COUNCIL OF GOVERNORS · COUNCIL OF GOVERNORS A meeting of the Council of Governors will be held at...

COUNCIL OF GOVERNORS A meeting of the Council of Governors will be held

at 10.00 am on Wednesday 25th

May 2016,

in Rooms 9 & 10, Education Centre, Queen Elizabeth Hospital

Presentation:

Community Services Update – Gill Wiggham

A G E N D A

1. Apologies for Absence:

2. To Sign the Attendance Register:

3. Chairman’s Business

4. Minutes of the Previous Meeting Enclosure

To approve the minutes of the previous meeting of the

Council of Governors held on Wednesday 24th

February 2016

5. Matters Arising from the Minutes

6. Chief Executive’s Briefing Enclosure

To receive the Chief Executive’s routine briefing report

Items for Decision:-

7. Quality Account 2015/16 Enclosure

To approve the Council of Governors’ response to the

Quality Account 2015/16, presented by the Head of Quality

Items for Discussion:-

8. Membership Development Working Group Enclosure

To receive a progress report on the work of the Membership Group,

presented by the Chairman of the Group

9. Membership Feedback Verbal

For governors to feedback on events attended and activities undertaken,

and to report any queries or comments received

Items for Assurance:-

10. National Surveys:

To receive a briefing report on:

i) National Patient survey Presentation

presented by the SafeCare Clinical Lead

ii) National Staff Survey Presentation

presented by the E-learning and OLM Lead

11. Finance and Activity Performance Presentation

To receive a report on the Trust’s current performance,

presented by the Director of Finance and Information

12. Monitor Q3 Return Enclosure

To receive the Q3 return and correspondence from Monitor


13. Performance Report Enclosure

To receive the routine briefing report

presented by the Director of Strategy and Transformation

14. Complaints, Litigation, Incident and PALS (CLIP) Report Summary Enclosure

To receive a summary report from the Head of Quality and Head of Risk

on the Complaints, Litigation, Incident and PALS Report

Items for Information:-

15. Governor Activities Enclosure

To receive a report on the activities of governors,

presented by the Trust Secretary

16. Feedback from Governor Focus Conference Enclosure

To receive a report from the event,

presented by Mrs J Coleman, staff governor

17. Operational Plan and Self Declarations 2016/17 Presentation

To receive for information the final Operational Plan,


18. Date and Time of Next Meeting

The next meeting of the Council of Governors will be held on

Wednesday 28th

September 2016 at 10.00am in the Lecture Theatre, Education Centre

19. Exclusion of the Press and Public

To resolve to exclude the press and public from the remainder of the meeting,

due to the confidential nature of the business to be discussed

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COUNCIL OF GOVERNORS’ Minutes of the Council of Governors’ Meeting

held at 10.00 am on Wednesday 24th

February 2016, in

Rooms 9 & 10, Education Centre, Queen Elizabeth Hospital

Present:

Mrs JEA Hickey Chairman

Mrs E Adams Public Governor – Central

Dr F Ahmad Staff Governor

Mrs S Begg Public Governor – Central

Mr S Connolly Public Governor – Central

Professor P Dawson Appointed Governor

Mr A Dougall Public Governor – Eastern

Ms J Doyle Appointed Governor

Mr J Holmes Public Governor – Central

Mrs M Jobson Public Governor – Eastern

Mr A Kumar Appointed Governor

Mrs J Lockwood Public Governor – Western

Mr M Loome Public Governor – Central

Mrs P MacGregor Staff Governor

Miss L Ritchie Public Governor – Western

Mr I Stafford Staff Governor

Mrs M Summers Public Governor – Western

Mrs J Todd Public Governor – Western

Professor T Waring Public Governor – Central

In Attendance:

Mrs D Atkinson Trust Secretary

Mr S Bowron Non-Executive Director

Dr J Bryson Non-Executive Director

Mr K Godfrey Medical Director

Councillor M Henry Non-Executive Director

Mr P Hopkinson Non-Executive Director

Mrs K Larkin-Bramley Non-Executive Director

Ms A Lowery Deputy Director of Nursing, Midwifery and Quality

Mr J Maddison Director of Finance and Information

Mr ID Renwick Chief Executive

Mr J Robinson Non-Executive Director

Mr D Shilton Non-Executive Director

Mrs J Williamson Membership Co-ordinator

Apologies:

Mr S Atkinson Associate Director – Surgical Services

Mr J Bolam Public Governor – Central

Mrs J Coleman Staff Governor

Mrs C Coyne Associate Director – Clinical Support and Screening Services

Councillor J Hamilton Appointed Governor

Mr P Harding Deputy Chief Executive

Mrs A Hayward Staff Governor

Mrs H Lloyd Director of Nursing, Midwifery and Quality

Professor M Pearce Appointed Governor

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Mrs S Pearson Associate Director – Medical Services

Mr A Sandler Appointed Governor

Mrs S Watson Director of Strategy and Transformation

Agenda

Item Discussion and Action Points

Action

By

G/16/01 CHAIRMAN’S BUSINESS:

Mrs JEA Hickey, Chairman, opened the meeting by asking if anyone present had any

revisions to their declared interests.

She welcomed Mr S Connolly and Mr M Loome, public governors for Central, Dr F

Ahmad, staff governor and Ms J Doyle, appointed governor, to their first Council of

Governors meeting.

