staff have successfully recruited
5.5 WTE to the unit which with induction and
supernumerary status start to impact on the March fill rates.
Wards over 200% fill rate are:
33A CA fill rate both day and night. This is due to support
for the burns clinic on days and a patient requiring
enhanced care at night for most of the month.
IR: CA fill rate both day and night. This is the first month
reporting on the IR escalation beds as part of the winter
plan. The anticipated requirement for 2RN and 1CA has
been increased as required for the acuity, dependency and
actual patient numbers.
Cossham Midwifery Fill Rate and CHPPD:
Cossham Birth Suite continues to show a slight increase in
midnight census to 48. With decreased fill rate of RMs on
days the CHPPD is down 2.8 on last month. The RN fill rate
decrease this month is due to vacancy and 11% long term
sickness. The planned phased return to work will improve
this slowly but may impact until March. There is an increase
in the CA hours to support the unit and the supervisory
sister covered clinically as required to maintain safety.
The numbers of hours Registered Nurses (RN) / Registered Midwives (RM) and Care Assistants (CA), planned and actual, on both day and night shifts are collated . CHPPD for Southmead hospital includes ICU, NICU and the Birth Suite where 1:1 care is required. This data is uploaded on UNIFY for NHS Choices and also on our Website showing overall Trust position and each individual gate level. The breakdown for each of the ward areas is available on the external webpage.
Safe Staffing - Board Sponsor: Director of Nursing
29 29
Maternity Staffing
In January 2018 the unit closed on
one occasion due to a lack of beds.
The unit was closed for a total of 11.5
hours.
The Midwife to birth ratio remains at
1:30 in December and has been a
constant since April 2016.
The Birth Rate Plus report continues
to be used to inform business
planning for the future workforce plan,
alongside the introduction of
integrated working between the birth
centres and the community. The
midwife to birth ratio is currently
being re-evaluated in accordance
with updated acuity tools.
Safe Staffing - Board Sponsor: Director of Nursing
Dec-17 Jan-18Direction of Travel
last month - current
513 542 5
01:30 01:30 4
56.3% 56.7% 5
30.3% 28.9% 6
17.2% 20.4% 5
Cossham BC 6.4% 6.2% 5
Mendip BC 10.4% 13.3% 5
Home 1.0% 1.7% 5
CDS 81.8% 77.9% 6
97.2% 98.6% 5
Birth
Total births
Midwife to birth ratio
Normal birth rate
Caesarean birth rate
Total births in midwife led environment
Birth
Location
One to one care in labour
30 30 Serious Incidents (SI)
Four serious incidents were reported
to STEIS in January 2018:
3 x Delayed Treatment
1 x Fall
One serious fall identified for
externally reporting through the
SWARM process.
One serious fall was identified for
Internal QI investigation through the
SWARM process.
Never Event Description - None
SI and Incident Reporting Rates
Incident reporting has slightly
decreased to 45.0 per 1000 BD, still
well above the national median, which
indicates a positive reporting culture.
The serious incident reporting rate is
now at 0.15 per 1000 BD, below
national median.
Divisions:
SI rate by 1000 Bed Days:
CCS* - 1.53
ASCR - 0.38
Med - 0.27
WCH - 0.26
NMSK - 0.22
*CCS Bed Base Intentional Radiology
only
Quality and Patient Safety - Board Sponsor: Director of Nursing
31 31
Incident Reporting Deadlines for
RCA submission
Two serious incidents breached their
January 2018 reporting deadline to
commissioners.
One SI remains a breach:
1x (CCS) Delayed cancer diagnosis.
Top SI Types in Rolling 12 Months
Serious falls (either by SWARM, or
as STEIS reportable) are the most
prevalent of reported SI’s, followed
by delayed treatment.
*Other Categories:
1 Unintended Damage to Organ
1 Wrong Site Surgery
1 Lost to Follow Up
1 Adverse Media Event
1 Screening Issues
1 Equipment Failure
1 Transfusion Error
1 Operating without Valid Consent
1 Delayed Treatment of Deteriorating
Patient
Data Reporting basis
The data is based on the date a serious incident is
reported to STEIS. Serious incidents are open to being
downgraded if the resulting investigation concludes the
incident did not directly harm the patient i.e. Trolley
breaches. This may mean changes are seen when
compared to data contained within prior Months’ reports.
Central Alerting System (CAS)
Eight new alerts reported, none breaching alert target
dates. One previously issued alert patient safety alert
remains in breach of its deadlines.
PSA/2016/008: Restricted Use Of Open Systems For
Injectable Medication - Specialty: Pharmacy still remain
open.
32 32 Harm Free Care
The ‘harm free’ care reporting now
includes both overall harm free care
and the new harm rates which are
reflective of ‘hospital acquired harm’.
This month shows 97.34% for harm
free care compliance (adjusted for
hospital acquired harm). The
reduction in harm free care remains
a reflection of an increase in
pressure ulcers with harm. The
tissue viability team continue to
support the validation of pressure
ulcers on the day and further
education on assessment of
pressure ulcers has taken place.
Overall Falls
There were 223 falls recorded for
January with two recorded as
serious. Following a review of the
second national inpatients falls audit,
three areas have been identified to
build into the clinical audit action plan
and triangulation with the NICE
guidelines. These actions will inform
a revision of the Inpatients falls
policy, the monthly questionnaire and
Datix incident reporting questions.
The action plan is due to be finalised
following the February 2018 group
meeting.
Safety - Board Sponsor: Director of Nursing
33 33
Pressure Injuries
Pressure injury incidence per
thousand bed days observed an
increase this month at 0.53 per 1000
bed days.
