PUBLIC TRUST BOARD MEETING TO BE HELD ON THURSDAY 29 … · 2014. 6. 16. · public trust board meeting . to be held on thursday 29. th. march 2018 at 10.00 am . in room 10009/11,

PUBLIC TRUST BOARD MEETING

TO BE HELD ON THURSDAY 29th MARCH 2018 AT 10.00 AM IN ROOM 10009/11, CLINICAL SCIENCES BUILDING,

UNIVERSITY HOSPITAL, COVENTRY, CV2 2DX

PUBLIC BOARD AGENDA

ITEM TITLE BOARD ACTION PAPER TIME 1. World Class Colleague Award

Chairman For Noting Verbal 10

Standing Items

2. Apologies for Absence Chairman

For Noting Verbal

5

3. Confirmation of Quoracy Chairman For Assurance Verbal

4. Declarations of Interest Chairman For Assurance Verbal

5. Minutes of Public Board Meeting held on the 25th January 2018 Chairman

For Approval Enclosure 1

6. Matters Arising Chairman For Assurance Verbal

7. Trust Board Action Matrix Chairman For Approval Enclosure 2

8. Chairman’s Report Chairman For Assurance Enclosure 3 5

9. Chief Executive Officer and Chief Officers Report Chief Executive Officer

For Assurance Enclosure 4 10

Performance 10. Integrated Quality, Performance

and Finance Monthly Report • Operational Performance • Quality and Safety • Finance • Workforce

Chief Workforce & Information Officer


Patient Quality and Safety 11. Royal College of Surgeons’ Invited

Individual Review Report Chief Medical Officer


12. Board Assurance Framework including Corporate Risk Register Chief Medical Officer

For Approval Enclosure 7 5

13. Medical Education Quarterly Report Chief Medical Officer For Assurance Enclosure 8 5

14. Guardian of Safe Working Hours Trimester Report October 2017 to January 2018 Chief Medical Officer / Chief Workforce & Information Officer


ITEM TITLE BOARD ACTION PAPER TIME 15. Caldicot Guardian Annual Report

Chief Medical Officer For Assurance Enclosure 10 5

16. Electronic Patient Record ( EPR) Programme Update Chief Nursing Officer


Strategy 17. Strategy Refresh

Chief Finance and Strategy Officer For Approval Enclosure 12 5

18. Together Towards World Class Update Chief Workforce & Information Officer


19. Maggie’s Centre Chief Executive Officer For Assurance Enclosure 14 5

Research and Innovation No reports

Regulatory, Compliance and Corporate Governance 20. Information Governance Toolkit

Annual Submission Chief Operating Officer


21. Committee Terms of Reference: • Quality Governance • Finance and Performance • Audit • Remuneration

Interim Director of Corporate Affairs


22. Matters Delegated to Committees Chairman For Assurance Verbal 5

Feedback from Key Meetings 23. Quality Governance Committee

Meeting Reports from 19th February and 19th March 2018 Chair, Quality Governance Committee

For Assurance Enclosure 17

5

24. Finance & Performance Committee Meeting Reports from 28th February and 21st March 2018 Chair, Finance and Performance Committee


25. Audit Committee Meeting Report from 12th February 2018 Chair, Audit Committee


26. Any Other Business 27. Questions from Members of the Public which relate to matters on the Agenda

Please submit questions to our Interim Director of Corporate Affairs by no later than close of business Tuesday 27 March 2018. ([email protected])

28. Date of Next Meeting: The next meeting of the Trust Board will take place on Thursday 31st May 2018 at 10.00 am, in the Clinical Sciences Building, University Hospital, Coventry, CV2 2DX

Resolution of Items to be Heard in Private (Chairman) In accordance with the provisions of Section 1(2) of the Public Bodies (Admission to Meetings) Act 1960, and the Public Bodies (Admissions to Meetings) (NHS Trusts) Order 1997, it is resolved that the representatives of the press and other members of the

TB Public Agenda 29 March

mailto:[email protected]

ITEM TITLE BOARD ACTION PAPER TIME public are excluded from the second part of the Trust Board meeting on the grounds that it is prejudicial to the public interest due to the confidential nature of the business about to be transacted. This section of the meeting will be held in private session.

TB Public Agenda 29 March

MINUTES OF A PUBLIC MEETING OF THE TRUST BOARD OF UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

HELD ON THURSDAY 25 JANUARY 2018 AT 10.00 A.M. IN ROOM 10009/11 OF THE CLINICAL SCIENCES BUILDING, UNIVERSITY HOSPITAL, COVENTRY

AGENDA ITEM

DISCUSSION ACTION

HTB 18/001

PRESENT

Mrs B Beal, Non-Executive Director (BB) Mr I Buckley, Vice Chair (IB) Mrs N Fraser, Chief Nursing Officer (NF) Professor A Hardy, Chief Executive Officer (AH) Mrs K Martin, Chief Workforce and Information Officer (KM) Mr A Meehan, Chairman (AM) Mr D Poynton, Non-Executive Director (DP) Mrs S Rollason, Chief Finance & Strategy Officer (SR) Mrs B Sheils, Non-Executive Director (BS)

IN ATTENDANCE

Dr R de Boer, Deputy Chief Medical Officer (RdB) Ms L Scott, Director of Marketing and Communications Mr G Stokes, Interim Director of Corporate Affairs (GS) Miss R Hough, Head of Corporate Affairs (RH) minute taker

HTB 18/002

APOLOGIES FOR ABSENCE

Professor S Kumar, Non-Executive Director (SK) Miss L Kelly, Chief Operating Officer (LK) Mr E Macalister-Smith, Non-Executive Director (EMS) Professor M Pandit, Chief Medical Officer/Deputy CEO (MP)

HTB 18/003

WORLD CLASS COLLEAGUE AWARD

AH was delighted to present two individuals with the Trust’s World Class Colleague award who had been nominated by their colleagues. The individuals were: Ian Friday, PODP, Theatres for the support he provided to his colleagues following the death of a team member. Ian had covered shifts to allow colleagues to attend the funeral and ensure all had extra pastoral care. Colleagues reported that he had made them feel cared for during a very sad time. Hazel Tippins, Assistant Director of ICT, for the assistance and support she provided to a visibly distressed patient who had lost her mother. The patient presented suicidal indications and Hazel talked with the woman to provide empathy and support until she calmed down and was assisted

Page 1 of 14

AGENDA ITEM

DISCUSSION ACTION

back to ED. Colleagues felt that she showed tremendous compassion outside of her responsibility.

HTB 18/004

CONFIRMATION OF QUORACY

The Chairman declared the meeting to be quorate.

HTB 18/005

DECLARATIONS OF INTEREST

There were no conflicts of interest declared.

HTB 18/006

MINUTES OF TRUST BOARD MEETING HELD ON 30 NOVEMBER 2017

The minutes were APPROVED by the Trust Board as a true and accurate record of the meeting.

HTB 18/007

MATTERS ARISING There were no matters arising that were not on the action matrix or the agenda.

HTB 18/008

TRUST BOARD ACTION MATRIX

The Trust Board NOTED the items in progress and APPROVED the removal of those actions marked as complete.

HTB 18/009

CHAIRMAN’S REPORT

The Chairman presented the report summarising the commitments he had attended since the previous Trust Board meeting. There were no questions raised by other Trust Board members. The Trust Board RECEIVED ASSURANCE from the Chairman’s report.

HTB 18/010

CHIEF EXECUTIVE OFFICER AND CHIEF OFFICERS’ REPORT

AH introduced his report and highlighted the following: He noted the pressure the emergency department was currently under whilst still treating patients in a safe manner and praised the staff. It is now becoming the flu season and it would be awaited to see the outcome of this to the Trust. To date teams have responded well, the Rapid Access Treatment Service opened in January and this has had a positive effect on patients who are now being seen by a Senior Doctor early on. AH has been reassured by this system by Mark Pell, ED Consultant advising him that this is a safer journey for the patient. Whilst

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AGENDA ITEM

DISCUSSION ACTION

the 4 hour ED target was not achieved he was assured that most importantly the patients had been kept safe. There is to be a CQC system-wide review and the Department of Health have identified 22 systems to be reviewed. A review is being undertaken this week and findings will be presented by the end of the week. As part of this review a number of interviews have already taken place and he advised that he had participated both as STP Lead and CEO. Daily feedback has been provided from the interviews, this was mostly positive. BS enquired about the influence of this report and if this would inform the impending CQC inspection. AH replied that the report should be viewed as a positive way forward and lessons can be learnt. AM enquired if Birmingham City Council had helped with the DTOC rates. He was advised by AH that these still remained high but the figures had decreased. Whilst partnership working between organisations was good there was still more to do to improve this. AH was pleased to confirm the following appointments: • Mr Pubdud Pathairaja has been appointed to the position of Consultant

Gynaecological Oncologist, • Dr Praveen Varra has been appointed to the position of Consultant

Clinical Radiologist with an interest in hepatobiliary and gastro-intestinal imaging,

• Dr Shalinini Umrankiar has been appointed as a Consultant Clinical Radiologist with an interest in general cross-sectional and pelvic imaging,

• Mr Basavaih Natesh has been appointed to Consultant in Otolaryngology with an interest in head and neck,

• Dr Dheeraj Karamchamandari has been appointed as Consultant in Otolaryngology with special interest in rhinology.

RdB, on behalf of MP, echoed the intense two week period of work and acknowledged the continued level of service being provided to patients. He informed the Trust Board that a visit by Professor Ted Baker, as his new role of Chief Inspector of Hospitals and Kathy McLean, Executive Medical Director NHSI had been undertaken to look at the work undertaken with the Virginia Mason Institute and in particular the Emergency Department. AH was pleased to report that Professor Ted Baker had personally written to him following the visit expressing his view that the Trust is an exemplar of a progressing acute trust. RdB confirmed that MP had held a meeting with the consultant body, Head of Medicine and Head of Surgery. The meeting had good engagement with 50 plus attending.

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AGENDA ITEM

DISCUSSION ACTION

NF was pleased to report on the appointments of two significant roles for the Trust, these were Head of Midwifery and Deputy Chief Nursing Officer. Within the Education and Research department, the first tranche of eight Band 3 HCA’s have been trained and an additional group of 15 trainees is to be added. She further reported that the Learning Zone, which was rolled out on 8th January, was proving to be successful. This has also had a positive effect for patients and their families. The Learning Zone allows students to look after their patients in a less restrictive manner and to have checks-in with their supervisor periodically. Students have already been giving encouraging feedback. BS was encouraged to see an increase in students and NF replied that this was reflective of the working relationship with the university and the Trust. NF further advised that Coventry University had come second in the Nursing Times Award for training nurses. AH and AM attended the Science Health Building opening at the University which was opened by the Duke of Cambridge. AH advised that the CQC report for the George Eliot Hospital had been released which rated the trust Requires Improvement. He confirmed the report will be reviewed for any learning to be taken from this. KM was delighted to introduce Ms Lynda Scott, Director of Communications and Marketing. She was also pleased to report that the Trust’s email system has received national SCCI1596 secure email standard, advising this now meets secure email standards, similar to NHS.net. UHCW has been awarded £750k by NHS England in support of cybersecurity developments. BB enquired about the Trust’s support to the City of Culture and questioned if UHCW was involved. AH advised that the Trust would be involved and that discussions had already been held and lessons were being understood from Hull’s submission which had included the health sector. The Board felt it was important for the Trust to be involved in this. The Trust Board NOTED the Chief Executive and Chief Officers’ reports and RATIFIED the consultant appointments made.

HTB 18/011

INTEGRATED QUALITY, PERFORMANCE AND FINANCE REPORT

AH presented the performance report on behalf of LK and highlighted the main points of the report. These were: The Emergency Department has not achieved the 4 Hour Wait

target of 95%. Whilst this target has not been achieved for other tertiary trauma centres, the Trust remains the 2nd highest performer,

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AGENDA ITEM

DISCUSSION ACTION

The Cancer 62 Day Urgent Referral to Treatment target had been achieved at 85.48%. The Trust is the only centre achieving this target out of the 4 cancer centres in the Midlands and East region and remains consistently in the top 10 nationally for performance against cancer targets,

Diagnostic waits 6 weeks and over target continues to be achieved. RTT incomplete pathway performance has further declined with the

Trust reporting 82.5% against the national target of 92%. An action plan to reduce the number of patients waiting over 52

weeks for their treatment is being implemented. The Trust is in the top 3 of teaching hospitals in respect of infection

control The Trust Board recognised that the 52 week target requires focus as it is imperative with the impending unannounced CQC visit. IB recognised the relationship between ED and RTT and enquired about the decision the Trust takes to reduce elective work when the Emergency Department is under significant pressure. AH replied that ring-fencing beds can affect the ability of achieving the RTT target and whilst the overriding message suggests there are ‘no more beds’, this is only one factor which inputs into this. Rugby St Cross is not affected by the immediate emergency pressures and this site needs to be utilised better and suggested that more elective work could be planned there. In response to a question from BS about the utilisation of theatres at Rugby, AH informed the board that he is the executive sponsor for a Rapid Process Improvement Workshop currently looking at the theatres value stream which includes aiming to make more efficient use of all the Trust’s theatres. He suggested that an update on this be provided to Finance and Performance Committee, Action: Finance and Performance Committee to receive a report on plans to improve theatre utilisation DP informed the Trust Board that the Audit Committee had asked for details of the 75% of cancellations that were within the Trust’s own gift to better understand this. RdB presented the quality sections of the report on behalf of MP. There have been two Never Events reported in December. There has been a wrong route administration of medication and NR Fit spinal needles have been trialled and are likely to be adopted. There has also been a maxillofacial wrong site surgery which was identified immediately following the initial incision. RdB informed the Board that the Trust had received a recent by Dr Kiran Patel, Medical Director, NHS England.

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AGENDA ITEM

DISCUSSION ACTION

NF advised the Trust Board that the infection controls and harm free rates were good. There has also been a reduction in falls. She was pleased to report that collaborative work undertaken with NHSi has resulted in a reduction of pressure ulcers and she anticipated that a reduction in the trajectory would be seen. During December the registered nurse/midwives fill rate in inpatient areas was below the target of 95%. There has been a difficulty of filling gaps with agency staff and as an exception higher cost agencies had been used. These agencies had not been used for a long time and these instances were an exception to ensure patients were kept safe. AH emphasised that the use of agency staff remains lower than in previous years and noted that this had halved in two years. BS queried if medical staffing were experiencing these difficulties and was advised that this was mostly within nursing. KM advised that costs remain under the agreed cap and reminded the of the work that had been undertaken to reduce fixed terms contracts and removing long standing locums. She did note that the national price battle with high agency costs remains and the Board felt strongly that further action should be taken nationally to reduce this cost pressure. SR presented the financial headlines of the report. A year-end forecast of £22.4m deficit which is £22.1m adverse variance to plan, is reported at Month 9. The deterioration has been driven by the assessment of the income risk, STF monies and the slippage of the car-park. It was confirmed that the deteriorating forecast position has been reported to both the Finance and Performance Committee and to the Trust’s regulator. The Cost Improvement Programme has an identified £26.1m potential saving which is below the required target by £3.0m. SR confirmed that FIP2 has now ended and the exit from this has been completed. This has been reviewed by the Finance & Performance Committee. KM presented the new flash report for workforce and asked for any comments to be fed back to her. UHCW headcount had decreased to 8,121 and the cost of agency staff had decreased. She was pleased to report that the Trust’s mandatory training compliance was currently at 92.3% for substantive staff and highlighted both Clinical Support Services and Theatres and Anaesthetics are above the 95% compliance rate. The Trust Board were pleased with this and discussed whether the recent downtime of ESR and the current pressures of acute work had impacted on this figure.

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AGENDA ITEM

DISCUSSION ACTION

AH reported that the CQC may enquire about mandatory training figures during their unannounced visit. KM confirmed that wards and departments have been reminded of the importance of mandatory training. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/012

INFECTION PREVENTION AND CONTROL QUARTER 3 REPORT

NF presented the report which continues to detail good metrics for MRSA, MSSA and c-difficile for quarter 3. The Trust Board were advised that the Trust continued to participate in the Gram Negative Blood Stream Infections Organism (GNBSI) initiative. Gram negative blood stream infections and e-coli are currently receiving national focus to reduce the number of cases. December has seen 14 cases of confirmed e-coli cases positive Bacteraemia results for UHCW. NF advised that sepsis is also on the national agenda, the Trust’s latest CQUIN result for timely identification and compliance with screening for ED and inpatients are 90% and 91% respectively. Compliance with antibiotics administered had slightly decreased to 38% but with the Rapid Access Treatment Service and treatment bays now in service to assess and treat patients straight away it is expected that performance against these targets will rise. There have been 96 reported cases of influenza in the Trust and NF confirmed that all four strands of flu have been identified. It was confirmed that influenza had been previously discussed at COG Delivery Group. BB enquired about the Trust’s staff uptake of the flu vaccine. It was reported that 73.3% of staff have received the flu vaccination and whilst this performance is decreased compared to last year’s, the Trust’s performance is better than other acute trusts. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/013

QUATERLY MORTALITY PERFORMANCE REPORT (QUARTER 3)

RdB presented the Chief Medical Officer’s report which detailed that quarter 3 was held as a model of good practice for primary mortality reviews with a compliance rate of 67.6.% and achieving this rate had been challenging due to sickness levels and locum and agency staff. The main points of the report highlighted by RdB included: A visit was undertaken by the Royal Free Hospital to learn from the Trust in respect of mortality governance..

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AGENDA ITEM

DISCUSSION ACTION

84.36% of completed primary reviews during Q3 received an NCEPOD grade A, which showed good standards of patient care. He further advised that there had been one death related to sepsis. There has been two deaths of patients with identified learning disabilities and 6 deaths of patients with identified mental health illness. The HSMR value of 96.9 is within the expected mortality rate range, for the latest 12 months of data (October 2016 to September 2017). There is an opportunity to resubmit data to Dr Foster and coding is currently being reviewed. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/014

PATIENT EXPERIENCE QUATERLY REPORT

RdB was pleased to report to the Trust Board that the number of complaints received for quarter 3 was lower than quarter 2, 158 formal complaints had been received. The main issues of complaint were related to car parking and provision of food within the Trust. The Complaints Team has been focused upon maintaining and attaining the 25 working day standard whilst ensuring the complaints which had breached 25 working days were given due attention.. During quarter 3 there were five complaint cases considered by the Parliamentary and Health Service Ombudsman, two cases were partially upheld and three were not upheld. The number of PALS enquiries had also reduced during quarter 3 with724 contacts had been made with the Trust. NF praised these results whilst noting that University Hospital had received 4 stars and Rugby Hospital of St Cross had received 5 stars on the NHS Choices ratings. The Trust Board was informed that Board Walk Rounds had taken place with eight areas being visited across cardiac and respiratory, women’s and children and surgery. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/015

SAFEGUARDING ADULTS AND CHILDREN REPORT

NF presented the report and advised the Trust Board that the trend for reporting children’s safeguarding issues to social services was significantly high, as per quarter two.

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AGENDA ITEM

DISCUSSION ACTION

The main reason seen for these referrals is related to behavioural issues and this is reflective of the work being undertaken by the team on the adolescent ward with patients admitted following self-harm. NF reported that the Safeguarding Adults Team continues to raise awareness around self-neglect which has seen a significant number of referrals for adult patients. The Board were informed that Age UK and the Fire Service are now trained to offer early intervention and this has received good feedback. There is a UHCW internal audit plan for safeguarding and the teams contribute to both the Adults and Children’s Safeguarding Board audits. The Safeguarding Team has implemented quarterly supervision for all community midwives which has been well attended. NF reported that she felt assured that staff are raising child protection concerns and notifying the appropriate local authority. Whilst there had been a good level of compliance there are some patients who have not been followed up in the right way. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/016

SERIOUS INCIDENTS REPORT

RdB presented the Chief Medical Officer’s report and discussed the main points highlighted from within the report that have taken place over the last six months. A weekly meeting is held by the Serious Incidents Group which ensures investigations have been undertaken and appropriate actions have been put in place. In addition to this, on a daily basis, the Patient Safety Response Team will meet to discuss incidents and to visit those patients who may have incurred severe or moderate harm. Within the last six months there have been five Never Events reported. These have been:

• two retained foreign objects • two wrong route administration of medicines • one wrong site surgery.

Only one of the reported incidents caused harm to the patient whereby a colorectal swab was retained which needed to be removed. The remaining four incidents were low or of no harm to the patient. A Rapid Process Improvement Workshop has been undertaken, as part of the UHCWi Improvement System, which is intended to improve the reporting and investigation process of incidents.

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AGENDA ITEM

DISCUSSION ACTION

BS observed the quality and rigour of the investigations which have improved and she is more assured of the service following the CQC visit and from the completeness of the report presented. She believed that there is now an element of learning to improve from the first CQC visit. BB supported this and advised that the learning culture needed to be embedded within the Trust. RdB expressed MP’s and his thanks to the Patient Safety Team for the work they have done to reduce the number of outstanding caseloads. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/017

CANCER SERVICES ANNUAL REPORT

AH presented the report on behalf of LK and advised the Trust Board of its pertinent points. The Somerset Cancer Registry has been purchased and the transfer of work from Dendrite was undertaken in early 2017. This system has improved the tracking of patient treatment and further work is being taken by the PPMO to provide real-time data to clinicians. The 62 Day performance has been improving and was 83.3% for 2016/17. Focus on this remains important to achieve the performance target of 85%. AM queried the number of patients waiting over 100 days and was advised that these patients have complex diagnostics and associated co-morbidities and problems which take time to be resolved in order to treat the patient safely. AM suggested that a presentation on cancer could be provided to the Trust Board for further understanding, which should also include data regarding survival rates. The Trust Board RECEIVED the report and requested that further data on cancer is presented at a future meeting.

HTB 18/019

UHCW IMPROVEMENT SYSTEM (UHCWi) QUATERLY REPORT

KM introduced the new report which she advised would be shared wider within the organisation. The Board were advised that improvements included the removal of 238 staff steps by implementing an electronic transfer of information, 55% reduction in wasted appointments by increased visibility of slots and 85 clinical areas were now conducting daily patient safety huddles. Importantly the Trust Board was informed that a 100% improvement in

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AGENDA ITEM

DISCUSSION ACTION

patients that actually go home when identified at Board Round as ready for discharge. AH informed the Trust Board of a forthcoming event planned for Non-Executive Directors, to be held during May, aimed at developing the learning across the five trusts involved within the Virginia Mason Institute programme. He further advised that NHS Improvement had released details of an upcoming programme, Lean Academy, for six new trusts to apply. BS enquired if learning from other trusts was being taken from the programme. AH confirmed that the CEO’s of the trusts meet regularly and share best practice. There have been two national learning events and the networks are designed to bring everyone together. The Trust Board was reminded that each Tuesday morning Stand Ups are held to provide staff with information of current projects, which this week was a presentation by the Emergency Department. The RPIW report on the theatres value stream would be presented on Friday. IB suggested that all the work streams and ongoing work should be triangulated. KM supported this and believed that the links have not been explicit as of yet because the projects were still in their first stages and coming to their fruition. The Trust Board RECEIVED the report.

HTB 18/020

NON CLINICAL RISK (HEALTH AND SAFETY) ANNUAL REPORT 2016/17

GS introduced the Health and Safety Annual Report which summarised the performance, key issues and achievements. The Health & Safety Committee meets on a bi-monthly and has agreed the three year strategy (2017-18) aimed to improve health and safety management and support. The Board were informed that the number of incidents required to be reported to the Health and Safety Executive (HSE) has marginally increased. The HSE has followed up one reportable incident and whilst verbal advice was received, no enforcement action was taken. BB raised her concern with regard to the figure relating to violence and aggression towards staff. The Trust Board agreed that this was one areas of significant concern. The Trust Board APPROVED the annual report.

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AGENDA ITEM

DISCUSSION ACTION

HTB 18/021

FREEDOM TO SPEAK UP GUARDIAN UPDATE

GS presented the report and advised the Board that provisions were in place for staff to raise any concerns which ensures the Trust to be compliant with best practice as advised by the National Guardian. He further anticipated that the CQC may enquire into this area of work, especially the extent to which the Board is sighted on issues raised. The process allows individuals to raise any concerns that they feel uncomfortable to do so with their line manager. The Trust Board was informed that there are Confidential Contacts across the Trust for issues to be reported to. The Trust Board recognised this and understood that any issues may not always be raised as a grievance or within exit interviews. DP expressed his surprised that there had been no issues raised correlating this to the result of the staff survey in relation to reports of bullying. GS advised the low number of cases means that it is difficult to draw any real conclusions from the data, which KM supported. KM advised that whilst staff are signposted to raise their concerns, many conversations may be held with staff which once aired are resolved for the individual. There is no process to capture these conversations under the auspices of this policy. GS and DP will discuss how the Trust can capture the full extent of what may be taking place within the process. GS advised that he would keep this under constant review. The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/022

FIT AND PROPER PERSONS

GS introduced the report and advised that all members of the Trust Board are required to declare their compliance against Regulation 5 of the CQC fundamental standards, the Fit and Proper Persons Test. GS confirmed that all members of the Trust Board had declared themselves compliant with the requirement. The Trust Board RECIEVED ASSURED from the report.

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AGENDA ITEM

DISCUSSION ACTION

HTB 18/023

HEALTH AND CARE WORKFORCE STRATEGY FOR ENGLAND TO 2027 - CONSULTATION

KM presented the strategy and advised that there would be an opportunity to discuss the contents in more detail during the Board away day on 8th February. This is an important document which has been developed with input from NHS Improvement, Public Health England, the Care Quality Commission, NICE and the Department of Health. The release of the NHS Health and Care Workforce Strategy for England is being timed with the NHS 70 Years Anniversary in July. KM believes it to be important that UHCW is engaged with the consultation and asked for Board members to send their comments to her so these could be included with the consultation submission. KM confirmed that she would share the response to the consultation with the Trust Board and confirmed that future work of UHCW workforce plans would be based upon the final strategy. The Trust Board RECEIVED the report.

MATTERS DELEGATED TO COMMITTEES HTB 18/024

QUALITY GOVERNANCE COMMITTEE MEETING REPORTS OF 18 DECEMBER 2017 AND 15 JANUARY 2018

The Trust Board RECEIVED ASSURANCE from the reports.

HTB 18/025

FINANCE AND PERFORMANCE COMMITTEE MEETING REPORTS OF 20 DECEMBER 2017 AND 17 JANUARY 2017

The Trust Board RECEIVED ASSURANCE from the report.

HTB 18/026

ANY OTHER BUSINESS

AH informed the Trust Board that the delay in the car park development has had a financially adverse impact on the Trust accounts. The application for the development of the new car park would be submitted within the week, the application includes a new entry via Farber Road. The application is being submitted by the developer, who will hold a number of public consultation events as part of the application. The Board felt the development is very important for UHCW because the additional spaces will free up spaces allowing these to be allocated to visitors and congestion around the site is expected to be significantly reduced. AH reported that the Trust had been chosen for a Maggie’s Centre to be developed on site. This will be reported further during March’s Board.

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AGENDA ITEM

DISCUSSION ACTION

AH reported that the Rugby Town Plan is currently being appealed. The Board noted that the development was also important for the ‘blue light’ access onto the site.

HTB 18/027

QUESTIONS FROM MEMBERS OF THE PUBLIC

There were no questions from members of the public.

HTB 18/028

DATE OF THE NEXT MEETING The next Public Trust Board will be held on Thursday 29 March 2018 at 10.00am in the Clinical Sciences Building, University Hospital, Coventry, CV2 2DX. The minutes are approved.

SIGNED

………………………………………….................

CHAIRMAN

DATE

………………………………………….................

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UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST ACTION MATRIX PUBLIC TRUST BOARD MEETINGS

29 MARCH 2018

The Trust Board is asked to NOTE the progress with regards to the actions below and to APPROVE the removal of those that are marked completed.

AGENDA ITEM ACTION RESPONSIBLE OFFICER

COMPLETION DATE

UPDATE REMOVAL

ACTIONS FROM NOVEMBER 2017 MEETING HTB 17/196 CHIEF EXECUTIVE OFFICER AND CHIEF OFFICERS’ REPORT

In response to a query from DP regarding the financial provision for any CQC inspection; DM confirmed that this is included within the CQC registration fee, which is linked to the size and turnover of the Trust. He was unable to confirm exact costings and would arrange to provide DP with this information outside of the meeting.

DM January 2018 COMPLETED 25.01.18 – DP confirmed that he has received this information.

Yes

HTB 17/196 CHIEF EXECUTIVE OFFICER AND CHIEF OFFICERS’ REPORT

The new Trust website is on track to be launched by the end of January 2018 and she advised that she would arrange to send an illustration of this to Board members outside of the meeting.

KM January 2018 COMPLETED 29.01.18 – The website was launched on 29 January

Yes

HTB/17/204 PATIENT EXPERIENCE QUARTERLY REPORT

EMS drew attention to page 10 of the report and the issues relating to provision of a discharge summary to the patient’s GP and George Eliot Hospital (ID 12686) and sought to understand whether there was an underlying ICT issue. MP agreed to look into this and provide feedback to EMS outside of the meeting.

MP January 2018 COMPLETED 22.02.18 – It has been confirmed that discharge summaries are sent to GPs within North Warwickshire electronically.

YES

1

UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST ACTION MATRIX PUBLIC TRUST BOARD MEETINGS

29 MARCH 2018

AGENDA ITEM ACTION RESPONSIBLE OFFICER

COMPLETION DATE

UPDATE REMOVAL

HTB 17/196 CHIEF EXECUTIVE OFFICER AND CHIEF OFFICERS’ REPORT

KM was pleased to report that as part of the talent mapping process 70% of staff had now received a talent rating. This will help identify staff with potential to progress to the next level and inform succession planning as part of the wider OD programme. EMS suggested it would be helpful to hold a strategic talent discussion as a Board. KM would be pleased to deliver a session around succession planning at a future Strategic Board meeting.

KM June 2018 25.01.18 - Scheduled on the Strategic Board Work Programme for June 2018

No

2

PUBLIC TRUST BOARD PAPER

Subject: Chairman’s Report Report By: Andy Meehan, Chairman Author: Andy Meehan, Chairman Accountable Executive Director: Andy Meehan, Chairman Date: 29 March 2018

PURPOSE OF THE REPORT:

To update the Trust Board of the key details of meetings and events attended by the Chairman.

SUMMARY OF KEY ISSUES:

The key meetings and areas of interest, since the previous Board meeting were as follows:

• Met with Glen Burley and Russell Hardy (from South Warwickshire NHS Foundation Trust) • End of Life Care Committee • NHS Improvement Midlands & East Chairs networking event in Leicester • VMI Chairs meeting in Leeds • Monthly Charity meeting • Board Session on Strategy with Warwick Medical School • Board Walk-round (Ward 41 - Stroke Medicine)

STRATEGIC PRIORITIES THIS PAPER RELATES TO: To Deliver Excellent Patient Care and Experience To Deliver Value for Money To be an Employer of Choice To be a Research Based Healthcare Organisation To be a Leading Training and Education Centre

RECOMMENDATION / DECISION REQUIRED:

The Trust Board are asked to RECEIVE ASSURANCE from the report.

IMPLICATIONS: Financial: None HR/Equality & Diversity:

None

Governance: None Legal: None NHS Constitution: None Risk: None

PUBLIC TRUST BOARD PAPER Title Chief Executive and Chief Officer Updates Author Chief Officer’s Responsible Chief Officer Andy Hardy, Chief Executive Officer

Date 29 March 2018 1. Purpose This paper provides an update to the Board in relation to the work undertaken by each of the Chief Officers each month and gives the opportunity to bring key issues in relation to areas within their respective portfolios and external issues to the attention of the Board. 2. Background and Links to Previous Papers The paper is presented to each Trust Board meeting. 3. Narrative Each of the Chief Officers has provided brief details of their key areas of focus during February and March 2018. Mr Andrew Hardy – Chief Executive Officer Since the last Trust Board meeting I have hosted and participated in the following meetings, discussions and events:

• Met with Jeremy Wright MP • Met with Glen Burley and Russell Hardy (South Warwickshire NHS Trust) • Visited the Emergency Department with Andrea Green and Glen Burley • Attended a Deloitte Healthcare Dinner and Discussion with Ed Smith • Attended the Joint STP and Clinical Leads Development Day in London • Attended the West Midlands Health & Wellbeing STP Executive Group • Attended the Coventry Health and Well-being Board • Attended the HFMA CEO Forum and HFMA CEO Networking Dinner in London • Attended the Midlands and East STP Leaders Event • Attended the Health Partnership Board • Attended a ‘Dragon’s Den’ event hosted by University of Warwick • Undertook TTWC presentations for Night Workers • Attended the Coventry & Warwickshire STP Q3 Stocktake Follow-up Meeting with NHS

England • Attended the Leading Together Cohort 11 Service Leader Q&A session (Residential 1) • Attended the Transformation Guiding Board meeting • Attended the Better Health, Better Care, Better Value (STP) meetings • Attended the CIPFA Board Dinner in London • Took part in the ‘A day in the life of programme’ and observed Pharmacy • Visited the ANP Service at Rugby St Cross • Attended the Joint Health and Overview Scrutiny Committee • Met with Ophthalmology Consultants along with Meghana Pandit • Took part in a Charity Pub Quiz (with all proceeds going to UHCW Charity) • Hosted a visit by Jeremy Hunt MP (Secretary of State for Health and Social Care) • Attended the NHS Provider event for Chief Executives event in London • Attended the CQC System Feedback Summit • Attended the 'Being a Chief Executive' event in London

• Attended the Leading Together Cohort 12 Team Leader Q&A session (Residential 1) • Attended the STP Awayday (Elephant Safari) • Attended the Chief Officer Group Residential event

Consultant Appointments: Through the nominated Chief Executive Representative and other Committee Members, the Trust Board is advised to note and ratify the following appointments:

Appointed Candidate Consultant Position Dr Margaret Hufton Consultant Paediatrician with Specialist Interest in Respiratory

Medicine Dr Rajesh Srikantaiah Consultant Paediatrician with Specialist Interest in Respiratory

Medicine Dr Raj Kumar Shrimali Consultant Clinical Oncologist with interest in Urology and

Lung Dr Katharine Marshall Consultant Clinical Oncologist with interest in Lung and Skin

Dr Lucy McAvan Consultant Medical Oncologist

Mr Digant Kamdar Consultant Neurosurgeon Mr Sandeep Solanki Consultant Neurosurgeon

Publications: NHSI have published guidance on achieving zero tolerance of MRSA https://improvement.nhs.uk/resources/mrsa-guidance-post-infection-review/ The NHSI page on the partnership with Virginia Mason Institute has been updated https://improvement.nhs.uk/resources/virginia-mason-institute/ An analysis of patient safety incidents in England up to December 2017 has been published. https://improvement.nhs.uk/resources/national-patient-safety-incident-reports-21-march-2018/ A set of case studies on implementing 7 day working has been published https://improvement.nhs.uk/resources/implementing-seven-day-hospital-services/ Guidance has been jointly produce by the CQC and NHSI that explain the special measures programme for NHS trusts and foundation trusts https://improvement.nhs.uk/resources/special-measures-guide-nhs-trusts-and-foundation-trusts/ NHSI have published guidance on executive appointment processes and guidance on pay for very senior managers https://improvement.nhs.uk/resources/supporting-providers-executive-hr-issues/ Lisa Kelly – Chief Operating Officer In addition to the regular meetings such as, COG, COG Delivery Group, CO/CDG, COAG, F & P, Financial & Quality Star Chamber, Quality Governance Committee, and Risk Committee, I have undertaken the following: • Participated in UHCW Progress Review Meetings • Met with Amanda Royston Coventry University re Leadership Management opportunities • Hosted AGM meeting • Attended Seven Day Service Steering Group • Chaired Elective Care Board meetings • Chaired Emergency Care Improvement Board meetings • Attended UHCW Project & Co meetings

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https://improvement.nhs.uk/resources/mrsa-guidance-post-infection-review/

https://improvement.nhs.uk/resources/virginia-mason-institute/

https://improvement.nhs.uk/resources/national-patient-safety-incident-reports-21-march-2018/

https://improvement.nhs.uk/resources/implementing-seven-day-hospital-services/

https://improvement.nhs.uk/resources/special-measures-guide-nhs-trusts-and-foundation-trusts/

https://improvement.nhs.uk/resources/supporting-providers-executive-hr-issues/

• Met with Dr Pijush as Dementia lead • Chaired Patient flow meetings with PwC • I continue to chair Coventry and Rugby Local A & E Delivery Group • Attended Coventry and Warwickshire A & E Delivery Group • Attended Leadership forums • Attended VM Team Guiding Meetings • Chairing the Group Manager Meetings • PDR/job planning with Clinical Directors • Attended Lean for Leaders • Attended Thought Leadership • Participated in CQC Feedback summit following System Review • I met with Head of Volunteer Services • Participated in VMI Sensei/coaching sessions • Attended Clinical Site Team Away Day • Appointed Rob Simpson as Clinical Director Acute and Emergency Medicine • Participated in Exercise Tartar (Emergency planning exercise)

Su Rollason – Chief Finance & Strategy Officer Since the last Trust Board Meeting and, in addition to the routine corporate meetings such as COG; COG Financial & Quality Star Chamber; Risk Committee; Strategy Group & Board Seminars, F&P, Audit Committee, IDMs, VMI Trust Guiding Team, CIP Steering Group, C3 and Strategy Unit; I have undertaken the following commitments: January 2018 National CIP Group Meeting Attended a number of Stroke meetings Introductory meeting with Johann Alberts – Alliance Medical Meeting with Jonathan Young Meeting with Lisa O'Brien (CW Audit) - draft 18/19 Audit plan NHS Provider Sector Finance Directors meeting February 2017 UHCW & Medtronic Collaboration meeting Meeting with Clare Hollingworth - 17/18 position Meeting to discuss space and expansion of Spec Medicine at St Cross Numerous meetings regarding Stroke Meeting regarding Radiology Consultant Establishment Coventry and Rugby Delivery Board NHSI (14 February) CQC Staff Engagement Briefing Session Strategy Consultation Drop In Session for night shift March 2017 Meeting with NHSI (Adam Hawker) Attended 5 Days of Women Event Numerous contract negotiation meetings with CR CCG Attended West Midlands DOF Meeting Attended meeting with Department of Health and Social Care Cost - Recovery Support Team

revisit Introductory meeting with Mel Duffy - General Manager, Coventry and Rugby GP Alliance

Limited CQC Exec Led Briefing Three way risk share proposal meeting with CRCCG / CWPT Attended a number of STP Finance Meeting – future finance discussions A number of meetings / telephone discussions with Alliance Medical

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Various meetings with Groups to discuss business cases Guest speaker at HFMA Conference - Healthcare Costing for Value Institute ‘Clinical Forum 2018’:

‘Following the patient – linking costs and outcomes for prostate cancer pathways’ Professor Meghana Pandit – Chief Medical & Quality Officer/Deputy CEO In addition to all the regular meetings such as Chief Officers Group, Strategy Group, COG Delivery Group, Patient Safety Committee, Risk Committee, Mortality Review Committee, Serious Incident Group (SIG), Medical Concerns meeting, 7 day Services Steering Group, Quality Star Chamber, Quality Governance Committee and my own clinical work, I have undertaken the following activities since the last Trust Board meeting on 25 January 2018: • Visited wards (40, 42, 43, 21, 20, Clinics 8 and 9, ED, AMU, MDU, 34, 35) speaking to

Junior Doctors, Nurses, Pharmacists and Consultant colleagues and helping with bed flow • Attended Leading Together Q and A • Chief Officer Forum • Trust Guiding Team and VSST • Complaint letters review and sign off • UHCW Progress Review Meeting • Invited speaker at Frontiers in Laboratory Medicine in Birmingham • Attended West Midlands Clinical Senate • Gave testimony at Employment Tribunal and preparatory meeting with Barrister • Attended Grand Rounds • Took part in A Day in the Life – spending an afternoon with the Bowel Cancer Screening

Team • GMC ELA/RO meeting • Junior Doctors Induction • Trust Induction • Attended Strategic Board Away Day • Attended Health Partnership Board • Attended Pre-CQC Inspection Meetings • Telephone call with Julie Daunt, CQC (system review) • CQC Self – Assessment meetings • Consultant Interview Panel - Neurosurgery • Daniel Hayes / Neil Anderson – meeting to discuss Interventional Radiology cover • Childrens ED – Karen Mclachlan • Shadowed by anaesthetics trainee - Mohammed Audin • Met with Consultants regarding various concerns • Held two Consultant meetings (n=70) • Met with Mark Kemp regarding Robotic Surgery • Met with Claire Bonniger, Anne Scase and Abigail Tomlins regarding value stream 3 -

theatres • Met with a team from Oxford University Hospitals regarding Neuro Intervention • Meetings with clinical teams and CEO - Never Events • Consultant Meeting – Ophthalmology • Ophthalmology QIPS meeting • Revalidation officer meeting • Secretary of State visit and presentation on patient safety • Opening – UHCWi Learning Event • CQC briefings / engagement sessions • Interviewed for CD post for ED and Acute Medicine • Set up Clinical Advisory Group and held weekly meetings • Radiology QIPS meeting • Healthcare Systems Mapping event, Coventry • Meeting with radiologists and CEO • COG away day • Undertook GTBR visits

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• Attended Stand Up • Managed the response to all internal and external stakeholders and actions resulting from

RCS report and media exposure

Nina Fraser – Chief Nursing Officer In addition to all regular meetings; Chief Officers’ Group, Chief Officers’ Delivery Group, Quality Star Chamber, COG Advisory Group, Patient Safety & Effectiveness Committee, Risk Committee, Quality Governance Committee, Nursing & Midwifery Committee/Forums, Serious Incident Group (SIG), Strategy Group; I have undertaken the following activities since the last Trust Board meeting held in January 2018:

• Hosted Q&A session – Leading Together • Participated in an Assessment & Accreditation Visit to Northampton General Hospital • Delivered the opening address for Trust’s ‘Blooming with Pride’ event in the CSB • Led a recruitment & retention workshop for Nursing portfolio entitled ‘Where Careers

Grow’ • Conducted interview process for the recruitment to two posts; ADN Research & Education

and Professional Standards. • Chair of Trust-Wide Strategic Committee for Children and Young People

UHCW’s Maternity Team awarded Midwifery Service of the Year

The Maternity team at University Hospitals Coventry and Warwickshire (UHCW) NHS Trust have been named the best in the country by the Royal College of Midwives (RCM). At a special awards ceremony held in London on Tuesday, 6 March 2018 , the team were named ‘The Kellogg’s All-Bran Midwifery Service of the year’ in recognition of the care they provide to mums and babies.