Grade 4: Nil reported
Grade 3: Four reported, on three
patients within NMSK (3) and
Medicine Division (1). All located on
heels, learning from SWARMs
related to re-assessment of risk
following transfer and / or
deterioration in clinical condition.
Grade 2: Fifteen reported, 63% were
validated on heels - the clinical
teams are completing local level
reviews to look for themes and
trends.
The Trust is part of the BNSSG
Multi-agency strategy for the
prevention and management of
pressure injuries.
VTE Risk Assessment
Timely VTE Risk Assessments
above the 95% national standard
have continued.
The emphasis on broader quality
improvement work in relation to
cases of Hospital Acquired
Thrombosis continues, overseen by
the Thrombosis Committee and in
line with the approach endorsed
within the ward of VTE Exemplar
Centre status in October 2017.
QP2 QP2
QP2
Safety - Board Sponsor: Director of Nursing
34 34
Malnutrition
Malnutrition compliance for January
was 78.67%, December was
81.33%. All Divisions were non
compliant with the 90% target.
Targeted work being undertaken
within the divisions to address poor
compliance
WHO Checklist Compliance
Measured compliance with the WHO
checklist was 97.20% in January
2018.
The WHO checklist compliance
improvement programme continues
to be overseen by the Theatre
Board. WHO safer surgery list
compliance through is being
reviewed by a sub group to report
into Theatre Board focusing on
clinical governance. This outcome of
this is a process to validate all non-
compliant cases and the removal of
patients whose surgery has been
cancelled from the data.
QP1
Safety - Board Sponsor: Director of Nursing
35 35 Medicines Management
Severity of Medication Error
Reporting will be highlighted in
Pharmacy staff briefings over the
coming month and with additional
training sessions from the Datix team
as we would want increased reporting
of low harm events.
High Risk Drugs
Moving to Datix has provided an
opportunity to review how to report on
high risk drugs. A new category has
been added to the chart for
Chemotherapy. Due to resources
being focused to support patient flow
and winter pressures, data is shown a
month in arrears.
Themes of Medication Error
Omitted doses remains the top theme
in January but data shows
improvement compared to the
previous month and is now below
target.
Missed Doses
Currently both nursing and pharmacy
undertake missed doses audits and
this is in the process of being
rationalised.
Safety - Board Sponsor: Director of Nursing
36 36
Safety - Board Sponsor: Medical Director
MRSA
There was one reported case of
MRSA bacteraemia in January.
The Trust position is four in 2017/18 ,
the previous reported case was in
August. The Trust MRSA remedial
action plan has been submitted to the
CCG Quality committee for closure,
we await their decision.
C. Difficile
There were two reported cases in
January, occurring within the Medical
Division. The graphs now include
reported lapses in care. Lapses are
nationally defined as evidenced care
not meeting an expected standard
which would enable transmission of
C. Difficile within the hospital
environment - whether or not there
was evidence the ‘lapse’ was a
specific risk factor in the individually
reported cases.
Public Health England (PHE)
Benchmarks
Data from the latest published report
is shown.
Influenza
The increase in influenza within the
organisation reflects the position
within the community, and having an
impact on hospital admissions, with
an increase in patients admitted with
respiratory symptoms. Daily flu
submissions are being submitted by
the Trust
37 37 E. Coli
There were six cases of E. Coli
bacteraemia reported in January
and the total is within our planned
trajectory. There is a BNSSG
system action plan in place to
address this infection to which NBT
is contributing.
MSSA
There were three reported cases of
MSSA bacteraemia in January. The
RCAs for cases are reviewed and
presented at a bi-monthly Steering
Group chaired by the Trust Infection
Control Doctor. Good management
of indwelling devices is the focus of
the Trust improvement action plan.
Norovirus
During January there were two bays
placed under restricted access due
to norovirus. No bed days were lost.
Hand Hygiene
Hand Hygiene compliance reported
at 94%, this is below the required
95% target for the first time in a
year. The information is being
reviewed by ward teams to ensure a
rapid return to the Trust standard.
Safety - Board Sponsor: Medical Director
38 38 Learning from Deaths
All deaths should be reviewed (either screened or full case note review)
within three months of the death. For this reason, the data for the IPR is
shown up to 31 October 2017 to allow for allocation of cases, pulling of
notes and notes arriving with clinicians.
The completion rate of SCRs has remained at 62% whilst the screening
process continues to improve. Specific work is being undertaken with
teams that are struggling to meet the review requirements.
In this report time period (October 2017) there have been no new cases
where problems in care were thought to have contributed to death.
There have been 3 cases in the year to date where problems in care
were initially thought to be contributory to death. One has completed
Root Cause Analyses (RCA), one is awaiting RCA completion and the
remaining case has been reviewed in the Executive led Incident Review
Group where it was agreed that the identified care problems were not
contributory to the death.
Quality Improvement work has started to improve the processes for
completion of death certification by medical staff.
QP4
Effectiveness - Board Sponsor: Medical Director
39 39
Quality Experience
Board Sponsor: Director of Nursing
Sue Jones
40 40
Caring - Board Sponsor: Director of Nursing
Friends and Family Test Actions
Root cause analysis into reasons for
low response rates is near completion.
The aim is to:
Reduce the errors in telephone
numbers in the data feed.
Explore ways to reduce survey fatigue
protection whilst remaining within
budget.
To re-promote FFT across NBT during
March, April and May with staff and to
patients.
Inpatients
A relaunch of FFT is planned as above.
NICU to commence FFT surveys.