They were given their special trophy at the ceremony by Good Morning Britain’s news anchor Charlotte Hawkins.

UHCW were joint winners of the top award, along with NHS Lanarkshire in Scotland.

HSJ Value Awards 2018 Shortlist Announcement The Trust has successfully been shortlisted for the 2018 HSJ Value Awards: Organisation Name University Hospitals Coventry and Warwickshire Trust Project Name Evolution of the Research Workforce Category Shortlisted In Workforce efficiency

Education & Research

• Trainee Nursing Associates: o A second cohort of 15 trainee nursing associates has been successfully recruited

to commence the 2 year training on 2nd April as apprenticeships. They are all staff who have worked for the Trust in healthcare roles.

o There is Interest in staff to undertake training for future cohorts - numbers and start dates to be agreed.

o The first cohort of 8 trainee nursing associates who are part of the fast follower/test site pilot partnership will enter their 2nd year on the 23rd April 2018. All are proud to be progressing and are ambassadors for this new role.

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o A summit is being planned for next April to share the journey and experiences of implementing this new role and to celebrate the achievement of our first cohort of Nursing Associates.

o Attended Nursing Associate Summit in Birmingham to share learning, best practice and challenges from test sites across the West Midlands. Update from NMC in relation to regulation of the role. Insight and understanding from trainees and employers on the lessons learnt from implementation. For all of us these were similar.

• The Learning Zone – new model of practice learning successfully implemented on wards 52 and 20 and now rolled out onto wards 42 and 11, with first year students who commenced this March. Feedback from the first cohort of students to be involved in the Learning Zone are positive. There has also been positive feedback from staff and patients. The implementation has demonstrated that it builds student capacity e.g. ward 52 traditionally had 3 students allocated at any one time; this has now increased to 9. Practice Educators displayed The Learning Zone Model on the poster at the Blooming with Pride Event on 14th March 2018.

• CareClox – in partnership with Coventry University a proposal is being developed to undertake a research project utilising the CareClox with pre-registration student nurses on placement at UHCW and trainee nursing associates. The focus being placement learning.

• Gillian Arblaster Associate Director of Nursing - nominated and invited to a reception at Buckingham Palace for those engaged in front line Nursing in the UK in the presence of HRH The Prince of Wales 14th March 2018.

Women’s and Childrens

• Plan to open remaining Neonatal transitional cots in April. • New Head of Midwifery / ADN Alison Talbot commenced with trust 5th March • Maternal & Neonatal Improvement collaborative team will be leading on a National

Maternity Culture Survey. Wave 1 has now ended and the UHCW team presented at the launch of Wave 2 in London.

• RCM award for Midwifery Service of the Year in March. • Paediatrics has developed an innovative recruitment plan which was approved by

Transforming Workforce supply committee to address their high vacancy rate. • Manual Vacuum Extraction (for miscarriage management) service in gynaecology

commences in April – this will improve choices for women experiencing miscarriage. • Business case for midwifery staffing presented at Strategy unit on 14th March, the group

are providing further information as requested by the panel for a final decision to be made. • A-EQUIP full model launched across 3 maternity sites. Lead Professional Midwifery

Advocate now in post working across sites. • CED entrance is being refurbished w/c 19th March via charitable funds to improve

environment for children attending. • Maternity is preparing for NHSR CNST incentive scheme which includes signing up to the

Perinatal Mortality Tool.

Operations & Delivery

• Multi-Agency Discharge event (MADE) organised and coordinated in January (repeat at Easter)

• Attendance at NHSi Criteria-Led discharge collaborative • Involvement in CQC local system review of health and social care in Coventry

Karen Martin, Chief Workforce and Information Officer CWIO diary: Since the last Trust Board Meeting I have attended all the usual Chief Officer meetings including COG, F&P, QGC, Strategy Group, Chief Officer Forum, Quality Star Chamber, EPR Programme Board and Leadership Forums. I have also, in my capacity as CWIO chaired Transforming

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Workforce Supply Committee, Workforce and Engagement Committee, Partnership Engagement Forum and Transformation MDT. Other commitments have included:

• Welcomed Lynda Scott as Director of Marketing and Communications • Conducted coaching sessions including department walkarounds • Undertaken a number of informal ward and department visits • Attended a meeting of the Regional Talent Board • Attended the HoE & ISS annual staff awards event • Invited and attended the Women in Leadership Lunch at the House of Lords with Lord Dr.

Hastings of Scarisbrick CBE • Leading Together, Orientation and Closing events • Attended Midlands and East LETB Session on LWAB Development • Panel attendance for Ideas Den

Communications:

• In March we were privileged to be joined at University Hospital by the Secretary of State for Health and Social Care, Jeremy Hunt. Mr Hunt was welcomed to the Trust by Professor Andrew Hardy, CEO. Professor Meghana Pandit, Chief Medical Officer and Deputy CEO, presented the work that Trust staff have been doing to improve the safety of the care provided to our patients. Meghana also highlighted our work on the UHCW Improvement System. During his speech, Mr Hunt detailed the improvements the NHS was making in patient safety. In particular, he praised our work as part of the partnership with the Virginia Mason Institute, as well as the Trust’s culture of reporting incidents.

• The new Trust website was launched on the 29 January following engagement with patients, community groups and staff. Visits to the site rose to over 96,000, an increase of around 12%. There has also been a lot of positive feedback from patients, members of the public and from staff.

• We celebrated the birth of triplets at the Trust, which we promoted on Facebook in February. The posts received 17,645 ‘likes’, the most liked for the Trust so far.

• The Trust has promoted a partnership with Coventry City Council, Warwickshire Council and Public Health Coventry to deliver a Sepsis campaign “recognise the symptoms” (#sepsisandme).

• Campaigns to increase the visibility and reinforce both the CQC inspection and UHCW Improvement system amongst staff have been approved and are being implemented. These campaigns are key to our preparation for the coming CQC inspection and to embedding UHCWi across the organisation.

Performance and Programme Management Office (PPMO): • The Performance team has redesigned new Clinical Group packs for their quarterly

reviews with Chief Officers in April. The team is also working with the Corporate Directors Group to develop a comprehensive performance framework.

• The Corporate Information team has created a data quality strategy for the Trust and will follow this up by introducing standard operating procedures in readiness for the introduction of the Electronic Patient Record system. The team has also compiled responses to the provider information requests from the CQC in advance of its forthcoming visit.

• The Information Systems Development team has identified the changes necessary for the Trust to meet the nationally required Emergency Care Data Set (ECDS) submission.

• The Clinical Coding team continues to explore income opportunities through collaborative working with clinicians, Outpatients and the Emergency Department. Regular audits and data quality checks are now routine practice, improving income generation and coding depth. The result of this work is that UHCW NHS Trust now falls into the upper quartile for depth of coding across the NHS.

Information and Communication Technology (ICT):

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• The overseas visitors IT infrastructure is now live. This provides the overseas visitors team with the means to increase the Trust’s income from overseas patients. The Department of Health suggests trusts can double or even triple the income from overseas visitors.

• Two CRRS changes have gone live, these for respiratory and sleep investigations. They will remove paper, fax and phone call requests to the clinical teams involved and automatically update the requesting consultant.

• A new alert for non-invasive ventilation (NIV) is available in CRRS. This will assist the NIV team to identify and review patients more quickly who may have spinal cord injury, sleep apnoea, COPD and obesity hypoventilation syndrome.

• The alcohol assessment module in VitalPac is now live on all inpatient wards. This provides the Alcohol Liaison nurses with a dashboard of patients they need to see.

• A pathology and radiology results interface into the Somerset Cancer Registry has been implemented. This will enable more efficient coding of patients to increase income.

• An upgrade to the Trust’s Patient Administration system was successfully completed in February. This upgrade delivers the capability to collect the Emergency Care Data Set (ECDS), which is the new national data set for urgent and emergency care.

Workforce:

• UHCW has developed a strategic approach to apprenticeships that outlines what we want to achieve over the next three years. Our aim is to promote wider access to a variety of apprenticeships across UHCW, maximising our use of the national levy and developing a career framework that attracts people to work and grow their career in our organisation and the NHS.

• The results of the 2017 National Staff Survey have now been released. The four key areas of which showed a statistically significant deterioration are: – KF17 - % feeling unwell due to work related stress in last 12 months – KF3 - % agreeing that their role makes a difference to patients/service users – KF3 - Staff recommendation of the organisation as a place to work or receive

treatment – KF2 - Staff satisfaction with the quality of work and care they are able to deliver

Improvement plans for these areas are being developed. • Funding to support phase four of Leading Together was approved by Chief Officers and

will enable a further 300 leaders to participate in our flagship leadership development programme during 2018/19. Over 550 of our leaders have already benefitted from this programme.

• UHCW held a Recruitment Open Day at UHCW on 10 March for clinical and non-clinical roles. The event offered advice, information, practical support and opportunities to meet staff and visit departments along with interviews on the day and interview skills workshops. 281 people attended, 53 of these were interested in nursing vacancies and nine were offered registered nurse positions on the day.

• UHCW has prepared its Gender Pay Gap Report in readiness for publication by 31 March 2018. This report is a requirement of the Equality Act 2010 (Specific Duties and Public Authorities) Regulations 2017. The report was reviewed by the Workforce and Engagement Committee in March.

• Latest statistics from the Employment Tribunals show that the removal of tribunal fees in July 2017 resulted nationally in a 90% increase of claims being lodged with the Employment Tribunals in the period October to December 2017. This increase has not yet been reflected in the number of claims against the Trust.

Equality and Diversity:

• The team delivered transgender training at Rugby St Cross, two Leading Together unconscious bias sessions, together with regular sessions as part of the Trust induction programme.

• The last Independent Advisory Group (IAG) meeting took place in January. Key points included:

o Communications to highlight successes of the Supported Internship programme.

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o Exploration of how we might be able to support deaf patients through recruiting deaf people to our volunteering service.

o How the IAG may be able to support the implementation of the EPR system by identifying potential equality issues and solutions.

o Use of community venues for IAG meetings to be more visible and working in the spirit of partnership.

• The Disability Confident Scheme has replaced the Two Ticks or disability symbol scheme. There are three levels of attainment. UHCW has been given ‘committed’ status and the Equality and Diversity team are working towards the next level, ‘disability confident employer’. The Trust is already able to use the scheme logo.

Transformation:

• The KPO have launched a Passport to Improvement - bite size learning sessions in the UHCW Improvement System method, this to create an ‘army of problem solvers’ across the Trust. This initiative is based on the premise that staff doing the work being best placed to know how to improve it. The sessions are open to all staff. To date 64 staff have attended an introductory session

• The KPO team have developed a strategy for the UHCW Improvement system following discussions at the Trust Guiding Team and with the five VMI Trusts at the Trust Guiding Board. This strategy is aligned to the three simple messages: Putting Patients First, Empowering Our Staff, and Delivering Safer Care.

• The Discharge Value Stream had its first Rapid Process Improvement Workshop (RPIW) and continues to test improvements around visibility and standard work to improve the discharge time and process for patients on Ward 3 (Acute Medicine). Planning is underway for a second RPIW looking at the process for blood tests for patients for discharge.

• The Pre-Operative Process Value Stream had its first RPIW at the end of January and is testing the improvements to reduce the number of repeat attendances for pre-op clinics.

• The second round of Innovation’s quarterly Ideas Call took place in February and featured the second monthly Ideas Clinic during which staff could visit the Innovation Hub and have their idea sense-checked, as well as being provided with support from a number of teams. The Ideas Call and Ideas Clinic will lead to UHCW’s Ideas Den in March. To date seven ideas have been submitted.

• Azimah Faiz has been appointed as the Trust’s Innovation Manager. • Following the success of the pilot virtual video clinics in Rheumatology, the team is now

engaging with Group Managers to investigate further use of this technology to develop a business case to roll out this technology across other specialties.

• In accordance with the national mandate to switch to electronic patient referrals, the Trust has begun a pilot with two specialties this month. Appointment slot issues, creating difficulties for patients booking appointments electronically, have reduced from 33% in July 17 to under 12% in January, improving the experience of many patients and giving them greater control when booking their first appointment.

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Title Integrated Quality, Performance & Finance Report – Month 11 – 2017/18

Author Miss. Lynda Cockrill, Head of Performance and Programme Analytics

Responsible Chief Officer

Mrs. Karen Martin, Chief Workforce and Information Officer

Date 29th March 2018 1. Purpose To inform the Board of the performance against the key performance indicators for the month of February 2018. 2. Narrative The attached Integrated Quality, Performance & Finance Report covers the reported performance for the period ending 28th February 2018. The Trust has achieved 10 of the 24 indicators reported within the Trusts new performance scorecard. The Trust scorecard has now been streamlined and aligns the Trust level indicators with the Trusts corporate objectives, highlighting relationships to the CQC domains. Key indicators in breach are the Trusts performance against:

• the 4 hour Emergency Care target; • Referral to Treatment incomplete standards (including 43 breaches of the RTT 52

week wait standard), • Never Events

Key indicators achieving the target include:

• Trust acquired Clostridium Difficile • Harm Free Care • Cancer 62 day Urgent Referral to Treatment

The Value for Money indicators have been updated and brought in-line with the "Single oversight framework". The Trust is reporting a £19.6m year-to-date deficit against a planned year-to-date deficit of £7.5m; an adverse of £12.1m.

3. Areas of Risk As detailed in the performance trends pages.

4. Recommendations The Board is asked to confirm their understanding of the contents of the February 2018 Integrated Quality, Performance and Finance Report and note the associated actions. Name and Title of Author: Miss. Lynda Cockrill, Head of Performance and Programme Analytics Date: 23rd March 2018

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Integrated Quality, Performance and Finance Reporting Framework Reporting period: February 2018

Page

Performance Summary

Executive Summary 3

Trust Scorecard 4

Performance Trends 5

Trust Heatmap 6

Group Summary of Performance 7

Quality and Safety Summary

Quality and Safety Summary 10

Quality and Safety Scorecard 11

Performance Trends 13

Ward Staffing Levels 14

Finance and Workforce Summary

Finance and Workforce Summary 15

Finance and Workforce Scorecard 16

Finance Headlines 18

Statement of Comprehensive Income (SOCI) 19

Statement of Financial Plan (SOFP) 20

Efficiency Delivery Programme 21

Workforce Information 22

Integrated Quality, Performance and Finance Reporting Framework

Contents

2

Executive Summary

Integrated Quality, Performance and Finance Reporting Framework 3

Indicators achieved

Indicators in exception

Indicators in watching

status

Total indicators

Objective 1 - Getting to Good CQC Rating 5 4 1 10

Objective 2 - Meet National Performance Objectives 3 8 0 11

Objective 3 - Achieve the Financial Plan 2 1 0 3

All domains 10 13 1 24

10 KPIs achieved the target in February

The Trust has achieved 10 of the 24 indicators reported within the Trusts performance scorecard. The Trust scorecard aligns Trust level indicators with the Trust corporate objectives, highlighting relationships to the CQC domains. This includes two summary indicators: National Cancer Standards Achieved (1 month in arrears) - The number of the eight national cancer standards that have been met in the reporting month and Friends & Family Test - Recommender Targets Achieved - The number of the seven Friends & Family Test Recommender key performance indicators that have been met in the reporting month.

Targets related to aspects of the emergency pathway (A&E waiting times) and the elective pathway targets including RTT incomplete pathways and last minute non-clinical cancelled operations continue to underperform. Performance against the RTT incomplete target marginally improved with the Trust reporting 81.6% against the 92% national target. There have been 43 breaches of the RTT 52 week wait standard.

The Trust did not achieve the 62 day screening standard for January, there were 2.5 breaches (1 treated at UHCW) which had a significant impact on performance due to the small numbers of patients on this pathway (18 patients treated). The Trust is still on target to achieve this standard at year end.

The Trust’s latest available Hospital Standardised Mortality Ratio is 101.63.

Performance against the target for Trust aquired C-Difficile continues to be strong with 32 cases being reported against a target of 38 year to date.

The Trust is reporting a £19.6m year-to-date deficit against a planned year-to-date deficit of £7.5m; an adverse of £12.1m.

What’s Not So Good? 18 Weeks RTT - Incomplete RTT 52 week waits Emergency Care 4 hour wait

What’s Good? Diagnostic Waiters – 6 weeks and over Delayed Transfers as a percentage of admissions Cancer 62 day Urgent Referral to Treatment

KPI Hotspot


Trust Scorecard Reporting Month February 2018

4

Performance Trends

5 Integrated Quality, Performance and Finance Reporting Framework

Improving (3 months consecutive improvement)

Deteriorating (red indicators worsening)

(3 months consecutive deterioration)

Deteriorating (green/amber indicators worsening) (3 months consecutive deterioration)

• Continued progress has been made against the CIP target over the last three months. Further detail can be found in the Finance section of this report.

• None of the indicators that are achieving their targets this month have deteriorated for three consecutive months.

• The Trusts performance for the emergency care four hour wait has shown a deterioration through the winter months. Performance is discussed further in the A&E section of this report.

Failed Year End Target

• An MRSA bacteremia was reported in May. • Never events were reported for July, August and October. Two further events were reported in December.


Trust Heatmap

6

Group summary of performance – A&E and associated metrics


Last minute non-clinical cancelled operation rates has reduced slightly to 1.1% for February. Groups with the highest levels of such cancellations were Neurosciences (4.5%), Surgery (1.8%), St Cross and Orthopaedics (1.6%). Bed availability on the ward, the requirement for an emergency theatre slot and equipment failure were the main reasons for these cancellations.

The percentage of diagnostic waiters who waited over 6 weeks has decreased this month to 0.11% against the 1% target. The number of breaches has fallen to 11. 1 breach was within Imaging, 6 in Cardiology, 1 in Neurophysiology, 2 in cystoscopy and 1 in Audiology. The total number of waiters has risen to 10,300 in February. 7

The Trust’s performance against the 4 hour standard for February fell to 78.1% (81.4% January). This is against a national backdrop of rapidly deteriorating performance in many other acute providers. A challenging discharge profile and some poor flow metrics remain ongoing issues. Additional winter funding resource to support R2G has been approved for Q4 and improved compliance is expected by March. The ED minors pathway has seen a deterioration performance this month at 88.2%. The ENP recruitment has been very successful: These new staff provide a more stable and consistent minors workforce; In month minors pathway breaches relating to ED staffing and grip have been consistently reduced, those waiting for specialty team assessment and admission have increased. A new breech analysis and validation from mid-March onwards will inform the ED plan to improve performance. There has also been successful ED medical staff recruitment with 11 clinical fellows being appointed; we continue to work on the recruitment of consultants. The Trust continues to focus on its underperformance against the 4 hour standard, with the refresh of a focused ED plan with clear milestones to deliver improved performance. Acute Bed Occupancy was high over this period at 102% for the UH site. There has been a continued improvement of the use of the beds at Rugby, the last 3 months occupancy has been around 85%. The DTOC position has improved and has averaged 3.8% (42 patients) against the 3.5% standard. The overall Medically Fit For Discharge (MFFD) figure reduced throughout the month from over 100 to 60-80 by the end of February. Additional Winter funding has allowed us to support a range of schemes including additional community capacity, Trusted assessor model, CAMHS acute liaison team, enhanced therapy provision for early supported discharge, and a project manager to support the acute internal medicine project. Additional pharmacy and therapy support to ED has also been put in place for Q4.

Group summary of performance – Referral To Treatment


In January Trust performance was 81.6% which was below the local trajectory of 88.6%. The Trust saw a increase of 1.4% from the December position. Referral numbers increased following the Christmas period alongside an increase in the numbers of long waiters treated in January. The RTT backlog reduced by 498. Twelve specialties reported an increase in performance for the month, with Dermatology showing the most improvement of 7.9%.

• Theatres & Anaesthetics (84.6%)

• Neurosciences (83.6%) • Surgery (79.2%) • Specialist Medicine

and Ophthalmology (78.2%)

• Trauma & Orthopaedics (75.9%)

• Clinical Diagnostics (64.3%)

4 out of 10 groups achieved the National RTT incomplete target

The Trust has reported forty three 52 week incomplete pathway breaches in January. Eighteen of these were within the Surgery group. Ten were Neurosurgery, nine Ophthalmology, three Pain Management, two Trauma & Orthopaedics and one Cardiothoracic Surgery. Twenty seven of these patients received their treatment in February. Consultant capacity issues remain the cause of most breaches, however six related to prison initiated delays and cancellations. UHCW is working with the prison service to identify a solution.

Behind target (number behind)

On target

123

RTT Incomplete 81.6% (Last month 80.2%) National Target 92%

• Oncology, Haematology and Renal (95.8%)

• Cardiac and Respiratory (95.4%)

• Women & Childrens (93.9%)

• Care of the Elderly (93.5%)

Group summary of performance – Cancer Standards


In January the Trust achieved seven of the eight national cancer standards. The Trust did not achieve the 62 day screening standard for January, there were 2.5 breaches (1 treated at UHCW) which had a significant impact on performance due to the small numbers of patients on this pathway (18 patients treated). The Trust is still on target to achieve this standard at year end. The 62 day time to first treatment target was achieved for each month, however performance remains below the 85% target for the year to date (84.7%). Data completeness reports are being rolled out to support collection of mandatory Cancer Outcomes and Services Dataset (COSD) data. The weekly cancer access meeting has been successful in driving a reduction in the numbers of patients waiting greater than 100 days for their first treatment.

7 cancer standards

achieved in January

100 days and over target not met

4.5 breaches (6 patients) of the 100 days and over target were reported in January. The breaches occurred within:

• Head and neck (3 breaches, 3 patients) • Gynaecology (1 breach, 2 patients) • Haematology (0.5 breaches, 1 patient)

2WW 31 day 62 day

Performance against cancer standards by tumour site – 2017/18 year to date

1

Quality and Safety Summary

This section includes the Quality and Safety scorecard which contains all relevant indicators that are included within the overarching Trust scorecard, together with additional pertinent KPIs that enable headline areas such as harm free care to be explored in more detail e.g. with the underpinning pressure ulcer and falls KPIs. Ward staffing information is also included in this section.


Quality & Safety Scorecard Indicators

achieved Indicators

in exception


status

Total indicators

Excellence in Patient care and experience

26 11 7 44

Leading research based health care organisation

2 1 2 5

Leading training and education centre 1 0 0 1


11 7 26 Excellence in Patient Care and Experience

Leading Research Based Health Care Organisation

1

Leading Training and Education Centre

The Trust’s latest available Hospital Standardised Mortality Ratio is 101.63 Progress is being made in lowering the number of RTT 52 week waits which has reduced to 43 from 60 last month. All four maternity touchpoints continued to achieve their coverage targets and this month three out of the four recommender targets were also achieved. MRSA high risk screening targets have been missed for both elective and emergency patients, however the MRSA decolonisation score remains at 100%. There has been one grade 3 avoidable Trust acquired pressure ulcer reported this month, which achieves the monthly target for the first time since April 2017. The Job Evaluation Survey Tool Score is not available for this report. Data has not yet been disseminated to Trusts from Health Education England (West Midlands) (HEWM).


2 2

11

Trust Scorecard – Quality and Governance Committee Reporting Month February 2018


12

Trust Scorecard – Quality and Governance Committee Reporting Month February 2018


Performance Trends


Improving (3 months consecutive improvement)

Deteriorating (red indicators worsening) (3 months consecutive deterioration)

Deteriorating (green indicators worsening) (3 months consecutive deterioration)

• There has been a steady decline in the postnatal hospital maternity FFT recommenders. Work is being undertaken to investigate whether particular themes can be identified that contribute towards this deterioration.

• The target for MRSA high risk emergency screening has not been achieved for the past three months and remains just under the 90% target.

Failed Year End Target

• An MRSA bacteremia was reported in May. • Never events were reported for July, August and October. Two further events were reported in December.

• The eligible patients having a VTE risk assessment continues to perform well, whilst it should also be noted that despite considerable pressures, there continue to be no 12 hour trolley waits in A&E and no urgent operations have been cancelled for the second time.

• None of the indicators that are achieving their targets this month have deteriorated for three consecutive months.


A report for all wards is submitted to the Department of Health via Unify on a monthly basis as per National Quality Board guidance. This information is also published on the Trust’s Internet Site.

14

Ward Staffing Levels

In February the Registered Midwives/Nurses (RN) fill rate in inpatient areas remained compliant on night shift and continues to improve on day shift, improving from 87.2% in December to 96% (target of 95%). A total of 8/45 inpatient areas were non-compliant in February which is a significant improvement from the previous 2 months (24/45 Jan and 32/45 Dec). The UHCW site continued to have significant inpatient escalation areas open which impacted the ability to fill all shifts. The Trust continues to takes steps to mitigate risk to patients and have had to use off framework agency to fill deficits this month. There is a Modern Matron bleep holder, responsible for safety and quality seven days a week and a hospital night team out of hours. An Associate Director of Nursing leads a twice daily safe staffing meeting where a number of actions are agreed to mitigate safety and staffing risks on that day and looking forward. During this reporting period these include moving staff from one area to another, moving staff out of non-clinical shifts and some training to support frontline activity. This month we continued to cancel shifts on e-roster that were deemed by ward teams and matrons as not required (e.g. not sent to bank or agency) to be filled and this also improved the fill rate.

RN - Registered Midwives/Nurse CS - Care Staff

2

1 1

Finance and Workforce Summary This section includes the Finance and Performance scorecard which contains all relevant indicators that are encompassed within the overarching Trust scorecard, together with additional pertinent KPIs such as theatre efficiency and utilisation, which underpin the headline indicators. This report highlights areas of compliance and underperformance. The Value for Money indicators have been updated and brought in-line with the "Single oversight framework". The reported position is against Trust's plan for 2017/18. Further details on revised KPIs have been provided in the Integrated Finance Report that is submitted to Finance and Performance Committee.


Indicators achieved

Indicators in

exception


status

Total indicators

Excellence in Patient care and experience 16 18 2 36

Delivery of value for money 7 2 1 10

Employer of choice 1 3 4 8

Leading research based health care organisation

1 1 0 2

Leading training and education centre 1 0 0 1


The performance against emergency care four hour wait target was 78.1% in February, it’s lowest for the past twelve months and reflective of current pressures not only here at UHCW but across the country.

The RTT incomplete position also remains below the 92% national target but has shown a marginal at 81.6% for January. There have been 43 breaches of the RTT 52 week wait standard which is a reduction from the 60 breaches reported last month, reflecting the efforts being taken to reduce these numbers through the regular patient access meetings.

2.5 patients (1 treated at UHCW) were not treated within the standard for the cancer 62 day screening pathway and because of the small number of patients on this pathway, this caused the target to be missed for January although the Trust is still on track to achieve this standard at year end. All other cancer standards were achieved.

18 2 16 Excellence in Patient Care and Experience

1 1 Leading Research Based Health Care Organisation

1 Leading Training and Education Centre

Delivery of Value for Money

3 4 1 Employer of Choice

15


7

16

Trust Scorecard – Finance and Performance Committee Reporting Month February 2018


17

Trust Scorecard – Finance and Performance Committee Reporting Month February 2018


Updates on Control Total Movements within the control total is impacted by under delivery on contract income (0.6% adverse to plan); other income (6.2% adverse to plan; and pay and non-pay overspends (3.2% adverse to plan). The Trust is reporting a forecast deficit of £22.4m as at month 11.

Trust Position Post Technical Adjustment (control total)

Updates on Net Surplus/(Deficit) position (before DH control adjustment) The forecast net deficit position is £22.1m adverse to plan of £0.023m, largely impacted STF Monies (£7.6m), Other risks (£12.3m), car park income of £4m and a benefit of £1.5m from winter funding. The Year-to-date position shows a £12.5m adverse variance (£19.8m deficit against a planned deficit of £7.3m.

Net Surplus / (Deficit) position

The Trust is forecasting a £22.4m deficit which is £22.1m adverse variance to plan as at month 11. The Trust is reporting a £19.6m year-to-date deficit against a planned year-to-date deficit of £7.5m; an adverse of £12.1m.

Finance | Headlines February 2018

AGENCY SPEND £20.2m

£20.2m actual spend on agency spend year to date against NHSI profile of £24.3m

Capital

Cost Improvement Programme is £29.1m against revised target of £29.1m.

The Trust has an STF target of £14.6m.

STF 100%

Year-to-date of £25.9m against target of £25.4m.

Year-to-date position reports a slippage of £5.9m against plan of £12.9m. This is due to the failure to meet the A&E and financial targets

Trust is forecasting £22.3m spend on agency which is £4.2m below target as at month 11.

Original Plan £40.2m Forecast Capital

Expenditure of £27.6m.

As at Month 11, the Trust is reporting a £11.5m

capital expenditure spend against a plan of £15.1m.

CONTRACT & ACTIVITY INCOME

0.6 % under-

performance

Under-performance on YTD income is largely driven by movements in Elective, and Outpatient activities.

Contract income from activities reports an adverse variance of £2.9m YTD against plan of £484.3m.

(£292)

(£22,438)

(£3,105)

(£6,279)

(£18,169)

£0

£5,005 £402

(£30,000)

(£25,000)

(£20,000)

(£15,000)

(£10,000)

(£5,000)

£0

Trust Plan ContractIncome

Performance

Other Income Expenditure Additionalsavingsrequired

Reserves Non OperatingExpenditure

Trust Outturn

£'00

0

Trust Plan £0.023 (£3.4) (£4.0)

(£4.4) (£7.7) (£7.6) (£8.8) (£7.6) (£6.8)

(£7.9) (£5.9) (£7.2)

(£0.023)

(£5.2) (£7.1) (£4.8)

(£9.3) (£9.9) (£10.3) (£11.1) (£11.0) (£11.0)

(£14.5)

(£19.8)

(£22.1) (£25.0)

(£20.0)

(£15.0)

(£10.0)

(£5.0)

£0.0

£5.0

April May June July August September October November December January February March

Trust Plan Cumulative Budget Cumulative Actual Cumulative Forecast

under-performance year-to-date


19

SOCI – Statement of Comprehensive Income Reporting Month February 2018


The Trust reports a £22.4m forecast control total deficit, £22.1m adverse to planned control total deficit of £0.3m in month 11.

The forecast deficit is explained by under-performance on contract income of (£3.1m), STF Monies (£7.7m), car park income (£4m), winter funding £1.5m and other risks (£8.9m). The year-to-date control total is £12.1m adverse to budget of £7.5m. The Trust’s efficiency programme continues to be measured against the revised target of £29.1m. The Trust as part of the FIP2 programme continues to drive the identification and delivery of recurrent savings. At month 11 the CIP is forecast to fully deliver. Group expenditure is forecast at £18.2m adverse to budget, primarily on pay.

Plan

£'000Budget (£'000)

Forecast (£'000) £'000 %

Budget (£'000)

Actual(£'000) £'000 %

Contract income from activities 521,547 529,400 526,295 (3,105) (0.6%) 484,318 481,421 (2,897) (0.6%)Other income from activities 23,286 21,119 17,512 (3,607) (17.1%) 18,693 16,113 (2,580) (13.8%)Other Operating Income 80,692 80,493 77,821 (2,672) 3.3% 69,646 70,068 422 (0.6%)

Total Income 625,525 631,012 621,628 (9,384) (1.5%) 572,657 567,602 (5,055) (0.9%)

Pay costs (352,710) (357,238) (372,068) (14,830) (4.2%) (326,883) (339,564) (12,681) (3.9%)Other operating expenses (209,279) (218,909) (222,248) (3,339) (1.5%) (201,062) (202,842) (1,780) 0.9%Reserves (10,456) (5,086) (81) 5,005 98.4% (6,295) 0 6,295 100.0%

Total Operating Expenses (572,445) (581,233) (594,397) (13,164) 2.3% (534,240) (542,406) (8,166) 1.5%

EBITDA 53,080 49,779 27,231 (22,548) (45.3%) 38,417 25,196 (13,221) (34.4%)

Depreciation (24,081) (21,680) (21,617) 63 (19,866) (19,729) 137Interest Receivable 50 50 50 0 44 49 5Interest Charges (691) (691) (707) (16) (638) (626) 12Financing Costs (26,007) (26,007) (26,007) 0 (23,842) (23,731) 111Unwinding Discount (34) (34) (6) 28 (34) (6) 28PDC Dividend (2,340) (1,440) (1,074) 366 (1,324) (985) 339Profit / loss on asset disposals 0 0 41 41 0 41 41

Net Surplus/(Deficit) (23) (23) (22,089) (22,066) (95939.1%) (7,243) (19,791) (12,548) (173.2%)

EBITDA % 8.5% 7.9% 4.4% 6.7% 4.4%Net Surplus % (0.0%) (0.0%) (3.6%) (1.3%) (3.5%)

Technical Adjustments:Donated/Government grant assets adjustment

(269) (269) (349) (80) (29.7%) (293) 203 496 169.3%

Impairments 0 0 0 0 0 0 0

Trust Position Post Technical Adjustment (Control total) (292) (292) (22,438) (22,146) (7584.2%) (7,536) (19,588) (12,052) (159.9%)

11 month ended 28 February 2018

Year to date Variance to planFull Year Variance to plan

19

20

SOFP – Statement of Financial Position Reporting Month February 2018


The statement of financial position shows the assets, liabilities and equity held by the Trust and is used to assess the financial soundness of an entity in terms of liquidity risk, financial risk, credit risk and business risk.

Significant variances for the year to date include: • Property, plant and equipment is £12.2m lower than plan due mainly

to slippage in the capital programme pending approval of the Trust's Capital Resource Limit (CRL) by NHSI partially offset by the part year impact of the reduction in depreciation charges.

• An increase in trade and other receivables of £23.4m is mainly due to delays in the receipt of accrued STF funds, accrued income (mainly in respect of contract overperformance), and ongoing SLA negotiations with other NHS bodies (offset by withholding of payables).

• An increase in trade and other payables of £4.5m is due to ongoing SLA negotiations with other NHS bodies and general fluctuations in levels of creditors and accruals.

• An increase in DH Interim Revenue Support Loans (current and non-current) of £21.5m which is a result of a loan needed to offset the current year deficit against plan and the delay in receipt of STF monies.

Forecast outturn key variances include: • Property, plant and equipment is forecast to be £9.5m lower than plan

due to the net impact of a reduction in forecast capital expenditure of £12.6m and a £2.5m saving on depreciation arising from: the year end revaluation of land and buildings and outturn capital expenditure at the end of 2016/17; and forecast phasing of expenditure in 2017/18.

• Borrowings(mainly comprising of the PFI liability and leases) are £11.7m less than plan due to the slippage of two capital projects which were due to be financed through leases.

• Forecast PDC funding shows a net additional sum of £1.9m which includes £0.9m which finances the settlement of provisions/creditors at the end of 2016/17 and a net £1.0m for capital allocations.

• The variance on capital loans £0.4m is the impact of variations in the estimate of loans repayable (caused by drawn down timing changes).

• The variance in retained earnings of £22.1m reflects the Trust's current forecast deficit - this is offset by increased revenue loans of £25.5m (to cover the deficit and the delayed receipt of Q3 STF monies).

Plan(£'000)

Forecast Outturn (£'000)

Variance(£'000)

Plan(£'000)

Actual(£'000)

Variance(£'000)

Non-current assetsProperty, plant and equipment 357,871 348,329 (9,542) 335,373 323,160 (12,213)Intangible assets 5,907 5,907 0 5,982 6,796 814Investment Property 8,230 8,230 0 8,230 8,230 0Trade and other receivables 34,618 33,923 (695) 37,759 41,701 3,942Total non-current assets 406,626 396,389 (10,237) 387,344 379,887 (7,457)

Current assetsInventories 14,544 13,369 (1,175) 14,524 13,349 (1,175)Trade and other receivables 30,820 38,096 7,276 34,188 57,652 23,464Cash and cash equivalents 1,007 1,007 0 9,384 1,300 (8,084)Total current assets 46,371 52,472 6,101 58,096 72,301 14,205

Total assets 452,997 448,861 (4,136) 445,440 452,188 6,748

Current liabilitiesTrade and other payables (60,367) (59,868) 499 (76,848) (81,447) (4,599)Borrowings (8,396) (7,540) 856 (8,396) (7,571) 825DH Interim Revenue Support loan (7,884) (11,793) (3,909) 0 (8,717) (8,717)DH Capital loan (3,966) (3,329) 637 (3,966) (3,330) 636Provisions (391) (2,492) (2,101) (391) (2,492) (2,101)Net current assets/(liabilities) (34,633) (32,550) 2,083 (31,505) (31,256) 249

Total assets less current liabilities 371,993 363,839 (8,154) 355,839 348,631 (7,208)

Non-current liabilities:Trade and other payablesBorrowings (262,460) (251,568) 10,892 (254,699) (251,428) 3,271DH Interim Revenue Support loan/RWCSF (12,479) (34,084) (21,605) (20,363) (33,183) (12,820)DH Capital loan (17,125) (18,185) (1,060) (17,875) (13,416) 4,459Provisions (3,466) (3,691) (225) (3,515) (3,740) (225)Total assets employed 76,463 56,311 (20,152) 59,387 46,864 (12,523)

Financed by taxpayers' equity:Public dividend capital 63,178 65,092 1,914 63,178 62,201 (977)Retained earnings (27,177) (49,243) (22,066) (35,399) (46,945) (11,546)Revaluation reserve 40,462 40,462 0 31,608 31,608 0

Total Taxpayers' Equity 76,463 56,311 (20,152) 59,387 46,864 (12,523)

11 month ended 28 February 2018

Year To DateFull Year

20

21

Efficiency Delivery Programme – CIP Reporting Month February 2018


Overview The Trust is forecasting delivery of £29.1m against £29.1m of identified savings.

£29.1m of the forecasted savings are fully implemented schemes.

Of the £29.1m forecast delivery, £14.6m is being delivered non-recurrently.

The Financial Improvement Programme has supported the Trust in identifying ideas (scoped opportunities) worth £1.5m as at month 11.

Quality Impact Assessment

Each scheme, at QIA requires clinical approval from individual Group‘s Clinical Director (CD) and Modern Matron (MM); and the Trust‘s Chief Nursing Officer (CNO) and Chief Medical Officer (CMO). As at month 11, all of the documented 331 schemes have been fully assessed for quality impact assessment and most signed off, with 6 awaiting full sign off.

At Operational and Finance sign-off stage, schemes

require Chief Operating Officer (DCOO/COO) and Associate Directors of Finance (ADoF – Ops/CC). All of the implemented schemes have received sign-off. These are schemes that have fully been assessed for QIA and have received full sign-off.

29.1 29.1 29.1

0 0

0

5

10

15

20

25

30

Identified CIPs Variance againstIdentified Savings

Forecast CIP delivery Forecast CIPs required Target CIP delivery

Efficiency Savings Slippage

21

Workforce Information | Headlines February 2018

* Headcount - includes ISS. WTE - excludes ISS and bank only staff

22

This report provides a summary overview of workforce data. A detailed analysis of this data is provided within the monthly workforce report presented to the Finance and Performance Committee.

Sickness 4.45%

Training 91.95% (Substantive Employees)

HEADCOUNT 8,832 (7,200.29wte)*

Turnover 9.75%

Vacancy Rate 12.58%

Agency Spend £1,875,372

90%Target

95%

10%

4%

10%

90%

Medical 83.14% Non-Medical 88.39%




23

Headcount/WTE

This report provides a summary overview of workforce data. A detailed analysis of this data is provided within the quarterly workforce report presented to the Finance and Performance Committee.

Staff Group in Post | Monthly Variation

Overall between January 2018 and February 2018 there has been an increase in staff in post of 20.01 WTE. The staff groups with the biggest increase in staff numbers are: • Additional Clinical Services (33.56 WTE) • Healthcare Scientist (1.80 WTE) • Additional Prof Scientific & Technical (1.73

WTE) Medical and Dental (1.03 WTE) & Students (1.08 WTE) also had an increase. The staff in post with the biggest decreases are : • Nursing & Midwifery (-7.82 WTE)

• Administration & Clerical (-6.18 WTE) • Allied Health Professionals (-0.19 WTE) also

had a decrease NB: Staff in Post data reflects new starters, monthly amendments to the increase and decrease hours and leavers. Therefore, whilst a number of staff may have been recruited in month the overall figure may go down due to the changes in hours and leavers.

Total Trust Headcount (including ISS) is 8832, an increase of 22 since January. Bank headcount has increased by 10.