Planning a three month pilot of
business cards handed to parents with
web address and QR code for online
completion.
Maternity
National maternity survey improvement
actions will feed into the improvement
of response rate and % recommend.
Work is also underway to follow the
delivery and administration process of
FFT in the antenatal clinics to identify
issues with poor response rates and
identify actions to deliver improvement.
Outpatients
Gate 5 MDC, are exploring ways with
PEX team to increase response rate.
The Brain Centre, at their request, are
being supported to relaunch their FFT
programme. Learning will be applied
elsewhere. Exploration work identified
that FFT card responses had been sent
to a previous company that managed
the FFT reporting, this now rectified.
N.B. NHS England FFT Official stats publish data one month behind current data presented in this IPR.
QP6 QP6
QP6 QP6
Owing to technical issues, NHS England have not published maternity FFT data for November 2017.
41 41
Inpatient Friends and Family Test
Actions
Would recommend percentage rate
has increased by one percentage
point to 93% whilst those who would
not recommend have decreased to
3%. The response rate has increased
by two percentage points of all who
were asked and by one percentage
point of all patients.
The user survey sent to staff who
should be using FFT has been
progressed. Results are expected by
the end of February 2018 and will help
inform the re-promotion of FFT, the
relaunch campaign for FFT continues
in planning stages to commence in
March.
Emergency Department
Continuing overall trend of increasing
the percentage who would
recommend. Support continues to be
given to those carrying out local
surveys within the Trust and systems
to register the projects and capture
their output
Outpatients
The patient experience team are
continuing to support the outpatient
review project with FFT being a
source of data.
Maternity
The patient experience team are
continuing to support the maternity
services team with activities to
improve the national survey results
which will in turn influence the
percentage recommend.
N.B. NHS England FFT Official stats publish data one month behind current data presented in this IPR.
QP6
Caring - Board Sponsor: Director of Nursing
Owing to technical issues, NHS England have not published maternity FFT data for November 2017.
QP6
QP6 QP6
42 42
.
Key: Would you recommend? 1. Extremely Likely 2. Likely 3. Neither Likely nor Unlikely 4. Unlikely 5. Extremely Unlikely 6. Don’t know
Friends and Family Test
“Please tell us the main reason for the answer you chose.”
Waited 3.5 hours
to get an injection that could
have been given earlier avoiding
the distress of being sick and
occupying a bed in AMU.
5 - ED
Excellent,
professional and
polite help when I
needed help, a bit of
a long wait but
otherwise excellent.
1 - ED
All staff so kind and caring.
In particular the theatre staff
and assigned nurse
practitioner. Treated as an
individual and not rushed.
1 - Gate 21
Too much
hanging around to decide
they were cancelling my
procedure, could of been
dealt with in a better way.
4 - Gate 21
All the staff are very helpful
and friendly. Nothing is ever
too much trouble.
1 - Gate 6B
I was moved six times in
eight days which did not help
with me getting better.
3 - Gate 9B
The reception staff at Gate
36 were non-attentive and
preferred to continue their personal
conversation before checking me
in. My appointment was late by
90mins, where I was sat waiting in
considerable pain as well as
running up parking charges
4 - Gate 36
I had excellent care
throughout the birth. The
midwives doctors and
students were very
attentive. I felt safe at all
times.
Birth - Southmead
I feel being made to travel
to Southmead hospital to get
my new baby weighed at a
clinic three days after a
C-Section pretty unreasonable, never
seen the same health professional
twice, not one of the people I have seen
have asked to check section wound
since the day after hospital discharge.
4 - Post
Natal Community
Another wait of over an hour.
When you have you leave work
to get there in good time, to find
published delays of 45 minutes,
rising to 50, but actually closer to
70 minutes, that is three hours
out of a working day. It highlights
the ridiculously short targets for
consultancy window (time with
the patient) Doctors are given.
3 - Cossham OP
Very friendly and
professional service by
all staff I came into
contact with.
2 - Cossham
Ultrasound
No communication of
ward rules. Had to find
out myself by mistakes.
3 - CDS
43 43 Complaints and Concerns
In January there were 58 complaints,
an increase of 13, and 70 concerns
received.
Compliments
The number of compliments returned to
ACT for recording for January
decreased in this month. This will be
monitored moving forward. Work is
also being undertaken to see how
teams can log their compliments via the
new Datix system.
NHS Complaints National Guideline
Targets
The three day acknowledgment was
met for all complaints (100%).
Overdue Cases
The number of overdue cases slightly
increased in January from 27 to 39.
Actions - DoN meeting two weekly with
HoN. Divisions addressing
sustainability in the change to SLM.
Monthly overdue complaints on
Safeguard system reported to Divisions
by ACT Overdue complaints entered
into Datix can be tracked by Divisions
independently. New complaints and
patient experience manager due to start
in April 2018. A workshop with each
Division will be held to identify barriers
they are encountering with meeting the
performance target and to help facilitate
participants to seek solutions to
minimise the risk of reoccurrence. Work
is also being undertaken with the
Urology team who have the highest
activity.
. Caring - Board Sponsor: Director of Nursing
44 44 Further detail of Final Response
Compliance (overdue complaints)
Of the cases closed in January 2018 (to
account for over due responses), 47
(70%) were completed within the
agreed timescale. The exceptions
were:
Nine were 1-10 days overdue
Two were 10-20 days overdue
Eight were greater than 20 days
overdue.
Complaint Handling
The top three categories of complaints
in October reflect the ongoing trend of
clinical care, communication (including
staff attitude), delays and
cancellations. This correlates with FFT
data.