Overall, WTE has increased by 20.01 WTE (which will include existing staff increasing/decreasing hours)

HEADCOUNT Dec-17 Jan-18 Feb-18 Substantive/Fixed Term 8121 8205 8232

ISS 607 605 600 Totals 8728 8810 8832 Bank only 1798 1794 1804

WTE Dec-17 Jan-18 Feb-18

(excluding ISS/Bank Workers)

7181.84 7200.28 7220.29

Staff Group Staff In

Post WTE 31st Jan-18

Staff In Post WTE 28th Feb-

18

Variance (WTE) % Variance

Add Prof Scientific &Technic 263.14 264.87 1.73 0.66%

Additional Clinical Services 1677.71 1711.27 33.56 2.00%

Administrative & Clerical 1259.47 1253.29 -6.18 -0.49%

Allied Health Professionals 439.69 439.50 -0.19 -0.04%

Estates & Ancillary 2.00 2.00 0.00 0.00%

Healthcare Scientists 340.05 341.85 1.80 0.53%

Medical & Dental 970.72 971.75 1.03 0.11%

Nursing & Midwifery Registered

2210.23 2202.41 -7.82 -0.35%

Students 32.27 33.35 1.08 3.35%

Totals 7200.28 7220.29 20.01 0.28%

ISS 463.90 460.04 -3.86 -0.83%



24

Vacancy | by Staff Group

The Trust overall turnover rate (12 months rolling) has increased to 9.75% from 9.59%. The largest numbers of leavers (Headcount) in February are within the Medical and Dental (37) Nursing and Midwifery (15) and Additional Clinical Services (8) staff groups. The high number of leaver for Medics will relate to the February junior Doctor rotation. A “how to” guide has been developed and will be launched at the end of March. The guide will provide information on the correct process for leavers and promote the importance of consistently asking staff to complete a leavers questionnaire to enable us to gather meaningful data for review and action. This guide will ultimately form part of a managers toolkit.

Turnover | by Staff Group (inc Bank)

The overall vacancy rate is 12.58%. The largest proportion of vacancies are within the Nursing & Midwifery (18.93% = 514.43 WTE), Healthcare Scientists (15.96% = 64.92 WTE) and the Medical & Dental (13.41% = 149.30 WTE) staff groups. The forecast new starters for Nursing next month is 30 (Source – Resourcing Dept)

It is important to note that Medical and Dental leavers will be significantly higher within peak doctor rotation months which include August, September, December, February, March and April.

Add Prof Scientific and Technic, 2

Additional Clinical

Services, 8

Administrative and Clerical, 5

Allied Health Professionals, 4

Healthcare Scientists, 3

Medical and Dental, 37

Nursing and Midwifery

Registered, 15

Students, 2

Leavers Headcount



25

Pay Costs | Provided by Finance • The overall pay bill for February 2018

decreased by £388,024 from January. • Temporary costs equate to 12.81% of the

Trusts total pay bill (£31,248,854), this is a decrease of 12.81% from January 2017 which was 13.80%.

• Agency costs against total costs decreased from 6.24% to 6.00% which is an overall decrease in total agency spend by £99,120, against January 2017.

• Overall bank spend has decreased by £288,931.

NB: An error has been noted in last months report. Bank spend for January should have read £2,266,936 not £1,974,492.

NHSI Rate Caps | Percentage of Shifts Booked Over Cap • The % of medical shifts above agency cap rates

has remained consistently 100% throughout the last three months.

• Nursing shifts over cap rates have increased to between 61.18% - 69.85%.

• A&C workers over cap rates have increased to the same level as mid January (37.50%).

• AHP (53.06% - 75.00%) and Healthcare Scientists (39.02% - 58.14%) staff groups have also continued to fluctuate during February 2018.

Overall, there has been an significant increase in agency shifts in month for nursing and medics which does correlate with service pressures.



26

Absence | by Group The overall Trust sickness absence rate in February has decreased by 0.40% to 4.45.% and is above the current Trust 4% target. 26.50% of staff were absent due to Cold, Cough, Flu – Influenza within February 2018 which has reduced from last month. There are four specialty groups which met the 4% target and nine groups who have not achieved the target in February. The absence management team are undertaking a deep drive into Care of the Elderly as they are the Group with the highest absence %.

Absence | by Month/Year

Absence | by Staff Group

The sickness rate over the during last few months is still higher on average in comparison to the same period last year.

The staff group with the highest sickness % is the Additional Clinical Services Group which includes Healthcare Workers who also have the highest turnover rates.

The absence management team work with managers to regularly review all cases with a focus on high % areas.

A significant number of long term sick staff have returned during the month of February which will have a positive impact on sickness % for March.

Specialty Group Jan % Abs Rate (WTE)

Feb % Abs Rate (WTE)

Cardiac & Respiratory (SG01) 4.27% 3.00% Care of the Elderly (SG13) 6.29% 6.78% Clinical Diagnostics (SG14) 4.74% 4.57% Clinical Support Services (SG16) 6.06% 5.38% Core Services (SG21) 4.56% 3.97% Emergency Department and Acute Medicine(SG04) 6.19% 4.99% Neurosciences (SG05) 4.02% 3.56% Oncology, Haematology & Renal (SG06) 3.83% 2.76% Specialist Medicine & Ophthalmology(SG10) 5.00% 4.27% St Cross and Trauma & Orthopaedics (SG08) 4.41% 4.32% Surgery (SG07) 4.19% 4.43% Theatres and Anaesthetics (SG11) 5.43% 5.18% Women & Childrens (SG09) 4.68% 5.03%

Trust Totals 4.85% 4.45%



27

Mandatory Training | by Group

Mandatory Training compliance for substantive staff is currently 91.95%, against a target of 95%, it has remained almost static over the past 3 months. Total compliance, which includes bank only staff has increased this month by 0.26% to 84.55%

Clinical Support and Theatres & Anaesthetics remain the only groups to consistently maintain their compliance rates over 95% during the last three months. However all areas with the exception of TSS are rated amber, providing assurance that majority of our substantive staff are completing training and are able to work safely when providing care for our patients. We have a specific action plan in place to facilitate improvements in bank staff mandatory training compliance which is monitored through our Training, Education & Research Committee.

We continue to focus on making improvements to topics under 90% compliant with targeted actions monitored via our Training, Education & Research Committee (TERC) to ensure we are providing sufficient capacity and a range of opportunities for staff to undertake their mandatory training. Continued support and challenge is provided to Groups through monthly accountability meetings to maintain focus on increasing/maintaining their compliance rates.

Appraisals | by Group

Medical appraisal has decreased to 83.14% and is aligned to revalidation dates. We have an agreed process for validating the information each month between RMS and ESR. The CMO has written to all Medics without an in date appraisal advising these must be completed by 31.3.18.

We keep a continued focus on those areas rated red and provide both support and challenge through the monthly accountability meetings.

Group Dec-17 Jan-18 Feb-18 Cardiac & Respiratory (SG01) 80.14% 78.59% 76.40% Care of the Elderly (SG13) 89.95% 87.23% 84.04% Clinical Diagnostics (SG14) 82.84% 87.60% 90.76% Clinical Support Services (SG16) 93.92% 94.11% 94.38% Core Services (SG21) 81.55% 81.10% 83.57% Emergency Department and Acute Medicine (SG04) 70.98% 76.48% 80.73% Neurosciences (SG05) 70.26% 73.10% 68.81% Oncology, Haematology & Renal (SG06) 95.32% 93.70% 94.27% Specialist Medicine & Ophthalmology (SG10) 88.74% 85.78% 84.75% St Cross and Trauma & Orthopaedics (SG08) 92.55% 92.39% 91.86% Surgery (SG07) 88.87% 90.04% 91.09% Theatres and Anaesthetics (SG11) 93.72% 93.79% 94.47% Women & Childrens (SG09) 91.18% 91.34% 91.68%Trust Total 86.85% 87.59% 88.39%

Appraisals -Non Medical Appraisals - MedicalGroup Dec-17 Jan-18 Feb-18 Cardiac & Respiratory (SG01) 75.61% 87.80% 85.71% Care of the Elderly (SG13) 80.00% 100.00% 90.00% Clinical Diagnostics (SG14) 90.20% 92.16% 90.38% Clinical Support Services (SG16) N/A N/A N/A Core Services (SG21) 80.00% 80.00% 100.00% Emergency Department and Acute Medicine (SG04) 78.57% 83.05% 90.32% Neurosciences (SG05) 80.49% 85.37% 84.21% Oncology, Haematology & Renal (SG06) 72.92% 67.14% 78.85% Specialist Medicine & Ophthalmology (SG10) 78.69% 83.87% 80.65% St Cross and Trauma & Orthopaedics (SG08) 77.55% 88.24% 84.62% Surgery (SG07) 86.17% 89.58% 82.65% Theatres and Anaesthetics (SG11) 79.27% 81.71% 87.80% Women & Childrens (SG09) 82.98% 87.23% 72.92%Trust Total 79.06% 84.08% 83.14%

Specialty Group Dec-17 Jan-18 Feb-18 Cardiac & Respiratory (SG01) Total 88.76% 87.12% 86.48% Care of the Elderly (SG13) Total 93.70% 92.08% 91.03% Clinical Diagnostics (SG14) Total 90.91% 90.67% 93.05% Clinical Support Services (SG16) Total 95.52% 95.94% 96.31% Core Services (SG21) Total 92.97% 92.77% 93.04% Emergency Department and Acute Medicine (SG04) Total 88.98% 89.70% 90.63% Neurosciences (SG05) Total 88.22% 87.67% 87.14% Oncology, Haematology & Renal (SG06) Total 93.15% 92.40% 92.35% Specialist Medicine & Ophthalmology (SG10) Total 93.91% 93.16% 92.64% St Cross and Trauma & Orthopaedics (SG08) Total 91.66% 90.30% 91.73% Surgery (SG07) Total 91.86% 91.26% 91.82% Temporary Staffing Division Total 48.53% 47.27% 46.67% Theatres and Anaesthetics (SG11) Total 95.68% 95.27% 95.39% Women & Childrens (SG09) Total 91.79% 92.29% 92.93%Grand Totals 85.10% 84.29% 84.55%Substantive Staff Only Totals 92.30% 91.95% 91.95%

Non-medical appraisal compliance has slightly increased from last month and currently stands at 88.39%, against a target of 90%. This financial year we moved to a six monthly appraisal cycle during April to September that included talent conversations and we are now planning the 2018 cycle.


Title Royal College of Surgeons’ Invited Individual Review Author Meghana Pandit, Chief Medical Officer and Deputy CEO Responsible Director

Meghana Pandit, Chief Medical Officer and Deputy CEO

Date 29 March 2018 1. Purpose This report sets out the background to a request made by the Trust to the Royal College of Surgeons (RCS) for an invited individual review. It also addresses the recent BBC Inside Out Programme that was broadcast about the Trust and a consultant surgeon from UHCW. 2. Background The CMO decided to invite the Royal College of Surgeons for an invited individual review in June 2017 due to there being two ongoing inquests in patients under the care of a particular consultant and two further serious incidents (SIs) going through the Trust’s Serious Incident Group (SIG). 3. Executive Summary The review was conducted in September 2017 and the final report was received in January 2018. The report is detailed below along with the recommendations it makes and the Trust’s action plan in response to these. Since then the Trust received a letter from the BBC in late February informing us that they would be broadcasting a programme on Inside Out, West Midlands about the Consultant in question and the Trust’s management of the concerns raised about the Consultant by a previous employee. The Trust responded to the BBC on each point raised in their letter, always maintaining patient and staff confidentiality. Management of the impending media exposure including immediate and medium to long-term actions in response to the media exposure are detailed below. The following regulators and external agencies were contacted soon after the initial letter informing of a BBC programme was received by UHCW:

1. GMC employee liaison advisor 2. NHSI 3. NHSE 4. Coventry and Rugby CCG 5. CQC 6. All relevant private providers. 7. Royal College of Surgeons 8. External reviewer NK 9. Board members 10. All neurosurgical teams

Communications with all internal and external stakeholders was maintained throughout the period. A Clinical Advisory Group (CAG) has been set up, chaired by the CMO to ensure that a single, joint approach is taken in delivering assurance to the Trust Board and all partner organisations that appropriate actions are being taken with regard to the media exposure into the Consultant’s practice. The CAG will report its findings to Chief Officers’ Group, under whose governance the Group will meet regularly to assess the adequacy of response to the BBC programme. CAG will also provide assurance reports to the Trust Board. The CAG reports will be shared with NHSI and NHSE. All SIs in patients under the care of the Consultant and all patients who have undergone procedures for which he is now deemed to need further mentoring according to the RCS are being reviewed. All mortality reviews under the care of the consultant since 2015 (n=16, NCEPOD A) are being reassessed. The consultant’s mortality rate as published on the Society of British Neurosurgeon’s website is within the expected range and he is not an outlier on the UHCW morbidity scorecard. 4. Areas of Risk

Any risks to the safe and effective care of patents are taken seriously by the Trust and there are a variety of measures in place to mitigate these risks. These include carrying out internal investigations of any serious incidents and seeking external independent reviews where necessary 5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks This is related to the Trust’s corporate objective of delivering excellent patient care and experience 6. Governance of Invited Reviews from Royal Colleges Invited individual reviews are agreed, received and actions arising are monitored by the Medical Concerns Group with reports to the Chief Executive, the Board Member linked to this Group and presented to the Board by the CWIO and CMO. Invited Service reviews are requested by the CMO after discussion with the Chief Executive and the relevant Clinical Group. The report is presented to COG and the actions are monitored at Quality Star Chamber and the Patient Safety and Effectiveness Committee which reports to the Quality Governance Committee. 7. Responsibility Professor Meghana Pandit, Chief Medical Officer and Deputy CEO 8. Recommendations The Board is invited to NOTE the attached report.

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Report of the Invited Individual Review of the Royal College of Surgeons 2017/18

This report summarises a review carried out by the Royal College of Surgeons (RCS) about the clinical practice of one of the Trust’s consultant neuro-surgeons. Throughout this report he will be referred to as ‘the Consultant’. This is important so that we can maximise the learning from the report whilst maintaining the confidentiality of both the consultant and his patients.

On 16 June 2017, University Hospitals Coventry and Warwickshire NHS Trust wrote to the Chair of the Invited Review Mechanism (IRM) to request an ‘invited individual review’ into the Consultant’s clinical practice. In particular, the request highlighted four clinical adverse events, which had raised concerns about his work. This request was considered by the Chair of the RCS IRM and a representative of The Society of British Neurological Surgeons, and it was agreed that an invited individual review would take place.

Terms of Reference

The following terms of reference for this review were agreed prior to the RCS review visit between the RCS and the Trust.

a) To consider concerns raised about the Consultant’s clinical practice with specific reference to:

• Quality and safety of surgical practice

• Clinical decision making

• Behaviour and team working

• Engagement with service governance arrangements

b) To review 4 clinical records about which concerns have been raised by the Trust.

c) To make recommendations for the consideration of the Chief Executive and Medical Director of University Hospitals Coventry and Warwickshire NHS Trust as to: -

• Whether there is a basis for concern about the Consultant’s practice in light of the findings of review

• Possible courses of action which may be taken to address any specific areas of concern which have been identified

Review Process A review team was appointed and an invited review visit was held on 27th and 28th

September 2017 and the final report of the review was received on 10 January 2018.

In order to address the terms of reference, the review team considered a range of interview and documentary evidence. The team produced detailed findings in each area, which focussed on the Consultant’s clinical practice, but which also highlighted matters of team working and clinical governance. The Consultant’s performance was, therefore, assessed on its

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own merits, but also in the context of service-related issues. The team’s conclusions and recommendations were similarly broad as they covered both individual performance and service issues.

A list of the team members interviewed during the visit and the documents reviewed (redacted where necessary) are shown as appendices A and B.

Summary of the cases reviewed

In all, five cases were reviewed1, and brief summaries of them are shown below.

Event 1 Patient A underwent anterior and posterior spinal fixation in July 2015. The patient subsequently died of pulmonary embolus.

Event 2 Patient B had a known recurrent brain abscess and was discharged home in January 2017 and readmitted 3 days later when the Consultant carried out a craniotomy on the patient, who made a good recovery.

Event 3 Patient C underwent surgery to remove a meningioma (brain tumour) in September 2016. Whilst in recovery, an emergency CT scan revealed a post-operative haematoma (internal bleeding) and the Consultant performed a further craniotomy to evacuate the haematoma. Another operation was required the same evening for which the Consultant requested assistance from a colleague. At this point the plan was for ‘supportive care’ but no escalation of treatment or resuscitation and the patient was managed on an end of life pathway. Six weeks later, the Consultant proposed an external ventricular drain (to relieve pressure on the brain) but the patient deteriorated and died at end of October 2016.

Event 4 Patient D underwent a lumbar decompression and fusion procedure by the Consultant at a private hospital in May 2017 and subsequently presented to UHCW a week or so later with wound discharge and signs of infection. The Consultant performed a surgical debridement and inserted suction drains at the end of the procedure. The patient failed to wake up and an emergency CT scan showed a tight posterior fossa with brain stem compression and tonsillar herniation. After a hindbrain decompression, the patient made a slow and incomplete recovery.

Event 5 This case involving was not initially referred to the RCS team but they reviewed the ‘concise’ investigation report. Patient E underwent an elective resection of a posterior fossa brain tumour in November 2016 by consultant B. The patient initially made a good recovery but 36 hours later became unconscious due to a post-operative haematoma. The on-call registrar was operating on another patient so the Consultant was contacted as the on-call consultant surgeon

1 The reviewers had initially reviewed four cases, but interviewees highlighted a fifth case of some concern

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at 3:15 am. The Consultant was unable to leave home immediately due to feeling unwell and advised the on-call registrar to operate on patient E as soon as he finished the other operation. An hour later the Consultant was advised that patient E was in theatre and the registrar felt able to operate and the Consultant remained at home. Patient E suffered a further bleed later that day and was returned to theatre to be operated on by consultant B, but despite this intervention, the patient died.

Overall conclusion on the five index events

Based on these five cases, the reviewers did not believe the Consultant’s technical competence to be the key issue. They thought the cases highlighted team working issues, specifically in relation to patient handover. In three cases, they believed that better communication between the treating consultant and the on-call consultant would have led to a more coordinated care of the patients.

The reviewers also found that the cases illustrated significant shortcomings with the root cause analysis (RCA) process, as three out of the five cases, resulted in criticism of the accuracy of the investigation findings and in each case the level of input from the relevant consultant surgeons was inadequate.

The reviewers also identified a lack of insight from the Consultant concerning adverse outcomes. The reviewers thought that such unwillingness to accept criticism had hampered professional discussion at subsequent team meetings, which had further damaged the Consultant’s closest colleagues.

Recommendations to address patient safety risks

The RCS made the following recommendations which it considered to be highly important actions for the Trust to take to ensure patient safety is protected. These recommendations should be shared with the private hospitals where the Consultant has admitting rights.

1. With immediate effect, the Consultant should cease to perform awake craniotomy for intrinsic primary brain tumours. As soon as is possible, he should seek to attend a specialist centre, where he can observe and be supervised in this procedure, and aim to participate in at least five procedures. Formal feedback on his performance, and whether he is regarded as fully trained in both selection and practical performance of the procedure, should be requested by the Trust. This feedback should then be used by the Trust to inform whether he should recommence this area of clinical practice.

2. With immediate effect, the Consultant should avoid performing certain ‘complex’ spinal surgical procedures, as agreed between him and Trust. As soon as is possible, the Consultant should arrange to undertake further advanced training in these specific complex spinal operations. This training should include patient assessment, treatment planning as well as the technical aspects of surgery. This should entail at least six months’ mentorship by a consultant surgeon with sufficient expertise in complex spinal surgery, who could be from within or outside the Trust, depending upon the Consultant’s preference and other practical considerations. Formal feedback from this mentorship process as to which

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procedures he is considered sufficiently competent in should be requested by the Trust. This feedback should then be used by the Trust to inform which procedures he should recommence performing.

Recommendations for individual performance improvement

These recommendations are for the Consultant and the Trust to consider with a view to agreeing actions to be taken to improve patient care and patient experience.

3. Within the next three months, if agreed to by the Consultant, the Trust should arrange for individual behavioural coaching. The coaching would be targeted towards the behavioural concerns identified by this review. The skills to be developed are likely to include team working, communication with colleagues and resilience. The Consultant is strongly encouraged to sign up to and learn from this process.

4. If agreement cannot be reached regarding coaching, the Trust should arrange for the Consultant’s attendance at an advanced communication course, focused on team communication skills in the medical environment. This would be very much a second best option as it lacks individual focus, breadth of discussion and sustained input provided by individual coaching.

5. Within the next three months, the Consultant should be required to reflect upon his behaviour at, and attendance of team meetings, specifically the MDT, QIPS and M&M meetings. Expectations around how participants should conduct themselves may need to be stated formally. His behaviour and attendance should be firmly agreed and monitored as part of his appraisal process.

6. Within the next three months, the Consultant’s (including his private practice commitments), should be reviewed to remove any obstacles to his attendance at team meetings and to address an underlying concern that he could be overcommitted, particularly in view of his teaching and education commitments.

7. Within six months, in order to improve the Consultant’s acceptance of, and willingness to discuss, adverse clinical events, including post-operative complications, 10 of his more challenging cases from within the past two years should be selected (with his input) for discussion with a trusted senior colleague, either from within or outside his own speciality. These reflections should be recorded and the learning and actions arising should be incorporated into the Consultant’s appraisal.

Recommendations for Service Improvement

The following recommendations are for the healthcare organisation to consider as part of its efforts to ensure continuous service improvement.

8. Within six months, in order to maintain skillsets in subspecialist areas, the consultant neurosurgeons should reach documented agreement on the allocation of categories of cases falling into subspecialist areas such as skull base surgery and awake craniotomy. This will promote concentration of expertise, which should help to ensure patient care is optimised and advance individual services.

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9. Within six months, the consultant neurosurgeons should seek to implement improvements to the awake craniotomy service. This should include development of:

a. Complete team agreement on case selection criteria, which should be explicit and heavily inclined towards what are believed to be low-grade gliomas. Options should be discussed with patients in clinic to decide whether to proceed with an awake craniotomy or undergo another treatment option.

b. Clear documentation of the initial assessment of suitability at the neuro-oncology MDT meeting with expert input from a neuro-radiologist, neurosurgeon and neuro-oncologist for every case.

c. Concentration of the service with one neurosurgeon and specialist training for this surgeon, and with one (or possibly two) neuropsychologists (depending on the number required for speech assessment during the procedures) and specialist training for them. Allocation of the cases to a single anaesthetist, would be ideal, but not essential.

d. Annual audit of awake craniotomy outcomes and the presentation of results at a QIPS meeting.

10. If not already in place, within nine months, the Trust should work with the consultant neurosurgeons to develop a departmental policy for end-of-life decision making, in line with other end-of-life care policies in the Trust. This policy should cover both individual and team considerations, working with other disciplines, internal and external communication and expert and legal support.

11. Within the next three months, the Trust should attempt to arrange for mediation between the Consultant and the consultant neurosurgeons with whom he has particularly come into conflict. This should be provided by an external expert mediation team. There should be a follow-up meeting with the mediator(s) after six months and 12 months to ensure that improvements are sustained.

12. Within three months, the Trust should review its RCA process. It should ensure that during future investigations:

a. Detailed reference is made to all available clinical records and full account is taken of all relevant factors.

b. Statements are obtained from all staff involved.

c. Early discussions are held with principal clinicians to allow questioning regarding discrepancies between clinical notes and evidence from others.

d. For matters requiring particular surgical expertise, an expert perspective is obtained.

e. A welfare support process is introduced and offered to all staff involved (including consideration of an ‘all staff’ debrief)

f. A formal process to share an RCA’s outcome and learning with key parties is introduced.

g. There is timely discussion of the outcomes for all RCAs within departmental QIPS meetings.

13. Within three months, the Trust should discuss with the consultant surgeons the need for a 5 of 6

weekly neurosurgery consultants meeting, which should be a forum for the discussion of team-related issues, as opposed to individual patient cases. Job plans may need to be revised to accommodate this. There will need to be agreement on expected attendance rates and the agenda for discussion.

14. Within the next three months, the Trust’s senior management should revisit the issue of clinical leadership of the neurosurgery department with the consultant surgeons. Solutions to address any outstanding, fundamental concerns should be implemented. The efficacy of these solutions should be monitored via follow-up meetings at three and six months. This should be an objective undertaking, with a practical, rather than personal focus, which should aim to end ongoing speculation and negativity. However, mediation between certain individuals may be necessary as a result.

15. Within three months, the Trust should review the consultant surgeon handover process in place within the neurosurgery team to avoid the treating surgeon’s intended patient management plan from being overlooked. A local process, reflecting any wider Trust policy, should be developed. This should include specific arrangements for the daily and weekend on-call handovers as well as requirements before a period of leave. The records of handovers for all consultants should be subject to Trust audit on an annual basis.

16. Within three months, further to the recent introduction of the consultant of the day (COD) on-call rota, an exercise to review how well it is working should be undertaken. This should include an analysis of the rota’s strengths and weaknesses, paying particular attention to any occasions when consultants had been on-call overnight after having an all-day theatre list. This review should entail agreement on expectations for when an on-call consultant is unavoidably detained and cannot attend a neurosurgical emergency.

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Appendix A

The following were interviewed as part of this invited review. The RCS provided guidance on who it considered relevant to the Terms of Reference and the individuals listed were selected by the healthcare organisation that commissioned this review

• Group Manager

• Chief Medical Officer and Deputy chief Executive

• Head of Legal Services

• Consultant Neurosurgeon

• Consultant Anaesthetist and lntensivist

• Consultant Anaesthetist and lntensivist


• Ward Manager ward 43, neurosurgery

• Neurovascular CNS

• Neuro-oncology CNS

• Matron

• Charge Nurse - neurosurgery theatre


• Associate Specialist Neurosurgery

• Consultant Anaesthetist

• Clinical Lead for Neurosurgery

• Clinical Director for Neurosurgery


• Deputy Chief Medical Officer

• Theatres Sister

• Middle Grade Doctor




• Associate Specialist Neurosurgery

Appendix B The following items of documentation were provided to the review team before, during or after the review visit. 1.) Trust organisational structures. 2.) Neurosurgery consultant rota from April 2017. 3.) Proposal for ‘Consultant of the Day’ rota 4.) Departmental advice regarding Thromboprophylaxis following neurosurgery and pre-and

post-operative management of elective spinal patients. 5.) List of recent audits, presentations and publications undertaken by the Consultant

6.) Annual Report for the Neuro-oncology MDT 2016-2017.

7.) Sample record of Neuro-oncology MDT outcomes meeting 30/06/2017. 8.) Neurosurgeons’ attendance at Quality Improvement and Patient Safety Meeting to 2016 and

2016 to 2017. 9.) Minutes from QlPS Meetings, July 2016, March 2017, April 2017, May 2017, June 2017,

July 2017 and August 2017. 10.) Minutes from Neurosurgery M&M meetings, February 2017, March 2017, May 2017, June

2017, July 2017 and August 2017. 11.) Neurosurgery mortality profiles January 2016, July 2016, February 2017 and June 2017.

12.) Comprehensive lnvestigation Report for clinical case A1.

13.) Concise lnvestigation Report for clinical case A2. 14.) Expert report and the Consultant's statement for clinical case A3. 15.) Preliminary review of clinical case A4 (x2). 16.) The Consultant’s job plan 17.) Consultant neurosurgeon job description.

18.) The Consultant’s Curriculum Vitae.

19.) The Consultant’s anonymised patient waiting list 20.) Sample neurosurgery theatre list. 21.) The Consultant’s 2016-2017 appraisal. 22.) The Consultant’s 2015-2016 appraisal. 23.) The Consultant’s 2014-2015 appraisal.

Appendix B 24.) The Consultant’s 2014 colleague and 360 feedback 25.) Summary of the Consultant’s patient complaints 2016-2017. 26.) UHCW morbidity register: unit- and surgeon-specific outcome data 2016-2017.

27.) Minutes from meeting of neurosurgeons with the Chief Operating Officer November 2016.

28.) Preliminary and secondary review of May 2014 clinical event involving the Consultant 29.) Preliminary review of a clinical event involving the Consultant, completed in March 2014. 30.) August 2014 investigation meeting with the Consultant regarding two adverse clinical

events. 31.) 2014 expert report regarding two adverse clinical events. 32.) Written support for the Consultant from July 2014 from the neurosurgical trainees.

33.) September 2014 investigation meeting regarding the Consultant’s allegation of bullying

33.) Mortality Review and Monitoring Policy. 33.) Action Plan for Neurosurgery from February 2012. 34.) Prevention of wrong-level spinal surgery guidelines and April 2016 audit. 35.) Concise lnvestigation Report for additional clinical incident from November 2016 36.) lnvestigation documentation for additional clinical incident from November 2016, including a

record from an MHPS investigation meeting held in June 2017 and the Consultant’s account of events (January 2017).

37.) Thrombo-prophylaxis guidelines for neurosurgical patients.

38.) Record of the Consultant’s private patient cases from 2014 to 2016

39.) Record of the Consultant’s elective cases performed at UHCW between August 2016 and August 2017

40.) Neurosurgical National Audit Programme 30-day (unit and individual) mortality data. 41.) Awake craniotomy documentation: neuro-oncology business meeting minutes

November 2014, letter to Chief Medical Officer (12 May 2015) patient pathway, patient information and letters of thanks.

42.) Letter to Chair of the lnvited Review Mechanism from the Consultant, dated 26 November

2017. 43.) List of the Consultant’s neurosurgical training posts - spinal and oncological.

44.) Press releases for operations performed by the Consultant.

Appendix C

PRIVATE AND CONFIDENTIAL Dear Dr Phillips, Further to the RCS invited review visit held at your Trust at the end of last week, the review team would like to thank you for the effort made to coordinate the review visit. Lesley Terry was extremely helpful and tried to make the visit proceed as smoothly as possible. Your feedback regarding some misunderstanding about the scope of the background information to be provided before the review visit was appreciated, and will be used to avoid confusion ahead of future review visits. I am writing to confirm the discussion at the end of the visit, when the review team provided you with an outline of their initial findings. The team’s initial findings were also shared directly with Mr El-Maghraby. • The review team identified that, through personal choice, some of Mr El-

Maghraby’s clinical practice was now within two areas of neurosurgery subspecialisation to which the Trust had not originally appointed him and in which he had not received any formal, advanced training. Accordingly, the review team would strongly advise the Trust to arrange for a period of external training / secondment in these two areas: complex spinal surgery (including internal fixation and trauma) and case selection and technique for awake craniotomies1.

• Additionally, the review team would advise the Trust to consider appointing an

external mentor for Mr El-Maghraby, agreeable to both parties, in order to further his advanced training. The review team would be willing to provide further advice on both suitable advanced training and mentoring.

• For clarification, the review team did not consider that Mr El-Maghraby needed to

be formally restricted from undertaking these forms of complex spinal and oncological surgery until he had had the further training, however, the reviewers

1 http://www.aomrc.org.uk/revalidation-cpd/remediation-resources/ This webpage from the Academy of Medical Royal Colleges should be a useful starting point for seeking further guidance. It advises on the following areas: revalidation help desks, mentoring/peer coaching, CPD which may be relevant to remediation, guidance (relevant to remediation) and named Remediation Leads and contact points for each College.

Dr Andy Phillips Deputy Chief Medical Officer University Hospitals Coventry and Warwickshire NHS Trust Via email to: [email protected]

Professional and Clinical Standards Contact: Angela McKelvie Direct Tel: 020 7869 6223 Direct Fax: 020 7869 6220 Direct Email: [email protected]

2 October 2017

http://www.aomrc.org.uk/revalidation-cpd/remediation-resources/



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would urge tight oversight of these aspects of his practice by the respective MDTs in the meantime, and, where possible, would suggest that he undertakes such operations with a colleague with the necessary expertise.

• The review team was disappointed that full copies of the clinical records for the

pre-agreed cases were not made available to them on the first morning. However, from discussion with interviewees and a review of some components of the records, they were able to reach an overall view on each case. They concluded that whilst there were deficiencies in care in each, these were not so serious as to have jeopardised patient safety.

• As the review visit was heavily focused around these four cases, the review team

thought it would be useful to provide a few comments on each case. For case A1, patient GD, a patient with an incomplete spinal cord injury, the reviewers identified several unsatisfactory components of the patient’s management. In formulating a diagnosis, Mr El-Maghraby had not reviewed the scans on admission and had not appreciated the complexity of the injury. Early reduction and internal fixation of the spine is the gold standard management in a patient with an incomplete cord injury in order to relieve spinal cord compression and protect it from further injury. The surgery did not achieve reduction and cord compression was only partly relieved. Anterior bone fixation took place without reduction making it impossible to reduce the bifacet dislocation when the patient was turned over to undertake posterior fixation. The reviewers were disappointed by Mr El-Maghraby’s unwillingness to accept shortcomings in his management and to accept that his assessment of the patient’s outcome was at odds with objective records and other witness accounts. He would not accept that following surgery the patient had a complete cord lesion below the level of the injury.

• For case A2, patient DW, a patient with a recurrent intracerebral abscess, the

review team identified a failure by Mr El-Maghraby to review the patient’s investigations, leading to the patient’s inappropriate discharge. He accepted his registrar’s understanding of the imaging report, rather than reviewing the scans or the report himself. Mr El-Maghraby’s view was that the patient was not his and that the registrar had simply been updating him ahead of the patient’s discharge. Whilst the patient did not come to any harm as a result of the delay to surgery, which took place following readmission a few days later, the review team thought that the case indicated that Mr El-Maghraby could be rushed, leading him not to pay sufficient attention to detail. Furthermore, they were disappointed by his lack of reflection on this case and his continued denial of direct responsibility for this patient (initially a neurosurgical “outlier” in another ward).

• For case A3, patient SB, a patient with a meningioma, the review team questioned

whether Mr El-Maghraby had the appropriate sub-speciality skills to take on the case, when he had given up skull-base surgery several years earlier and there were other colleagues who specialised in this type of surgery. The review team was also concerned about the speed and care with which the tumour was removed and whether Mr El-Maghraby had achieved complete haemostasis (video evidence). The review team also had concerns about aspects of the post-operative care, including Mr El-Maghraby’s communication with the patient’s family regarding his decision to reinstitute active care in a patient with a very poor prognosis and in whom consensus around end-of-life care had already been reached.

• Case A4, patient KP, was a patient who had undergone a lumbar decompression

and fusion in the private sector by Mr El-Maghraby. They were later admitted with a wound infection. Suction drains were introduced at the end of the procedure to wash out the wound. The patient did not wake up after surgery, and an emergency

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CT scan showed a tight posterior fossa with brain stem compression. A posterior fossa decompression was performed by another colleague. The patient has since made a slow and incomplete recovery. The review team believed that this complication could not have been predicted and was extremely rare. They thought that it was almost certainly because of an unrecognised dural injury at the time of the first operation and the use of suction drainage following the wound washout. The reviewers did not think the outcome could be attributed to deficient surgical technique or case selection.

• The review team did not detect particular clinical themes with these cases, as they

were all very different, but the reviewers did think that they indicated that Mr El-Maghraby was overcommitted and was spreading himself too thinly. This had led him to rush some aspects of his practice, and could have led him to not devoting enough time to putting things right when they had gone wrong.

• The review team heard some very positive comments from many staff, who held Mr

El-Maghraby in high regard and trusted his surgical ability. However, his management of the reviewed cases and additional cases, brought to the review team’s attention, had raised significant doubts among some of his consultant colleagues about his decision-making, his competence and his motivations.

• The review team identified that whilst Mr El-Maghraby generally had support from

members of the wider surgical team, he lacked support from some consultant colleagues.

• The review team concluded that the neurosurgeons were not a cohesive team, as

they were not always open with each other, which meant that concerns were left unspoken and tensions escalated. It was thought that the team as a whole needed to function more closely and that trust between them should be re-built.

• In terms of communication, it was identified that Mr El-Maghraby could be

emotional and defensive during discussions, especially when he believed himself to be the subject of criticism. There was a perception that he did not respond well to challenge and would deflect it, rather than seek to learn from it. It was also felt that Mr El-Maghraby did not always answer questions directly, and had a tendency to obfuscate, which also hampered discussion of his cases.

• The review team considered that Mr El-Maghraby lacked awareness about his

prevarication and how it affected his interactions with his colleagues. In order to address these communication issues, it was thought that Mr El-Maghraby would benefit from an advanced communication skills course.

• Finally, the review team heard repeated concerns about the Trust’s ‘root cause

analysis’ (RCA) process. It was said that the (relevant) consultant surgeons were not always involved in the process, and that it could, in fact, take place without them knowing. There was also disappointment that the outcomes of investigations were not always shared openly, to enable departmental learning.

• Exclusion from the process had ultimately led to an overall lack of confidence in it,

with surgeons feeling that their actions had not been fairly represented by it. Alleged inaccurate investigation findings had also aggravated tensions between individuals, as they had been left with an incomplete picture of events. The review team thought that a more inclusive and transparent process could have avoided some inaccurate conclusions and unnecessary tensions.

4

The review team is now in the process of producing the invited review report and will keep you informed of their progress and likely date of completion. I trust that this letter is clear and helpful in clarifying the immediate feedback provided to you following our invited review, but should you require any further advice, please contact the Invited Review Mechanism (IRM) office on: 020 7869 6223. Yours sincerely Chair of the Invited Review Mechanism

Appendix D

Email dated 24 October 2017 From: Invited Review Manager, RCS To: Dr Andrew Phillips, Deputy Chief Medical Officer, UHCW NHS Trust

Dear Andy, I have liaised with the reviewers and they have agreed the following regarding Mr El-Maghraby’s clinical practice:

1. Mr El-Maghraby should avoid spinal trauma cases and vertebral body tumours with cord compression necessitating internal fixation in the thoracic and lumbar spine until he has had some additional training (in both assessment and planning, as well as the technical aspects of the surgery).

2. In respect of NHSE’s document classifying the procedures of the spine as complex or not, using OPCS 4 categories, the reviewers disagreed with some classifications. In their view, the following procedures did not constitute neurosurgical complex procedures, and Mr El-Maghraby should be permitted to perform them:

V226 Primary decompression of posterior fossa and upper cervical spinal cord

NEC

V492 Exploratory thoracic laminectomy

V242 Primary decompression of thoracic spinal cord NEC V494 Exploratory laminectomy NEC

The final category, interventions for persistent non-specific spinal pain and

intradural spinal procedures, was considered by the reviewers to be of mixed complexity. Accordingly, intradural neurosurgical procedures should be permitted, whilst interventions for persistent non-specific spinal pain should not be permitted.

The reviewers agreed that single-level lumbar instrumentation and fusion was

acceptable, but agreed that more than one level was complex and should be avoided.

The reviewers believed that the remaining procedures, identified as complex,

should be avoided by Mr El-Maghraby pending the period of additional training, because there were other surgeons available and because Mr El-Maghraby had not done a spinal surgical fellowship (and these procedures fall outside of the routine training offered to CCT).

3. The reviewers thought he should not undertake skull base tumour surgery (unless in

an emergency setting) because he had agreed with the Trust that he would cease doing it meaning that his caseload had not been sufficient to maintain his competence. The reviewers thought he should not, pending further training, be undertaking awake craniotomy for intrinsic primary brain tumours, as this is never an emergency, or even an urgent, operation. Furthermore, he was in any event, by his own disclosure, planning on visiting another centre to see this type of surgery .

4. The reviewers believed he should continue to perform routine neuro-oncology surgery for primary brain tumours, metastases and convexity meningeal and skull tumours, with the proviso that he is actively participating in the neuro-oncology MDT process, as no evidence of any shortcomings had come to light during the review.

Appendix E

Action Plan Populated from RCS Review Report (Formal Listed Recommendations), dated 10 January 2018.

A Phillips 24 February 2018 CD: Clinical Director Neurosciences, GM: Group Manager, CL: Clinical Lead Neurosurgery, CMO: Chief Medical Officer, COO: Chief Operating Officer.

Ref no. Source Category Recommendation Action Owner When Status

1 RCS 5.1 Patient Safety

HEM should cease to perform awake craniotomy for intrinsic primary brain tumours.

Cease procedure

CD Sep-17 Completed


As soon as is possible, he should seek to attend a specialist centre, where he can observe and be supervised in this procedure, and aim to participate in at least five procedures. (Awake craniotomy)

Group Leads require to confirm need for procedure and identify operator.

CD/CL/GM Aug-18 Review not commenced.

Attend specialist centre

CD/CMO Awaiting service review.


Formal feedback on his performance, and whether he is regarded as fully trained in both selection and practical performance of the procedure, should be requested by the Trust (Awake craniotomy).

Request formal feedback following supervised practice.

CMO Tbc Not commenced.

Appendix E



This feedback should then be used by the Trust to inform whether he should recommence this area of clinical practice.

Review formal feedback and agree define sub-speciality role.

CMO Tbc Not commenced.


With immediate effect, HEM should avoid performing certain "complex" spinal surgical procedures, as agreed between him and Trust.

Implement recommendation.

CD Sep-17 Completed


As soon as is possible, HEM should arrange to undertake further advanced training in these specific complex spinal operations. This training should include patient assessment, treatment planning as well as the technical aspects of surgery. This should entail at least six months' mentorship by a consultant surgeon with sufficient expertise in complex spinal surgery, who could be from within or outside the Trust, depending upon HEM's preference and other practical considerations. Formal feedback from this mentorship process as to which procedures he is considered sufficiently competent in should be

HEM to identify possible centre. CMO formally request support of identified centre. Request formal feedback following supervised practice. Review formal

CD/CMO TBC 9 February 2018 HEM met AP and HA. HEM proposed unit in London. HEM to make initial informal contact with consultant. If this generates a positive response, to be reported to UHCW CMO. 22 Feb- no

Appendix E


requested by the Trust. This feedback should then be used by the Trust to inform which procedures he should recommence performing.

feedback and agree define sub-speciality role.

feedback from HEM.