The advice and complaints team work
closely with divisions to inform good
practice in responding to complainants.
NHS Choices Web posts
Southmead Hospital has an overall star
rating of 4.5 out of 5 from 239 reviews,
an increase 0.5. Cossham Hospital has
a rating of 4.5 out of 5 from 16 reviews.
In January, the star ratings given were:
1x 1 star, 1x 3 star and 11x 5 stars. The
advice and complaints team provide
feedback comments to each reviewer,
usually within a day of receipt.
Ombudsman Cases
No new cases were referred to the
Ombudsman in January 2018, Two
were closed; one case was not upheld
by the Ombudsman and one case was
upheld with a financial penalty of £500.
N.B. If all avenues for complaint resolution have been exhausted and the complainant is still
dissatisfied with the Trust’s response, the complainant has the right to take their complaint to the
PHSO. Cases can take many Months from ‘new’ to ‘decision’ which means the volumes shown
represent differing time periods and will not therefore ‘add up’ within any given period.
Caring – Quality Experience - Board Sponsor: Director of Nursing
Q1 17/18 Q2 17/18 Q3 17/18 Jan-18
New Cases referred to PHSO 5 2 2 0
No. of cases fully upheld 0 0 0 1
No. of cases partially upheld 1 0 0 0
No. of cases not upheld 1 2 2 1
Fines levied £350 0 0 £500
Corrective Actions Compliant
within timescales0 0 0 0
Non- compliant 0 1 0 0
Parliamentary Health Service Ombudsman (PHSO) Cases
45 45
Facilities
Board Sponsor: Director of Facilities
Simon Wood
46 46
Very High Risk Areas
Target Score 98%
Audited Weekly
Include: Augmented Care Wards and areas such as ICU, NICU,
AMU, Emergency Department, Renal Dialysis Unit
High Risk Areas
Target Score 95%
Audited Fortnightly
Include: Wards, Inpatient & Outpatient Therapies, Neuro Out
Patient Department, Cardiac/Respiratory Outpatient Department,
Imaging Services
Significant Areas
Target Score 90%
Audited Monthly
Include: Audiology, Plaster rooms, Cotswold Out Patient
Department
Low Risk Areas
Target Score 80%
Audited Every 13 weeks
Include: Christopher Hancock, Data Centre, Seminar Rooms,
Office Areas, Learning and Research Building (non-lab areas)
Operational Services Report on
Cleaning Performance against
the 49 Elements of PAS 5748
v.2014 (Specification for the
planning, application,
measurement and review of
cleanliness in hospitals)
Cleaning scores have remained
high throughout January with only
a minor dip in Very High Risk
Areas due to staff shortages and
winter pressures.
Mandatory training compliance for
December still exceeds the 85%
target, currently at 91% and 89% of
staff appraisals have been
completed against the 90% target.
Facilities is the highest performing
Division for appraisal completion.
There were a significant number of
additional deep cleans throughout
January - approximately 50 extra
per week against average months.
Our rapid response teams showed
resilience reporting only a 5%
breach rate overall.
Facilities Management - Board Sponsor: Director of Facilities
47 47
Well Led
Board Sponsors: Medical Director and Director of People and Transformation
Chris Burton and Jacolyn Fergusson
48 48
Well Led - Board Sponsor: Director of People and Transformation
Workforce Utilisation Trust
position
Worked WTE and pay expenditure
increased in January. The largest
increase was in bank usage which
increased by 16.7% in terms of
worked wte and 14.3% in terms of
expenditure.
87% of the increased use is
registered and unregistered nurses.
The biggest increase was in
Medicine with an additional 50 WTE
used in January. This represents
over half of the Trust’s increase for
December. The additional usage is
linked to the escalation areas
currently open within Medicine.
49 49 Bank and Agency
Winter pressures and additional capacity
has driven the bank’s expenditure to the
second highest point for this financial year,
along with an increase in agency
expenditure and reliance of non framework
agencies.
Month three of the neutral vendor contract
to supply nursing agency staff remains
challenging and this remains under review
to identify changes to improve performance
e.g. a change in our booking processes and
the early release of shifts to be filled by
agencies.
The bank team continue to work closely
with DePoel (neutral vendor) and have met
with suppliers to work together to improve
the fill rates.
Recruitment activity for bank staff remains
a high priority for all staffing groups and
includes Facebook campaigns, specialist
areas of recruitment for nursing staff, whilst
ensuring our Health Care Assistant and
Registered Nursing pipeline continues to
have a consist flow of candidates.
Well Led - Board Sponsor: Director of People and Transformation
50 50
ESR - Finance System Alignment
Alignment between ESR and the Trust’s
Financial System is a recommendation of
the Carter Review. A 95% minimum
alignment is required.
Compliance with this metric continues to
remain steady; not dropping below 98%.
Well Led - Board Sponsor: Director of People and Transformation
51 51
Vacancy Factor
The vacancy factor overall has
increased very slightly from 6.8% in
December to 7.0% in January. The
majority of the increase mostly came
from the registered nursing and
midwifery staff group.
Nurse/HCA Recruitment
Cohesion
HCA recruitment continues with 193
offers accepted to date since
September 2017.
Experienced Band 5 nursing
recruitment has seen 26 offers
accepted to date through the
cohesion approach.
SLA
Time to recruit continues to perform
below the SLA of 17 working days.
The Resourcing team maintained the
below 17 working days position since
October 2017. Work continues on
reducing the total end to end
recruitment time with shortlisting
delays being the highest priority.