The recommendations above (5.1) are considered to be highly important actions for the healthcare organisation to take to ensure patient safety is protected. These recommendations should be shared with the private hospitals where Mr HEM has admitting rights.

Assurance received from HEM that he would not perform procedures that were not approved by RCS at any hospital.

CMO 22 Feb- HEM not operating.

8 RCS 5.2 Individual performance improvement.

Within the next three months, if agreed to by HEM, the Trust should arrange for individual behavioural coaching. The coaching would be targeted towards the behavioural concerns identified by this review. The skills to be developed are likely to include team working, communication with colleagues and resilience. HEM is strongly encouraged to sign up to and learn from this process.

Arrange coaching.

CMO TBC (April 2018)

9 Feb meeting with AP and HA, HEM. HEM agreed to fully engage. Ongoing

Appendix E



If agreement cannot be reached regarding coaching, the Trust should arrange for HEM's attendance at an advanced communication course, focused on team communication skills in the medical environment. This would be very much a second best option as it lacks the individual focus, breadth of discussion and sustained input provided by individual coaching.

To be undertaken in addition to coaching. CD/GM to arrange.

CD/GM Tbc Ongoing.


Within the next three months, Mr El-Maghraby should be required to reflect upon his behaviour at, and attendance of team meetings, specifically the MDT, QIPS and M&M meetings. Expectations around how participants should conduct themselves may need to be stated formally. His behaviour and attendance should be firmly agreed and monitored as part of his appraisal process.

Record reflections in appraisal documentation. Meet and discuss with appraiser. Agree desired outcomes. Monitor desired outcomes.

HEM's Appraiser/RO

Tbc (April 2018)

Ongoing.

Appendix E



Within the next three months, HEM's job plan (including his private practice commitments), should be reviewed to remove any obstacles to his attendance at team meetings and to address an underlying concern that he could be overcommitted, particularly in view of his teaching and education commitments.

To undertake job plan review.

CD/GM Tbc (April 2018)

Ongoing.


Within six months, in order to improve HEM's acceptance of, and willingness to discuss, adverse clinical events, including post-operative complications, 10 of his more challenging cases from within the past two years should be selected (with his input) for discussion with a trusted senior colleague, either from within or outside his own speciality. These reflections should be recorded and the learning and actions arising should be incorporated into HEM's next appraisal.

To review cases with colleague.

CD/HEM Tbc (July 2018)

HEM expressed support at meeting on 9 Feb with AP and HA. HEM identified a possible consultant colleague (RD).

The following recommendations are for the healthcare organisation to consider as part of its efforts to ensure continuous service improvement.

Appendix E


13 RCS 5.3 Service Improvement

Within six months, in order to maintain skillsets in subspecialist areas, the consultant neurosurgeons should reach documented agreement on the allocation of categories of cases falling into subspecialist areas such as skull base surgery and awake craniotomy. This will promote concentration of expertise, which should help to ensure patient care is optimised and advance individual services.

Group CD and GM and Clinical Lead to arrange review process and circulate agreed design, structure and model of delivery of sub-speciality services.

CL/GM/CD Jul-18 Ongoing.


Within six months, the consultant neurosurgeons should seek to implement improvements to the awake craniotomy service. This should include development of:

Agree model of care, develop model. Produce Clinical Operating Procedure.

CD/GM/CL and sub-speciality lead for Awake Craniotomy.

Jul-18 Ongoing.

Appendix E


a. Complete team agreement on case selection criteria, which should be explicit and heavily inclined towards what are believed to be low-grade gliomas. Options should be discussed with patients in clinic to decide whether to proceed with an awake craniotomy or undergo another treatment option.


CD/GM/CL and sub-specaility lead for Awake Craniotomy.

Jul-18 Ongoing.

b. Clear documentation of the initial assessment of suitability at the neuro-oncology MDT meeting with expert input from a neuro-radiologist, neurosurgeon and neuro-oncologist for every case.



Jul-18 Ongoing.

Appendix E


c. Concentration of the service with one neurosurgeon and specialist training for this surgeon, and with one (or possibly two) neuropsychologists (depending on the number required for speech assessment during the procedures) and specialist training for them. Allocation of the cases to a single anaesthetist, would be ideal, but not essential.



Jul-18 Ongoing.

d. Annual audit of awake craniotomy outcomes and the presentation of results at a QIPS meeting.



Jul-18 Ongoing.

Appendix E



If not already in place, within nine months, the Trust should work with the consultant neurosurgeons to develop a departmental policy for end-of-life decision making, in line with other end-of-life care policies in the Trust. This policy should cover both individual and team considerations, working with other disciplines, internal and external communication and expert and legal support.

Align service practice to enact Trust policies for this aspect of care. Produce a Clinical Operating Procedure to identify how to be delivered in service. Consultant neurosurgeons to receive training in EOLC.

CD/GM/MM/CL.

Oct-08 Ongoing.

Appendix E



Within the next three months, the Trust should attempt to arrange for mediation between HEM and the consultant neurosurgeons with whom he has particularly come into conflict. This should be provided by an external expert mediation team. There should be a follow-up meeting with the mediator(s) after six months and 12 months to ensure that improvements are sustained.

Identify and engage with mediators and agree work plan.

CMO Apr-18 Ongoing.


Within three months, the Trust should review its RCA process. It should ensure that during future investigations:

RCA process to be reviewed taking note of the RCS recommendations and response to be documented at Serious Incident Group Governance meeting. Agreed review to be reported to Patient

Director of Patient Safety

Apr-18 Director of Patient Safety emailed recommendations on 1st February 2018.

Completed

Appendix E


Safety and Engagement Committee.

a. Detailed reference is made to all available clinical records and full account is taken of all relevant factors.

b. Statements are obtained from all staff involved.

c. Early discussions are held with principal clinicians to allow questioning regarding discrepancies between clinical notes and evidence from others.

d. For matters requiring particular surgical expertise, an expert perspective is obtained.

e. A welfare support process is introduced and offered to all staff involved (including consideration of an "all staff brief".

f. A formal process to share an learning with key parties is introduced.

Appendix E


g. There is timely discussion of the outcomes for all RCAs within departmental QIPS meetings.


Within three months, the Trust should discuss with the consultant surgeons the need for a weekly neurosurgery consultants meeting, which should be a forum for the discussion of team-related issues, as opposed to individual patient cases. Job plans may need to be revised to accommodate this. There will need to be agreement on expected attendance rates and the agenda for discussion.

CD to discuss recommendation with consultants.

CD Apr-18 Ongoing.

Appendix E



Within the next 3 months the Trust's senior management should revisit the issue of clinical leadership of the neurosurgery department with the consultant surgeons. Solutions to address any outstanding, fundamental concerns should be implemented. The efficacy of these solutions should be monitored via follow-up meetings at three and six months. This should be an objective undertaking, with a practical, rather than personal focus, which should aim to end ongoing speculation and negativity. However, mediation between certain individuals may be necessary as a result.

Trust's senior management to meet consultants and Group Management Team.

CMO and COO

Apr-18 Ongoing.


Within three months, the Trust should review the consultant surgeon handover process in place within the neurosurgery team to avoid the treating surgeon's intended management plan from being overlooked. A local process, reflecting any wider Trust policy, should be developed. This should include specific arrangements for the daily and weekend on-call handovers as well as

CD/GM and CL to organise meeting to agree process. Clinical Operating Procedure to record process. Audit tool to be

CD/GM/CL Apr-18 Ongoing.

Appendix E


requirements before a period of leave. The records of handovers for all consultants should be subject to Trust audit on an annual basis.

developed with support of QIPS service and audit plan to be agreed and implemented.


Within three months, further to the recent introduction of the COD on-call rota, an exercise to review how well it is working should be undertaken. This should include an analysis of the rota's strengths and weaknesses, paying particular attention to any occasions when consultants had been on-call overnight after having an all-day theatre list. This review should entail agreement on expectations for when an on-call consultant is unavoidably detained and cannot attend a neurosurgical emergency.

Survey consultants, trainees and nursing team to assess effectiveness of the COD being practiced. Produce Clinical Operating Procedure to document intended model.

CD/GM/CL. Apr-18 Ongoing.

Appendix F

CLINICAL ADVISORY GROUP

TERMS OF REFERENCE

Introduction The Trust has established a Clinical Advisory Group (CAG) to ensure that a single, joint approach is taken in delivering assurance to the Trust Board and all partner organisations that appropriate actions are being taken with regard to the media exposure into the Consultant’s practice.

Governance This Task and Finish Group will report its findings to Chief Officers Group, under whose governance the Group will meet regularly to assess the adequacy of response to the BBC programme. CAG will also provide assurance reports to the Trust Board. The CAG reports will be shared with NHSI and NHSE / CQC if requested.

Membership of CAG • The CAG will be chaired by the CMO. • Membership will include representatives of some partner organisations and the

Trust • CMO • Deputy CMO • CNO or delegate • CD for Neurosciences / Group Manager of Neurosciences • Chair of Ethics Committee • Director of Quality • Director of Corporate Affairs • CCG representative • Director of Marketing and Communications • Head of Surgery

Attendance and quorum • Others may attend by the invitation of the Chair for specific agenda items. • Meetings will be quorate when attended by no less than four members from the

Trust and one external representatives • In the absence of the Chair, the Deputy CMO will Chair the meeting.

Frequency of meetings • Meetings will be held initially weekly and then less frequently according to need. • Additional meetings will be scheduled as necessary at the request of the Chair.

Secretariat • The Director of Corporate Affairs will ensure that the Trust’s Corporate Services

function provides a Secretary and appropriate support to the Group.

Purpose The CAG remit is to:

Appendix F

• Develop an action plan where it is agreed that action is required • Monitor compliance with the agreed action plan • Identify all patients affected by this media exposure • Delegate to the clinicians within this group to identify and agree the most

appropriate clinical pathway for patients who may have to be recalled including investigations and interventions.

• Provide guidance to the Trust on communication with patients (past, present and future) and primary care including a telephone helpline, information packs and letters to stakeholders.

• Agree guidance to support staff affected and necessary communications within the Trust

• Develop a communications strategy for the media etc. • Consider the governance implications of this event and the need for wider

governance reviews. • Report all findings to the Trust Board • Report progress to the following external partner organisations as required

NHSI

Care Quality Commission

NHS England

Local Clinical Commissioning Groups


Title Board Assurance Framework and Corporate Risk Register Author Geoff Stokes, Interim Director of Corporate Affairs Responsible Chief Officer

Meghana Pandit, Chief Medical Officer and Deputy CEO

Date 29 March 2018 1. Purpose To present the latest update against the Board Assurance Framework (BAF) 2017/18 and the Corporate Risk Register as at March 2017. 2. Background and Links to Previous Papers The BAF (attached as appendix 1) is an important document that identifies the risks to delivering key organisational objectives and the controls in place to mitigate those risks. The Trust Board approved the BAF for 2017/18 at the March 2017 meeting and has received regular updates throughout the year For completeness, the Corporate Risk Register as at March 2018 is also attached 3. Board Assurance Framework 2017/18 Chief Officers have reviewed the risks assigned to them and in so doing have considered the current risk rating using the Trust’s risk matrix, provided updates against the controls to mitigate those risks and added further actions where appropriate. These updates were discussed at the Risk Committee on 7 March 2018. Following their review, the Risk Committee proposed the following changes to the BAF:

• BAF risk 2 (meeting financial targets) to be downgraded to reflect the change in the forecast outturn which has now been accepted by NHSI. Although the likelihood of missing the original 17/18 financial target remains high, the consequence has significantly reduced.

• BAF risk 3 (Failure to achieve GOOD following CQC inspection) to be increased to a risk score of 12 to reflect a view of the Risk Committee that the consequence of failing to achieve GOOD should be rated as 4 not 3

• BAF risk 7 (failing to secure financing for the capital programme) to be downgraded to a risk score of 4 due to capital finance now being secured. As this matches the target risk score, it is proposed that this risk be closed.

Following discussion at the Audit Committee the BAF format has been altered to better reflect the links that should exist between the controls for a risk and the assurances that assess the effectiveness of those controls. To that end a rating system for assurances

1 of 3

has been introduced, to assist the Board in determining the level of assurance being provide which should prompt questions about whether further assurance is required. The proposed assurance ratings are as follows;

0 No independent assurance 1 Internal review or Trust governance meeting 2 Board or committee 3 External review

If the Board find this rating system useful, it will be incorporated formally into the next review of the Risk Management Policy. 4. Board Assurance Framework 2018/19 and Beyond Following discussion with board members, it has been agreed that the BAF in future will relate to delivery of the Trust’s strategy and therefore will not be limited to a single financial year. Elsewhere on this agenda the Board will be asked to approve the Trust’s strategy and following this, the risks associated with delivery of this strategy will be discussed at the strategic board meeting in April to create a new BAF. This will then be formally report to the Board in July 2018. 5. Corporate Risk Register Attached at appendix 2 is the Corporate Risk Register report as at March 2018. A corporate “High” rated risk is classified as any risk with a rating of 15-25 on the Corporate Risk Register. The highest rated corporate risks currently (Risk score = 20) are:

• Risk ID 1984: RTT Performance • Risk ID 2680: The ongoing use of MDU for contingency beds • Risk ID 2784: Income from Activities

The Risk Committee reviews and challenges the inclusion of risks on the corporate risk register to ensure that they are appropriate and are being effectively managed.

6. Areas of Risk If the Trust does not have a robust Board Assurance Framework and process in then place there is the risk that the strategic objectives will not be achieved, which could have regulatory, reputational and financial implications and could impact on the quality of care that is provided and the sustainability of services. Lack of a robust system of risk management could also impact on the Trust’s CQC rating and upon the opinion given by the Head of Internal Audit each year, which would have reputation and possible regulatory implications.

Page 2 of 3

7. Governance The Trust Board will monitor progress against the management and mitigation of the Board Assurance Framework on a quarterly basis, at the board meeting that follows the quarter end. The Audit Committee will ensure that the Internal Audit Strategic Plan reflects the risks set out in the BAF. 8. Responsibility

Geoff Stokes, Interim Director of Corporate Affairs Meghana Pandit, Chief Medical Officer and Deputy CEO 9. Recommendations

The Board is invited to NOTE the content of the report to seek further information where required and to APPROVE the Board Assurance Framework including the proposed changes highlighted in section 3.

Page 3 of 3

Appendix 1 BOARD ASSURANCE FRAMEWORK

PREVIOUS

PROPOSED

CHAN

GE

LAST REVIEW

NEXT REVIEW

RISK

NU

MBE

R

DATI

X RE

F

RISK TITLE EXEC LEAD MANAGEMENT LEAD

LIKE

LIHO

OD

CON

SEQ

UEN

CE

RISK

RAT

ING

1

LIKE

LIHO

OD

CON

SEQ

UEN

CE

RISK

RAT

ING

1 2813 Performance standards Chief Operating Officer Director of Operations 4 4 16 4 4 16 28 Feb 2018 31 Jul 2018

2 Meet financial targets Chief Finance & Strategy Officer

Director of Strategy & Finance

5 4 20 5 1 5 28 Feb 2018 31 Jul 2018

3 Failure to achieve at least GOOD In CQC inspection

Chief Medical Officer & Chief Nursing Officer

Director of Quality 3 3 9 3 4 12 7 Mar 2018 31 Jul 2018

4 Resources for research Chief Medical Officer Head of Research & Development

3 3 9 3 3 9 28 Feb 2018 31 Jul 2018

5 Failure to work in partnership

Chief Executive Officer Director of Corporate Affairs

3 4 12 3 4 12 28 Feb 2018 31 Jul 2018

6 Fire stopping remediation Chief Operating Officer Director of Estates and Facilities

3 5 15 3 5 15 28 Feb 2018 31 Jul 2018

7 Failure to secure financing for capital programme

Chief Finance & Strategy Officer

Director of Strategy & Finance

4 4 16 1 4 4

28 Feb 2018 31 Jul 2018

8 Lack of consultant neuro-interventional radiologist

Chief Medical Officer Clinical Director for Clinical Diagnostics Group

4 4 16 4 4 16 28 Feb 2018 31 Jul 2018

RISK RATING 1-3 Very Low risk | 4-6 Low risk | 8-12 Moderate risk | 15-25 High risk 1 of 16


BAF RISK REFERENCE 1 Performance standards DATE OF REVIEW 28 February 2018

DATIX REF 2813 (Linked to corporate risks 1984, 2185) NEXT REVIEW DATE 31 July 2018

RISK DETAILS RISK DESCRIPTION RATING L C R CHANGE

IF the Trust does not meet its national performance objectives THEN patients will receive a poorer standard of service and experience, and we will be unable to demonstrate that we optimise the use of our resources. RESULTING IN potential harm to patients, regulatory intervention as outlined in the Single Oversight Framework with consequent damage to the Trust’s reputation and standing

INITIAL 3 4 12

TARGET 2 4 8 PREVIOUS 4 4 16 CURRENT 4 4 16

CONTEXT ACCOUNTABILITY

STRATEGIC OBJECTIVE To deliver excellent patient care and experience CHIEF OFFICER LEAD Chief Operating Officer

ANNUAL OBJECTIVE Meet national performance objectives MANAGEMENT LEAD Director of Operations

CQC DOMAIN Responsive RESPONSIBLE COMMITTEE Finance & Performance Committee

CONTROLS AND ASSURANCE REF CONTROL ASSURANCE LEVEL

1 Rapid access and triage (RAT) space reducing ambulance handover times NHSI meeting re handover Emergency Care Board

3

2 Clear priorities in place for ED management team around minors, streaming, RATing etc.

Weekly progress meetings 0

3 Daily activity reporting for A&E performance Health economy A&E Delivery Board 3

4 Cancer software implemented to ensure enhanced tracking Weekly meeting with relevant groups 0

5 Investment to enhance ED staffing model agreed and temporary staff in post pending permanent appointments

Weekly meeting with relevant groups 0

6 Review of stranded patients Formal reporting mechanism for Delayed Transfers of Care to NHSI 3

7 Red 2 Green and SAFER initiatives rolled out Weekly meeting to review progress with CNO/COO 0

ASSURANCE LEVELS: 0 No independent assurance |1 Internal review or Trust governance meeting | 2 Board or committee| 3 External review 2 of 16


REF CONTROL ASSURANCE LEVEL 8 Demand and capacity modelling carried out to identify recovery

trajectories for all elective specialties Performance monitored via Board (IPR) and Finance & Performance Committee

2

9 Recovery plans in place for RTT and improvements being delivered Performance monitored via Board (IPR) and Finance & Performance Committee

2

ACTIONS REF GAP ACTION BY WHEN PROGRESS

1 Additional staff in ED Emergency Nurse Practitioners in place and effective 31 Mar 2018 All staff in place. Plan to deliver improved performance from April 2018

2 Improve flow and patient experience

Electronic bed management and co-ordination being rolled out 11 May 2018 Trial with surgery and T&O started 21 Mar 2018 for two weeks.



BAF RISK REFERENCE 2 Meet financial targets DATE OF REVIEW 28 February 2018

DATIX REF 2814 (linked to corporate risks 2783, 2784, 2785) NEXT REVIEW DATE 31 July 2018


IF the Trust does not meet its agency target, improve its income position, achieve its cost efficiency programme and receive financial performance related Sustainability & Transformation Funding THEN our financial position will deteriorate further and we will not achieve our 2017/18 financial plan RESULTING IN the requirement for external cash support and the potential for regulatory intervention as described in the Single Outcome Framework, with consequent damage to our reputation and our ability to continue to deliver services

INITIAL 3 4 12

TARGET 1 4 4

PREVIOUS 5 4 20 CURRENT 5 1 5


STRATEGIC OBJECTIVE To deliver excellent patient care and experience To deliver value for money To be an employer of choice

CHIEF OFFICER LEAD Chief Finance and Strategy Officer

ANNUAL OBJECTIVE Achieve the 2017/18 financial plan MANAGEMENT LEAD Director of Finance

CQC DOMAIN Well Led RESPONSIBLE COMMITTEE Finance & Performance Committee


1 Agency authorisation process in place and agency spending below threshold

Board (IPR) and Finance & Performance Committee 2

2 Programme Delivery Office (PDO) monitoring delivery CIP Steering Group 1

3 Forecast outturn has been formally amended NHSI 3

4 Budget setting process is robust Budget setting internal audit review (significant assurance) 3

5 RTT recovery plan in place to improve income position Board (IPR) and Finance & Performance Committee 2


1 Gap between Trust and Alignment of forecast income with commissioners 31 Mar 2018



REF GAP ACTION BY WHEN PROGRESS commissioners regarding affordability

RECOMMEND to reduce scoring to taking account of reduced impact following acceptance of revised forecast outturn



BAF RISK REFERENCE 3 Failure to achieve at least GOOD in CQC inspection DATE OF REVIEW

DATIX REF 2815 (linked to corporate risks 2656, 1864, 2255) NEXT REVIEW DATE 31 July 2018


IF the Trust fails to show evidence of improvement further to our previous CQC inspection THEN we will not get an overall rating of “good”. RESULTING IN damage to our reputation and standing which could affect staff morale, impact on our ability to recruit and increased regulatory scrutiny and possible intervention.

INITIAL 3 3 9

TARGET 2 3 6



STRATEGIC OBJECTIVE To deliver excellent patient care and experience CHIEF OFFICER LEAD Chief Nursing Officer

ANNUAL OBJECTIVE Achieve a rating of at least “good” at Trust level in the next inspection

MANAGEMENT LEAD Director of Quality

CQC DOMAIN Well Led RESPONSIBLE COMMITTEE Quality Governance Committee


1 Preparation being managed by CQC Steering Group and overseen by Quality Star Chamber

Progress reported to Quality Governance Committee 2

2 Peer review programme (Getting the Basics Right) in place Progress monitored at Quality Star Chamber 1

3 Clinical groups addressing local issues through QIPS meetings etc. Quarterly Performance Reviews 1

4 Baseline self-assessment undertaken supported by confirm and challenge sessions

Progress monitored at Quality Star Chamber 1

5 CQC Insight reported monitored for any contra-indicators Review at CQC Steering Group 1

6 Service leads identified to match CQC core services Quality Star Chamber 1

7 Action plan in place for progress against the recommendations from PwC against the NHSI Well Led Framework

Report to Board 2



REF CONTROL ASSURANCE LEVEL 8 CQC Provider Information Request submission complete Progress reported to Quality Governance Committee, CQC Steering

Group and weekly discussions with CQC Analyst 2

9 Regular dialogue with CQC Inspection Leads Updates fed into Quality Star Chamber as appropriate 1


RECOMMEND to increase scoring following reassessment of consequence of failing to achieve a ‘good’ following CQC inspection



BAF RISK REFERENCE 4 Resources for research DATE OF REVIEW 28 February 2018

DATIX REF 2816 NEXT REVIEW DATE 31 July 2018


IF the Trust does not ensure that researchers have the necessary resources, space and time to undertake research, THEN we will not improve on our recruitment into research trials. RESULTING IN a reduction in research income, failing to achieve the improvements to patient care that research brings and consequent damage to our reputation, standing and ability to recruit.

INITIAL 3 3 9

TARGET 2 3 6



STRATEGIC OBJECTIVE To deliver excellent patient care and experience To be a research based healthcare organisation

CHIEF OFFICER LEAD Chief Medical Officer

ANNUAL OBJECTIVE Increase the level of participation in research trials

MANAGEMENT LEAD Head of Research and Development

CQC DOMAIN Effective RESPONSIBLE COMMITTEE Quality Governance Committee


1 KPIs used to track; resources (applications for resources , research income, research set-up and delivery times and grants submitted) and performance (number of patients recruited)

KPIs monitored at Board via Integrated Performance Report 2

2 Check and challenge of the wider research issues needed to support research (e.g. resource, space, culture etc.)

Regular report to the Board 2

3 Check and challenge of financial implications of research Research and grant income reported twice yearly to Finance and Performance Committee

2

4 Opportunities for staff to do research: Research Fellowships and INCA (Interdisciplinary Non-medical Clinical Academic) research programme.

Fellowships reported to R&D Strategy Committee; INCA programme reports to Nurses Midwives and AHPs (NMAHPs) Research Strategy Committee.

1




1 Research and Development strategy to be refreshed

Revised R&D strategy to be approved 30 Sep 2018 Consultation underway overseen by R&D Committee

2 Opportunities to free up staff time for research (e.g. 3 of 8 fellowships not taken up, 4 examples of failure to release staff for INCA)

Review of Fellowships underway Association of UK University Hospitals (AUKUH) producing national data to enable comparison for NMAHPs.

30 Sep 2018 UHCW INCA data collected. Developing questionnaire for Fellowship holders to assess programme.



BAF RISK REFERENCE 5 Failure to work in partnership DATE OF REVIEW 28 February 2018



IF the Trust does not work collaboratively with partners THEN we may not be in a position to deliver safe, high quality services on a sustainable basis, patients might not receive the services that they require and we may not be in a position to meet contractual and NHS constitutional requirements. RESULTING IN quality, financial and performance risks, which could lead to regulatory intervention with consequent damage to our reputation and standing.

INITIAL 3 4 12

TARGET 2 4 8 PREVIOUS 3 4 12 CURRENT 3 4 12


STRATEGIC OBJECTIVE To deliver excellent patient care and experience To deliver value for money

CHIEF OFFICER LEAD Chief Executive Officer

ANNUAL OBJECTIVE Continue to actively participate in system wide working within Coventry & Warwickshire to ensure effective population health

MANAGEMENT LEAD Director of Corporate Affairs

CQC DOMAIN Effective RESPONSIBLE COMMITTEE Trust Board


1 Better Health Better Care Better Value Board in place with membership from all health and local authority partners

NHSI & NHSE 3

2 Resource to provide programme support for workstreams and communications in place

Better Health Better Care Better Value Board 3

3 Health and Wellbeing Board concordat in place Health and Wellbeing Boards (CCC & WCC) 3

4 Agreement to adopt system wide control total in place

Better Health Better Care Better Value Board 3

5 Programme mandates exist for each workstream Better Health Better Care Better Value Board 3



REF CONTROL ASSURANCE LEVEL


Coherent plans to achieve greater levels of integrated care across the system

Key principles being developed to agree approach to system-wide planning.

30 Apr 2018 Away day taking place 26 Mar 2018 to address key issues



BAF RISK REFERENCE 6 Fire stopping remediation DATE OF REVIEW 28 February 2018



IF the Trust does not deliver the fire compartmentation remediation plan and maintain our current high levels of control and risk mitigation THEN the risk of a fire incident developing might increase. RESULTING IN potential patient harm and/or consequent risks to the Trust’s ability to deliver effective and safe services

INITIAL 3 5 15

TARGET 2 4 8



STRATEGIC OBJECTIVE To deliver excellent patient care and experience CHIEF OFFICER LEAD Chief Operating Officer

ANNUAL OBJECTIVE Not applicable MANAGEMENT LEAD Director of Estates and Facilities

CQC DOMAIN Safe RESPONSIBLE COMMITTEE Trust Board


1 Full range of measures implemented aimed at preventing fire and dealing with fire, should one break out.

West Midlands Fire Service review 3

2 Agreement signed with Project Co and funders to complete remediation work and provide decant space

Board 2

3 Phase 1 remediation work complete Fully assessed by independent fire safety expert and verified by a further independent expert.

3

4 On-going risk assessment and dialogue with WM Fire Service To Health & Safety Committee as part of Fire Safety Officer’s report 1


1 Some beds will be taken out of use for short periods

12 bedded bay to be built to provide decant space to enable work to be undertaken

30 Apr 2018 Work currently underway



REF GAP ACTION BY WHEN PROGRESS 2 Decant not appropriate for Centre

for Reproductive Medicine (CRM) and emergency department (ED)

Firebreak areas prepared to isolate significant risk in CRM and ED

31 Aug 2018 At design phase

3 Fabric of University Hospital restored to originally specified standards

Complete fire stopping remediation work 31 Mar 2020 Currently on track as per the settlement agreement.



BAF RISK REFERENCE 7 Failing to secure financing for the capital programme DATE OF REVIEW 28 February 2018



IF there is insufficient capital financing THEN the Trust will not be able to invest in strategic and operational developments RESULTING IN reduction in the Trust’s ability to achieve its strategic objectives.

INITIAL 3 4 12 TARGET 1 4 4



STRATEGIC OBJECTIVE To deliver excellent patient care and experience To deliver value for money To be an employer of choice

CHIEF OFFICER LEAD Chief Finance & Strategy Officer

ANNUAL OBJECTIVE Achieve the 2017/18 financial plan MANAGEMENT LEAD Director of Finance CQC DOMAIN Well Led RESPONSIBLE COMMITTEE Finance & Performance Committee


Capital finance now released by NHSI


None

RECOMMENDED to close following release of capital funds



BAF RISK REFERENCE 8 Lack of consultant neuro-interventional radiologist DATE OF REVIEW



IF we are unable to provide a full interventional radiology service due to shortages in consultant staff THEN there is the risk that access targets will not be achieved RESULTING IN patients coming to avoidable harm and the Trust may losing its major trauma centre status.

INITIAL 5 4 20

TARGET 2 4 8


CONTEXT ACCOUNTABILITY STRATEGIC OBJECTIVE To deliver excellent patient care and experience. CHIEF OFFICER LEAD Chief Medical Officer and Deputy CEO

ANNUAL OBJECTIVE Achieve a rating of at least “good” at Trust level in the next inspection MANAGEMENT LEAD David White, Head of Operations

CQC DOMAIN Effective RESPONSIBLE COMMITTEE Quality Governance Committee


1 Neuro intervention service temporarily suspended Group management risk meeting & Radiology QIPS 0

2 Emergency patients re-directed to University Hospitals North Midlands, Nottingham and Oxford

Group management risk meeting & Radiology QIPS 0

3 Elective backlog reduced following appointment of locum for 3 months Group management risk meeting & Radiology QIPS 0

4 Cross cover for reporting covered by other consultants in event of emergency intervention procedure


5 Excess back log to be managed by use of external reporting agency and Advanced Practitioner reporting radiographers



3 Agreement with neighbouring neuroscience centres to support

OUH to provide 5 clinical lists per week within the Trust to support elective work

31 May 2018 Honorary contracts sent to OUH staff for completion. Specification drafted.



REF GAP ACTION BY WHEN PROGRESS elective work Way forward on image sharing agreed.

Clinical work due to start early May 2018


Corporate Risk Register Appendx 2

ID

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Description

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k l

ev

el

(in

itia

l)

Ex

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uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler

Current controls Gaps in controls

Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te

Assurance Gaps in assurance

1984

01

/04

/20

15

21

/10

/20

13

RTT Performance

Co

rpo

rate

Op

era

tio

na

l

All

Gro

up

s

The Trust is failing the RTT standard for

incomplete pathways. This will lead to patients

waiting a long time for their treatment; a standard

within the NHS constitution will not be met; and a

corporate target will not be achieved.

HIG

H

Lis

a K

elly

Ms J

an

e T

om

ble

so

n

Mis

s S

ara

h R

od

dis

Update: 07/12/2015

(i) revised trajectory agreed and signed off by CCG and SRG.

(ii) Revised action plans and performance management tools.

(iii) Weekly performance tracker designed and implemented.

(iv) Surgical control room set up.

(v) Additional theatre lists identified.

(vi) Additional resources allocated to validation.

(vii) Additional consultants in plastic surgery; Urology; General Surgery; and T&O.

Update 10/02/2016 -

(i) Weekly review of all Group plans.

(ii) Weekly trajectory identified.

(iii) Addiitonal monthly performance review by executive team.

(iv) Additional and specific RTT objectives set by the Executive team.

Update 11/05/16

(i) Additional capacity identified as part of ODP

(ii) Targets for theatre efficiency and closed session rates

(iii) Daily Delivery Plan launched with Groups. Weekly review of DDP.

Update 26/08/16

The Trust has committed resource to rebook patients in chronological order and increase the

investment in training against the new patient access policy. Improvement is performance is

expected as a result of this exercise in 3 months.

Update 2.5.17: ODP completed and trajectory based on activity levels within - only possible

to deliver 89% if deliver all activity as planned in 17/18. Additional work to close the gap

ongoing. Weekly access meetings to ensure good grip and governance in place. Action plan

in place to improve IST sustainability score. Moved from 77/188 in April 2016 to 94/188 in

April 2017.

No identified gaps in

controls

HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

ast

Da

ily

Ma

jor

20

LO

W 6

30

/04

/20

18

The RTT trajectory

will be validated by

IMAS (Intensive

Support and

Management).

The Trust's waiting

list has been

validated and signed

off by NHS England.

RTT Board with

CCG/TDA and

UHCW exec

membership

Signed off by TDA,

NHSE & CCG

None identified

2680

26

/01

/20

17

26

/01

/20

17 Reduction in AEC

capacity, and inability to

run AEC separetly from

MDU Co

rpo

rate

Sa

fety

- C

linic

al

Acu

te M

ed

icin

e

Em

erg

en

cy S

erv

ice

s &

Acu

te M

ed

icin

e

For the past 18 months the AEC area within MDU

has been used consistently as an area for

contingency beds. The area has trolley spaces

which have to be used as bed spaces.

In the recently published NHSi document National

priorities for acute hospitals 2017 Good practice

guide: Focus on improving patient flow

July 2017, it clearly states that

"AEC must not be used for patients waiting for

admission as part of ‘escalation’ when the hospital

is under pressure."

Having a bedded area also reduces our capacity to

take patients from ED and from GP referrals. It also

results in considerable delays for patients attending

MDU as medical staff have to complete the ward

round before seeing new patients presenting to the

unit.

HIG

H

Lis

a K

elly

Dr

Ro

be

rt S

imp

so

n

Mrs

He

len

Pic

ka

rd

Acute medicine are unable to establish any controls over this. The decision to use

contingency beds are made by the exec team and site team.

15/03/18 - Current operational pressures have seen MDU almost entirely "bedded down"

severely compromising efficeinecy

MDU is often bedded

before other areas

used for contingency

beds HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

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Da

ily

Ma

jor

20

VLO

W

1

28

/09

/20

18 To be discussed at

risk committee

meeting

2784

21

/06

/20

17

Income from activities

Co

rpo

rate

Fin

an

cia

l

Failure to secure planned levels of income from

activities in 2017/18 HIG

H

Su

sa

n R

olla

so

n

Ms S

usa

n R

olla

so

n

Ms S

usa

n R

olla

so

n

Key contracts agreed (by specialty and POD) for 2017/18.

Agreed Operational delivery plans.

FIP focus on operational productivity.

Budgetary control processes.

Monthly operational accountability meetings.

Quarterly performance review meetings.

HIG

H

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ecte

d t

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Da

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MO

D

12

31

/03

/20

18

1 of 18


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ub

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k S

pe

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y G

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p

Description

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k l

ev

el

(in

itia

l)

Ex

ec

uti

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Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

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k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2162

09

/09

/20

14

22

/09

/20

14 EPR Procurement

timetable must be

adhered to in order to

replace Evolution before

contract end.

Co

rpo

rate

Op

era

tio

na

l

Tra

nsfo

rma

tio

n /

EP

R T

ea

m

Co

re S

erv

ice

s

Diminishing timescales associated with current

contract end dates and National mandates (Lord

Carter) to implement critical systems means the

Trust risk being in a position where key

Departments such as Maternity (contract end Jun

2019 with a possible extension to Dec 2019) and

Pharmacy (ePrescribing) have no electronic

system in place.

This places the safety of Trust patients and

compliance with specific targets around Maternity

services and prescribing at risk

Other systems such as PAS and Renal are old and

also at risk of becoming non compliant with specific

MO

D

Nin

a F

rase

r

Mrs

Be

ve

rle

y T

ho

mp

so

n

Mr

Na

tha

n S

tra

tto

n

Current Control:

THe EPR Programme went out to procurement at the end of Nov 17.

NHSI approval for Trust to procure four systems as part of single integrated EPR.

Alternate procurement approach based on using a "Competitive procedure with negotiation"

has been developed. This will recover some of the lost time by reducing the timescales for

the procurement and still allow sufficient time for the implementation period provided the

procurement commences by Oct 2017

Planned Control:

Planned Control:To extend current contract from June 2019 to Dec 2019 and discuss further

extension into early 2020.

Reviewed by team,

none at present.

HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Ma

jor

16

LO

W 4

28

/02

/20

18

This will be managed

by the EPR

Programme Board

with regular updates

to Planning Unit and

Chief Officers Group.

None noted.

2185

01

/04

/20

17

06

/11

/20

14

Cancer (62 day

standard)

Co

rpo

rate

Sa

fety

- C

linic

al

Risk that the Trust is failing the overall 62 day

standard. There are a number of high volume

specialties including urology, Lung, head & neck

cancer and gynaecology where there is a risk of

failing the standard. Theatre capacity is a real

issue for urology and gynaecology. The Trust

continues to experience late referrals from other

Trusts.

HIG

H

Lis

a K

elly

Ms J

an

e T

om

ble

so

n

Ms H

ele

n W

est

Update 08/12/2015:

(i) Revised Cancer trajectory signed off by the CCG and SRG.

(ii) Revised plan for prostatectomy including potentially transferring of activity to alternative

providers.

(iii) Additional consultants across four tumour sites plus histo pathology recruited.

Update 10/02/16:

(i) Additional Prostate capacity in place;

(ii) Weekly review of all long waiters to ensure there are treatment dates;

(iii) Additional consultant started and being trained.

Update 19/10/16

Pathway tracking continues for all sites. 62 day target has been met for the last 3 months.

8.12.16 - Q2 achieved, October 62 days target not achieved, cancer team working with all

groups.

Update 2/05/17 - capacity constrants in consultant workforce in head and neck and

colorectal, cancer action plan in place, transformation support to review histology processes

and new management team, somerset cancer database being implemented - go live date

June 2017 - improving data collection, recordinga dn reporting.

Update 5/9/17 - Weekly Cancer Access Meetings commenced in August for close and active

monitoring of all pts on cancer pathways. Weekly update slide for COG updated by PPMO

for real time performance monitoring.

None identified

HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Ma

jor

16

LO

W 5

30

/04

/20

18

Cancer action plan &

trajectory signed off

at COG

Action plan goes to

RTT Board, TDA &

NHSE

External review of

performance

management and

information reporting

Internal audit of

information and

performance

management

systems and

processes

undertaken

Action plan and

trajectory reviewed

by NHSE / TDA as

part of region wide

assurance

None identified

2237

01

/04

/20

16

05

/01

/20

15 Severe shortage of

permanent storage

capacity in mortuary at

UHCW Co

rpo

rate

Op

era

tio

na

l

Mo

rtu

ary

Clin

ica

l D

iag

no

stics (

Pa

tho

log

y &

Im

ag

ing

)

Severely limited storage across the network during

times of high death rates and bank holidays

particularly during the winter period. This has the

potential to lead to reputational damage, stress &

upset to relatives.

HIG

H

Lis

a K

elly

Mr

Ne

il A

nd

ers

on

Mr

Ch

ris W

oo

ke

y

05.03.18 - as of 02.03.18 41 Trust patients with Cream/Death forms incomplete or

outstanding – spreadsheet with details sent to Trust and CDs for support with timely

management. Risk grading reduced (still remains red risk) as additional temporary storage

unit arrived at RSX on 03.03.18.

23.02.18 Options appraisal submitted to Ian Sturgess and Malcolm Hunter. Pressures raised

at Path Management Board 27.2.18 with DS to email CDs to ensure timely completion of

cremation papers.

19.03.18 Additional temporary storage unit acquired for rugby st cross increasing capacity to

33 permanent and 36 temporary spaces. Escalation to clinicians for crem form completion

and death rate decreasing the capacity situation has improved. Further drive for clear forms

before the easter break required.

Human Tissue

Authority inspection

took place August

2016, HTA have

highlighted current

temporary storage

solution in report and

require assurance

that a permanent

storage solution is in

progressive.

Re-location of

surgical training

school approximately

12 months.

HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Ma

jor

16

LO

W 6

04

/04

/20

18

Regular review,

updates to Chief

Officers

Pathology Director of

Operations to

prepare paper for

COG

None identified

2 of 18


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y G

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p

Description

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k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2318

21

/04

/20

15

21

/04

/20

15

Delays in patient

assessment MDU

Co

rpo

rate

Sa

fety

- C

linic

al

Acu

te M

ed

icin

e

Em

erg

en

cy S

erv

ice

s &

Acu

te

Me

dic

ine

When demand increases in MDU there are

significant delays in both the nursing and medical

assessment of patients. This results in delays in

care and treatment of patients. This is particularly

a problem in the evenings when demand is at its

greatest. Accepting patients after 6 pm when the

department is already full results in severe delays.

HIG

H

Lis

a K

elly

Dr

Ro

be

rt S

imp

so

n

Mrs

He

len

Pic

ka

rd Extramed is used to record the time of arrival, triage and medical review.

If numbers of patients waiting for assessment at 6 pm is greater than 15 this is escalated to

the control room.

Opening times to be reviewed.

There are frequent incidents where we have reached unsafe levels and the site team have

refused our request to close.

Current staffing

levels do not reflect

the demand of the

service

Business case

written and

presented to

planning

Site team overule

request to close

HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Ma

jor

16

LO

W 4

28

/09

/20

18

To be discussed at

risk committee

meeting in April

Proposal for revised

staffing completed

Discussed at QIPs

each month

None identified

Operational policy

agreed with CMO

Tariff to be agreed

and staffing issues

need to be resolved

Review of

operational hours

needs to take place

2785

21

/06

/20

17

Cost Improvement

Programme

Co

rpo

rate

Fin

an

cia

l

Failure to fully identify and deliver the CIP

Programme for 2017/18 HIG

H

Su

sa

n R

olla

so

n

Ms S

usa

n R

olla

so

n

Ms S

usa

n R

olla

so

n

CIP targets allocated as part of budget setting process.

CIP system used to record/monitor progress.

CIP Steering Group reviews progress.

Part of FIP programme.

HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Ma

jor

16

LO

W 6

31

/03

/20

18

2278

19

/02

/20

15

03

/03

/20

15 Lack of nursing and

medical staff available to

monitor AKI Alert System

and review patients Co

rpo

rate

Sa

fety

- C

linic

al

Re

na

l S

erv

ice

s

On

co

log

y &

Ha

em

ato

log

y &

Re

na

l

NHS England issued a patient safety alert that a

specific AKI alert algoritm and system should be in

place by 9th March 2015.

It is likely that this will only be partially complete by

this date.

This could lead to patients developing AKI not

being recognised by the renal team.

MO

D

Me

gh

an

a P

an

dit

Dr

Lyd

ia F

resco

Dr

Sim

on

Fle

tch

er

There is currently an AKI alert system in place which is monitored by the Renal SpR under

supervision of the renal consultant of the week. This allows surveillance of patients

developing AKI. It is a different algorithm from the one mandated by NHS England.

07.08.15 It was identified that this would require appointment of an ANP unfortunately due to

current financial controls this will not be possible.

08.05.17 To identify funding for ANP. Job description with SF.

04.09.17 Business case to be prepared by Group Manager.

15/09/17 Business case approved to recruit 1xANP 1xCNS to take on AKI workload

15/09/17-01/10/17 JDs for post created and review

01/10/17-14/10/17 approval process for advertisement

27/10/17 Posts out to advert - to interview mid November with aim for having new starters in

post March 2018

24.11.17 ANP and B7 interviewed and appointed. Await start dates

02/03/18 - staff due to start CNS / ANP for AKI March/April 2018

HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

ast

Da

ily

Mo

de

rate

15

LO

W 6

02

/04

/20

18

3 of 18


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k T

yp

e

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k S

ub

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e

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k S

pe

cia

lty

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ec

ialt

y G

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p

Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2472

25

/01

/20

16

25

/01

/20

16

LACK OF HYBRID

OPERATING THEATRE

Co

rpo

rate

Sa

fety

- C

linic

al

Th

ea

tre

s

Th

ea

tre

s &

An

ae

sth

etics

A hybrid operating theatre is an operating theatre

which has a fixed image intensifier and equipment

for performing vascular surgery. Modern vascular

surgery requires good quality imaging and stock of

equipment kept in theatre to perform modern

surgical techniques. These cannot be carried out

using the current facilities in both elective or acute

settings. Hence patients are being offered 'older'

techniques which have a higher morbidity and

mortality rather than modern techniques.

In addition, staff are being exposed to higher levels

of radiation than would occur if we had a fixed

system for imaging.

A hybrid operating theatre is recommeded by the

MHRA for the above reasons on safety grounds.

HIG

H

Su

sa

n R

olla

so

n

Dr

An

ne

Sca

se

Dr

An

ne

Sca

se No current controls in place. Access to interventional radiology on an adhoc basis. Working

party for hybrid theatre.

11/03/16 Risk escalated to "corporate" at Theatre Management meeting. To be approved by

D Moon.

Use of interventional

radiology is sub-

optimal, with no

immediate access to

surgery.

HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Ca

tastr

op

hic

15

LO

W 6

31

/12

/20

18 Monitored through

incident reporting &

Mortality review

None identified

2646

08

/11

/20

16

24

/11

/20

16

Increase of Cyber

Security Threats to the

Trust

Co

rpo

rate

Info

rma

tio

n T

ech

no

log

y

Info

rma

tio

n &

Co

mm

un

ica

tio

ns t

ech

no

log

y

The number of Cyber Security threats have

increased and NHS Trusts appear to be targeted,

with these attacks already leading to severe

consequences for other Trusts. The outcome of an

attack can be severe due to the potential loss of

business critical systems in the Trust for a

considerable period, which could affect patient

care.

HIG

H

Ka

ren

Ma

rtin

Mr

Ro

bin

Arn

old

Mr

Te

jul G

ud

ka ICT have highlighted a program of work to be carried out following funding received by NHS

Digital to aid cyber security enhancements. This includes expanding the scope of ISO 27001,

renewing Cyber Essentials certification and regular penetration tests are being conducted on

our network from external auditors. Routine security patching is also being undertaken at

regular intervals, all of the listed programmes of work is being led by Assistant Director of

ICT and Technical Services Manger Security.

Not all devices on

our corporate

network are

managed by ICT,

notably MEBS

equipment.

A Firewall refresh is

required as the the

current hardware is

end of life. Once

procured and

implemented it will

bolster the security

position to further

prevent external

attacks.

Despite ICT's

continuous efforts to

combat threats there

will always be

unforseen risks that

ICT will not be able

to mitigate.

In particular risks

around poor practice

by staff which can be

partly mitigated by

education,

awareness and

technical security

measures but not

totally removed.

HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

ast

Da

ily

Mo

de

rate

15

MO

D

10

31

/05

/20

18

Assurance is

provided by the ICT

Security sub-group,

reporting through ICT

Security and

Compliance to the

Trust's Information

Governance

Committee.

External assurance

is led by NHS Digital

and independant

third party cyber

security provider.

None noted

4 of 18


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ub

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k S

pe

cia

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Description

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k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2832

03

/07

/20

17

09

/08

/20

17

Patients lost to follow up

Co

rpo

rate

Op

era

tio

na

l

All

Gro

up

s

If patients are lost to follow up then their care could

be delayed and this could result in clinical harm.

March 2018 - to date 11 x cases of harm identified.

Risk to be updated by Clinical Harm Review group

with details of current controls.

HIG

H

Lis

a K

elly

Ms J

an

e T

om

ble

so

n

Mrs

Sa

ra L

ee

Chief Officers have been briefed. Weekly task and finish group commenced. PPMO

developing reports for managers to validate the backlog. New SOP being developed to

reduce risk going forwards. HIG

H

Exp

ecte

d t

o o

ccu

r a

t le

ast

Da

ily

Mo

de

rate

15

LO

W 6

30

/04

/20

18

107

01

/04

/20

14

04

/06

/20

09

Storage on Hospital

Corridors

Co

rpo

rate

He

alth

an

d S

afe

ty

Esta

tes

Co

re S

erv

ice

s

Fire Implications - Beds, mattresses, cages of

linen, waste trolleys etc, are temporarily stored in

back corridors. This can impede or slow down an

evacuation from a fire that occurs in another area.

There are also legal implications for the Trust from

the Fire Authority regarding storage of beds and

other items in hospital corridors. The risk rating

refects both safety and legal aspects of this risk.

Security Implications - When valuable equipment

and supplies are left on hospital corridors then

there is the potential for theft. Any theft can have

financial implications for the Trust and could

disrupt the medical service.

Clinical Risk Implications - When medical

equipment and supplies are left on hospital

corridors there is the risk that this equipment

and/or the supplies could be tampered with. This

could have serious consequences for the Trust.

HIG

H

Lis

a K

elly

Mr

Lin

co

ln D

aw

kin

Mrs

Ju

lie R

ice

10/01/17 - The issue of excessive storage on hospital corridors still continues to be a fire

safety concern, with the amount of items being stored on corridors now getting out of control.

This issue was first highlighted as early as 2008 and the situation is getting worse. The

‘Hospital Storage Working Group concentrated its efforts initially on the domestic HUB

corridors, and initially some progress was made. But a recent walk around showed that

nearly every ward and department has storage issues and the hospital corridors are routinely

being regarded by staff as overflow storage areas. The lack of suitable storage space

throughout the hospital is now critical with broken beds, trolleys, supplies and other items

routinely being left on these corridors. As a result of this, staff, patients and visitors are

having to constantly endure blocked corridors. This not only looks bad but it is also hindering

the ability of the Trust to carry out its clinical service. Ward staff and managers have now

become complacent to the risk and simply regard the corridors and circulation spaces as

overflow storage areas for their ward or department.

27 04 2017 - Risk review carried out. - see notepad entry by DL and Revised risk

management plan attached in documents field

Risk review 31.07.2017 - No change to risk level or rating. Monitoring and reduction plan

developed. (D Lord H&SM)

24/10/2017 - Risk review - slight improvement in number of occurrences following

introduction of safety walkabouts. However risk rating remains the same until sufficient

evidence corridor housekeeping is sufficiently under control. D Lord HSM.

None identified

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Ma

jor

12

LO

W 4

31

/01

/20

18 Discussed at NCRM

committee and Risk

Committee

None identified

1102

01

/04

/20

16

01

/03

/20

12

Serious patient falls

Co

rpo

rate

Sa

fety

- C

linic

al

All

Gro

up

s Concern that a patient will have a serious injury

from a fall in hospital because of the large number

of patient falls reported across the Trust, resulting

in financial and reputational loss.

HIG

H

Nin

a F

rase

r

Ms E

lain

e C

lark

e

Dia

ne

Sh

ep

pa

rd

Roll out of falls pathway underway completion date end of August 2017

falls Alarms are available within the Trust.

5 Sara Steady's are in use in wards areas which require this specialist handling equipment.

New replacement beds all have ultra low feature to reduce risk of harm from a fall from a

bed.

Roll out of falls pathway underway completion date end of August 2017

Quarterly reviews with wards/department to monitor/support falls reduction

None identified

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Mo

de

rate

12

MO

D

8

30

/04

/20

18

Benchmarking -

Monthly safety

thermometer data on

falls

Monthly Falls Forum

minutes

Falls Trend analysis

available in Insite

Report to NMC

quarterly and PCS

from April 2017

National Falls Audit

2015. Royal college

of physicians audit

planned June 2017

Falls lead attends

Network meeting

with other regional

hospitals

No gaps in

assurances currently

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k T

yp

e

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k S

ub

typ

e

Ris

k S

pe

cia

lty

Sp

ec

ialt

y G

rou

p

Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2067

24

/04

/20

15

24

/04

/20

14

Patient Flow (ED 4hr

wait)

Co

rpo

rate

Op

era

tio

na

l

All

Gro

up

s The risk is that that we do not have the right

capacity to meet demand which prevents the

attainment of the Constitutional 4 Hour Standard

for A&E.

MO

D

Da

vid

Eltrin

gh

am

Ms E

mm

a L

ive

sle

y

DD

1 - Use of predictive capacity and demand models to identify shortfalls in capacity.

2 - Introduction of MAU, incorporating short stay beds, AEC and GPAU.

3. - The development, with partners, of a frailty service to reduce length of stay and and

admission avoid.

4. - The creation of ringfenced surgical capacity to protect a volume of elective activity.

5. - The introduction of a Trigger sytem within ED to provide early alerts to enhance breach

avoidance.

6. - The uplift of 3 middle grade doctors to allow capacity to meet demand.

18/5/2016 DS - HR analysis of junior rotas has not identified any capacity to improve staffing

out-of-hours within establishment, as all tiers are working to maximum contractual limits.

Focus on improving evening performance to reduce backlog going into the night should

mitigate overnight performance issues.

22/09/2016 - DS - Short paper submitted to COG by invitation July 2016 for additional MG

tier - no response. Formal business case in development. Interim additional evening staffing

via bank / agency when available.

Risk reviewed at Risk Committee on 02.08.2017. Risk now escalted to the Board Assurance

Framework for 2017/18 therefore risk closed on system, and risk mitigationa nd controls will

contonue to be tracked via the BAF. (CG)

re-discussed at risk commitee in November, group manager asked to re-open risk. Re-

opened by Head of Patient Safety and Risk 2018

Clinical engagement

and resources

Lack of 7 day

working

Development of staff

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Mo

de

rate

12

MO

D

8

01

/12

/20

16

Hourly monitoring

Process & o/c

indicators

Mortality

KPIs - FREED

metrics

Complex patient

pathways with large

numbers of patients

affected.

Capacity is reliant

upon external

partnerships, and

community pathways

being updated

limited capacity

forces short term

plans to deal with

constraints

2195

29

/03

/20

16

20

/11

/20

14

HPB- compliance with

IOG guidelines

Co

rpo

rate

Str

ate

gic

Up

pe

r G

astr

oin

testin

al (G

I) &

He

pa

tob

ilia

ry (

HP

B)S

urg

ery

Su

rge

ry

If we do not serve a population of 2 million people

we are not able to continue to provide the service

according to the recent peer review. HIG

H

Su

sa

n R

olla

so

n

Mrs

Ha

rka

ma

l W

eb

ste

r

Ms H

ele

n W

est

26.9.16

Specialised commissioners have confirmed their intent to support a combined UHBFT and

UHCW HPB service from 01.04.2017.

A guiding principles document is in circulation to confirm legal and governance

responsibilities and discussions are expected to agree a proposed model of clinical delivery

by Dec 2016

Regular meetings underway

UHCW are working with UHB to amalgamate the 2 HPB services to create a West Midlands

HPB service via UHB. A business case should be presented to both Trust Boards and

Specialised Commissioners during the summer of 2017 detailing how the service will meet

the requirements coming from the Senate review - DM 03.04.2017

2.5.17

Meetings now underway between UHB and UHCW

To be reviewed with Group Management January 2018.

16.1.17

Discussions underway with neighbouring Trusts to increase the population served

Delays to meetings

going ahead

Clinical model yet to

be agreed MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Ma

jor

12

LO

W 6

30

/03

/20

18

Additional

management

resource - one day a

week

Agreed pathways

and governance

ensuring on-going

service at UH

Delays during the

process as a result

of cancelled

meetings

2416

04

/05

/20

16

02

/10

/20

15

Potential Breaches of

Confidentiality

Co

rpo

rate

Info

rma

tio

n G

ove

rna

nce

All

Gro

up

s

If documents contaning highly sensitive and

confidential information are not disposed of

correctly breaches of confidentiality may occur.

This gives rise to the risk of reportable breaches

with a potential fine from the ICO, consequent

reputation damage and a loss of Trust and

confidence in the organisation.

HIG

H

Lis

a K

elly

Mr

Ge

off

Sto

ke

s

Ms H

arjit M

ath

aru

Policies and procedures are in place that deal with the safe disposal of patient identifiable

information

Unable at present to

prevent handover

and other notes from

being printed (due to

operational

considerations)

Ward staff to be

engaged in ideas for

improving

compliance

(following human

factors report)

Lack of follow up for

missing records

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Mo

de

rate

12

LO

W 4

30

/04

/20

18

IGC review incidents

to assess adequacy

of current controls

and determine

further controls

needed

There are still

incidents of patient

identifiable

information being

found within the

Trust

6 of 18


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e

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k S

ub

typ

e

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k S

pe

cia

lty

Sp

ec

ialt

y G

rou

p

Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2537

01

/04

/20

16

19

/05

/20

16

Improve ICT

Intrastructure

Co

rpo

rate

Info

rma

tio

n T

ech

no

log

y

Info

rma

tio

n &

Co

mm

un

ica

tio

ns t

ech

no

log

y

Co

re S

erv

ice

s

If we do not continue to improve our ICT

infrastructure we may not have the ability to

transform our services in line with the Trust’s

strategic objectives and the Sustainability and

Transformation Plan, which could impact upon

patient safety, our financial position and

reputation.

HIG

H

Ka

ren

Ma

rtin

Mr

Ro

bin

Arn

old

Mr

Ma

rk P

ow

ell Information Strategy in place, supported by ICT Plan and rolling ICT programme of work.

Trust representatives are involved in developing the locality Digital Roadmap.

ICT restructured to protect time for ICT developments.

Electronic Citizen Record is part of the STP vision.

This risk was de-escalated from BAF 2016/17 to Corporate (agreed at Trust Board).

Urgent clinical and

service

developments

needing unplanned

ICT resources

bypass assurance

mechanisms.

Limited capital

funding for major IT

developments.

Challenge of

recruitment and

retention of scarce

ICT resources.

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Ma

jor

12

LO

W 6

31

/05

/20

18

ICT programme

assured by

Transformation–MDT

.

ICT Security assured

by Information

Governance

Committee.

Locality's Digital

Transformation

Board assures the

development of the

Local Digital

Roadmap.

ICT projects and

upgrades managed

using standard

methods (eg.

Prince2)

None noted.

2656

21

/12

/20

16

21

/12

/20

16

Drug Security

Co

rpo

rate

Sa

fety

- C

linic

al

All

Gro

up

s

If the security of medicines is compromised then

this results in failure to comply with CQC standards

and regulations. HIG

H

Me

gh

an

a P

an

dit

Mr

Ma

rk E

aste

r

Mrs

Ja

ne

tte

Kn

igh

tComprehensive medicines policy. Drug security breaches reported via Datix. Process for

replacement of faulty locks and drug storage facilities. Medicines management training

workshops for nursing & ODPs. Medicines security risk assessments completed and

reviewed annually by ward and department managers.

Training and

education for

medical and non

clinical staff

Drug security relies

on mannal lockdown

systems

Insufficient drug

storage facilities on a

number of clinical

areas resulting in

medicines stored in

unlockable

cupboards and

drawers to enable

segregation of

medicines.

No policy for the

secure storage of

PODs

No automated drug

storage facilities

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Mo

de

rate

12

MO

D

9

30

/03

/20

18

Drug security

breaches discussed

at ward or

departmental QIPS

Pharmacy, Modern

Matron and GTBR

Audit programme

presented at MMC

N&WQSM & PSC

Risk assessments

are monitored by the

Trusts Riisk

Committee

Groups - Quarterly

Board Review,

monitoring risk

No annual Medicines

Optimisation Report

to Trust Board

2737

17

/04

/20

17

27

/03

/20

17

Sustainability of Rugby

Theatres Impacting on

Delivery of Service

Co

rpo

rate

Op

era

tio

na

l

Ort

ho

pa

ed

ics

Tra

um

a a

nd

Ort

ho

pa

ed

ics &

Ru

gb

y

The concern is that the current theatres are

reaching the end of their life expectancy and that

failures are occurring with increasing frequency

leading to an impact on the ability to deliver the

service.

MO

D

Lis

a K

elly

Mr

Jo

na

tha

n Y

ou

ng

Mrs

Ju

liet

Sta

rke

y Reactive maintenance

Planned preventative maintenance(PPM)

Project Group established to build a business case for a new theatre complex

17/01/18 Project group developing a back up plan initial plan to utilise additional Vanguards

at Rugby deemed uneconomic and inefficient due to limitations on case mix suitability. Now

looking at feasibility of utilising UHCW theatres for theatre capacity and developing a

process to repatriate patients post op to St Cross

PPM not completed

in a timely fashion

resulting in failures MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Ma

jor

12

LO

W 4

31

/07

/20

18 Discussed at April's

Risk Committee

Departmental

Meeting

Potential for it not to

be discussed

Potential for item not

being discussed

7 of 18


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yp

e

Ris

k S

ub

typ

e

Ris

k S

pe

cia

lty

Sp

ec

ialt

y G

rou

p

Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2933

17

/01

/20

18

17

/01

/20

18

Outlier Status for

Fractured neck of Femur

30 day Mortality

Co

rpo

rate

Re

pu

tatio

na

l

Ort

ho

pa

ed

ics

Tra

um

a a

nd

Ort

ho

pa

ed

ics &

Ru

gb

y The risk is that we continue to sit as an outlier for

30 day mortality resulting in a clinical, reputational

and financial impact.

MO

D

Me

gh

an

a P

an

dit

Mr

Jo

na

tha

n Y

ou

ng

Mr

Ste

ph

en

Dre

w

#NOF action plan in place

- MDT Mortality reviews

- Junior Dr training on induction

- Introduction of dedicated #NOF bay to allow Orthogeriatric consultants to review patients in

amore efficient and timely manner

- Dedicated #NOF nurse role for #NOF bay

- Introduction of # NOF bleep for early escalation direct from ED

Failure to review

NHFD

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Mo

de

rate

12

LO

W 6

31

/07

/20

18

#NOF Group

QIPS Meeting

Compliance not

discussed

2633

26

/10

/20

16

26

/10

/20

16

UHCW Failure of the pod

system for pathology

sample delivery

Co

rpo

rate

Sa

fety

- C

linic

al

Sp

ecim

en

Re

ce

ptio

n

Clin

ica

l D

iag

no

stics (

Pa

tho

log

y &

Im

ag

ing

)

The regular failures of the pod system which is the

primary way that blood samples (particularly urgent

samples), are transported to Pathology for testing.

As has recently happened, the continuous failure of

the system has led to numerous blood samples

being trapped in the system for days, impacting on

patient care pathways and aiding discharge. On

12th October, a pod with no lid attached arrived in

Pathology covered in blood where the pod had

broken and the samples had leaked in transit. The

system had to be completely decontaminated

which too almost a week when no one could use it.

During this time, there were insufficient porters to

ensure that all urgent samples were delivered from

ED, and turnaround times suffered as a result with

samples being sent up in batches. Around 50 pods

containing specimens that were several days old

were then delivered to Pathology in a wheelie bin,

as they had all been found lost somewhere in the

system. All of these patient samples had to be

rebled. On 26th October, another incident occurred

where a damaged/worn pod from ED was found in

the system, again with a broken sample inside, and

evidence that the blood has leaked out of the

container. Again, the pod system had to be

decontaminated, but on a much smaller scale than

on the previous occasion as this sample had

clearly come from ED. On examination, it became

clear that the sample was from 16th October,

nearly two weeks old.

MO

D

Lis

a K

elly

Mr

Ne

il A

nd

ers

on

Ms J

oa

nn

e N

ich

ols

on

21/02/18 - further meeting held with Vinci and Project-co on 14/02/18. Pods have still not

been fully replaced, and allocation and labelling of pods within the system for each area has

not been completed. Team given two weeks to complete this piece of work. Pathology

Specimen Reception Supervisor to chase before the end of the two weeks to see where we

are up to with this part of the project.

There is so far no-

one taking direct

ownership of the

system, and

therefore we are

unable to hold

anyone directly to

account when the

system fails

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Da

ily

Min

or

10

LO

W 4

31

/03

/20

18

There have so far

been two meetings

of the 'Pod Capability

Group' on 14th July

and 12th September

2016. A further

meeting has not

been planned

currently.

No further Air Tube

capability meetings

have been arranged

currently

8 of 18


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yp

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k S

ub

typ

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Ris

k S

pe

cia

lty

Sp

ec

ialt

y G

rou

p

Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2664

01

/09

/20

16

05

/01

/20

17

Decommisioning of

Rugby St Cross

Theatres

Co

rpo

rate

Op

era

tio

na

l

Th

ea

tre

s

Th

ea

tre

s &

An

ae

sth

etics

Rugby St Cross theatres are nearing the end of

their useful life: in terms of maintenance, upkeep,

size and storage. They are currently revalidated on

an annual basis. This means that following the next

inspection, should they fail to achieve the minimum

required standards in terms of airflow/air changes

etc, they could be decommissioned or put out of

action. This would result in loss of theatre capacity,

increased waiting times, failure to retrieve income

and detrimental impact on reputation.

MO

D

Su

sa

n R

olla

so

n

Dr

An

ne

Sca

se

Dr

An

ne

Sca

se

Regular assessment and support from Estates. Yearly revalidation. Plans for building new

Theatres Suite at Rugby St Cross underway.

No gaps in controls

identified.

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

An

nu

ally

Ca

tastr

op

hic

10

LO

W 5

02

/04

/20

18

Entered onto the

Risk Register

Mobile theatre

providers to be

asked to assess

Rugby site, with

Estates, for suitabe

position for mobile

theatre

CD, MM and GM of

theatres to look at

ways of increasing

staffing to run longer

days should Rugby

Theatres fail

validation

Rugby Theatres

Project Group has

sent SOC to NHSI

for approval

Theatres vaildated

for one year

NHSI approval for

FBC

Increasing working

hours for theatre

staff may involve

management of

change process

which will take time

No gaps in controls

identified

393

01

/04

/20

17

15

/03

/20

12

Inability to open funded

cots in SCBU

Co

rpo

rate

Op

era

tio

na

l

Ne

on

ato

log

y

Wo

me

n &

Ch

ildre

n's

The final model of Transitional Care and Special

Care is yet to be achieved, due to an inability to

staff the separate bay with senior nursing 24/7.

There is an average of 12% of the Neonatal clinical

nursing workforce on maternity leave.

There is a financial implication for Trust failure to

meet service demands for local patients in

Coventry and Warwickshire.

HIG

H

Lis

a K

elly

Ms K

ara

Ma

rsh

all

Mrs

Su

e E

llis

Over recruitment to Neonatal nurses has been agreed as per the Chief Nursing Officer.

As of 6th September 2017 we will have a net increase of 1 cot meaning Critical Care

capacity is maintained but this will alter the ratio's of Special care and Transitional care.

16.03.2018 Anticipated opening of cots on the 3rd April 2018.

Risk 415 "Failure to staff the different categories of neonatal care in line with National

Guidance", which links with this risk, has been archived based on the requirement to be

closer to full establishment against current funded neonatal nursing posts, will be

reassessed in line with recruitment to vacant posts and will be reopened when necessary.

15/01/18 Additional three cots aim to be opened February 2018

National shortage of

trained Neonatal

Nurses.

Demand for Neonatal

Intensive Care

increasing.

Training time to

recruit and train new

nurses.

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Mo

de

rate

9

LO

W 6

09

/04

/20

18

South West Midlands

Network working

pathways to support

capacity across the

network

approval to over

recruit to neonatal

nurse staffing

Risk of reliance on

South West Midlands

network as an

assurance, can

result in poor patient

experience for

parents if baby is

transferred to trusts

across the country

9 of 18


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lo

gg

ed

on

Da

tix

Title

Ris

k T

yp

e

Ris

k S

ub

typ

e

Ris

k S

pe

cia

lty

Sp

ec

ialt

y G

rou

p

Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


1864

01

/04

/20

14

23

/05

/20

13

Unauthorised access of

Trust systems - Mis-use

of access by Trust Staff

Co

rpo

rate

Info

rma

tio

n G

ove

rna

nce

All

Gro

up

s

If staff share passwords/access cards there is the

risk of unauthorised access to systems and misuse

of data. This could lead to breaches of the data

protection act, the potential for financial penalty

from the ICO and a negative finding from the CQC

at inspection, with consequent damage to

reputation.

MO

D

Lis

a K

elly

Mr

Ge

off

Sto

ke

s

Ms H

arjit M

ath

aru

Access to patient and staff data is only permitted if it is required as part of the member of

staff's job role, or if a patient is under their care and staff are given unique log in details.

Further

communication to

staff reminding them

of policy

Ward staff to be

engaged in raising

awareness and

improving

compliance

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Mo

de

rate

9

LO

W 6

30

/04

/20

18

Incidents raised on

Datix are reviewed at

Information

Governance

Committee to identify

patterns and

evidence of

compliance

Examples of

disciplinary action

being taken against

staff know to have

breached policy

The Trust is currently

unable to undertake

pro-active auditing

which means that

unauthorised access

could be taking place

and not come to

light.

Increase in number

of requests for

retrospective

auditing of system

access which would

suggest that

unauthorised access

is occurring.

1898

01

/04

/20

14

24

/07

/20

13 Limited (and cost of) Car

parking for staff leads to

recruitment and retention

issues Co

rpo

rate

Op

era

tio

na

l

Esta

tes

Co

re S

erv

ice

s

Recruitment and retention issues due to lack of car

parking for staff, which will prevent Prevent quality

delivery of services.

Impact on safety

MO

D

Lis

a K

elly

Mr

Lin

co

ln D

aw

kin

Mrs

Ju

lie R

ice

10/01/17 – The new staff permit system is due to be implemented shortly. It is hoped that

this will be up and running by the summer of 2017.

13/07/2017 Risk Review: Risk circumstances and rating remain the same until car parking

work schedule is approved and phases completed. - D Lord (HSM)

06/11/2017: Risk review - Currently no change to the circumstances outlined above - risk

level remains the same until progress is made. Plans for an extra 1500 space car park on

the site has been submitted for consultation. (D Lord HSM)

Project plan being

developed and to be

implemented -

following planning

permission

Submitted a variation

enquiry into Project

co to price.

Are developing a

revised sustainable

car parking plan with

revised criterion for

the issue of staff

passes.

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Mo

de

rate

9

LO

W 6

31

/01

/20

18

None identified

2127

01

/04

/20

16

11

/07

/20

14 Ambulance Deck outside

ED and risk of tripping

on kerbs designed to

create discrete

ambulance bays

Co

rpo

rate

He

alth

an

d S

afe

ty

Esta

tes

Co

re S

erv

ice

s

The raised kerbs in this area create a tripping

hazard which could result in injury to users of the

area resulting in personal injury claims and loss of

time from work due to injury.

MO

D

Lis

a K

elly

Mr

Lin

co

ln D

aw

kin

Mrs

Ju

lie R

ice

10/01/17 – Project is currently working with Skanska and Vinci to ascertain the defect issue

on the deck. The Trust awaits confirmation of how the defect will be resolved which will

enable the Trust to then progress the variation for the removal of the kerbs.

Risk review: Originally intended to be addressed as part of the lifecycle refurb work for the

Ambulance deck. Due to delays a separate variation order for work to remove the raised

edges has now been submitted. Awaiting works approval and plan from Project Co/Skanska.

Risk remains same until remedial work is carried out - D Lord (HSM) 13/07/2017.

24/10/2017 - Risk Review - Risk level remains the same - works variation submitted to

Project Co to remove the raised edges. Awaiting confirmation of cost and approval of work -

D Lord HSM.

05/01/2018 Risk review - Risk remains the same. Still awaiting costings and work schedule

from P Co. -D Lord HSM

None identified

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Mo

de

rate

9

VLO

W

2

05

/04

/20

18

None identified

10 of 18


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tix

Title

Ris

k T

yp

e

Ris

k S

ub

typ

e

Ris

k S

pe

cia

lty

Sp

ec

ialt

y G

rou

p

Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2230

22

/12

/20

14

22

/12

/20

14

Failure to comply with

Last Offices Policy

Co

rpo

rate

Sa

fety

- C

linic

al

Mo

rtu

ary

Clin

ica

l D

iag

no

stics (

Pa

tho

log

y &

Im

ag

ing

)

Failure to comply to policy results in an immediate

health and safety risk to the mortuary staff, funeral

operatives and family. Failure to dress patients

appropriately results in a lack of dignity and respect

for the patient and time required to appropriately

dress pt.

MO

D

Nin

a F

rase

r

Mr

Ch

ris W

oo

ke

y

Mis

s H

arr

iet

Tu

nsta

ll

15.02.18 - Mortuary now report into the End of Life Care (EoLC) committee. Report

presented to committee (29.01.18) on datix incidents associated with this risk (See attached

report) :

During 2017 there were 12 CAEs raised (Obs=3 / ED / Paed / W31=2 / W34 / W41/ W42 /

CCTC/ W12 ) :

oPatient not in correct clothing or a shroud

oNo ID tags / incomplete documentation

oNo body bag used – known cat 3 blood borne virus.

27.02.18 Still an ongoing issue - escalated to EOLC.

New starters

attending mandatory

Last Offices training,

however there needs

to be refresher

training for those

established staff that

haven't had the

opportunity to update

skills.

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Mo

de

rate

9

LO

W 6

30

/03

/20

18

2255

01

/04

/20

16

03

/02

/20

15

Quality of Duty of

Candour

Co

rpo

rate

Op

era

tio

na

l

Qu

alit

y D

ep

art

me

nt

Co

re S

erv

ice

s If the Trust is not fully compliant with the statutory

Duty of Candour, then this may lead to contractual

penalties from the CCG and regulatory action by

the CQC. in addition, the patient experience and

evaluation of the process will be poor which may

lead to further complaints and concerns.

MO

D

Me

gh

an

a P

an

dit

Mr

Ju

stin

Kin

g

Mis

s C

he

lse

a G

ilse

na

n

November 2017 Annual Audit completed. Quality of current Duty of Candour to be improved.

Development plan to be devised to monitor improvements over the next 12 months. Results

for presentation at Patient Safety and Effectiveness Committee.

Meeting arranged with DOC leads to review and discuss a training package for 2018 to help

support the delivery of DOC.

Further details are included in the quality account for assurance.

DOC training planned for 13.02.2018 to begin establishing a training needs analysis for

DOC.

Need to provide

further

communications to

staff

Need to provide

support/training to

staff to have DoC

conversations

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Mo

de

rate

9

LO

W 4

31

/03

/20

18

Review of relevant

incidents on Datix by

the Quality Team

SIG review of RCA

reports for evidence

of DoC

Review of complaints

relating to breach of

DoC

DoC Audit

established

Until the new

process has been

agreed &

communicated there

may be gaps in

compliance

Need for more

frequent (eg monthly)

review of compliance

as part of Trust

performance

dashboards

2787

21

/06

/20

17

Capital financing

Co

rpo

rate

Fin

an

cia

l If there is insufficient capital financing then the

Trust will not be able to invest in strategic and

operational developments affecting the Trust’s

ability to achieve its strategic objectives.

MO

D

Su

sa

n R

olla

so

n

Ms S

usa

n R

olla

so

n

Ms S

usa

n R

olla

so

n

Working with capital budget holders to prioritise funding

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Mo

de

rate

9

MO

D

9

31

/03

/20

18

Monitoring

programme through

capital group with

regular report to

Board

11 of 18


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on

Da

tix

Title

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k T

yp

e

Ris

k S

ub

typ

e

Ris

k S

pe

cia

lty

Sp

ec

ialt

y G

rou

p

Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2845

31

/07

/20

17

06

/09

/20

17

Age and Increasing

failures of Endoscopy

Reprocessing Equipment

Co

rpo

rate

Infe

ctio

n C

on

tro

l

De

co

nta

min

atio

n

Co

re S

erv

ice

s

The Trust currently has a tot al number of 9

Automated Endoscope Reprocessors (AER) within

the Trust. Some are 12 years old and other 6 years

old. Further to this the RO Plant water purifiers

which provide the sterile water to these machines

which is a mandatory requirements were put in in

2003 when the trust was being built.

This RO Plant employ chemicals to maintain the

sanitising aspect of the water and associated

pipework. This required repeated shutdown on the

machines and manual chlorination using manpower

and expensive chemical when weekly water test

result indicate a fail.

Any failure of water test results required a

shutdown of the equipment and chemical cleaning

by Vinci. this is disruptive to clinical workload.

AER's typically have a lifespan of 8 years. RO plant

is not typically a thermal system which self

disinfects itself requiring less down time and no

disruption to clinical services or manpower to

maintain and clean these systems.

MO

D

Nin

a F

rase

r

Mr

Ro

bb

ie C

orm

ie

Mr

Ro

bb

ie C

orm

ie

Both the RO plant and the AER's themselves have sterile water samples taken each week

and are sent to an authorised and Trust approved laboratory. When these indicate a fail of

these water test results, all machinery is put out of action until cleaning and retesting is

carried out.

A recent external review of these areas was carried out by a decontamination consultant the

the report delivered to the Trust on the 28th February. The trust ids currently reviewing this

report and will update this Datix once executive decisions have been made.

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Mo

nth

ly

Mo

de

rate

9

VLO

W

2

30

/04

/20

18

2159

01

/04

/20

16

15

/09

/20

14

Medical and Surgical

Rota Management

Co

rpo

rate

Op

era

tio

na

l

Wo

rkfo

rce

(H

R)

De

pa

rtm

en

t

Co

re S

erv

ice

s

Gaps in the Medical Rota which have not been

filled with either Internal or Agency doctors. This

can leave essential shifts such as 1st and 2nd on

call not appropriatly covered. No contingency plan

in place to support the gaps if unable to fill.

HIG

H

Lis

a K

elly

Ms W

en

dy B

ow

es

Mr

Ma

tth

ew

Bo

nn

ige

r 24/11/2016 Medical and Surgical rotas have been inputted into the E Rostering software.

Completed Re write of the F1 Rota and SHO rota for the December rotation.

7th June 2017 - existing controls remain in place. in addition, daily escalation report is

produced and given to execs and site ops teams. ongoing work regarding rota oversight

committee and creation of medical staffing department. SHO, F1 and Reg rotas for Medicine

for August 2017 have been re-written and agreed with CDs and are compliant.

None identified

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Min

or

8

LO

W 6

08

/12

/20

17

Medical Rota

planned in advance

and distributed to the

rotational Doctors in

advance. Any

forcasted gaps in the

Rota are sent to the

internal Medical staff

to fill. All unfilled

gaps are sent to TSS

to be filled via

Agency. If gaps not

filled then these are

escalated to the on

call teams.

None identified

12 of 18


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Da

tix

Title

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k T

yp

e

Ris

k S

ub

typ

e

Ris

k S

pe

cia

lty

Sp

ec

ialt

y G

rou

p

Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2279

01

/04

/20

16

04

/03

/20

15

Trustwide Clinical

Staffing Vacancies

Co

rpo

rate

Wo

rkfo

rce

(H

R)

All

Gro

up

s

Demand outstrips supply for both nursing and key

medical consultant posts.

High agency usage in most wards/ departments.

Framework agencies utilised, but variable quality of

skills of RN/ HCA/ medical locum leading to

potential increased risk to quality of care to

patients. Evidence shows poorer patient

experience in hospitals with high agency use.

Evidence demonstrates link with increased falls.

Financial impact- may not meet Trust trajectory as

set by NHSI.

Impact of additional open beds (short term over

winter in renal, cardiology, day surgery, MDU)

requiring additional staffing, all agency.

HIG

H

Nin

a F

rase

r

Nin

a F

rase

r

SN

Ro

ssly

n Y

ou

ng

Twice daily safe staffing meetings to review wards departments staffing situation across the

trust. Attendance by Matron and an associate director of nursing. Escalation process to CNO

in place.

Recruitment Lead Nurse in post since 1st December 2014 with a specific focus on registered

and non-registered nurse recruitment/ retention.

Recruitment and Retentions nursing plan since November 2016.

Overseas recruitment commenced in August 2016.

HR review and streamline of recruitment process.

Implementation of the Enhanced care team to focus specifically in providing 1:1 support to

identified patient group.

Targeted risk assessment and plans of actions for areas with particular pressures e.g. renal,

neurosciences, respiratory

There are a number of difficult medical posts that the Trust is actively trying to recruit to.

These posts are temporarily being covered by locum doctors. Work on-going to review use

of locums and alternative options

Process in place to monitor use of agency staff, with non framework RN requests, and

HCSW framework requests requiring authorised at daily safer staffing meetings

National guidance on agency caps came since November 2015. Review and oversight at

COG Star Chamber. Recruitment monitored by COG, on monthly IPR and monthly workforce

report to F&P Committee/ Trust Board.

Update: RC March 2017 Downgraded from High to Moderate - CWIO updated by EC August

2017

Timescale from

advert to staff on site

has improved but

ongoing work to

streamline this and

reduce further to no

longer than 3 months

Agreement to employ

greater number of

newly qualiifed staff (

work to look at

support required for

this) as experienced

B5 staff not avaialble

to match current

vacancy levels.

Vacancies for

nursing remain static

cica 200 every

month ( Jan 2017)

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Min

or

8

MO

D

8

31

/03

/20

18

Carter Nursing

Workforce metrics

developed November

2016, performance

managemtn of

Groups from Jan

2017

Turnover for RN=

6%,HCA = 8%,

below Trust target of

10%

Reduced external

agencies from 24 to

12, all framework ,

better quality

assurance

New Enhanced Care

Team commenced in

October 2015.

Further recruitment

to 10wte vacancies

in February 2015

Monitored at COG,

F&P Committee,

NMC and quarterly

Performance

Reviews

Bi annual review of

risk assessment at

Nursing and

Midwifery Committee

Twice yearly Safer

Staffing report to

Trust Board

Deep dive review ( of

quality metrics) on

those wards with

1:12 staffing at night

received at QGC in

june 2015.

HCSW recruitment

excellent and

vacancy numbers

reduced to below 30

across Trust

Nursing metrics

reviewed monthly

Vacancy rate

remains high despite

active recruitment

activities

Agency use still

similar to January

2016 but over cap

shifts reduced to 40-

50%

RN vacancy 20%,

HCA vacancy 12%

as at December

2016

13 of 18


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Description

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k l

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cu

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2316

20

/04

/20

15

20

/04

/20

15

Generic Business

Continuity Risks

Co

rpo

rate

Op

era

tio

na

l

All

Gro

up

s

Under the Civil Contingencies Act 2004 and NHS

EPRR Guidance 2013 NHS organisations are

required to plan for incidents that pose a threat to

the operational capability of the Trust ensuring that

all critical functions can continue as required.

Service interruptions can occur for a variety of

reasons including; adverse weather, industrial

action, ICT disruptions, supplier failure, loss of

acccess to buildings, fires and floods (though this

list is not exhaustive).

Each incident can pose multiple threats including

but not limited to; loss of service delivery, and

reputational damage.

MO

D

Lis

a K

elly

Mr

Lu

ke

Pe

ach

ey

The Trust has in a place a Strategic Level Business Continuity Plan that can be delivered

along side the Major Incident Plan.

The Trust has in place a Business Continuity Policy and Process that clearly identifies the

roles and responsibilities of each group in developing business continuity plans.

ICT and Information Governance require all ICT system owners to have in place a business

continuity plan as part of the ICT System Standards to ensure that all systems within the

Trust have a plan.

Each ward area have in place red Contingency Boxes that contain the paper copies required

to complete patient investigations, observations and TTOs. This box has recently been

audited and guidance is being circulated to all clinical areas to ensure the documents stored

meet their local needs.

Trust BCP incorporates Business Impact Analysis (BIA) to determine criticality of functions,

and have detailed arrangement covered in the MIP and Trust BCP.

None identified

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

An

nu

ally

Ma

jor

8

LO

W 6

01

/09

/20

18

SEPTEMBER 2017

update: All groups

will shortly undergo

training on how to

complete BIA's and

create group BCP's

with deadlines to

comply with.