Nurse Recruitment Open Day
The latest open day was held on
Saturday 27 January 2018 and was
a success with 55 offers made in
total, with the majority of these as
newly qualified nurses. Our next
open day is on 21 April 2018.
Vacancy Factor by Staff Group
Well Led - Board Sponsor: Director of People and Transformation
Staff Group
Vacancy
Factor Dec-
17
Vacancy
WTE Dec-
17
Vacancy
Factor Jan-
18
Vacancy
WTE Jan-
18
Variance
Add Prof Scientif ic and Technic 6.2% 10.1 3.5% 5.8 -2.6%
Additional Clinical Services 7.2% 104.4 6.4% 94.3 -0.8%
Administrative and Clerical 8.3% 120.3 8.7% 125.9 0.4%
Allied Health Professionals 7.4% 26.8 6.3% 22.8 -1.1%
Estates and Ancillary 11.0% 81.5 11.1% 82.7 0.2%
Healthcare Scientists 4.1% 14.2 4.0% 13.7 -0.2%
Medical and Dental 2.4% 22.6 3.0% 28.2 0.6%
Nursing and Midw ifery Registered 6.5% 137.2 7.5% 158.3 1.0%
Trust 6.8% 517.0 7.0% 531.7 0.2%
52 52
Turnover
Turnover decreased in January 2018
and there were less leavers
compared with December 2017.
Registered nursing and midwifery
saw a reduction in leavers in January
but still an overall net loss of staff.
Unregistered nursing and midwifery
saw the number of leavers in January
reduced by 10 WTE compared with
December and a net gain of staff
overall with an increased number of
starters in January.
Work life balance and relocation
remain the first and largest reason for
voluntary leavers with little change in
number of leavers attributed to these
reasons compared with December.
Turnover Summary
In Month Turnover by Staff Group
Well Led - Board Sponsor: Director of People and Transformation
Staff GroupTurnover
Dec-17
Leavers
WTE
Dec-17
Turnover
Jan-18
Leavers
WTE
Jan-18
Variance
Add Prof Scientific and Technic 1.75% 3.7 0.00% 0.0 -1.75%
Additional Clinical Services 1.86% 25.6 0.99% 13.8 -0.87%
Administrative and Clerical 2.05% 28.0 1.89% 25.5 -0.15%
Allied Health Professionals 1.95% 7.0 0.34% 1.2 -1.61%
Estates and Ancillary 1.39% 9.1 1.59% 10.5 0.21%
Healthcare Scientists 0.58% 2.0 1.36% 4.7 0.78%
Medical and Dental 0.62% 3.0 0.28% 1.3 -0.34%
Nursing and Midwifery Registered 1.68% 34.0 1.16% 23.2 -0.52%
Trust 1.65% 112.4 1.18% 80.2 -0.46%
Rolling 12 Months Dec-17 Jan-18 Variance
Total Turnover 15.99% 16.28% 0.29%
Voluntary Turnover 12.50% 12.74% 0.23%
Stability 85.47% 85.48% 0.02%
53 53
Sickness
The percentage of sickness absence
remained the same in December,
however the number of FTE days lost
to increased compared with November.
Short term sickness increased in
December compared with November
with a 62% increase in FTE days lost to
“Cough/cold/influenza” and a 68%
increase in FTE days lost to
“Gastrointestinal problems”.
Short term sickness due to
“Anxiety/stress/depression/other
psychiatric reason” saw a 24%
reduction in reason for absence,
although it remains the top reason for
long term sickness with a slight
increase in December.
Well Led - Board Sponsor: Director of People and Transformation
54 54
In Month Sickness Absence by Staff Group
Well Led - Board Sponsor: Director of People and Transformation
Staff Group Variance Nov-17 Dec-17
Add Prof Scientific and Technic -0.53% 5.06% 4.52%
Additional Clinical Services -0.14% 5.69% 5.55%
Administrative and Clerical 0.09% 5.07% 5.16%
Allied Health Professionals -0.77% 3.08% 2.31%
Estates and Ancillary 0.64% 5.67% 6.31%
Healthcare Scientists -1.37% 2.38% 1.02%
Nursing and Midwifery Registered 0.16% 4.30% 4.46%
Medical and Dental 0.18% 0.66% 0.83%
Trust 0.00% 4.25% 4.25%
Rolling 12 Month Sickness Absence Nov-17 Dec-17 Variance
Total Absence 4.46% 4.39% -0.07%
55 55
Essential Training
The proactively planned reduction of
face-to-face MaST sessions will
cease at the end of February.
Current figures show that the
percentage compliance has
remained on track thanks to the
available eLearning and in situ
options available during this time.
The L and D team are working with
subject matter experts to review
training delivery and format. Options
for reducing staff absence from
clinical areas to undertake training is
being encouraged.
Well Led - Board Sponsor: Director of People and Transformation
Training Topic Variance Dec-17 Jan-18
Infection Control 0.6% 84.8% 85.4%
Health and Safety 0.6% 87.7% 88.2%
Waste 0.3% 88.0% 88.3%
Information Governance 1.1% 81.9% 83.0%
Child Protection 0.1% 85.7% 85.7%
Equality and Diversity -0.4% 85.4% 85.0%
Fire -0.1% 82.1% 82.0%
Manual Handling -1.2% 79.3% 78.2%
Total 0.1% 84.4% 84.5%
56 56
Medical Appraisal and Revalidation The fifth appraisal and revalidation year started on 1 April 2017.
91% of the appraisals that were due between April 2017 and January 2018 have been
completed. In 2016 this figure stood at 90% for the same timescale.