Previous BIA's and

BCP's will then be re

reviewed by all

groups to ensure

information is

accurate and up to

date. Data will then

feed in local groups

management

meetings and

approved at local

groups QUIPS,

before submitting to

EPSC. This process

will be updated

through the Risk

Committee as part of

the EPSC TOR.

Dec 2017: All group

managers have

received training and

groups are

revaluating their

BIAs. A update has

been requested to all

groups on 1st

December on their

progress.

None identified

14 of 18


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Description

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k l

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el

(in

itia

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ec

uti

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ad

Ris

k O

wn

er

Ha

nd

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Ris

k l

ev

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(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

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k l

ev

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(Ta

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2546

08

/04

/20

16

06

/06

/20

16

Delayed discharge for

fast track patients

Co

rpo

rate

Op

era

tio

na

l

Inte

gra

ted

Dis

ch

arg

e T

ea

m

Clin

ica

l S

up

po

rt This risk is shared across the Trust. Fast Track

patients are delayed in UHCW awaitng POC or

NH's, or become too unwell to leave the hospital

due to the current process. The provision of Fast

Track services is the responsibility of CHC who are

commissioned by the CCG.

HIG

H

Lis

a K

elly

Ms C

lare

Ph

ea

sa

nt

Ms K

err

ie M

an

nin

g

Discussed within the community hub on a Mon - Fri basis with partner organisations.

Patients who are not discharged within 48 hours are challenged. Reducing the overall days

delayed moving the risk from Major to Minor

No longer a duty clinician role within CHC therefore should stream line the referral process

with IDT completing paperwork.

IDT report findings into EOL committee

Daily updates do not

always result in an

imminent discharge

Escalation at the

twice weekly meeting

does not always

result in an imminent

discharge

UHCW have no

authority over the

CHC SPA function

and the process

There is nothing in

the NH contracts to

specify a time frame

from referral to

assessment to

decision.

CCG offered 5 NH

beds to trail fast

track pathway, once

these beds were

filled no additional

beds available

New paperwork

leading to delays as

CHC requesting

additional

information. Training

to take place

MO

D

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ecte

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o o

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r a

t le

ast

We

ekly

Min

or

8

LO

W 6

05

/11

/20

18

Escalated to the

CCG work stream in

progress to explore

the CHC SPA

process

Escalated to the EOL

committee meeting,

letter sent from Mark

Radford to CHC

leads.

Completion of Fast

track audit

New Chief nurse met

with CCG Chief

nurse to discuss

possible solutions

New community Hub

mapped out pathway

and revised the

pathway to trail from

end of Jan2017

In house brokerage

function for CHC

being explored as

part of a D2A model

which will support

fast tracks

CCG are bringing

CHC back in house

so will be able to

manage the sourcing

process directly

No Authority to

implement / influence

a change in the CHC

process as managed

externally.

Fast tracks do not sit

within D2A modelling

15 of 18


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Description

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k l

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(in

itia

l)

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ec

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k l

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(cu

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ho

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(c

urr

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eq

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nc

e (

cu

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cu

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2655

28

/11

/20

16

21

/12

/20

16

Failure of Pharmacy

Aseptic Suite Business

Continuity Plan

Co

rpo

rate

Em

erg

en

cy P

lan

nin

g

Ph

arm

acy

Clin

ica

l S

up

po

rt

If the BCP for the pharmacy aseptic lab fails then

this will result in an inability to deliver aseptically

prepared clinical trials and short-shelf life

chemotherapy. Patients may be unable to receive

planned chemotherapy and/or clinical trial

medication.

Escalated to corporate risk register July 2017

following discussion at Risk Committee

LO

W

Mr

Ma

rk E

aste

r

Mr

Ste

ph

en

Alm

on

d BCP in place. Informal agreement with GEH/SWFT to assist with access to facilities to

prepare short notice treatments. Agreement with nuclear medicine (radiopharmacy) to use

their isolator to prepare occasional items with particularly short shelf life. Planned

chemotherapy may be purchased from other NHS Pharmacies or commercial Specials

Manufacturers.

Licensed external

suppliers may lack

capacity to provide

treatment.

If unable to source

IMPs from external

suppliers, will be

reliant on staff

travelling to another

hospital to make.

GEH/ SWFT

pharmacies may lack

capacity to enable

sharing of facilities.

GEH/ SWFT

pharmacies may

become non-

operational i.e. out of

use

Nuclear Medicine

has own workload

therefore spare

capacity for sharing

isolator is minimal.

Brief SLA is not as

detailed as full

technical agreement

with NGH

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

An

nu

ally

Ma

jor

8

LO

W 4

20

/06

/20

18

QC for GEH/ SWFT

is provided by

UHCW, therefore

quality of facilities is

known.

Licensed units

selected for

outsourced products

& certificates of

conformity recieved.

2783

21

/06

/20

17

Agency Expenditure

Co

rpo

rate

Fin

an

cia

l

Failure to control and reduce agency staffing

expenditure MO

D

Su

sa

n R

olla

so

n

Ms S

usa

n R

olla

so

n

Ms S

usa

n R

olla

so

n

Budgetary control processes.

FIP focus on agency controls.

Monthly operational delivery meetings.

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Min

or

8

MO

D

9

31

/03

/20

18

2822

03

/08

/20

17

03

/08

/20

17

Hepatitis B vaccine

shortage

Co

rpo

rate

Infe

ctio

n C

on

tro

l

Public Health England have notified all Trusts that

there is currently a global shortage of Hep B

vaccines.

PHE are advising dose sparing, therefore there will

be a delay in protecting clinical staff from hep B via

vaccination.

MO

D

Nin

a F

rase

r

Nin

a F

rase

r

Ms E

ilee

n W

illia

ms For staff involved in blood contamination incidents where patient is Hep B +, a booster dose

will be given if previously immunised.

If staff member is unvaccinated, they will receive Hep B immunoglobulin and a booster.

Staff awaiting 3rd and 5year boosters will be delayed until stock improve.

Communication will be sent to all staff to remind them of universal precautions and

procedures for the management of post exposures as per sharps policy.

No gaps in control

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

Annually

Ma

jor

8

VLO

W

2

30

/03

/20

18 IPC will be updated

on availability of

stock and controls in

place.

No gaps identified

16 of 18


ID

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Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

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Le

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Ris

k O

wn

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Ha

nd

ler


Ris

k l

ev

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(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

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(Ta

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Ne

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2877

20

/10

/20

17

20

/10

/20

17 Increased service

disruption due to

deteriorating mobile units

and ineffective x-ray

machines.

Co

rpo

rate

Op

era

tio

na

l

Bre

ast

Scre

en

ing

Clin

ica

l D

iag

no

stics (

Pa

tho

log

y &

Im

ag

ing

)

Overview of the context: The Breast Screening

department is responsible for the provision of the

screening service across Warwickshire, Solihull

and Coventry. We currently serve a screening

population of 171,780 ladies every 3 years and this

work incurs a high amount of revenue for the

Trust.

We have 3 mobile screening units that are 20

years old and in need of replacement. On the

19.10.201, a second report of a leaking roof was

submitted onto Datix [WEB-105320] from mobile 1.

Mobile 2 has a broken fridge which was considered

too expensive to repair and therefore a counter top

fridge has been installed. The actual x-ray

machines on the mobiles are recommended to be

replaced every 8 to 10 years. The x-ray machines

on the mobiles are now approaching 10 years old

and are less effective [please see summary of

service disruption as a result of break downs in the

document section].

The Risk: If we do not procure new mobile units

and new x-ray equipment staff will continue to work

in an environment that is unfit for purpose, we will

continue to experience service disruption and there

is a risk that our round length targets will not be

met.

This will impact upon the reputation of our

screening service, the working conditions for staff

will continue to be suboptimal, we will continue to

spend additional monies on requesting engineers

to assess and correct faults [which are

counterproductive]. This will impact upon the

length of time we can enter into a planned service

maintenance contract with the current providers.

Additional cost pressures need to be factored in

that were not previously anticipated and are likely

to increase.

MO

D

Su

sa

n R

olla

so

n

Dr

Alis

on

Du

nca

n

Mrs

Cla

ire

Pitta

m

Procurement strategy in place but this has been identified in the 2018/2019 capital plan.

We have completed

all actions that we

can locally

[procurment

processes] and are

now waiting for the

capital funds to be

made available.

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

We

ekly

Min

or

8

VLO

W

2

31

/03

/20

18

Any updates will be

communicated with

the Head of

Operations for

Imaging.

We will continue to

operate the service

and make the best

decisions that we

can within the

context and available

resources,

We recognise that

we are dependant on

the procurement

process being

authorised.

2904

23

/11

/20

17

23

/11

/20

17

Mass Casualty Incident

Co

rpo

rate

Em

erg

en

cy P

lan

nin

g

All

Gro

up

s

Fire/explosion/marauding terrorist firearms

attack/aviation accident/major roadways or Rail

incident creating a casualty load (either

contaminated or non-contaminated):

a) not exceeding 100 casualties

b) exceeding 100 casualities

MO

D

Lis

a K

elly

Mr

Lu

ke

Pe

ach

ey

Mr

Lu

ke

Pe

ach

ey

* Regional and local Health economy major incident plans.

* Surge/escalation plans.

* Casualty regulation plan in place

* Lock down plan in place

Applying lessons learnt from recent incidents and making necessary adjustments in plans as

listed below following the publication of NHSE Concept of Operations for managing mass

casualties

* Business continuity plans - UNDER REVIEW

* Mass casualty SOP - UNDER REVIEW

In addition for contaminated casualties:

* Trust CBRN SOP in place & trained staff with regular on-going

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

An

nu

ally

Ma

jor

8

MO

D

8

21

/04

/20

18

EPM has reviewed

the Mass Casualty

SOP. This has been

mapped against new

legislation released

by NHSE – Concept

of Operations for

managing Mass

Casualties and is for

comments by EPSC

on 7th March, and

will be presented at

the next Risk

Committee for final

sign off.

17 of 18


ID

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Da

tix

Title

Ris

k T

yp

e

Ris

k S

ub

typ

e

Ris

k S

pe

cia

lty

Sp

ec

ialt

y G

rou

p

Description

Ris

k l

ev

el

(in

itia

l)

Ex

ec

uti

ve

Le

ad

Ris

k O

wn

er

Ha

nd

ler


Ris

k l

ev

el

(cu

rre

nt)

Lik

eli

ho

od

(c

urr

en

t)

Co

ns

eq

ue

nc

e (

cu

rre

nt)

Ra

tin

g (

cu

rre

nt)

Ris

k l

ev

el

(Ta

rge

t)

Ra

tin

g (

Ta

rge

t)

Ne

xt

rev

iew

da

te


2906

23

/11

/20

17

23

/11

/20

17

Psychosocial support

Co

rpo

rate

Em

erg

en

cy P

lan

nin

g

Psychological support for people directly or

indirectly involved in an incident on a mass or small

scale, working with individuals affected for up to

two years after the initial incident

MO

D

Lis

a K

elly

Mr

Lu

ke

Pe

ach

ey

Mr

Lu

ke

Pe

ach

ey

* Use of Chaplin service

* Occupation Health Department

* MH providers major incident or business continuity plans (CWPT) to help people affected

by a significant or major incident.

* Use of third sector support (such as Samaritans, Cruse Bereavement Care, Disaster

Action, MH Services)

* EPO reviewing other options available (e.g. TRIM) following lessons learnt from recent

events following national guidance

External services will

quickly become

overwhelmed

following a incident.

EPO reviewing other

options for UHCW to

become self reliant

and resilient

MO

D

Exp

ecte

d t

o o

ccu

r a

t le

ast

An

nu

ally

Ma

jor

8

LO

W 6

21

/04

/20

17

EPM contacted TRiM

re course availability.

TRiM is a trauma-

focused peer support

system designed to

help people who

have experienced a

traumatic, or

potentially traumatic,

event. With a view to

train a cohort of staff

who have undergone

specific training

allowing them to

understand the

effects that traumatic

events can have

upon people and are

able to listen and

offer practical advice

and assistance

supporting our OOH

Department

18 of 18


Title Medical Education Quarterly Report Author Dr Sailesh Sankar Responsible Director

Professor Meghana Pandit, Chief Medical Officer

Date 29 March 2018 1. Purpose This report focuses on the activities in Medical Education. Activities of Medical Education include providing support for undergraduate and postgraduate medical education and training, the Resuscitation, Clinical Skills and Simulation team providing Trust wide support for resuscitation training and development, clinical skills training predominantly for undergraduate medical students and simulation training for all staff groups and the Surgical training Centre, which provides surgical training and anatomy teaching for undergraduate and postgraduate medical students/trainees, consultants and training to professions allied to medicine. 2. Background and Links to Previous Papers This paper provides an update on activity within medical education since our previous report in Nov 2017 3. Executive Summary Update from Medical Education – Undergraduate WMS programme Progress The National Student Survey was not completed this year due to the student union’s national protest and therefore it has not been possible to monitor the progress of the Warwick course in terms of national rankings. However, the teething problems with the roll out of the refreshed curriculum have now been resolved and the improvements in locally reported student satisfaction reflect the work that has been put in. As reported previously the Trust is currently seeking to expand its junior tier of clinical teaching staff by expanding the number of 50:50 clinical teaching fellows. These appointments will allow the Trust to significantly reduce the spend on locums, increase the quality and consistency of clinical staff and address the teaching requirements. We are currently recruiting to five full time teaching fellow posts, five 50:50 teaching posts in a variety of specialties, an airway teaching fellow and two 50:50 simulation fellows.

Postgraduate Medical Education Progress The monitoring systems for tracking and responding to any breaches of the new doctors contracts is working well and is now well embedded in the Trust. The system for automatically recording educational appraisals for the Trust’s Educational and Clinical supervisors on ESR is also running efficiently. The audit tool for assessing the quality of the appraisal documentation has now been developed (see Appendix 1) and a system for auditing 10% of the appraisals annually has been agreed. The new procedures have been incorporated into the relevant Trust policy and KPIs related to this work will be added to the matrix once the first audit is completed. In addition an on line system for recording evidence of involvement in teaching (for Consultant staff) has been developed and is currently being populated with existing evidence of teaching, helping with exams and attending education related courses and once ready it will be made accessible to its users. This data will help Consultants with the process of gathering evidence for their educational appraisals and thus it is hoped it will make the process easier for clinicians and encourage them to be involved in medical education. A snap shot of the new data base is shown in Appendix 2. It will also help with the development of further education KPIs. As part of our International Fellowship Programme UHCW Trust is now on the GMC website as an independent sponsor. Challenges The medical education team continue to work with the quality governance team to gather information in a systematic and timely manner for trainees involved in SUI, complaints and conduct issues. We are also exploring to set up an automated system for recording and managing and action on this data. The senior medical education team continue to support the group that the Trust has set up to look at the challenges related to filling the trainee doctor’s rotas. The problem is becoming particularly acute because of the changes brought by the introduction of the new doctors contracts and the changes in patterns of employment (with for example significant numbers of trainees dropping out of run through training this year). New and innovative solutions will be needed to resolve these difficulties and changes in training and new ways of working are likely to provide some of the answers. A number of innovative projects to encourage new sources of staffing are being developed including running medical registrar ready courses and simulation courses to help doctors who have not practised medicine for some time to get safely back into the work place. We are currently in discussion with Universities in India and UAE regarding an International Fellowship Programme which will be mutually beneficial and will help address some the workforce pressures. This will also enable to brand UHCW on a global platform and enable further international collaborative work. A paper for this is being presented to COG this month. HEEWM visits The standard review of the Foundation programme in November 2017 went well with only two areas of concern being identified. There was concern that there is no phlebotomy service on Sundays which as a result increases the workload of inappropriate tasks for junior doctors on that day. A business case to address this concern is currently being considered. The other

Page 2 of 5

area of concern is the lack of car parking permits available for doctors rotating into the Trust in August 2017. The problem is a lack of capacity which has resulted in significant difficulties for those who travel significant distances and work unsocial hours that are unable to park on site. Provision of off-site parking and out of hour’s arrangements has helped to alleviate some of the pressure, however in the recent months this continues to cause significant anxiety and financial difficulties for trainees who rotate through the trust. Resuscitation, Clinical Skills and Simulation Progress The successful launch of the “Recommended Summary Plan for Emergency Care and Treatment” (ReSPECT) at UHCW has led to the Trust being cited by the Resuscitation Council (UK) as a flagship for this process. UHCW was the first Trust in the country to “go live.” Catherine Baldock the Head of Department is currently undertaking some work with the Resuscitation Council to help roll out the scheme nationwide while continuing to manage the smooth running of her department. She is managing both roles very successfully and is proving to be an excellent ambassador for the Trust. The Trust’s compliance rates for mandatory resuscitation training are improving as a result of the extensive work the department has undertaken using UHCWi methodology. The appointment of two Simulation teaching fellows (working 50:50 with Acute medicine) has proved to be a very effective model and the Trust is seeking to replace them as they rotate on to their next posts. The current post holders have pioneered a new course for the Core Medical trainees which has been highly evaluated and have plans for further courses to help trainees bridge the gaps between stages in training. Surgical Training Centre Progress The Surgical Centre has an ever increasing portfolio of surgical and allied health professional training courses running in 2017/18. The centre is offering post graduate training, ranging from medical students to world renowned surgical training including new courses in topics ranging from Heart Academy master classes in heart transplant and mitral valve repair, Major incident surgical training and Neurosurgery dissection master class. Challenges The Surgical training committee is working well and is beginning to cement in the new governance systems essential to support the on-going growth and development of the centre. The expansion of the WMS student numbers will add to the current concerns about the limitations with the centres capacity which is constraining the opportunities to expand and grow.

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Innovative solutions to address this problem are needed particularly against the backdrop of the other service needs of the Trust. SUMMARY The medical education team have continued to make improvements in all areas and have continued to achieve the current quality targets (i.e. the Trust has not had any further Level 3/4 HEEWM inspections). Significant progress has been made towards developing additional KPIs to monitor both undergraduate and postgraduate education. The HEEWM inspection team which looked at the Foundation programme recognised the progress that has been made and have complimented the Trust on the support it gives to education. The expansion of student numbers, changes in student expectations, and changes in training patterns for trainee doctors all present on-going challenges for the team and Trust. The Resuscitation, Clinical Skills and Simulation team have achieved a number of significant gains for the Trust including being a national leader in the ReSPECT project, working in partnership with WMS to deliver a well respected clinical skills programme and are working hard to develop the simulation programme. In addition they have made significant improvements in the Trust’s compliance figures for mandatory training for resuscitation. The Surgical training centre continues to provide high quality national and international courses and is currently reviewing its governance structures and facilities to ensure that they continue to match the service needs. 4. Areas of Risk

• Clinical Risk. If we lose trainees due to unsatisfactory standards of training or

lack of suitable facilities we lose high standard clinical staff and will need to employ (at full cost) other clinical staff to fill the gaps. We may not have as much assurance on the standard of those replacement staff. Due to current workload pressures our highest current risk areas are our most pressurised.

• Financial. Funding now directly follows both medical students and PG trainees. Gaps in training posts is undoubtedly going to have an impact on the locum expense for the trust.

• Business. The success of our outward reaching educational ventures is in part built upon our general teaching and training reputation.

• Reputation. It is unthinkable that we should not maintain our status as a major teaching and training hospital. This has brought many advantages and improvements to the Trust and our local population and health care community

• Performance. As with clinical risk losing trainees will impact on performance in areas already under particular pressure

5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks This paper links to the Trust’s objective to become a Leading Training and Education Centre.

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6. Governance Medical Education is subject to the GMC rules and regulations and the undergraduate medical education is also governed by the regulations of Warwick University 7. Responsibility Associate Medical Director for Education with UG and PG Education teams, reporting to Chief Medical Officer. 7. Recommendations The Board is invited to NOTE:

1. The on-going work in respect of the Medical Education Directorate 2. Continue to provide oversight particularly in respect of HEEWM visits.

Dr Sailesh Sankar. Associate Medical Director for Education Date: 11th March 2018.

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Appendix 1

Domain 1 : Ensuring safe and effective patient care through training

This area is about how you protect patients and enhance their care through your supervision of doctors in training, and how you balance the needs of your patients and service with the educational needs of your trainees.

General examples of relevant evidence:-

• Courses attended or programmes undertaken including, face-to-face and online learning • GMC trainee survey results or equivalent • Feedback from patients about care received • Details of measures put in place to ensure supervision appropriate to trainee’s competence

and confidence • Trainee audits, examples of topics critically appraised by trainees • Examples of near miss/critical incident analysis

Evidence requirement Examples of evidence provided by appraisee ALL EVIDENCE TO WITHIN LAST 12 MONTHS

1.1 Balances the needs of service delivery with education

Evidence of action taken on the GMC/JEST survey results including drafting action plan and/or taking lead on actions listed.

1.2 Acts to ensure the health, wellbeing and safety of patients at all times

Evidence of involvement in relevant discussions at QIPs meeting – from minutes of meeting – attendance records, lead on action points etc.

1.3 Ensures that trainees have undertaken appropriate induction

Evidence of providing induction registers to PMEC. Emails to trainees welcoming them to Trust. Induction programme with evidence of involvement. Evidence of induction appraisals from their trainees.

1.4 Allows trainees, when suitably competent, to take responsibility for care, appropriate to the needs of the patient.

Feedback from trainees on ES

1.5 Ensures that trainees understand the importance of providing culturally competent care.

Evidence of involvement in teaching programme addressing culturally competent care.

1.6 *Uses educational interventions to enhance patient care

Involvement in RCA/SUI/Complaint/Conduct reports investigations showing link back to clinical improvement projects. Evidence of education projects, audit projects etc used to enhance care. Evidence of journal club support and discussions.

1.7 *Involves trainees in service improvement

Evidence of supporting trainees in audit projects, research projects, innovation projects

1.8 *Involves patients as educators Feedback from patients, evidence of running teaching clinics.

*The excellent supervisor has evidence for these three criteria – not essential for the effective supervisor

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Domain 2 : Establishing and maintaining an environment for learning

This area is about how you make the clinical environment safe and conducive to effective learning for trainees and others.

Examples of relevant evidence

• Courses attended or programme undertaken, including face-to-face and online learning • GMC trainee survey results or equivalent • Other feedback from trainees from, for example, Shared Service’s multi-source feedback

tool for supervisors. • Details of learning programme, study schedules, timetables for trainees and clinical teachers • Feedback from colleagues


2.1 Encourage participation through provision of equality of opportunity and acknowledgement of diversity

Evidence of attending Eq & Div training events, Evidence from induction programme of coverage of topic and provision of information about services available, Evidence from management of a trainees needs related to this topic

2.2 Ensures that trainee receive the necessary instruction and protection in situations that might expose them to risk

Details of learning programmes, study schedules, timetables for trainees and clinical teachers. Details from induction pack covering local risks and advice on systems for protecting staff.

2.3 Encourages and maintains the confidence of trainees

Feedback from trainees. Evidence of involvement in SIG/untoward incident/complaint investigations and/or evidence of actions taken following such investigations.

2.4 Is open, approachable and available. Feedback from trainees, feedback from colleagues. Evidence from induction pack and/or other correspondence showing sharing of diary with trainees and advising them of how they can be contacted.

2.5 Maintains good interpersonal relationships with trainees and colleagues.

Evidenc e of 360 degree feedback from colleagues or ‘Shared Service’s multi-source feedback’ tool for supervisors

2.6 Provides protected time for teaching and learning

Evidence of appraisees work schedule showing teaching and supervision slots. Email correspondence with trainee setting out times to meet. Evidence of correspondence supporting/encouraging trainees to go for protected teaching. Evidence of support for study leave requests.

2.7 Involves the multiprofessional team in the delivery of teaching and supervision

Email correspondence demonstrating multiprofessional team working. Teaching programmes organised by appraisee showing

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Evidence requirement Examples of evidence provided by appraisee ALL EVIDENCE TO WITHIN LAST 12 MONTHS involvement of others.

2.8 Is aware of the team’s experience and skills relating to teaching and supervision

Chart of department showing training roles. Minutes from department meeting where training needs discussed.

2.9 Ensures that workload requirements on trainees are legal and that, wherever possible they do not compromise learning

Email correspondence with trainees showing monitoring of workload and contracts, evidence from induction advising how to contact Trust guardian

2.10 Makes provision for the specific training needs of trainees with disabilities

Evidence of arrangements made to accommodate individual needs. Evidence of knowledge of department/Trusts policies on this area. Evidence of information, materials relevant to organising provision of services needed for individual needs.

2.11 * Proactively seeks the views of trainees on their experience

360 degree appraisal involving feedback from trainees. Email evidence of feedback from trainees, minutes from JDF. Relevant evidence from trainees eportfolio.

2.12 * Takes steps to establish a learning community within their department and/or organisation

Evidence of involvement in QIPs, journal club, teaching programme, department meetings.

2.13 * Monitors, evaluates and takes steps to address areas for improvement in teaching and learning

Minutes from QIPs showing attendance and involvement in improving teaching. GMC/JEST action plan showing appraisee involvement in improving provision. Email evidence from trainees of improvements made. Feedback from training sessions with associated action planning.


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Domain 3 : Teaching and facilitating learning

This area is about how you work with trainees to facilitate their learning


• Courses attended or programme undertaken, including face-to-face and online learning. • GMC trainee results or equivalent. • Other feedback from trainees from, for example, the Shared Service’s multi-source feedback

tool for supervisors. • Details of learning programmes, study schedules and timetables for trainees. • Feedback from colleagues. • Evidence of recent initiatives to enhance the provision of learning opportunities.


3.1 Has up-to-date subject knowledge and/or skills

Certificates from courses attended to up date/extend knowledge/skills in specialty. Evidence of innovation e.g. updated teaching programme, audit projects, research projects etc.

3.2 Provides direct guidance on clinical work where appropriate.

Email evidence of arrangements to meet with and supervise trainees. Feedback from trainees. Work schedule of appraisee showing slots for clinical supervision.

3.3 Has effective supervisory conversational skills

Feedback from trainees. Evidence of attending courses related to developing/enhancing supervisory skills e.g. TTT course certificate.

3.4 Plans learning and teaching episodes Teaching programme developed by or showing contributions from appraisee. Feedback from teaching sessions.

3.5 Uses a range of appropriate teaching interventions in the clinical setting

Evidence from teaching portfolio of the teaching methods used e.g. one to one, small group teaching etc.

3.6 Facilitates a wide variety of learning opportunities

Evidence from teaching portfolio.

3.7 Helps the trainee develop an ability for self-directed learning

Feedback from trainees, evidence from eportfolio, evidence from teaching delivered.

3.8 Allows the trainee to make contributions to clinical practice of graduated value and importance commensurate with their competence.

Evidence from trainee eportfolio (redacted and with permission). Email evidence. Timetable/rota evidence showing supervision and delegation of appropriate tasks. Evidence of signing off competencies.

3.9 Uses technology-enhanced learning where appropriate e.g. simulation.

Programmes from running simulation sessions. Minutes of meetings showing involvement in technology-enhanced learning.

3.10 Encourages access to formal learning opportunities e.g. study days

Email evidence signing off study leave. Induction programme showing instructions on how to apply for study leave.

3.11 *Demonstrates exemplary subject Conference attendance certificates. Excellence

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knowledge or skills awards, publications, research/audit projects. 3.12 *Understands and can apply theoretical

frameworks to their practice. Conference attendance certificates. Excellence awards, publications, research/audit projects.

3.13 *Is involved with curriculum development beyond the supervisory relationship

Minutes showing attendance at meetings related to curriculum development e.g. School board. Attendance at PMEC and UMEC meetings. Attendance at courses related to responding to changes in curriculum.

3.14 *Works with the department and/or provides to ensure a widerange of learning opportunities is available, e.g. simulation facilities, courses.

Evidence of involvement in teaching programmes and programme development.

*The excellent supervisor has evidence for these criteria – not essential for the effective supervisor

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Domain 4 : Enhancing learning through assessment

This area is about your approach to assessment and feedback


• Courses attended or programmes undertaken, including face-to-face and online learning • GMC trainee survey results or equivalent. • Other feedback from trainees from, for example, the Shared Service’s multi-source feedback

tool for supervisors • Details of programmes, study schedules and timetables or trainees indicating assessment

modes, patterns and relevance to learning. • Feedback from peers, e.g. relating to external examining or professional assessment.


44.1 Regularly observes the trainee’s performance and offers feedback.

Evidence of involvement in ARCP meetings.

4.2 Plans and/or monitors assessment activities.

Evidence of involvement in Examination

4.3 Uses work place-based assessments appropriately.

Evidence from trainee feedback. Example of assessment. 360 degree feedback from colleagues.

4.4 Provides feedback that is clear, focused and aimed at improving specific aspects of trainee performance.

Trainee feedback. Evidence of attendance at courses related to improving

4.5 Ensures that the trainee participates in 360 degree appraisal.

Email evidence of setting up appraisals

4.6 Supports the trainee in preparation for professional external examinations

Email evidence. Trainee feedback.

4.7 *Demonstrates exemplary subject knowledge or skills

Conference attendance certificates. Excellence awards, publications, research/audit projects.

4.8 *Understands and can apply theoretical frameworks to their practice.

Conference attendance certificates. Excellence awards, publications, research/audit projects.

4.9 *Is involved with curriculum development beyond the supervisory relationship.

Minutes showing attendance at meetings related to curriculum development e.g. School board. Attendance at PMEC and UMEC meetings. Attendance at courses related to responding to changes in curriculum.

4.10 *Works with the department and/or provider to ensure a wide range of learningopportunities is available, e.g. simulation facilities, courses.

Evidence of involvement in teaching programmes and programme development.


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Domain 5 : Supporting and monitoring educational progress

This area is about the support you provide to trainees in their progression towards a Certificate of Completion of Training and their intended career destination.


5.1 Agrees an educational contract at the outset of the training period.

Copy of educational contract with trainee (redacted and with permission) Evidence from induction programme

5.2 Understands the curricula requirements of the specialty and stage of training.

TTT certificate, attendance at School Board, evidence of discussion of curriculum and training at department meetings. Matching of training programme to curriculum

5.3 Identifies learning needs and sets educational objectives.

Emails with trainees, copy of trainees timetable, evidence of discussions and setting of plans at initial meeting with trainee.

5.4 Involves the trainee in the above processes.

Emails, evidence of sharing programme, trainee feedback

5.5 Reviews and monitors progress through regular timetabled meetings.

Emails, copy of diary entries/work schedule showing review slots. Evidence from induction programme

5.6 Ensures that appropriate records are kept in relation to trainee progress.

Evidence from trainee portfolio (redacted and with permission).

5.7 Uses the educational portfolio appropriately and encourages its use by trainees.

Evidence from trainee portfolio (redacted and with permission). Emails, evidence from induction programme.

5.8 Provides continuity of supervision or ensures effective educational handover

Evidence from trainee portfolio (redacted and with permission).

5.9 Responds efficiently and effectively to emerging problems of trainee progress.

Evidence from trainee portfolio (redacted and with permission). Email evidence, Minutes from department meetings evidencing review of trainee progress. Evidence of use of referral process for trainees in difficulties.

5.10 Is aware of, and can access, available support for the trainee in difficulty.

Flow chart of how to access services. Evidence from emails, Evidence from trainee portfolio (redacted and with permission).

5.11 Understands their role and responsibilities within the educational governance structures of their local education provider, lead provider, LETB and College.

Diagram of the educational governance structure.

5.12 Provides reports for Annual Review of Competency Progression (ARCP) panels and responds appropriately to panel outcome

Reports from ARCP panels evidencing involvement (attendance records etc.)

5.13 *Proactively seeks out opportunities for providing formal support and career development activities for trainees

Trainee feedback. Minutes from department meetings.

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5.14 *Establishes and/or evaluates schemes for monitoring trainee progress across the department/organisation.

Evidence of developing programmes.

5.15 *Involves themselves in external activities relevant to doctors in difficulty or career progression (e.g. ARCP panels, GMC, GDC or college committees).

Minutes from ARCP meetings, Emails, 360 degree evaluation from colleagues.


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Domain 6 : Guiding personal and professional development

This area is about the support you provide to trainees in relation to their personal and professional development


• Courses attended or programmes undertaken, including face-to-face and online learning • GMC trainee survey results or equivalent • Other feedback from trainees from, for example, the Shared Service’s multi-source feedback

tool for supervisors • Examples of meetings, records, case studies (suitably anonymised). • Examples of support, challenge and careers guidance provided to trainees (anonymised). • Feedback from peers, e.g. relating to involvement in organisational/professional activities.


6.1 Provides a positive role model 360 degree feedback, feedback from trainees, email evidence

6.2 Has effective supervisory conversational skills

Trainee feedback, email evidence.

6.3 Utilises a range of skills and techniques relevant to personal and professional development

Courses attended or programmes undertaken – certificates, email evidence. 360 degree feedback.

6.4 Is able to set and maintain appropriate boundaries.

Induction materials showing the establishment of working relationship. 360 degree feedback.

6.5 Understands when and where to refer on to other agencies e.g. occupational health, counselling, MedNEt, Professional Development Careers Unit.

Evidence of awareness of agencies, attendance at TTT and other relevant training. Attendance at training events, school boards etc.

6.6 Ensures that the trainee is aware of the requirements of, and participates in, NHS Appraisal.

Evidence from eportfolio of trainee redacted and with permission, attendance at ARCP and other assessment meetings.

6.7 Ensures that the trainee participates in 360 degree appraisal

Evidence from eportfolio, email correspondence.

*6.8 Demonstrates exemplary subject knowledge or skills

360 degree feedback, attendance and participation as faculty in relevant courses.

*6.9 Understands and can apply theoretical frameworks to their practice

Evidence of theoretical frameworks and how applied from appraisal discussions.

*6.10 Is involved in curriculum development beyond the supervisory relationship

Evidence of attendance at curriculum development events.

*6.11 Works with the department and/or provider to ensure wide range of learning is available, e.g. simulation facilities, courses.

Evidence of participation in department teaching programme.


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Domain 7 : Continuing professional development as an educator

This area is about you own professional development as a medical educator


• Courses or programmes recently undertaken, including face-to-face and online learning. • Results of 360 degree appraisal, such as the Shared Services’s multi-source feedback tool for

supervisors • Certificates or qualifications obtained • Critical comments on relevant books or articles read recently • Results of peer review or professional observation of teaching • Keeps up date on specific specialty and/or Foundation training requirements.


7.1 Evaluates own supervisory practice Evidence of evaluation – email correspondence,

7.2 Evaluates own practice as an educator Evidence of evaluation – email correspondence 7.3 Takes action to improve own practice on

the basis of feedback received e.g. appraisal, informal feedback.

360 degree feedback and evidence of reflection and changes based on this.

7.4 Maintains professional practice in line with specialty and regulatory requirements

Attendance at courses.

*7.5 Actively seeks the views of colleagues through , e.g. 360 degree appraisal, peer observation.

360 degree appraisal

*7.6 Engages in programmes of educational development, e.g. training the trainers courses, postgraduate certificates, Masters programmes.

TTT certificate, course certificates

*7.7 Assists the development of others as educators, including trainees.

Emails, evidence of trainee involvement in research, audits and teaching programmes.


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Appendix 2

Medical Education website: educational supervision dashboard (example screenshot)


Title Guardian of Safe Working Hours Trimester Report October 2017 to January 2018

Author Dr Andreas Ruhnke Responsible Chief Officer

Professor Meghana Pandit – Chief Medical Officer & Deputy CEO Karen Martin – Chief Workforce and Information Officer

Date 29 March 2018 1. Purpose To give assurance to the Trust Board that Junior Doctors in Training (JDT) are safely rostered and their working hours are compliant with the Terms and Conditions of Service for NHS Doctors and Dentists in Training (England) 2016 (TCS). This paper provides a summary of the following areas related to JDT and the 2016 TCS:-

• Exception reports • Rota Redesign • Work schedule review • Locum processes • Rotational Training Vacancies

2. Background and Links to Previous Papers In October 2016 a new contract was introduced for JDT with a new schedule of 2016 TCS. As part of the new 2016 TCS the post of Guardian of Safe Working Hours (GSW) was introduced. The role of the GSW is to:

• Ensure the confidence of doctors that their concerns will be addressed • Require improvements in working hours and work schedules for JDTs • Provide Boards with assurance that junior medical staff are safe and able to work,

identifying risks and advising Board on the required response • Ensure the fair distribution of any financial penalty income, to the benefit of JDTs.

This GSW report covers the period from 01 October 2017 to 31 January 2018 (4 months). Future GSW reports will cover 4-month-periods to align better with the bimonthly Trust Board Meetings. UHCW NHS Trust currently employs 392 JDTs of whom 392 work under the new 2016 TCS. Additionally there are 141 (136.5 WTE) Trust Doctors of various grades who also work on JDT rotas. For the purpose of this report, Trust doctors are not included in the scope of the Guardian role for the data presented here. .

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The GSW receives 2 job-planned Programmed Activities (PAs) to undertake this role. Educational supervisors receive 0.25 job-planned PAs per trainee. 3. Exception reports (with regard to working hours) Exception reports are a new requirement under the 2016 TCS. Where JDTs feel that their working arrangements in practice deviate significantly and/or regularly from the agreed work schedule, they should raise their concerns to their Educational Supervisor or Clinical Supervisor through the electronic exception reporting system. Primarily the variations will be:

• Differences in the total hours of work (including rest breaks) • Differences in the pattern of hours worked • Differences in the educational opportunities and support available to the doctor • Differences in the support available to the doctor during service commitments The role of the Guardian is to provide oversight of these exception reports. Exception reports (ERs) received between 01 Oct 17 and 31 Jan 18 by specialty: Specialty ERs carried

over from last report

ERs raised ERs closed ERs outstanding

General Surgery

2 39 41* 0

General Medicine

0 10 10** 0

Anaesthetics 0 4 4 0 Psychiatry*** 1 0 1** 0 RespMed 0 1 1 0 RenDermRheu 0 10 5 5 Neurosciences 0 3 2 1 ITU 0 1 1 0 Plastics 0 5 5 0 Endocrinology 0 1 0 1 Acute Medicine 0 2**** 2**** 0 Obs/Gyn 0 1 1** 0 STX Medicine 0 1 1 0 Total 3 78 74 7 * 4 re-submitted, 1 shows as 'unresolved' 1 awaiting doctor's agreement ** 4 non-electronically completed (2 GenMed 1 Psych 1 ObsGyn) *** not a UHCW specialty but under UHCW GSW **** 1 ER submitted 2 months late

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ERs by grade: Grade ERs carried

over from last report

ERs raised ERs closed ERs outstanding

F1 3 49 52 0 F2/CT/ST1-2 0 19 12 7 ST3+ 0 10 10 0 ERs response time Response time <48h <7d >7d Still

outstanding F1 8 15 22* 0 F2/CT/ST1-2 3 4 4 7 ST3+ 0 8 2** 0 Total*** 11 27 28 7 * 2 ERs completed non-electronically ** 1 ERs completed non-electronically *** not included 1 late ER and 4 re-submitted ERs There is a significant increase in exception reporting. This Trust Board Report covers a 4-month-period from Oct 2017 to Jan 2018 during which the overall number of ERs has more than doubled compared to the number of ERs covered by my Annual Report (78 versus 58 ERs). Exactly half of all ERs have been raised by F1 Doctors in General Surgery and most of those 39 ERs originated from Hepato-Biliary Surgery. That means that the work schedule review undertaken by the department did not lead to the desired reduction in exception reporting. Most claims for TOIL are based on staying late due to late ward rounds, late handover and volume of work. The F1 Doctors Rota in HPB Surgery needs a further review. Slightly more than 50% of all ERs have been reviewed within 7 days. The delayed review times are mainly caused by an unfamiliarity with the electronic reporting system and failure to find a meeting date within 7 days due to leave. 3 ERs have been reviewed and completed but not via the electronic reporting system. These reviews might have taken place within 7 days of ER submission. I have contacted the trainees and educational supervisors in question to encourage them to only use the electronic ER system in the future. 4. Rota Redesign All 58 JDT rotas are 2016 TCS-compliant (100% compliance rate on paper).

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The rota redesign work was overseen by the Junior Doctor Project Group of which the Guardian is a member of. The Rota Oversight Committee is a new group which has been established to look into all medical rotas at UHCW NHS Trust. The Guardian is a member of this group. 5. Work schedule reviews The F1 rota in General Surgery (HPB surgery) has been reviewed by the department and the following changes have been made.

• F1 doctors should start to handover to PSPs at 16:00 to be able to leave on time • Start and finish times during normal working days should be delayed by half an hour

These changes will be monitored via the exception reporting system. Locum Processes Locum Bookings and Expenditure Information on locum expenditure is reported through to the Finance and Performance Committee and Trust Board so are not included in this report. Locum Process JDT are able to undertake voluntary additional hours at this or any other Trust under the 2016 TCS, these are normally for a whole shift. When undertaking these additional voluntary hours within the Trust, these hours are worked as a locum duty conducted through the internal bank paid at set pay rates. Requests for locum duties are submitted by departments and are approved and agreed in line with current internal authorisation processes. At group level, JDT can sometimes be asked to stay over to provide additional cover which is not captured centrally as they would not be classed as locum duties but claimed as extra hours or time off in lieu at a local level. The Trust is working on a process to capture these additional hours for monitoring and reporting, moving forward. Monitoring of Additional Working Time The Trust had traditionally monitored staff working bank shifts and agency workers through the Temporary Staffing Services (TSS) RAG report. The RAG report is a spreadsheet which records the status of additional cover requests for medical locums across the Trust, whether they are filled and if so, the individual covering the duty. Since March 2017 the Trust has implemented a new electronic web based booking and approval system (Agency Approval Software) which was meant to replace the RAG reports to ensure more robust tracking of locum requirements and duties worked for both agency and internal workers. Most departments still find locum cover for vacant shifts internally and do not report such additional work to TSS which means the database of the Agency Approval Software continues to be inaccurate. To monitor additional working hours for individual doctors in training remains very difficult. The RAG reports are still in use.

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As the Trust would rather want our staff to work additional hours for us when they wish to do so, new starters are auto-enrolled onto the bank when they join the Trust, with the option to opt out if they wish to do so. This auto enrollment onto the bank was implemented to support operational delivery and to make it a less bureaucratic and more streamlined process for individuals if they wished to undertake additional duties. Additional Duties under 2016 Contract When transferring to the 2016 contract and being auto-enrolled onto the internal Trust bank, trainees will be asked if they wish to opt out of the European Working Time Directive (EWTD) limit of 48 hours per week on average, which they are entitled to do. This is an individual decision and the Trust does not exert any pressure for trainees to do so. Anyone who does not wish to opt out of the EWTD will be limited to a maximum of 48 hours of work in total within the Trust. Monitoring of Additional Duties There is still no effective system in place to monitor the additional hours undertaken by trainees when undertaking additional duties correctly. Therefore it remains important that Junior Doctors are reminded of their ongoing obligations around the controls on their working time, which is highlighted at induction, through discussions when exceptions are raised and in their contracts of employment issued to them. Opting-out of WTR: As previously reported there is still no central data base for opting-out of WTR. Locum Work carried out by trainees All Junior Doctors in Training at UHCW NHS Trust are now working under the 2016 TCS which oblige them but also the employing Trust to monitor their working hours for compliance with the WTR.Due to the absence of an e-roster software at UHCW which would allow to update Junior Doctors' actual working hours in real-time it has not been possible to monitor their working times for possible breaches of their working hours. This monitoring needs to be done manually at the moment requiring checks of all locum time sheets to identify the additional locum work undertaken at UHCW by our Junior Doctors in Training. I would like to thank Nick Rees and his team for doing this time-intensive data-search. In my last report I pointed out that 3 trainees were on course to breach the maximum 56 hours weekly averaged working time unless they reduced their additional work significantly. 2 of those 3 trainees kept within the limits over the reference period of 4 and 6 months. The third trainee breached the 56h limit by a significant margin. At the West Midlands Regional Meeting of Guardians of Safe Working Hours in February 2018 I asked my colleagues how they would proceed and we agreed that no Trust fine should be levied at this occasion as neither trainee nor the locum coordinator were aware of the limit on total working hours. However future breaches should be fined. Over the period of the last report 23 trainees were projected to breach their 48 hours weekly averaged working time limit unless they had signed opt-out forms. After several requests for e-mail confirmation of their opt-out status I was only able to verify 7 opt-out forms. The remainder of the trainees did not respond.

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As emphasized in my last report breaching of WTR limits of average weekly working time constitutes a risk to patient-safety and doctor's wellbeing. By opting out of the 48h WTR limit a Junior Doctor in Training declares themselves mentally and physically fit to safely work for up to 56 averaged weekly working hours without risking patient safety. I suggest that only trainees who opted-out of the EWTD should be allowed to do additional work as locums and that a central opt-out database should be established within HR. 6. Vacancies The table below details the vacancies by month (TCS 2016 trainees). Specialty Grade Oct17 Nov17 Dec17 Jan18 average Acute Med ST3+ 1 1 1 1 1 Anaes ICM ST3+ 5 4 4 4 4.25 Cardiology F2/CT/GPST* 2 2 1 2 1.75 Cardiac S ST3+ 1 1 1 1 1 Radiology ST3+ 2 2 1 1 1.5 EM ST3+ 2 2 2 2 2 EM F2/CT/GPST* 1 1 1 1 1 Gastro F2/CT/GPST* 2 2 2 2 2 General S ST3+ 0 4 4 4 3 General S F2/CT/GPST* 1 1 0 0 0.5 GUM F2/CT/GPST* 1 1 0 0 0.5 Geriatric ST3+ 1 1 1 1 1 Geriatric F2/CT/GPST* 1 1 1 1 1 Haema F2/CT/GPST* 0 0 0 1 0.25 Histopath ST3+ 2 1 3 3 2.25 Neurology ST3+ 1 1 1 1 1 Neuro S ST3+ 1 1 1 1 1 ObsGyn ST3+ 3 3 3 3 3 ObsGyn F2/CT/GPST* 1 1 0 0 0.5 Oncology F2/CT/GPST* 0 0 0 1 0.25 MaxFax St3+ 1 1 1 1 1 MaxFax F2/CT/GPST* 0 0 0 1 0.25 Paeds F2/CT/GPST* 2 2 2 2 2 Plastic S F2/CT/GPST* 1 1 1 1 1 Resp Med F1 1 1 0 0 0.5 Resp Med F2/CT/GPST* 2 2 2 3 2.25 Renal ST3+ 0 0 0 1 0.25 Rheuma F1 1 1 0 0 0.5 Rheuma ST3+ 1 1 1 1 1 Rheuma F2/CT/GPST* 1 1 0 0 0.5

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Specialty Grade Oct17 Nov17 Dec17 Jan18 average Trauma ST3+ 1 1 1 1 1 Trauma F2/CT/GPST* 1 1 1 1 1 Total All grades* 40 42 36 42 40 * F2/CT/GPST includes 9.5 average GPST vacancies HEE (West Midlands) has been unable to recruit enough doctors to fill all available training posts. There is a particular problem with recruitment into GP training as seen in the relatively high number of vacant GPST positions at UHCW (9.5 average vacancies). At the moment vacancies and vacant shifts are either covered by employing non-training grade doctors or locum doctors. Some work is done by non-medical staff. In some specialties consultants are acting-down to cover vacant shifts. As there is no integrated system in place I am unable to comment on the overall number of uncovered shifts. There is no guarantee future recruitment rounds will attract enough doctors to fill all HEE training posts and vacant posts might be placed with UHCW due to the ongoing car parking issue where some of the Junior Doctors in Training sent to UHCW do not receive on-site parking permits. Recruitment of more non-medical and overseas medical staff should continue to avoid any vacancies across the 58 training rotas. 7. Fines There were neither fines nor disbursements during the last quarter. The annual balance of the GSW account (penalties) is £0. 8. Qualitative Information All published trainee-rotas are TCS2016 compliant on paper. There is an improvement in reviewing exception reports within 7 days but still nearly 50% of all ERs are not dealt with within that timeframe. Most ERs are now reviewed electronically. There were monthly JDF meetings during the period of this report. Information about the GSW's role and exception reporting is available under ‘Junior Doctors’ in the A-Z Departments listing of the intrane 9. Issues arising Nearly 10% of all training posts were vacant during the period covered by this report (an average of 40 posts per month). This has been an increase compared to the vacancy rate in September 2017 (8%).

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Until many more doctors are trained UHCW specialties should continue or explore recruiting non-medical staff and overseas doctors (Medical Training Initiatives) to ensure safe staffing levels. Without an appropriate electronic system in place to monitor the total working hours (normal rota hours plus additional locum work) of the Junior Doctors in Training covered by the TCS2016 the Trust might fail on its obligation to monitor safe working hours. Breaches of the 48h (56h if opted-out) maximum weekly average working time might continue to occur. 10. Conclusions 1. The GSW is able to give assurance to the Board that the published specialty rotas of

all current JDTs (2016 TCS) are compliant with Working Time Regulations. 2. An integrated system is needed to monitor the contracted and additional working

hours with regards to opt-out status and individual average working hour week. 3. Assurance of support with regard to the exception reporting process should be given

to all trainees. 4. Recruitment of more non-training-grade medical staff (nationally or internationally) and non-medical staff would improve cover of the 58 training rotas. 5. The next GSW report will be the second Trimester Report on 26 July 2018. 11. Link to Trust Objectives and Corporate/Board Assurance Framework Risks To provide world-class education and training. 12. Governance The GSW works in conjunction with the Associate Director of Medical Education reporting to the CMO and CWIO. 13. Responsibility

GSW Dr Andreas Ruhnke CMO Professor Meghana Pandit CWIO Karen Martin 15. Recommendations The Board is invited to note the content of the report and receive assurance Name and Title of Author: Dr Andreas Ruhnke, Guardian of Safe Working Hours Date: 14/03/2018

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Title Caldicott Guardian Annual Report Author Jenny Gardiner, Director of Quality & Caldicott Guardian Responsible Director

Meghana Pandit, Chief Medical Officer & Caldicott Guardian

Date 29th March 2018 1. Purpose This is a routine annual report to advise the Board of work undertaken by the Caldicott Guardians during 2017/18. Trust Board is asked to note the work undertaken to date and the plans for 2018/19. 2. Background and Links to Previous Papers Dame Fiona Caldicott was appointed as the National Data Guardian (NGD) in November 2014. The NDG’s role is to help make sure the public can trust their confidential information is securely safeguarded and to ensure that it is used to support citizens’ care and to achieve better outcomes from health and care services. In July 2016 the NDG together with the CQC published ‘Review of data security, consent and opt-outs’. Dame Fiona’s report discusses that the public should be engaged about how their information is used and safeguarded, and the benefits of data sharing beyond direct clinical care, with a wide-ranging consultation on her proposals as a first step. The Manual for the Caldicott Guardians published in 2017 states that the NHS Information Governance Framework mandates the appointment of two senior roles, typically at Board or Governing Body level within each NHS organisation. These roles are the Caldicott Guardian (GC) and the Senior Information Risk Officer (SIRO). 3. Executive Summary 3.1 National Developments As of 1st January 2017, responsibility for the management of recording all new user access requests to the NHS Digital Bowel Cancer Screening System (BCSS) was transferred to the Trust’s Senior Information Risk Officer and is therefore not captured within this report. 3.2 Information Governance Framework The Trust has a comprehensive IG Framework in place and responsibilities for the CG continues to be shared jointly by the Chief Medical Officer / Deputy Chief Executive Officer and the Director of Quality. The Senior Information Risk Officer is the Chief Operating Officer.

The Director of Corporate Affairs is responsible for Subject Access Requests and Freedom of Information requests and also Chair’s the Information Governance (IG) Committee. The Head of IG leads a team of IG specialists and liaises directly with the Information Commissioner's Office in relation to IG breaches. 3.3 Key Achievements during 2017/18 3.3.1 Outward Patient Information Flow

A formal log of CG requests is maintained within the Trust which captures and demonstrates the approval and non-approval of the different categories of outward flow of patient information to ensure such information is adequately protected. A total of 32 applications were submitted in 2017/18 and all were approved.

3.3.2 Caldicott Guardian Manual – Checklist The Trust has reviewed its self-assessment of the CG Checklist and plans to improve compliance with this are laid out in the following section.

3.4 Plans for 2018/19 Following assessment against the CG Checklist intentions for the next financial year include: • Improve internet page content by adding the other Caldicott Guardian – Director of

Quality. Enhancements to be made to intranet for better staff access to this information.

• Quarterly testing of switchboard to ensure CG details are consistently accessible across the organisation.

• Scheduling of biannual meetings for CG with SIRO & Head of IG to gauge the organisation’s IG maturity, support joint working and discuss expectations.

• Initiate a discussion for further assurance that CG related issues from internal audit are reported to the Caldicott Guardians, and to consider any CG related audits required.

• Review changes between Caldicott2 and Caldicott3 to ensure an adequate action plan is in place.

• Head of IG to assess for any CG aspects of the EU General Data Protection Regulation when live in May 2018

4. Areas of Risk

Failure to comply with Caldicott principles and guidance could result in regulatory and reputation damage. A risk has been added to the Quality Department Risk register to capture the above actions. 5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks N/A

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6. Governance Progress against the Caldicott Guardian actions are monitored via the Quality Department and the Information Governance Committee. The Annual Caldicott Guardians report was presented in full to the Information Governance Committee on 8th March 2018. 7. Responsibility The Associate Director Quality Patient Safety & Risk is responsible on behalf of the Director of Quality & Chief Medical Officer for implementing the actions described in this paper. 8. Recommendations Trust Board is asked to note the work undertaken to date and the plans for 2018/19. Name and Title of Author: Jenny Gardiner, Director of Quality & Meghana Pandit, CMO – Caldicott Guardians Date: 14th March 2018

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Title Electronic Patient Record ( EPR) Programme Update

Author Robyn Tolley, EPR Programme Director

Responsible Director Nina Fraser, Chief Nursing Officer

Date 29 March 2018

1. Purpose

This paper is being presented to update the board on the status of the EPR Programme with respect to the preparation of the business case that supports the investment required to deploy a world class Electronic Patient Record across the Trust.

2. Background and Links to Previous Papers

• The Trust Board approved the EPR Programme team to enter a procurement process for an EPR that started on the 30th November 2017 and is due to complete at the end of May 2018.

• The EPR Programme is aiming to start deployment of the chosen EPR solution on 1st September 2018 with an intended go live within the first quarter of 2020.

• The Trust has a requirement to move at pace, with both the procurement and deployment process, as there are a number of existing software solutions in use that are nearing, or are at the end of their life.

• The original business case created in 2015 was designed for an all-encompassing EPR that was also the foundation for a wider Electronic Citizen Record (ECR) to be used across the STP. After discussion with NHSI permission was granted for the Trust to embark on a smaller scope EPR that would replace burning platforms and also allow the deployment of electronic prescribing.

3. Executive Summary

Procurement Update

The OJEU notice was published on the 30th November 2018 and seven suppliers submitted a selection questionnaire. The seven submissions were scored and three suppliers, Allscripts, Cerner and Epic, were selected to progress to the next stage and complete the full tender documentation.

Cerner have withdrawn from the procurement for reasons unknown. We will debrief with them formally at the end of the process.

At the time of writing Allscripts had completed their demonstration scenarios to a wide selection of Trust colleagues. Epic are due to go through their product demonstration on the 20th and 21st March.

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The two remaining suppliers will commence negotiations with the Trust on the 22nd March and we are aiming to select a preferred supplier by the end of May 2018.

Business Case Update

The EPR business case that supports the new reduced scope, as instructed by NHSI, is currently being developed. We have taken a cautious approach to the realisation of cash releasing benefits and have also taken into consideration the cash realised from switching off legacy systems as a result of deploying a new EPR solution.

The cash releasing benefits have been identified in many areas across the trust and have been signed of as achievable by the respective departmental or group managers.

As a result of the current stage of the procurement the costs involved with deploying the EPR are now becoming more visible. As it currently stands there is a gap between the overall costs of the new EPR solution and the business case to support the investment. The EPR Team is therefore focusing on ensuring that all costs associated with the EPR solution & its implementation are minimized but are realistic and deliver a fit for purpose solution.

There are a number of areas we are looking at with respect to managing the supplier costs. As we are in a negotiated procurement process with our suppliers we have the ability to discuss a number of areas that will allow us to close this gap. We are exploring the payment terms with our supplier including the possibility of smoothing payments over the contract term and deferring payments for software licences and services.

Whilst the scope of the solution is limited to PAS, Maternity, Renal, and e-Prescribing, both suppliers have included value add components that maybe adding out of scope cost. The Programme team are working through these value add components to ensure that their inclusion will derive tangible benefit.

The team is also investigating how we might be able to manage the deployment timelines in a more robust manner to reduce the supplier involvement, and ways in which the Trust can limit its own deployment costs.

The deployment of an EPR does not give rise to matched cost and benefits, with a requirement to invest heavily in the first two years in order that the benefits can be realised through the adoption of the system in the later years. This is primarily linked to the initial costs of the Trust releasing both clinical and operational staff to work with the software supplier to design, build and test the new solution. We are exploring ways in which these costs can be minimised through the use of secondments, backfill arrangements, and re–purposing existing staff.

Due to the shortage of capital funding within the NHS, the Trust needs to find a way to limit the loan requirement from NHSI arising from the implementation phase. Discussions are ongoing with NHSI and we are actively engaging with them with respect to the business case sign off process, and the subsequent loan application. Due to the very tight timelines required to enter into a contract with our preferred supplier we have agreed to share our draft business case options to NHSI prior to the completion of the full business case. In addition we are trying to gain approval to move forward with a combined OBC/FBC submission. This will allow NHSI to hopefully shorten the time required for approval following submission of the full business case in July 2018.

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The current plan is to submit to the Trust Board in April a draft business case that will identify the full cost and affordability envelopes.

The procurement timeline is attached as appendix A

4. Areas of Risk

If the Trust cannot move forward with an EPR solution it will have to consider its options with respect to the systems that are currently nearing or are at end of life. The business case does identify some of these options.

5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks

The Trust is committed to becoming world class and the EPR Programme is a fundamental corner stone to this strategy.

6. Governance

The diagram below represents the governance structure in place for the EPR Programme

7. Responsibility

The EPR Programme Director is responsible for the delivery of the Programme and reports to the Chief Nursing officer as the SRO of the Programme.

8. Recommendations

The Board is invited to note:

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The progress being made on the development of the business case to support the deployment of the EPR solution across the Trust

Name and Title of Author: Robyn Tolley EPR Programme Director

Date: 15th March 2018

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EPR Procurement Key Decision Dates

Key MilestonesPapers

due FebruaryPapers

due March April May JuneITN Submission 19th Strategy Unit - FBC overview 21st 28th EPR Programme Board 1st / 2nd Strategy Unit 7th 14thTrust Board - Business Case Update 19th 29thNHS I Engagement starts 1st Negotiation stageFinal Evaluation 24th - 31stPreferred Bidder 1stEPR Programme Board - approval of Final Bidder 5thStrategy Unit approval 13thStrategic Trust Board - approve Full Business Case 28thExternal Approval starts 29th

10th April - 9th May

EPR Demonstration Conference Facility Costs

Venue Cost Per Person x 50 Delegates Total Cost Comments

Double Tree Hilton - Wasgrave Coventry £35pp inc VAT 1,750£ 10,500£ Day Delegrate Rate (room hire, refreshments & lunch)

Warwick University - Scarman House £48 + VAT 2,400£ 14,400£ Day Delegrate Rate (room hire, refreshments & lunch)

Coventry University - Techno Centre £33 + VAT 1,650£ 9,900£ Day Delegrate Rate (room hire, refreshments & lunch)


Title 2018-2021 Strategy Author Susan Rollason, Chief Financial and Strategy Officer Responsible Director

Susan Rollason, Chief Financial and Strategy Officer

Date 29 March 2018 1. Purpose The 2018-2021 is presented to Board for approval.

2. Background and Links to Previous Papers The strategy was discussed at the Board away day on the 21st December. It builds upon the existing strategy and includes six refreshed strategic objectives.

3. Executive Summary The strategy takes full account of the context within which we operate and has two key pillars. Firstly, the empowerment of our staff through UHCWi, and secondly the need to vertically and horizontally integrate pathways to manage local demand growth and ensure sustainable specialised services.

3.1. Context

3.1.1. Growing demand Coventry is the fastest growing population outside London and the South East. It is a multi-national population with areas of significant deprivation and a growing student population from the two Universities of Coventry and Warwick. Whilst Warwickshire growth predictions are less steep there are significant housing development plans and there is a high proportion of elderly people in some areas. In addition people are living longer with multiple long term conditions that require greater support.

3.1.2. Specialised services As a large teaching trust, we are commissioned to provide a number of specialised services to our main populations of Coventry, Warwickshire and beyond. The nature of these services means that patient numbers are small and national service specifications often require populations greater than the local health system. This is to ensure sufficient numbers of patients are treated to optimise outcomes. Services are therefore being concentrated in fewer numbers of Trusts and thus it is important that there is sufficient population size and capacity to retain and develop specialist services

3.1.3. UHCWi UHCWi is the methodology by which the Trust will improve patient safety and experience by eliminating waste from our processes. This has arisen out of our partnership with the Virginia Mason Institute

The strategy gives a clear message for the organisation and is underpinned by each of the clinical group strategies and enabling strategies. There has been a period of engagement across the Trust at all levels culminating in a series of Chief Officer sessions open to all Trust staff.

3.2. Strategic objectives

There are six underpinning strategic objectives:

• deliver the safest care and excellence in patient experience • be a model employer • be a leader in operational performance • lead the integration of care pathways for the populations we serve • be a front runner in research, innovation and education • achieve financial sustainability

Once the strategy has been approved the enabling strategies which support these objectives will be finalised, along with the annual goals. 4. Areas of Risk Once approved the BAF will link to the strategic objectives. 5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks Approval of the strategy will set the Trust’s strategic objectives for the next three years. 6. Governance The strategy will provide the framework through which the operation of the Trust will take place and as such is a key part of the governance framework. 7. Responsibility Susan Rollason, Chief Finance and Strategy Officer 8. Recommendations These need to clearly state what you are asking the Board to consider e.g. The Board is invited to APPROVE the Trust’s strategy. Name and Title of Author: Susan Rollason, Chief Finance and Strategy Officer Date: 29 March 2018

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OUR STRATEGY TO DELIVER WORLD CLASS HEALTH CARE

Version Content Date Draft v1 Based on Trust Board sessions – October 2017 & December 2017

Strategy Unit – January 2018 23/02/2018

Draft v2 Revised in line with SU 28.02.17 02/02/2018 Draft v3 Revised following meeting with chief officers and non-executive

directors 20/03/2018

ORGANISATIONAL STRATEGY 2018 - 2021

UHCW NHS Trust Organisational Strategy 2018-2021

Contents Page

Our Vision, Mission and Values 1

Our strategy 2

Our strategy triangle 6


Our Vision, Mission and Values Patients First We will put patients first in everything we do, every decision we make, every process we design and re-design. This is reflected in our vision, mission and values. Our Vision is to be a National and International Leader in Healthcare We will ensure that all our patients receive the very best care possible and so our ambition is to provide care that compares with the best, not only in the UK but also with the rest of the world. Our Mission is to Care, Achieve and Innovate Our focus is on providing and improving quality of care which includes patient experience, safety and outcomes. At the same time embracing innovation to deliver enhanced productivity and improved services. As such our mission is to Care, Achieve and Innovate Our Values Our values reflect what is important to us and have been developed by staff to reflect the culture we want to live. We will use our UHCW improvement [UHCWi] methodology described in our strategy below to deliver our values. Information about the Trust – who we are and what we do - is available at https://www.uhcw.nhs.uk

Pride

We take pride in all we do and aspire to do.

Compassion

We treat everyone with courtesy and compassion.

Partnership

We work in partnership to deliver and improve

the services we provide for our patients.

Openness

We act with openness, honesty and integrity in

all we do.

Respect

We treat everyone with respect and dignity.

Improve

We are open to change and seek to innovate to

improve what we do.

Learn

We see education,

research and learning as central to improvement.

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Our Strategy Our strategic solutions respond to and are consistent with the national ‘Five Year Forward View’, the local Coventry and Warwickshire ‘System Transformation Plans’ and our internal UHCW challenges – see Appendix 1 for more information. Our vision, mission and values remain. We are committed to putting patients first in everything we do. Our strategy to achieving our vision, mission and values is threefold. Namely it is about empowering our staff, integrating our services and building strong foundations. Empowering Our Staff We will empower our staff to ensure that patients are put first. We will achieve this through the implementation and spread of our improvement methodology, known as UHCWi. The approach supports staff to use advanced lean methodology which not only improves patient care, it also helps reduce waste. This will ensure that on a day to day basis we are making best use of the resources available. In addition to UHCWi, we will invest in our staff through our Leadership Programme, skills and mandatory training. Integrating Our Services We will work with our partners to rapidly integrate our care pathways to deliver the best patient care. We will integrate ‘vertically’ with primary care, community health and social care providers to help people stay well and reduce demand. Where care is needed, we will develop new models of care, outside of hospital, that will improve both quality and efficiency. By reducing and managing demand outside of hospital, we will improve waiting times for our acute and specialist services. We will further improve waiting times by separating planned and unplanned care as much as possible. We will increase the use of our site at Rugby St Cross for less complex, planned care, We will also maintain and develop the services we provide at other sites such as George Eliot Hospital and Warwick Hospital. We will maintain and develop our specialist services by expanding the populations covered to ensure that we meet national standards for population size. We will build on our partnership with Worcester Acute Hospitals NHS Trust to include cancer renal, respiratory and cardiothoracic. We will also build partnerships with providers outside our network. This will provide a population base of circa 2m. University Hospital site will be used for emergency and specialist activity that requires the particular expertise and facilities available but, where appropriate, specialist services will be provided locally.

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Trust Strategy [2018-2021]

Strategic Objectives We have identified the following strategic objectives to help assess whether we are delivering our strategy. These are to:

• deliver the safest care and excellence in patient experience • be a model employer • be a leader in operational performance • lead the integration of care pathways for the populations we serve • be a front runner in research, innovation and education • achieve financial sustainability

Performance against the objectives will be monitored through the performance framework. We will give additional assurance by regular updates to Strategy Unit and Trust Board. Delivery We will use our annual planning process to review and agree our annual goals. Details of specific service strategies that are developed through ‘Specialty Strategies on a Page’ for all Groups will be translated into annual plans. Individual roles and responsibilities will be identified and monitored through the Individual Performance Review process. Establishing Strong Foundations We recognise that the staff and service elements described above need strong foundations. The foundations will include enabling strategies as summarised in the diagram below

Organisational Strategy

Organisational development & workforce

capacity/ redesign

Research & innovation

with academic & industry partners

Quality for patient

safety, experience &

outcomes

Digital & mobile

technology health sector

leaders

Estates & facilities capacity, quality &

sustainability

Finance Productive &

efficient use of resources

Specialty Strategies ‘on a

page’ (various)

Specialty Strategies ‘on a

page; (various)

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OUR STRATEGY TRIANGLE

Empowered Staff Integrated services

Our Objectives

Page | 4


Title Together Towards World Class Programme Update Author Michelle Brookhouse, Associate Director of Workforce Responsible Chief Officer

Karen Martin, Chief Workforce and Information Officer

Date 29th March 2018 1. Purpose To inform the Board of progress of the Together Towards World Class programme. 2. Background and Links to Previous Papers Together Towards World Class (TTWC) was launched in March 2014 and has provided the focus for our organisational development programme at UHCW. The programme has been successful and has supported a range of projects through the work streams (World Class Experience, Services, Conversations, Leadership and People). The Board has previously received update reports every 6 months, the last one being September 2017. In 2015 we began our journey as one of the 5 NHS Virginia Mason trusts and have since adopted the improvement methodology, now known as the UHCW Improvement System (UHCWi). TTWC provides the overarching direction for the organisation in the transformation of our culture; recognising the important role that UHCWi plays within this. The success of the organisation in improving the healthcare we provide to our patients and for increasing the level of involvement, engagement and satisfaction of our staff lies with the effectiveness of the TTWC programme. 3. TTWC Projects Some of our highlights of work under the TTWC umbrella include: Over 1000 staff completing the Brilliant Basics programme in customer care. This

is now included in Trust Induction for all our new starters. Launch of our new Trust website in January 2018. A flagship leadership development programme, Leading Together, established

with our delivery partners NHS Elect. Over 500 leaders have already participated. Alignment of Leading Together with UHCWi for Leaders through the development

of the UHCWi masterclass. Introduction of our trust values, developed through engagement with staff Values based appraisal process including talent conversations. Values based induction

Staff health and wellbeing programme and the award of the Workplace Wellbeing Charter.

Developed the role of the Change Maker Introduced a range of recognition schemes, including appreciation cards, World

Class Colleagues and OSCAs. During the autumn the TTWC Board reviewed the projects under the TTWC programme and agreed those we would support through to March 2019. A list of projects against each work stream is provided below, with a brief status against each one. World Class Experience: Ref: Project Name Notes 2016/17 5.1 Introduction of the ‘How May I

Help you’ Bedside Folders Communication Booklet

Completed - Booklets received and distributed

2016/17 5.8 Delivering the Brilliant Basics Completed – L&D co-ordinating future delivery with inhouse trainers. Embedded in Trust Induction for new starters.

2017/19 9.0 Patient Experience Dashboard Phase one launched , phase 2 on schedule

2017/19 10.0

You said, we did Draft posters - developed, proof to be shared and consulted on with nurses, along with branded post boxes

2017/19 11.0

Engagement (working with Services)

Completed - Involvement Hub officially opened by Andy Hardy on the 12th March

One of the key aims of UHCWi is patient experience, putting patients first and looking at value from a patient perspective.

World Class Services: Ref: Project Name Notes 2016/17 1.47

Collaboration tools Due to start April 2018. Business Case under development

2017/19 3.0 Creation of Innovation Blueprint methodology

Working with Warwick and Coventry universities in AI, including telehealth.

2017/19 4.0 Project Management Portal Working with iNexus. Plan being developed for roll out, initial meeting scheduled 11 April.

2017/19 5.0 Development of Innovation Hub Business case signed off for changes to environment.

The UHCW Improvement system aligns with Innovation in the Innovation Hub developing the continuum of improvement ideas from incremental ‘baby step’ service improvement to the innovative ideas that create a step improvement.

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World Class Leadership: Ref: Project Name Notes 2016/17 3.1 Day in the Life of Programme Ongoing. Dates for 2018 currently

being arranged 2016/17 3.8 Leading Together Business case for phase 4

approved 30 January. Recruitment of additional 300 leaders to the programme underway. Warwick University evaluation results received; report going to COG on 17 April then schedule of presentations to organisations to be agreed.

2016/17 3.9 Talent Management Moderation of talent ratings reported to COG in December 2017. Succession planning and Preparation for 2018 appraisal cycle underway.

2017.19 12.0

Scope leadership offer for aspiring leaders

Due to start April 2018

2017/19 13.0

Leadership Conference, alumni events and networking

Following meeting with executive sponsor, we are developing a paper to COG on 17 April to consider our wider leadership offer, Thought Leadership events, etc.

2017/19 14.0

New manager/leader ‘induction’ Manager’s toolkit/checklist in development. To be launched in April 2018

2017/19 15.0

Take a Coach Approach Coaching Conversations masterclass established. Good feedback to date with participants indicating an improved coaching style as a result. Access to formal inhouse coaching in progress.

The UHCWi for Leaders trains staff to know, run and improve their service, using daily management and a coaching approach.

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World Class People (inc. World Class Conversations): Ref: Project Name Notes 2016/17 2.12

Values Based Recruitment Established. Pilot for inclusion in consultant recruitment commenced.

2017/18 16.0

Improving how we promote opportunities for development

Due to start April 2018 – Aim is to make it easier for staff to identify what development opportunities we offer across the Trust and have all the information in one place.

2017/19 17.0

Career Development Framework

Due to start April 2018

2017/19 18.0

Improve access for staff to provide feedback and see outcomes

Issue of engagement bulletin (Involving You). Appointment of Employee Engagement Officer. Pilot of “Anytime Impressions” launched in March.

2017/19 19.0

Health & Wellbeing Strategy Successfully achieved The Workplace Wellbeing Charter in November 2017. Strategy to be completed by end March 2018.

2017/19 6.0 More user-friendly information New website. Further work to be developed

2017/19 7.0 Trust website Completed – launched 29 January.

The UHCW Improvement System is about empowering staff, recognising that the staff who do the work know how to improve the service. We have also simplified its messaging so staff can easily understand what the method is and how it relates to the improvement and culture of our hospitals.

4. Staff Engagement and Promotion of TTWC This is our key strand of work for 2018 as we recognise engagement of our staff is crucial to the success of TTWC, UHCWi and our overall transformation agenda through culture shift. The recent results from the 2017 National Staff Survey show a slight decline in our engagement score to 3.82 (3.83 in 2016) although this is still above the national average for acute trusts. We appointed an Employee Engagement Officer in October 2018 and are currently reviewing how we resource this area of work given the focus and priority 4.1 TTWC @ Stand-up Since September we have presented updates of TTWC projects at the Tuesday morning stand ups alongside the Value Stream and UHCWi for Leaders updates. To date the following projects have been showcased:

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26 September World Class People - Trust Values 10 October World Class People – Recruitment 24 October World Class Leadership – Talent Management 21 November World Class People – Health & Wellbeing 9 January World Class Experience – Brilliant basics 30 January World Class Conversations – New Website

Future presentations will showcase the Change Maker role and our Leading Together participants and the impact of being on the programme. 4.2 TTWC and UHCWi Roadshows Following the success of our summer roadshows, Chief Officers, supported by the KPO and OD teams, continue their engagement with staff on the front line through the roadshows. Recently the roadshow visited:

Date Time Location Chief Offier Monday 6th November 2017

20:00 – 20:30pm CSSD (staff room)

Karen Martin

Wednesday 15th November 2017

20:00 – 20:30pm Ward 10 (staff room)

Andy Hardy


23:30 – 21:00pm Ward 11 (Staff room)

Andy Hardy


21:00 – 21:30pm Theatres (staff room

Andy Hardy


10:30 – 11:00am Emergency Department

David Eltringham

Monday 4th December 22:00 – 23:00pm Ground floor wards starting from Ward 1

Andy Hardy

Monday 12th February 2018

22:00 – 23:00pm 3rd floor wards starting from Ward 30

Andy Hardy

5. Areas of Risk

Each workstream completes risk assessments as part of its project management process. The overarching risk themes with regard to programme delivery and outcomes for 2017/18 are: (1) Key to the overall programme succeeding is wholescale adoption and demonstration

of the Trust’s Values and Behaviours, this requires changing hearts and minds and is not a quick process and requires continual focus. This has been a focus under the World Class People workstream with work to support the embedding of values and behaviours at all levels of the organisation.

(2) Capacity restraints within clinical and operational teams to participate in improvement work, whilst delivering against corporate objectives.

(3) Capacity restraints within the workstream leads will restrict the scope and scale of work that can be delivered.

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(4) Staff engagement, understanding and awareness of TTWC and UHCWi. 6. Link to Trust Objectives and Corporate/Board Assurance Framework Risks TTWC provides the overarching direction for the organisation in the transformation of our culture through increasing the level of involvement, engagement and satisfaction of our staff. It contributes to our objective of being an employer of choice and is a driver for achieving our vision of being a world class healthcare provider. Risk 2770 - Lack of staff engagement leading to inability to achieve cultural shift and improved performance is currently part of the Workforce Risk Register and is managed through the Trust’s Workforce and Engagement Committee who reports through to the Trust’s Quality Governance Committee. 7. Governance The Together Towards World Class Programme has been overseen by the dedicated programme board, which is chaired by the Chief Executive Officer and includes the Chairman as a Non-Executive Director representative, ensuring oversight through to Trust Board. In order to build on the success of TTWC we agreed to refocus so that our OD programme becomes the way of doing things rather than being purely project focussed. As a result, an agreement was reached at the November Programme Board to stand down the Board and align reporting with UHCWi through the Trust Guiding Team (TGT). We will work to move to the next stage and develop TGT to suit the priorities of the organisation. 8. The Future – Development of our Organisational Development Strategy Improving staff engagement is a high priority for the organisation; a refresh of TTWC through the development of an OD strategy will provide opportunity for co-creation with key stakeholders, including staff, thereby achieving greater buy in to help transform the culture. Organisational development should align strategy, processes and people in order to transform culture. The UHCWi system will continue to be an integral part of this work as it progresses. Our intended direction over the coming months is to find ways of bringing all of this work together (TTWC, UHCWi and Transformation) to facilitate alignment of work and resources for the biggest impact. Work on the OD strategy has commenced in alignment with the development of the overall trust strategy, with a view to it being finalised once we have agreed the trust strategy.

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9. Responsibility The Chief Executive Officer has overall ownership of the programme. The Trust Board will receive a bi-monthly up-date on the programme progress and outcomes. 10. Recommendations This report has been submitted for noting, provide reassurance on the current status of the programme and information on our future plans. Michelle Brookhouse, Associate Director of Workforce 14 March 2018

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Title Developing a Maggie’s Centre at the University Hospital Coventry site

Author Helen West Deputy Associate Director: Cancer / Carole Bailey Macmillan Lead Cancer Nurse

Responsible Director

Lisa Kelly, Chief Operating Officer

Date 29th March 2018 1. Purpose To update the Trust Board on the Maggie’s proposal to build a Centre on the University Hospital site. A business case was approved by Planning Unit and a paper presented to Board in 2014; however delays occurred due to Maggie’s busy national development plan. 2. Background and Links to Previous Papers A growing body of clinical research and government policy has been issued in relation to the benefits of timely access to comprehensive psycho-social services for anyone affected by cancer, including:

• Living with and beyond cancer: Taking action to improve outcomes. NCSI, DoH (2013)

• National Cancer Survivorship Initiative, DoH (2010) • Cancer Reform Strategy (2008) • Guidance for Improving Supportive and Palliative Care for Adults with Cancer

(2004) Maggie’s offers a comprehensive range of support services, that work to complement the clinical care and support services provided at UHCW, and which support local improved survivorship support via:

• New services to promote faster and more comprehensive recovery. • Fewer patients requiring routine face to-face follow-up. • More patients supported in caring for themselves, with effective monitoring and

surveillance systems in place. • Better ambulatory care assessment and management of patients when they

develop problems. Papers concerning the Maggie’s development were previously presented at;

• Planning Unit - August 2014 • Trust Board - September 2014 • Chief Officers - September 2014 • Maggie’s Board – 12th March 2018, Architect approached

All meetings fully supported the case to develop a Maggie’s Coventry. 3. Executive Summary Maggie’s Centre’s are designed to be warm and welcoming and full of light and open space, and are designed by leading Architects to be uplifting places for people with cancer and their families and friends. Each Architect offers a unique interpretation of the same brief, based on the needs of a person living with cancer, to create the calm environments so important to the people who visit and work in the Centre’s. Maggie’s offers free practical, emotional and social support to people with cancer and their families and friends. Built in the grounds of NHS cancer hospitals, Maggie’s Centres are places with professional staff on hand to offer support and advice, including Cancer Support Specialists, Benefits Advisors, Nutritionists and Psychologists according to individual needs. Maggie’s at UHCW will serve the whole referral area, but specifically those being treated for cancer at UHCW and surrounding hospitals. Maggie’s are currently working with Haven in Worcester on a pilot to provide services for patients, carers, family members and friends and therefore patients form that area will be able to access Maggie’ on UHCW site and also maybe closer to home. The team at Maggie’s will comprise:

• Centre Head (usually a senior cancer nurse or clinical psychologist) • A clinical psychologist • A cancer Information Specialist (a trained cancer nurse of therapeutic

radiographer) • Welfare benefits advisor • Sessional staff including: Relaxation specialist, Art Therapist, Creative writer, yoga

teacher and Tai Chi. The Maggie’s team will assess the supportive needs of everyone who comes into Maggie’s, creating an individually tailored programme for each person which complements the clinical care provided at UHCW, for those on active treatment, and will be a source of on-going support for those who have finished treatment and are adjusting back to ‘normal’ life. Maggie’s is generally open from 9am-5pm, but will open in the evenings to be as accessible for family members (visiting in-patients) and carers (who may work during the day) and for those patients post-treatment who are back in work. It is predicted that Maggie’s UHCW will record up to 7,000 visits per annum in its first few years of operation, increasing to 10-12,000 visits per annum by the time the centre is 5 years old. It is anticipated that Maggie’s UHCW will support at least 40% of the newly diagnosed cancer population by the time the centre is full established. Maggie’s will provide a useful venue for staff training and or meetings for clinical teams at the beginning and end of the day, or at weekends.

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Maggie’s UHCW will physically be a ‘haven’ away from the clinical environment, giving everyone who uses it the opportunity to address the issues that are really bothering them and the ability to learn new skills to be able to cope better with the impact of cancer. 4. Areas of Risk Appropriate location is not yet identified on the UHCW site – previous discussions have confirmed a range of potential locations, however Maggie’s Property Director, Sarah Beard Business Development Director and the newly appointed Architect will be visiting the Trust on 22nd March to do a site walk with Lincoln Dawkins and a representative from the Cancer Team.

Potential delays as the project originally started 4 years ago. The Cancer Team has discussed with the Business Development Manager who is confident that Maggie’s can and will deliver from now on. Their inability to deliver up to now has been linked to the number of live projects they have been managing, but now that they have the following centres open:

• Maggie’s Barts (Opened Dec 17) • Maggie’s Oldham (opened June 2017) • Maggie’s Forth Valley (opened March 2017)

In addition, they now have the following centres under construction:

• Maggie’s Leeds (construction commenced in Feb 2018) • Maggie’s Cardiff (construction to commence on March 12th 2018) • Maggie’s Royal Marsden (construction to commence in April 2018)

All of these projects came to fruition around the same kind of time and therefore priority and focus has now formally moved to their next phases of growth – they plan to deliver a further ten centres in the next 5 years. The first 3 campaigns that will be delivered are:

• Maggie’s Northampton (design complete and fundraiser appointed) • Maggie’s Taunton (design complete and fundraiser appointed) • Maggie’s Coventry

The implementation plan for Maggie’s Coventry is as follows:

• Proposal for Maggie’s’ Coventry formally approved by Maggie’s Board – March 12th 2018 and Jamie Fobert Architect will be approached to design the building.

• Project Outline approved by Board – Q2 2019 – (including Outline design for centre approved, Heads of Terms with hospital agreed and up to 10% funds raised)

• Delivery Strategy agreed - Q2 2020 – (including planning approval, budget confirmed, procurement strategy agreed and 50% of funds raised)

• Maggie’s Construction to begin – Q3 2021 (during city of culture year) this date is fundraising dependent

• Maggie’s Coventry operational Q3 2022.

5. Maggie’s fundraising campaign fails to deliver the anticipated £4.5 million - Maggie’s has successfully built 20 centres in the UK, the majority of which have been delivered through fundraising campaigns. Maggie’s will not commence the construction of the centre unless 90% of the fundraising campaign has been raised/pledged.