The August 2017 doctors changeover saw the number of clinical fellows employed by
the Trust increase by 18. As these individuals are not in recognised training posts with
Health Education England, they are required to appraise and revalidate with NBT.
The Trust has currently deferred 25% of all revalidation recommendations due over the
past 12 months. This number has been slowly decreasing since August 2017 when it
reached its peak of 43%. The overall number of revalidation recommendations have
been low in 2017 with the vast majority of them being clinical fellows.
The number of doctors going through revalidation will rise sharply in 2018 and the
deferral rate is expected to continue to drop as more consultants go through their
second revalidation since the process began in 2012. One non-engagement
recommendation was made to the GMC in May 2017. This is the only non-engagement
recommendation made at NBT since the introduction of revalidation in 2012.
The Trust’s revalidation support team have continued to provide medical appraiser CPD
update training in 2017 with a further session available to appraisers in 2018. The PReP
system remains the mandatory system for medical appraisals for all non-training grade
doctors employed by the Trust. The current contract for PReP is in place until November
2018 which is currently under review by the revalidation support team.
An annual report representing the 2016/17 appraisal year was returned to NHS England
in May 2017. An annual Trust Board report was presented to the Trust Board on 27 July
2017 and a statement of compliance signed and submitted to NHS England on 30 July
2017. This will all be due again in 2018.
Well Led - Board Sponsor: Medical Director
36
57 57
Finance
Board Sponsor: Director of Finance
Catherine Phillips
58 58
Assurances
The financial position at the end of January shows a
deficit of £21.1m, £4.2m adverse to the planned
deficit of £16.9m. The position excluding STF is
£1.4m favourable to plan.
Key Issues
• Contract income is £0.2m adverse to plan
reflecting under-performance in electives offset by
significant increases in non-elective. Other income
is £0.1m favourable including an increase in
overseas income.
• Pay is £5.5m adverse to plan mainly due to under-
delivery of savings and significant escalation costs
• Non pay is £2.1m favourable to plan with lower
independent sector and drug usage along with a
non-recurrent benefit of £0.6m partially offset by
higher consumable costs
• Delivery of savings was £6m less than required to
date (£4.1m less than revised profile submitted as
part of financial special measures).
Actions Planned
Continued focus on identification of the full savings
required as well as full delivery of planned activity
and income for the year will be crucial to ensure
delivery of the Trust’s control total.
Finance
Statement of Comprehensive Income Board Sponsor Director of Finance
Prior year
actual to 31
January 2017 17.18 Plan Actual
Variance
(Adverse) /
Favourable
£m £m £m £m
Income
378.1 Contract Income 395.1 394.9 (0.2)
65.0 Other Operating Income 62.4 62.5 0.1
0.1 Donations income for capital acquisitions 0.0 0.9 0.9
443.2 Total Income 457.5 458.3 0.8
Expenditure
(278.3) Pay (275.0) (280.5) (5.5)
(149.7) Non Pay (151.7) (149.6) 2.1
(4.7) PFI Operating Costs (5.1) (4.8) 0.3
(432.7) (431.8) (434.9) (3.1)
10.5 Earnings before Interest & Depreciation 25.7 23.4 (2.3)
2.4% 5.1%
(19.4) Depreciation & Amortisation (21.3) (19.1) 2.2
(27.5) PFI Interest (28.2) (28.0) 0.2
0.0 Interest receivable 0.1 0.0 (0.1)
(3.2) Interest payable (3.6) (4.7) (1.1)
0.0 PDC Dividend 0.0 0.0 0.0
0.0 Other Financing costs 0.0 0.0 0.0
0.0 Impairment 0.0 0.0 0.0
(39.6)Operational Retained Surplus /
(Deficit)(27.3) (28.4) (1.1)
(8.9%) (6.2%)
Add back items excluded for NHS
accountability
(0.1) Donations income for capital acquisitions 0.0 (0.9) (0.9)
0.6 Depreciation of donated assets 0.0 0.6 0.6
0.0 Impairment 0.0 0.0 0.0
(39.1)Adjusted surplus /(deficit) for NHS
accountability (excl STF)(27.3) (28.7) (1.4)
STF 10.4 7.6 (2.8)
Adjusted surplus /(deficit) for NHS
accountability (incl STF)(16.9) (21.1) (4.2)
Position as at 31 January 2018
59 59
Assurances
The Trust received new loan financing in
January of £2.8m. This is £24.5m compared
with the £18.7m planned for this year, which
takes the total Department of Health
borrowing to £159.1m.
The Trust ended the month with cash of
£12.8m, £10.3m higher than plan. The
higher balance is required in order to meet
contractual payments prior to receipts being
received from commissioners in January.
Concerns & Gaps
The level of payables is reflected in the
Better Payment Practice Code (BPPC)
performance for the year which is below the
required 95% with 73% by volume of
payments made within 30 days.
Actions Planned
The focus continues to be on maintaining
payments to key suppliers, reducing the
level of debts and ensuring cash financing is
available.