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6. Maggie’s fundraising campaign succeeds but after the initial 2 years of running

costs there are insufficient funds to continue the service- Maggie’s has been successfully operating for 22 years. Its fundraising strategy is robust and adapted to the local area. Maggie’s centres are sustained in areas of deprivation and affluence around the UK. To date, Maggie’s has never been unable to sustain the running of a centre. It is anticipated that Maggie’s Coventry will cost approximately £450,000 per annum to run. These costs are covered by voluntary contributions. Maggie’s will employ a centre fundraiser to co-ordinate fundraising activity throughout the region to support the centre.

7. UHCW/Maggie’s fail to agree peppercorn rent – this was an informal agreement at £1.00 per annum, which is included in the original business case

8. ISS/UHCW/Maggie’s fail to agree a mutually acceptable car parking policy –

Discussions to be held with Lincoln Dawkins to confirm expectations

Collaboration between UHCW charity and Maggie’s fails to agree communications and principles of donor management - Early confirmation of expectations from both parties. Maggie’s anticipates that there will be no impact on the Trust’s Charity income, as they tend to target high earning philanthropic individuals. According to Maggie’s there has never been a situation where a hospital has suffered reduced charitable income as a result.

9. Link to Trust Objectives and Corporate/Board Assurance Framework Risks

UHCW aims to provide patient centred care and this is reflected in the vision to provide world class health care and the mission to care, achieve and innovate. Cancer services are an integral part of the services provided by UHCW, not just to the local population but to a wider area to ensure a population size to comply with national standards. The integrated provision with Maggie’s centre will enhance and support the development of high quality, sustainable cancer services Participation in research is a Trust objective, Maggie’s offers ‘Science Cafes’ and other initiatives to inform people with cancer, their families and friends about research and potential future developments, raising awareness of research and enabling them to make the right choice for them’.

10. Governance A project group will be established to oversee the governance of the project, comprising of:

• Director of Estates • Lead Clinician • Cancer Team • Maggie’s representatives

11. Responsibility Helen West – Deputy Associate Director: Cancer Lisa Kelly – Chief Operating Officer

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8. Recommendations Due to the length of time since the paper was first discussed, the Trust Board is asked to note the current position and proposed development of a Maggie’s Centre on the University Hospital’s site in line with Maggie’s new Centre development strategy. Name and Title of Author: Helen West, Deputy Associate Director: Cancer / Carole Bailey Macmillan Lead Cancer Nurse Date: 29th March 2018

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Title Information Governance Toolkit annual submission 2017/18 – v14.1 Author Head of Information Governance Responsible Director

Chief Operating Officer

Date 29 March 2018 1. Purpose The purpose of this report is to inform Board members of the final scores that will be submitted for the Trust’s 2017/18 Information Governance Toolkit - version 14.1. The Information Governance (IG) Toolkit requires Trusts to submit their final scores by 31st March each year. The final scores will be published on the NHS Digital website and from there on will be in the public domain. 2. Background and Links to Previous Papers The IG Toolkit is a Department of Health (DH) policy delivery vehicle that is managed and administered by NHS Digital. The purpose of the IG Toolkit assessment is to enable organisations to measure their compliance against specific legislation and central guidance, and to ensure information is processed and handled correctly and protected from unauthorised access, loss, damage and destruction. 3. Executive Summary The table below shows the six areas of assessment of the IG Toolkit, with the attainment levels for each requirement and a comparison of the scores from 2016-2017. Last year, UHCW achieved its highest score ever on the Toolkit of 90% overall. The Trust has been able to maintain its scores on all but one requirement; the results of an external clinical coding audit are not available until the third week of March, so there is the possibility that 90% may still be achieved. The score for this year is currently 89% pending the results of the clinical coding audit. Requirement 112 always remains a challenge to the Trust; it states that 95% of all staff must complete competency based mandatory IG training annually between 1st April and 31st March. The mandatory training was revised this year to reflect the changes required by NHS Digital and Health Education England. The training is more in-depth and comprehensive and takes an hour to complete online, which has placed greater pressure on the Trust to achieve the 95% target. At the time of writing this report it is 93.08% and it is anticipated that the Trust will achieve the required 95% by 31st March 2017. The compliance rate for this target is monitored by the IG Unit on a daily basis during March to ensure that efforts are targeted at specific staff groups and outliers.

Information Governance Management

Assessment Level 1

Level 2

Level 3

Total Req'ts Score

Version 14.1 (2017-2018) 0 1 4 5 93% Version 14 (2016-2017) 0 1 4 5 93% Confidentiality and Data Protection Assurance

Assessment Level 1

Level 2

Level 3

Total Req'ts Score

Version 14.1 (2017-2018) 0 3 5 9 87% Version 14 (2016-2017) 0 3 5 9 87% Information Security Assurance

Assessment Level 1

Level 2

Level 3

Total Req'ts

Overall Score

Version 14.1 (2017-2018) 0 5 10 15 88% Version 14 (2016-2017) 0 5 10 15 88% Clinical Information Assurance

Assessment Level 1

Level 2

Level 3

Total Req'ts Score

Version 14.1 (2017-2018) 0 1 4 5 93% Version 14 (2016-2017) 0 1 4 5 93% Secondary Use Assurance

Assessment Level 1

Level 2

Level 3

Total Req'ts Score

Version 14.1 (2017-2018) 0 1 7 8 95% Version 14 (2016-2017) 0 0 8 8 100% Corporate Information Assurance

Assessment Level 1

Level 2

Level 3

Total Req'ts Score

Version 14.1 (2017-2018) 0 3 0 3 66% Version 14 (2016-2017) 0 3 0 3 66% Overall

Assessment Level 1

Level 2

Level 3

Total Req'ts

Overall Score

Version 14.1 (2017-2018) 0 14 30 45 89% Version 14 (2016-2017) 0 13 31 45 90%

4. Areas of Risk The IG Toolkit annual assessment is a requirement for provider organisations in the NHS England Standard Contract. The Trust must be able to demonstrate that it can be trusted to comply with all the rules regarding confidentiality and data protection and maintain information security. The Trust needs to attain level 2 or above on each of the IG Toolkit’s 45 requirements to achieve an overall ‘Satisfactory/Green’ rating. Failure to accomplish a satisfactory rating may have a financial impact on the Trust, as the IG Toolkit is the de facto standard for all NHS, social care, local authority, and private sector health organisations. It is the single measure of assurance for Information Governance.

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5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks Information Governance is a key performance measure for all NHS organisations. The IG Toolkit links to and cuts across all corporate objectives and assurance frameworks, because of our use and reliance on information. Having a robust Information Governance assurance framework in the organisation will aid the Trust for the challenges being faced by all UK of cyber security threats and the new General Data Protection Regulations coming into force from May 2018. 6. Governance The Trust’s performance on the IG Toolkit is validated by internal auditors (Coventry and Warwickshire Audit Services); an interim report was issued in November 2017, and a final report was issued during March 2018. CWAS audited the evidence for the requirements where we achieved attainment level 3 and for a sample of the requirements where attainment level 2 was achieved; in total 31 of the 45 requirements where reviewed. This report has been approved by the Chief Operating Officer and will be presented to the Audit Committee. 7. Responsibility The Head of Information Governance is the author of this report and is responsible for information governance in the organisation. The Head of Information Governance reports to the Director of Corporate Affairs, who is the chair of the Information Committee, is the Deputy SIRO, and reports directly to the Chief Executive. The Chief Operating Officer is the Senior Information Risk Owner (SIRO) and has board level accountability for Information Governance. 8. Recommendations The Board is asked:

i. To note the contents of this report. ii. To ratify the submission of the Information Governance Toolkit.

Name and Title of Author: Harjit Matharu – Head of Information Governance Date: 19 March 2018

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Title Board committee terms of reference Author Geoff Stokes, interim Director of Corporate Affairs Responsible Director

Andrew Meehan, Chairman

Date 29 March 2018 1. Purpose This paper presents the terms of reference for the four Board committees for approval. 2. Background and Links to Previous Papers The Board has two statutory committees (Remuneration and Audit Committees) and in addition also has two other committees (Finance and Performance Committee and Quality Governance Committee) All 4 committee terms of reference have been reviewed and are presented to the Board for approval. 3. Executive Summary Committee members have reviewed terms of reference for their committees, either at a committee meeting or virtually and comments received have been incorporated. The revised copies are attached for approval. There are no significant changes, as the amendments relate to updating job and committee titles and correcting some typographical errors. In presenting the terms of reference collectively, it enables the Board to assure itself that there is sufficient coverage to provide assurance to the Board in line with the Scheme of Delegation. 4. Areas of Risk

If terms of reference are not clear then there may be confusion about committee roles and responsibilities. If there is not a regular review of terms of reference then there is a risk that practice may become out of step with the terms of reference or committees may not fulfill the function required of them by the Board.

5. Link to Trust Objectives and Corporate/Board Assurance Framework Risks The committees provide assurance to the Board across the range of objectives, functions and areas of risk. 6. Governance Good practice suggests that terms of reference are reviewed on an annual basis. 7. Responsibility The Director of Corporate Governance ensures terms of reference are reviewed regularly on behalf of the Chairman, who is responsible for the effective running of the board. 8. Recommendations The Board is invited to approve the terms of reference of the following committees;

• Audit Committee • Finance and Performance Committee • Remuneration Committee • Quality Governance Committee

Name and Title of Author: Geoff Stokes, interim Director of Corporate Governance Date: 29 March 2018

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UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

QUALITY GOVERNANCE COMMITTEE TERMS OF REFERENCE

Constitution: The Board of Directors (“the Board) hereby resolves to establish a committee of the Board to be known as the Quality Governance Committee (“the Committee). The Committee of the Board has no executive powers other than those specifically delegated to it via these terms of reference. The Standing Orders adopted by the Trust Board are applicable to this Committee in as far as they are relevant.

Authority: The Committee is authorised by the Board to investigate any activity within its terms of reference and is authorised to seek any information that it requires from any member of staff. All members of staff are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain legal or other independent professional advice and to secure the attendance of others from outside of the Trust with relevant experience and expertise if it considers this necessary. Purpose of the Committee: The purpose of the Committee is to provide additional assurance to the Board that the Trust delivers high quality, safe services to patients. The Committee oversees and monitors the corporate delivery of patient safety, clinical effectiveness, patient experience, risk management, education and training, information governance and regulatory standards to ensure that the Trust has the appropriate strategies, processes, systems, policies, and procedures in place to deliver the necessary standards of care.

It acts as the principal source of advice and assurance to the Trust Board on patient safety, quality governance agenda and risk agenda. Membership and Quorum: Membership of the Committee will be appointed by the Board and shall consist of

Four Non-Executive Members, one of whom will appointed by the Board to be Chair and the following:

• Chief Medical and Quality Officer

• Chief Nursing Officer

• Chief Operating Officer

• Chief Workforce and Information Officer

In attendance: The following are required to be in attendance but do not count towards quorum:

• Director of Quality (or nominated deputy)

• Director of Corporate Affairs (or nominated deputy)

The following will normally be in attendance but do not count towards quorum:

January 2018 Page 1 of 4


• Trust Board Advisor

• Deputy Chief Medical Officer

• Deputy Chief Nursing Officer/Associate Director of Nursing

• Associate Directors of Quality

A quorum shall be 2 Non-Executive members, 2 Executive Members, one of which must be the Chief Medical & Quality Officer or Chief Nursing Officer. Deputies do not count towards a quorum.

In the absence of a quorum, meetings shall continue to be held and any decisions made will be ratified at the next quorate meeting of the Committee, in order for actions to be acted upon. Access: The Committee may invite authors of papers to attend the Committee from time to time to support the presentation of specific papers, as it considers necessary. Frequency: The Committee shall meet on a monthly basis. Reporting to the Board: The Chair of the Committee will report in writing to the Board at the Board meeting that follows the Committee meeting. This report will summarise the main issues of discussion and the Chair of the Committee will ensure that any attention is drawn to any issues that require Board or Executive action. The approved minutes of the meeting will be submitted to the private session of the Trust Board.

The Chair of the Committee will also provide assurance to the Audit Committee on an annual basis on the Committees processes and the work that it has undertaken through the provision of an annual report.

Sub-committees: The Committee will receive reports from its sub-committees that it formally establishes and any reports thereof that are deemed necessary to support the work of the Committee. The sub-committees are:

• Patient Safety Committee • Risk Committee • Patient Experience and Engagement Committee • Workforce and Engagement Committee • Training, Education and Research Committee • Information Governance Committee • Health and Safety Committee • Quality Governance Surveillance Committee

The Quality Governance Committee will, on an annual basis through its seven sub-committee's Annual Reports, obtain assurance that the further governance substructure of sub-committees actually meets, has a programme of work, and is effective.



Responsibilities: The Quality Governance Committee will have responsibility for the following:

1. Providing a forum for scrutiny of any of the Trust’s quality indicators or priorities at the request of the Board

2. Providing assurance to the Board that arrangements are in place for identifying, prioritising and managing risk and that risks are escalated to the Board as appropriate.

3. Promoting safety, quality and excellence in patient care

4. Ensuring the effective and efficient use of resources through the evidence-based clinical practice

5. Protecting the safety of employees and all others to whom the Trust owes a duty of care

6. Ensuring that effective systems and processes are in place to support high quality care through an effectual training and education and ICT infrastructure

7. Ensuring that the Health and Safety Committee has an overarching view of health and safety and provide assurance that non-clinical risks are effectively managed on behalf of the organisation.

The Committee will execute these responsibilities through the following:

Risk Management: 1. Monitoring the Risk Register and ensuring that risks are escalated to the

Board Assurance Framework, as appropriate

2. Ensuring that appropriate arrangements are in place in respect of Emergency Planning and Health & Safety

Quality Governance:

1. Undertaking in-depth reviews of the Quality Indicators reported to the Board at the request of the Board

2. Monitoring on-going compliance with Care Quality Commission Fundamental Standards and seek assurance that any areas of weakness are being addressed

3. Monitoring compliance against the Information Governance Toolkit to support the sign off of the submission document by the Board

4. Monitoring compliance against the Emergency Preparedness, Resilience and Response Core Standards

5. Receiving updates on an exception basis against the key strategies that are approved by the Committee and those that are approved by the Board where deemed appropriate, escalating to the Board as necessary

6. Receiving regular reports relating to progress against quality priorities and agreed quality related initiatives

7. Receiving internal inspection reports



Delegation: By approval of these terms of reference the Board delegates the following functions to the Committee:

• Ratification of Trust Policies that fall within the remit of the Committee and that are not reserved to the Trust Board, ensuring that due process has been followed

• Approval and monitoring of strategies that fall within the remit of the Committee as deemed appropriate by the Board as provided for in the Trust’s Standing Orders

• Monitoring progress against the actions set out in the Equality and Diversity Annual Report received and approved annually by the Board

• Scrutinising the draft annual Quality Account prior to submission to the Audit Committee and Trust Board for final approval

• Monitoring progress against the quality priorities set out in the Quality Account agreed by the Board

• Receive assurance from the Blood Transfusion Annual Report, including performance against local and national key performance indicators, escalating any issues to Board as appropriate, in accordance with the Medicines Healthcare Regulation Authority

The Committee is authorised to establish sub-committees to support its work subject to terms of reference that shall be approved by the Committee but shall not delegate the powers conferred upon it by these terms of reference to any other body without the express authorisation of the Board. Appraisal: The Committee will carry out an annual appraisal of its performance and will report this to the Audit Committee via an Annual Report. The content of the Annual Report to the Trust Board will be in keeping with the requirements of the Audit Committee Handbook Administration: The Director of Corporate Affairs will act as Committee Secretary and will agree the agenda with the Chair of the Committee, in conjunction with the Director of Quality. Review: These terms of reference will be reviewed in December 2017 unless there is a requirement to do so earlier.

Date of Quality Governance Committee Approval

15 January 2018

Date of Trust Board Approval

Version: v12 2018 Author: Geoff Stokes, interim Director of Corporate Affairs



FINANCE AND PERFORMANCE COMMITTEE TERMS OF REFERENCE

Constitution: The Board of Directors (“the Board”) hereby resolves to establish a committee of the Board to be known as the Finance and Performance Committee (“the Committee”). The Committee of the Board has no executive powers other than those specifically delegated to it via these terms of reference. The Standing Orders adopted by the Trust Board are applicable to the Committee in as far as they are relevant. Authority: The Committee is authorised by the Board to investigate any activity within its terms of reference and is authorised to seek any information that it requires from any member of staff. All members of staff are directed to co-operate with any request made by the committee. The Committee is authorised by the Board to obtain legal or other independent professional advice and to secure the attendance of others from outside of the Trust with relevant experience and expertise if it considers this necessary. Purpose of the Committee: The purpose of the Committee is to provide additional assurance to the Board in relation to all aspects of finance and performance. The Committee oversees and monitors performance against key financial and operational targets as well as reviewing the Trust’s financial management arrangements to ensure that the Trust has the appropriate strategies, processes, systems, policies and procedures in place to achieve operational performance and deliver the Financial Recovery Plan. Membership and Quorum: Membership of the Committee will be appointed by the Board and shall consist of three Non-Executive Members, one of whom will be appointed by the Board as Chair of the Committee, and the following:

• Chief Finance and Strategy Officer • Chief Operating Officer • Chief Workforce and Information Officer

In attendance: The following are required to be in attendance but do not count towards quorum:

• Director of Finance and Strategy • Associate Director of Finance, Corporate Services • Director of Corporate Affairs (or nominated deputy)

Finance and Performance Committee Terms of Reference January 2018 Page 1 of 4


A quorum shall be 2 Non Executive members and 2 Executive Members. Deputies will not count towards a quorum. In the absence of a quorum, meetings shall continue to be held, at the discretion of the Chair. Any decisions made will be ratified at the next quorate meeting of the Committee, to enable decisions to be enacted. Access: The Committee will invite authors of papers to attend the Committee from time to time to support the presentation of specific papers, as it considers necessary. Frequency: The Committee shall meet on a monthly basis with the exception of August when there is no meeting. Reporting to the Board: The Chair of the Committee will report in writing to the Board at the Board meeting that follows the Committee meeting. This report will summarise the main issues of discussion and the Chair of the Committee will ensure that any attention is drawn to any issues that require Board or Executive action. The approved minutes of the meeting will be submitted to the private session of the Trust Board. The Chair of the Committee will also provide assurance to the Audit Committee on an annual basis on the Committees processes and the work that it has undertaken through the provision of an annual report. Sub-committees: The Committee will receive reports from its sub-committees that it formally establishes and any reports thereof that are deemed necessary to support the work of the Committee. The sub-committees are: • Private Finance Initiative (PFI) Liaison Committee • Sustainability Development Management Group • Procurement Steering Committee The Committee will, on an annual basis through its three sub-committee's Annual Reports, obtain assurance that the further governance substructure of sub-committees actually meets, has a programme of work, and is effective. Responsibilities: The Finance and Performance Committee will have responsibility for the following:-

1. Monitoring monthly income and expenditure variance to provide assurance to the Board and escalate any emerging issues of concern



2. Monitoring delivery of key access targets and operational delivery plans to provide assurance to the Board and escalate any emerging issues of concern

3. Providing a forum for scrutiny of any of the Trust’s performance indicators at the request of the Board, referring any potential impact on quality to the Quality Governance Committee

4. Reviewing the performance management arrangements for each Group, scrutinising the arrangements in place to meet financial and operational targets

5. Reviewing the performance of Service Providers within the PFI contract

6. Providing effective oversight of all major capital and development projects including associated risks with the projects

7. Ensuring adequacy of the Trust’s Strategic Financial Planning

The Committee will execute these responsibilities through the following:-

1. Receiving regular reports from Chief Officers on key aspects of financial and operational delivery within an integrated reporting framework

2. Receiving briefings on the Trust’s financial planning and contracting arrangements

3. Receiving assurance that the Trust’s reference cost submission is in accordance with Monitor’s approved costing guidance

4. Evaluating business cases, undertaking post implementation reviews to seek assurance that anticipated benefits have been realised

5. Commissioning ‘deep dive’ analysis reports into areas of concern arising out of financial and operational performance including: activity and income, elective and emergency capacity, cash and liquidity, capital and PFI and a mid-year CIP review

6. Undertaking in-depth reviews of the finance and performance Indicators reported to the Board, as delegated by the Board

7. Evaluating performance against establishment and recruitment activity 8. Scrutinising benchmarking data against national targets for sickness

absence and use of agency staff 9. Receiving updates on an exception basis against the key strategies

that are approved by the Committee and those that are approved by the Board where deemed appropriate, escalating to the Board as necessary

Delegation: By approval of these terms of reference the Board delegates the following functions to the Committee:



• Ratification of Trust Policies that fall within the remit of the Committee and

that are not reserved to the Trust Board, ensuring that due process has been followed

• Approval and monitoring of strategies that fall within the remit of the Committee as deemed appropriate by the Board as provided for in the Trust’s Standing Orders

• Scrutinising the draft Corporate Annual Plan (including operational plans) Account prior to submission to the Trust Board for final approval

• Monitoring progress against the Procurement Transformation Plan to receive assurance of the Trust's delivery of the recommendations and targets detailed in the Lord Carter report on operational productivity and performance

• Monitoring progress against the Hospital Pharmacy Transformation Plan to receive assurance around performance against the Carter metrics and model hospital benchmarking

The Committee is authorised to establish sub-committees to support its work subject to terms of reference that shall be approved by the Committee but shall not delegate the powers conferred upon it by these terms of reference to any other body without the express authorisation of the Board. Appraisal: The Committee will carry out an annual appraisal of its performance and will report this to the Audit Committee via an Annual Report. The content of the Annual Report to the Trust Board will be in keeping with the requirements of the Audit Committee Handbook Administration: The Director of Corporate Affairs will act as Committee Secretary and will agree the agenda with the Chair of the Committee, in conjunction with the Chief Finance and Strategy Officer Review: These terms of reference will be reviewed in November 2017 unless there is a requirement to do so earlier. Date of Finance & Performance Committee Approval

7 January 2018

Date of Trust Board Approval Version: v10 January 2018 Author: Geoff Stokes, Interim Director of Corporate Affairs


UNIVERSITY HOSPITALS COVENTRY & WARWICKSHIRE NHS TRUST

AUDIT COMMITTEE TERMS OF REFERENCE

Constitution: The Board of Directors (“the Board”) hereby resolves to establish a standing committee of the Board to be known as the Audit Committee (“the Committee”). The Committee is a non-executive committee of the Board and has no executive powers other than those specifically delegated to it via these terms of reference. The Standing Orders adopted by the Trust Board are applicable to this Committee in as far as they are relevant. Authority: The Committee is authorised by the Board to investigate any activity within its terms of reference and is authorised to seek any information that it requires from any member of staff. All members of staff are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain legal or other independent professional advice and to secure the attendance of others from outside of the Trust with relevant experience and expertise if it considers this necessary. Purpose of the Committee: The purpose of the Committee is to focus upon establishing and ensuring the effectiveness of over-arching systems of integrated governance, risk management and internal control and to provide assurance to the Board thereon. The Committee will also act as the Auditor Panel for the Trust and operate under separate terms of reference. Membership & Quorum: Membership of the Committee will comprise four non-executive directors who will be appointed as committee members by the Trust Board. A quorum shall be two of the four non-executive directors. One of the members will be appointed as Chair of the Committee and another member will be appointed as vice chair by the Trust Board. The Chairman of the Trust Board shall not be a member of the Committee. The Chairs of the Quality Governance Committee and Finance & Performance Committees shall be members of the Committee to reflect the assurance function that these committees provide to the Audit Committee. Meeting dates will be agreed with committee members at the start of each calendar year. Members should make every effort to attend all meetings of the Committee but should maintain an 80% attendance level in order to ensure quoracy and consistency.

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In attendance: The following will be in regular attendance at Committee meetings unless the Chair of the Committee requests for them to be excluded.

• Chief Finance & Strategy Officer • Director of Corporate Affairs • Associate Director of Finance, Corporate Services • Representatives from the Trust’s external audit function • Representatives from the Trust’s internal audit function • The Trust’s Local Anti- Fraud Specialist (required to attend at least 2

meetings per year) • The Trust’s Local Security Services Manager (required to attend at least 2

meetings per year) The Chief Executive Officer shall attend on an annual basis to discuss the process that supports the Annual Governance Statement (AGS), the annual accounts and annual report. Other Chief Officers and senior members of staff will be invited to attend at the request of the Chair to discuss matters relating to their portfolio. Access: The Head of Internal Audit, representatives of external audit and the Trust’s Anti-Fraud Specialist and Local Security Management Specialist shall have a right of direct access to the Chair of the Committee. Members of the Committee will meet in private with the internal and external auditors at least once per year. Frequency: Five ordinary meetings of the Committee will be held per year and these will be scheduled in line with the business that the Committee is required to consider. One additional extraordinary meeting will take place to consider and approve the annual accounts and annual report each financial year. The Trust’s External Auditor or Head of Internal Audit may request a meeting if they consider this to be necessary. Reporting to the Board: The Chair of the Committee will report in writing to the Board at the Board meeting that follows the Committee meeting. This report will summarise the main issues of discussion and the Chair of the Committee will ensure that attention is drawn to any issues that require Board or Executive action or disclosure to the full Board.



The minutes of the meeting will be submitted to the private session of the Trust Board once approved by the Committee. Responsibilities: The Audit Committee will have responsibility for the following:

• Governance, risk management and internal control (in part, by overseeing the work of the Quality Governance Committee)

• Internal Audit • External Audit • Raising concerns • Anti-fraud • Other assurance functions • Financial reporting

Governance, Risk Management & Internal Control The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the spectrum of the Trust’s activities that supports the achievement of the Trust’s corporate objectives. In particular, the Committee will review the adequacy of:

• all risk and control related disclosure statements (in particular the Annual Governance Statement and declarations of compliance with the requirements for Care Quality Commission registration), together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to submission to the Board;

• The Board Assurance Framework process to ensure it identifies all key strategic risks that affect the Trust, that the controls in place are adequate and reasonable and that the Internal Audit Plan and Clinical Audit Plan remain appropriate in light of new and emerging risks.

• The underlying assurance processes that indicate the degree of the achievement of the corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements;

• The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and any related reporting and self-certifications;

• The policies and procedures for all work related to anti-fraud and security as required by the NHS Counter Fraud Authority, including approval and monitoring of the Anti-Fraud Annual Work Plan.

The Committee will primarily utilise the work of internal and external audit and other assurance functions to carry out these duties but will not be limited to these. Reports and assurances will also be sought from Chief Officers and other



managers as appropriate in relation to over-arching systems of integrated governance, risk management and internal control. In addition, the Committee will review the work of other Board committees within the Trust, whose work provides assurance to the Committee’s own scope of work. This will be achieved through the Chairs of the Quality Governance and Finance & Performance Committees being members of the Committee and the provision of an annual committee report detailing the effectiveness of the committee’s work. Finance and Performance and Quality Governance Committees both provide an annual assurance report to the Committee Internal Audit The Committee shall ensure that the Trust has an effective internal audit function that meets mandatory Public Sector Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Executive Officer and Board. This will be achieved by:

• Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal;

• Review and approval of the Internal Audit Annual Plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation as identified in the Assurance Framework;

• Approval of any proposed changes to the Internal Audit Annual Plan • Consideration of the major findings of internal audit work (and

management’s response), and ensuring co-ordination between the Internal and External Auditors to optimise audit resources;

• Ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the organisation;

• Monitoring the effectiveness of internal audit and carrying out an annual review.

Anti-Fraud The Audit Committee shall satisfy itself that the Trust has adequate arrangements in place for anti-fraud and security that meet the standards set by the NHS Counter Fraud Authority. This will be achieved by:

• Receiving reports and progress updates from the AFS in relation to anti-fraud

• Approval of the Fraud Policy drafted by the AFS. • Approval and monitoring of the AFS Annual Plan and approval of the

Annual Report



External Audit The Committee shall review and monitor the external auditors’ independence and objectivity and the effectiveness of the audit process. In particular, the Committee will review the work and findings of the External Auditor and consider the implications and management’s responses to their work. This will be achieved by:

• Consideration of the appointment and performance of the External Auditor, as far as the rules governing the appointment permit

• Discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in the Annual Plan.

• Discussion with External Auditors their evaluation of audit risks and assessment of the Trust and associated impact on the audit fee;

• Reviewing all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work carried outside the annual audit plan, together with the appropriateness of management responses.

• Ensuring that there is in place a clear policy for the engagement of external auditors to supply non-audit services

Other Assurance Functions The Audit Committee shall review the findings of other significant assurance functions, both internal and external to the Trust, and consider the implications to the governance of the Trust.

• These will include, but will not be limited to, any reviews by Department of Health Arms-Length Bodies or Regulators/Inspectors (e.g. Care Quality Commission, NHS Litigation Authority, etc.), professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges, accreditation bodies, etc.)

• In reviewing the work of the Quality Governance Committee the Audit Committee should satisfy itself on the assurance that can be gained from the Trust’s clinical audit function. This will be achieved through bi-annual submission of the Clinical Audit Plan to the Audit Committee to ensure its adequacy and to monitor that audits are taking place in line with the plan

• The Audit Committee may request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control

Financial Reporting The Audit Committee shall monitor the integrity of the financial statements of the Trust and any formal announcements relating to its financial performance.



The Committee should ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to the completeness and accuracy of the information provided. The Committee shall review the annual report and financial statements before submission to the Board, particularly focusing on:

• The wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the Committee

• Changes in, and compliance with, accounting policies and practices • Unadjusted mis-statements in the financial statements • Significant judgments in preparation of the financial statements • Letters of representation • Explanations for significant variances

The Committee will review and approve all losses and special payments. The Committee will review all instances where the Trust’s Standing Orders, Standing Financial Instructions and Scheme of Reservation and Delegation have been waived. The Committee will review all proposed changes to the Trust’s Standing Orders, Standing Financial Instructions and Scheme of Reservation and Delegation prior to submission to the Trust Board. Raising Concerns (Whistleblowing) The Committee shall review the effectiveness of the arrangements in place for allowing staff to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns are investigated proportionately and independently. This will be achieved through approval of the related Policies and monitoring of its usage. Delegation By approval of these terms of reference the Board delegates the following functions to the committee:

• Ratification of Trust Policies that fall within the remit of the committee and that are not reserved to the Trust Board

• Approval of the Internal Audit Annual Plan and any changes thereto • Approval of the Anti-Fraud Annual Work Plan and Annual Report

Appraisal The Committee will carry out an annual appraisal of its performance and will report this to the Trust Board via an Annual Report. The content of the Annual Report to the Trust Board will be in keeping with the requirements of the Audit Committee Handbook



Administration: The Director of Corporate Affairs will act as Committee Secretary and will agree the agenda with the Chair of the Committee. Review These terms of reference will be reviewed in annually unless there is a requirement to do so sooner. Date of Audit Committee Approval By email 20 March 2018 Date of Trust Board Approval Version: January 2018 Author: Geoff Stokes, Interim Director of Corporate Affairs


Enclosure 4 UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

REMUNERATION COMMITTEE TERMS OF REFERENCE

Constitution: The Board of Directors (“the Board”) hereby resolves to establish a committee of the Board to be known as the Remuneration Committee (“the Committee”). The Committee has no executive powers other than those specifically delegated to it via these terms of reference. The Standing Orders adopted by the Board are applicable to the Committee in as far as they are relevant. Authority: The Committee is authorised by the Board to investigate any activity within its terms of reference and is authorised to seek any information that it requires from any member of staff. All members of staff are directed to co-operate with any request made by the committee. The Committee is authorised by the Board to obtain legal or other independent professional advice and to secure the attendance of others from outside of the Trust with relevant experience and expertise if it considers this necessary. Purpose of the Committee: The purpose of the Committee is to determine the Trust policy on Chief Officer remuneration, and the specific remuneration packages of each Chief Officer, including compensation packages in the event of early termination. Membership and Quorum: Membership of the Committee will be appointed by the Board and shall consist of all the Non-Executive Directors. The committee will be chaired by the Chairman of the Board and the Vice Chairman of the Board will be Deputy Chair of the Committee.

In attendance: The following may be required to be in attendance but do not count towards quorum:

• Chief Executive Officer • Chief Workforce and Information Officer • Director of Corporate Affairs

A quorum shall be three members including either the Chair or the Deputy Chair Access: The Committee will invite authors of papers to attend the Committee from time to time to support the presentation of specific papers, as it considers necessary.

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Frequency: The Committee shall meet at least twice per financial year, although the Chair may call additional meetings as necessary. Reporting to the Board: The Chair of the Committee will report in writing to the Board at the Board meeting that follows the Committee meeting. This report will summarise the main issues of discussion but minutes of the meeting will not normally be shared with the board. The Chair of the Committee will also provide assurance to the Audit Committee on an annual basis on the Committee’s processes and the work that it has undertaken through the provision of an annual report. Sub-committees: There are no sub-committees of this Committee. Responsibilities: The Committee will have responsibility for the following:- 1. Agree the process for the recruitment of Chief Officers and make

appointments on behalf of the Board

2. Determine the appropriate remuneration and terms of service for the Chief Officers of the Trust on behalf of the Trust.; this will include

• All aspects of salary, including any performance related elements and

bonuses; • Provisions for other benefits in kind, including pensions and lease cars • Contractual arrangements, including severance packages for directors

in the event of termination of employment.

3. Review and approve the remuneration report for chief officers prior to inclusion in the annual report and the AGM.

4. Receive an annual report from the Chief Executive Officer on the performance objectives and appraisal of individual chief officers

5. Approve all termination payments made to senior managers (defined as the Chief Executive Officer or any director who reports to the Chief Executive Officer), including compromise agreements, which fall outside of contractual terms. In discharging this responsibility the Committee must; • satisfy itself that it has the relevant information to make a decision • conscientiously discuss and assess the merits of the business case



• consider the payment or payment range being proposed and address whether it is appropriate, taking into account the issues set out under initial considerations.

• keep a written record summarising its discussions and its decision (remembering that such a document could potentially be subject to public scrutiny in various ways e.g. by the Public Accounts Committee (PAC)).

The committee should only approve such a sum or range which it considers value for money, the best use of public funds and in the public interest

Appraisal: The Committee will carry out an annual appraisal of its performance and will report this to the Audit Committee via the Annual Report. The content of the Annual Report to the Board will be in keeping with the requirements of the Audit Committee Handbook Administration: The Director of Corporate Affairs will act as Committee Secretary and will agree the agenda with the Chair of the Committee, in conjunction with the Chief Workforce and Information Officer Review: These terms of reference will be reviewed in November 2018 unless there is a requirement to do so earlier. Date of Remuneration Committee Approval

21 December 2017

Date of Trust Board Approval Version: v6 2017 Author: Geoff Stokes, Interim Director of Corporate Affairs


INTERIM COMMITTEE REPORT TO BOARD

Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Quality Governance Committee Committee Meeting Date: 19 February 2018 Quoracy: Yes Apologies: Ed Macalister-Smith Committee Chair: Barbara Beal (in Ed Macalister-Smith’s absence) Report submitted by: Barbara Beal 1. CQC Inspection Preparation and Getting the Basics Right An update was given on the preparation for the forthcoming CQC inspection. There have been some helpful confirm and challenge sessions for core services (the classification of services the CQC use) to arrive at a self-assessment. Getting the Basics Right visits have been carried out and these have been useful in identifying areas where simple improvements can be made. 2. Quality Strategy The Committee were pleased to approve the updated Quality Strategy. This is supported by a Patient Experience and Engagement delivery plan.

3. Referral to Treatment Times (RTT) As part of the review of performance, the Committee were pleased to hear that the number of patients waiting of 52 weeks for treatment was reducing and should be zero by the end of March. This also mirrors an improvement in performance against the 18 week target with virtually all specialities planning a downward trajectory as better understanding of demand and capacity is gained.

4. Maternity Exception Report The Committee discussed the maternity dashboard and heard from the Modern Matron about the changes in complexity and number of inductions that has led to an increase in caesarean sections. Work is being done to target a reduction in smoking by pregnant women as testing currently shows below the national target. A new Head of Midwifery is about to start and a paper on staffing is being prepared. 5. Health and Safety Report The Health and Safety Committee report was discussed and concern was raised by the Committee of the number non-patient incidents currently outstanding. The Health and Safety Manager was asked to report back on progress at the next meeting of the Committee. 6. Policy, Procedure and Strategy Approval and Management Policy The Committee approved the updated policy which will provide a framework within which key non-clinical business documents are managed and approved.

The Board is asked to note the business discussed at the meeting and to raise any questions in relation to the same.


Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Quality Governance Committee Committee Meeting Date: 19 March 2018 Quoracy: Yes Apologies: Barbara Beal Committee Chair: Ed Macalister-Smith Report submitted by: Ed Macalister-Smith 1. CQC System Review The Committee received a verbal update following the CQC Local System Review Summit feedback, which took place in Coventry with all participant organisations on 14th March 2018. It was noted that the verbal feedback received was more positive in tone than the written report. The action plan arising from the review will be signed off by the Health and Wellbeing Board. 2. CQC Inspection A visit related to the ‘well led’ domain of the CQC will take place from 30 May to 1 June 2018 and interviews of key leaders in the organisation are being arranged.

The latest iteration of the ‘getting the basics right’ programme has been completed and reports on outcomes have been issued to all Group management teams. The high level themes are similar to those identified previously. .

3. Health Records Update The Committee were assured that the Trust’s health records partner are now operating as ‘business as usual’ following the cyber-attacks they suffered. There is still work to be done to prevent future attaches but there are currently no backlogs.

4. Quality Performance and Finance Report The QPR report highlighted a reduction in complaints and steady progress in maintaining turnaround time of responses. The Trust’s HSMR rate was discussed, especially in the context of Coventry having a relatively young population and the Committee heard that it is within in the expected range, taking into account the status of the Trust as a major tertiary centre. 5. Clinical Audit The Committee were pleased with the performance in the delivery of clinical audits and the dramatic improvement shown. 6. Patient Safety & Clinical Effectiveness Committee As part of the report from the Patient Safety and Clinical Effectiveness Committee, the issue of caesarean section rates was discussed and the Committee heard that due to increasing complexity and patient choice caesarean rates were not reducing as desired.



Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Finance and Performance Committee Committee Meeting Date: 28 February 2018 Quoracy: Yes Apologies: None Committee Chair: Ian Buckley Report submitted by: Ian Buckley 1. 2018/19 Annual Plan The Committee received the draft annual plan, which detailed a net deficit of £34.7million. A number of key performance targets to be achieved including ED 4 hour target of 95% by March 2019 was explained. Activity planning has been agreed by the Trust’s Groups. The Committee were informed that the Chief Finance Officer was preparing to liaise with NHSI with regards to accepting the Control Total for 2018/19. It is thought that the initial submission of £34.7million is likely to be too high for NHSI to accept. 2. Tender Acceptance Report – Storage Area Network Refresh As part of the capital programme the Trust’s Storage Area Network is required to be replaced; the existing solution nearing the end of its serviceable life.

The Committee were assured that a full tender process has been undertaken and three companies were evaluated. The clear outstanding supplier, whilst more expensive, would be able to support the Trust with its existing equipment and the skillset of staff would be retained and that the preferred supplier is a sound organisation.

Owing to the timing of the tender and requirement to replace equipment the Committee were advised that an emergency decision would be required to be taken; the Committee recommended approval of the tender.

3. Apprentice Levy The final version of the Strategic Approach to Apprenticeships was presented which sets out a new way of using apprentice including pre-employment and work placement and using apprenticeship as a way to develop existing staff. A full plan including action plan and performance targets were presented. The Committee were in full support of the scheme being implemented.



Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Finance and Performance Committee Committee Meeting Date: 21 March 2018 Quoracy: Yes Apologies: David Poynton, Karen Martin Committee Chair: Ian Buckley Report submitted by: Ian Buckley 1. RTT Performance The Committee was encouraged by the progress being made in some specialties to reduce waiting lists. Different strategies are being employed for different specialities, for example, buying in additional dermatology capacity has seen an improvement in both volume and productivity. The number of 52-week waiters continues to reduce and clear plans are in place to make that reduction sustainable. 2. 4 hour target The pressure on the emergency department continues and whilst this is mirrored across the country, plans have been reviewed to determine what can be addressed locally to reduce flow into the department, improve efficiency within the department and improve flow throughout the hospital. Whilst no improvement has yet been seen, the Committee were reassured that improvements were possible and should start to be reflected in the coming months.



Purpose: This report has two purposes; firstly to assure the Board that the committees that it has formally constituted are meeting in accordance with their terms of reference and secondly to advise Board Members of the business transacted at the most recent meeting and to invite questions from non-committee members thereon. Committee Name: Audit Committee Committee Meeting Date: 12 February 2018 Quoracy: Yes Apologies: Barbara Beal, Ed Macalister-Smith Committee Chair: David Poynton Report submitted by: David Poynton 1. Agreed audit plans for internal and external audit The Committee received audit plans for CW Audit and KPMG in relation to their respective internal and external audit plans. The committee noted that costs for both audits are stable 2. Fraud Cases Progress on closing fraud cases was received, with the Committee hearing that six cases have recently been closed.

3. Debt write-offs The number of debt write-offs was discussed and further information was sought by the Committee relating to cases relating to overseas patients.

4. Review of the Board Assurance Framework The Director of Corporate Affairs presented a revised format for the Board Assurance Framework (BAF) the adoption of which the Committee supported. This reflects feedback made from the internal audit review of the BAF 5. Conflicts of Interest Policy The Committee approved the Conflicts of Interest policy which had been amended to take account of national guidance to create a sub-set of ‘decision making staff’ for whom an annual declaration is required (even if that declaration is ‘nil’)


Documents

PUBLIC TRUST BOARD MEETING TO BE HELD ON THURSDAY 29 … · 2014. 6. 16. · public trust board meeting . to be held on thursday 29. th. march 2018 at 10.00 am . in room 10009/11,