Finance
Statement of Financial Position Board Sponsor Director of Finance
31 March
2017 £m
Statement of Financial Position as at
31st January 2018
Plan
£m
Actual
£m
Variance
above /
(below) plan
£m
Non Current Assets
518.0 Property, Plant and Equipment 509.9 510.8 0.9
15.8 Intangible Assets 10.6 14.4 3.8
20.0 Non-current receivables 19.0 14.0 (5.0)
553.9 Total non-current assets 539.5 539.2 (0.3)
Current Assets
10.2 Inventories 9.7 10.9 1.2
36.0 Trade and other receivables NHS 24.1 20.7 (3.4)
26.7 Trade and other receivables Non-NHS 30.8 31.4 0.6
4.7 Cash and Cash equivalents 2.5 12.8 10.3
77.5 Total current assets 67.1 75.7 8.6
1.6 Non-current assets held for sale 0.0 0.0 0.0
632.9 Total assets 606.6 614.9 8.3
Current Liabilities (< 1 Year)
18.3 Trade and Other payables - NHS 18.3 12.7 (5.5)
71.8 Trade and Other payables - Non-NHS 55.1 65.2 10.1
40.1 Borrowings 11.5 40.1 28.7
130.1 Total current liabilities 84.8 118.1 33.3
(51.1) Net current assets/(liabilities) (17.7) (42.4) (24.7)
502.8 Total assets less current liabilites 521.8 496.8 25.0
9.9 Trade payables and deferred income 18.4 9.3 (9.0)
514.3 Borrowings 545.5 529.6 (15.8)
(21.4) Total Net Assets (42.1) (42.2) (0.1)
Capital and Reserves
241.7 Public Dividend Capital 241.7 241.7 0.0
(312.4) Income and expenditure reserve (375.8) (363.5) 12.4
(51.1)Income and expenditure account - current
year(16.9) (20.8) (3.9)
100.4 Revaluation reserve 108.9 100.4 (8.6)
(21.4) Total Capital and Reserves (42.1) (42.2) (0.1)
60 60
The overall financial position was
£4.2m adverse against plan at the end
of January.
Capital expenditure was £10.4m
compared to a plan of £13.3m for the
year to date. The plan for the year is
£21.8m.
Available capital funding for the year
has reduced by £3.7m from the
planned level largely due to lower
forecast depreciation. This is reflected
in forecast expenditure of £18.1m.
Assurances and Actions Planned
• Ongoing monitoring of capital
expenditure with project leads.
• Cash for our planned deficit for the
year to date has been made
available to the Trust via DH
borrowing
Concerns & Gaps
The Trust is rated at 3 (a score of 1 is
the best) in the finance and use of
resources metric. This means the
financial position remains a concern
but is no longer the highest score of 4.
Finance Rolling Cash Forecast, In-year Surplus/Deficit, Capital Programme Expenditure and Financial Risk
Ratings Board Sponsor Director of Finance
0
5
10
15
20
£m
2017/18 Cumulative capital expenditure and forecast
Plan Actual Forecast
(150)
(125)
(100)
(75)
(50)
(25)
0
25
50
£m
Rolling cash flow forecast
Forecast including support Forecast excluding support
Weighting MetricYear to
dateForecast
0.2 Capital service cover capacity 4 4
0.2 Liquidity rating 4 4
0.2 I&E margin rating 4 4
0.2I&E margin: distance from
financial plan2 2
0.2 Agency rating 1 1
Overall finance and use of
resources risk rating 3 3
61 61
Assurances
£36.8m of the £39.4m efficiencies required have
been identified at the end of January. This has
reduced by £0.7m in month mainly due to slippage
into 2018/19.
Concerns & Gaps
Under-delivery of £6m year to date against the
original target of £32.2m. A revised profile was
submitted to NHSI as part of financial special
measures against which the shortfall is £4.1m.
The graphs show forecast delivery of £39.4m.
£35.2m is rated as green or amber.
Actions Planned
Continued monitoring of actions required to deliver
required savings in 2017/18 and catch up the year to
date shortfall.
Finance
Savings Board Sponsor: Director of Finance
62 62
Regulatory
Board Sponsor: Chief Executive
Andrea Young
63 63
Regulatory View - Board Sponsor: Chief Executive Officer
The Governance Risk Rating (GRR) for ED 4 hour performance continues to be a challenge through 2017/18, actions to improve and sustain this
standard are set out earlier in this report. A recovery plan is in place for RTT incompletes and long waiters (please see Key Operational Standards
section for commentary). In quarter, monthly cancer figures are provisional therefore, whilst indicative, the figures presented are not necessarily
reflective of the Trust’s final position which is finalised 25 working days after the quarter.
We are scoring ourselves against the Single Operating Framework (SOF). This requires that we use the performance indicator methodologies and
thresholds provided and a Finance Risk Assessment based upon in year financial delivery.
Board compliance statements - number 4 (going concern) and number 10 (ongoing plans to comply with targets) warrant continued Board consideration
in light of the in year financial position (as detailed within the Finance commentary) and ongoing performance challenges as outlined within this IPR. The
Trust is committed to tackling these challenges and recovery trajectories are scrutinised on an ongoing basis through the Monthly Integrated Delivery
Meetings.
CQC reports history (all sites)
* These services are no longer provided by NBT.
Location Standards Met Report
date
Overall Requires Improvement
Apr-16
Child and adolescent mental health wards (Riverside) *
Good Feb-15
Specialist community mental health services for children and young people *
Requires Improvement
Apr-16
Community health services for children, young people and families *
Outstanding Feb-15
Southmead Hospital Requires Improvement
Apr-16
Cossham Hospital Good Feb-15
Frenchay Hospital Requires Improvement
Feb-15
Regulatory Area Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18Finance Risk Rating
(FRR)Red Red Red Red Red Amber Amber Amber Amber Amber Amber Amber
Board non-compliant
statements2 1 1 1 1 1 1 1 1 1 1 1
Prov. Licence non-
compliant statements0 0 0 0 0 0 0 0 0 0 0 0
CQC Inspections RI RI RI RI RI RI RI RI RI RI RI RI
64 64
Monitor Provider Licence Compliance Statements at January 2018
Self-assessed, for submission to NHSI
Ref Criteria Comp
(Y/N) Comments where non compliant or at risk of non-compliance
G4
Fit and proper persons as
Governors and Directors (also
applicable to those performing
equivalent or similar functions)
Yes
A Fit and Proper Person Policy is in place.
All Executive and Non-Executive Directors have completed a self assessment and no issues have been
identified. Further external assurance checks have been completed on all Executive Directors and no issues
have been identified.
G5 Having regard to monitor Guidance Yes The Trust Board has regard to Monitor guidance where this is applicable.
G7 Registration with the Care Quality
Commission Yes
CQC registration is in place. The Trust received a rating of Requires Improvement from its inspection in
November 2014 and again in December 2015. A number of compliance actions were identified, which are
being addressed through an action Plan. The Trust Board receives regular updates on the progress of the
action plan through the IPR.
G8 Patient eligibility and
selection criteria Yes Trust Board has considered the assurances in place and considers them sufficient.
P1
Recording of information Yes
A range of measures and controls are in place to provide internal assurance on data quality. Further
developments to pull this together into an overall assurance framework are planned through strengthened
Information Governance Assurance Group.
P2
Provision of information Yes
Information provision to Monitor not yet required as an aspirant Foundation Trust (FT). However, in
preparation for this the Trust undertakes to comply with future Monitor requirements.
P3 Assurance report on
submissions to Monitor Yes
Assurance reports not as yet required by Monitor since NBT is not yet a FT. However, once applicable this
will be ensured. Scrutiny and oversight of assurance reports will be provided by Trust's Audit Committee as
currently for reports of this nature.
P4
Compliance with the National Tariff Yes
NBT complies with national tariff prices. Scrutiny by CCGs, NHS England and NHS Improvement provides
external assurance that tariff is being applied correctly.
P5 Constructive engagement
concerning local tariff modifications Yes Trust Board has considered the assurances in place and considers them sufficient.
C1 The right of patients to make choices Yes Trust Board has considered the assurances in place and considers them sufficient.
C2 Competition oversight Yes Trust Board has considered the assurances in place and considers them sufficient.
IC1 Provision of integrated care Yes Range of engagement internally and externally. No indication of any actions being taken detrimental to care
integration for the delivery of Licence objectives.
Regulatory View - Board Sponsor: Chief Executive Officer
65 65
Board Compliance Statements at January 2018
Self-assessed, for submission to NHSI
No. Criteria Comp
(Y/N) No. Criteria
Comp
(Y/N)
1
The Board is satisfied that, to the best of its knowledge and using its own
processes and having had regard to the TDA’s oversight model (supported
by Care Quality Commission information, its own information on serious
incidents, patterns of complaints, and including any further metrics it
chooses to adopt), the Trust has, and will keep in place, effective
arrangements for the purpose of monitoring and continually improving the
quality of healthcare provided to its patients.
Yes 8
The necessary planning, performance, corporate and clinical risk management
processes and mitigation plans are in place to deliver the annual operating plan,
including that all audit committee recommendations accepted by the Trust Board
are implemented satisfactorily.
Yes
2 The board is satisfied that plans in place are sufficient to ensure ongoing
compliance with the Care Quality Commission’s registration requirements. Yes 9
An Annual Governance Statement is in place, and the Trust is compliant with the
risk management and assurance framework requirements that support the
Statement pursuant to the most up to date guidance from HM Treasury
(www.hm-treasury.gov.uk).
Yes
3 The board is satisfied that processes and procedures are in place to ensure
all medical practitioners providing care on behalf of the Trust have met the
relevant registration and revalidation requirements. Yes 10
The Trust Board is satisfied that plans in place are sufficient to ensure ongoing
compliance with all existing targets (after the application of thresholds) as set out
in the relevant GRR; and a commitment to comply with all known targets going
forwards.
No
4 The board is satisfied that the Trust shall at all times remain an ongoing
concern, as defined by the most up to date accounting standards in force
from time to time. Yes 11
The Trust has achieved a minimum of Level 2 performance against the
requirements of the Information Governance Toolkit. Yes
5
The board will ensure that the Trust remains at all times compliant with
regard to the NHS Constitution.
Yes 12
The Trust Board will ensure that the Trust will at all times operate effectively. This
includes maintaining its register of interests, ensuring that there are no material
conflicts of interest in the Board of Directors; and that all Trust Board positions
are filled, or plans are in place to fill any vacancies.
Yes
6 All current key risks have been identified (raised either internally or by
external audit and assessment bodies) and addressed – or there are
appropriate action plans in place to address the issues – in a timely manner. Yes 13
The Trust Board is satisfied that all Executive and Non-executive Directors have
the appropriate qualifications, experience and skills to discharge their functions
effectively, including: setting strategy; monitoring and managing performance
and risks; and ensuring management capacity and capability.
Yes
7 The board has considered all likely future risks and has reviewed
appropriate evidence regarding the level of severity, likelihood of it occurring
and the plans for mitigation of these risks. Yes 14
The Trust Board is satisfied that: the management team has the capacity,
capability and experience necessary to deliver the annual operating plan; and
the management structure in place is adequate to deliver the annual operating
plan.
Yes
Comment where non-
compliant or at risk of
non-compliance
As the Trust has not yet achieved a sustainable position in relation to delivery of the 4
Hour A&E and RTT standards due to a reliance on external system changes/factors,
the Trust is unable to confirm compliance with this statement
Timescale for
compliance: Q4 2017/18 – for RTT
Regulatory View - Board Sponsor: Chief Executive Officer