She informed the group that Mrs J Coleman and Mrs A Hayward had also been elected as

staff governors but were unable to attend the meeting.

The Chairman also welcomed Mr D Shilton, Non-Executive Director, to his first Council of

Governors meeting.

She reported that, due to ill health, Ms C Squires, public governor, had resigned from her

post. She wished Ms Squires well and gave thanks for her time and input.

The Chairman concluded her report by reminding the group that the next governors’

workshop is being held on Wednesday 9th

March from 10.00 am to 12.30 pm. The topic

will be Quality and Patient Experience and will be led by Dr N Stefanou, Head of

SafeCare.

G/16/02 MINUTES OF THE PREVIOUS MEETING:

The minutes of the Council of Governors’ Meeting held on Wednesday 18th

November

2015 were approved as a correct record.

G/16/03 MATTERS ARISING FROM THE MINUTES:

The action plan was updated accordingly to reflect matters arising from the minutes.

G/15/69 Professor T Waring, public governor, commented that the merger of the

Clinical Commissioning Groups took place over 10 months ago and

expressed concern that there was still no information on the joint

strategy.

Mrs JEA Hickey, Chairman, commented that new planning guidelines

have recently been introduced and everyone must produce sustainability

and transformational plans by the Summer. She stated that meetings,

plans and discussions continue and once more information is available it

will be fed back to the Council of Governors.

G/15/73 Mrs D Atkinson, Trust Secretary, reported that there is no feedback as

yet from the comment from Mrs M Jobson, public governor. She will

pick this up with Mrs H Lloyd, Director of Nursing, Midwifery and Quality.

HL/AL

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Agenda


Action

By

G/15/45 Mr ID Renwick, Chief Executive, informed the group that the tender

documentation was submitted by the due date and the formal date of

notification is 8th

March 2016.

Mr J Holmes, public governor, asked if a replacement for Miss S Gascoigne, appointed

governor from Gateshead Youth Assembly had been sought. Mrs D Atkinson, Trust

Secretary, reported that Miss Gascoigne had left but the new nominated person was only

aged 14, and therefore not eligible to be a member or a governor. She is back in touch

with the Youth Council and discussions are ongoing.

G/16/04 CHIEF EXECUTIVE’S BRIEFING:

Mr ID Renwick, Chief Executive, presented his routine briefing report.

He drew attention to the paper, agenda item 6, and highlighted the following issues.

Mr Renwick reported a particular highpoint for the Trust is that the final report from the

recent CQC inspection has now been received.

He reported that the draft report was received in mid-January 2016, giving a formal

process which allowed the Trust to review the report and challenge any matters of

factual accuracy.

The final report showed that the Trust:

• has been rated as ‘GOOD’ overall;

• has been rated as ‘OUTSTANDING’ for ‘Caring’;

• Maternity and Family Planning services have been rated as ‘OUTSTANDING’;

• with 35 of 40 domains rated as ‘GOOD’; 3 as ‘OUTSTANDING’, one ‘REQUIRES

IMPROVEMENT’ (with one further which was not rated as part of the process),

we believe that the Trust’s inspection outcome is amongst the strongest of all

those rated as ‘GOOD’;

• the single ‘MUST DO’ improvement arising from the inspection has already been

actioned.

Mr Renwick stated that this is a fantastic outcome for the Trust, and in particular it is the

strongest possible testament to the hard work, commitment and patient focus for all

staff.

Mrs J Todd, public governor, stated that the report had received some coverage on BBC’s

Look North.

Mr J Holmes, public governor, gave thanks and appreciation to all staff, particularly those

in the outstanding areas. Mr Renwick agreed to send a note of thanks to all staff from

the Council of Governors.

Mrs JEA Hickey, Chairman, reported that, in appreciation and celebration of the

outcome, staff would be award an additional days holiday (pro rata).

After consideration, it was:

RESOLVED: to receive the report for information

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Agenda


Action

By

G/16/05 ANNUAL REVIEW OF THE DECLARATIONS OF INTEREST:

Mrs D Atkinson, Trust Secretary, presented a paper detailing the declared interests of

newly elected governors together with the Annual Declarations of all elected and

appointed governors.

RESOLVED: i) to note the declared interests of the newly elected governors, Dr F

Ahmad, Mrs J Coleman, Mr S Connolly, Mrs A Hayward and Mr M

Loome, detailed in paper agenda item 7 (i)

ii) to note the declared interests of the governors as contained in the

paper, agenda item 7 (ii)

G/16/06 QUALITY ACCOUNT 2015/16:

Dr N Stefanou, Head of SafeCare, presented to the group a briefing paper on the Quality

Account 2015/16.

She reminded the group that she had presented to the governors at a workshop in

January 2016, a progress report on the Trust’s quality priorities for delivery in 2015/16.

Following this, there was discussion regarding the potential priorities for 2016/17

spanning the three domains of quality.

At this workshop, governors were asked to consider and comment on the priorities of

Clinical Effectiveness, Patient Safety and Patient Experience for inclusion in the Quality

Account.

Dr Stefanou reported that recommendations on the choice of priorities for 2016/17,

based on governor feedback and wider consultation, had been made to the Board of

Directors earlier that day.

She reported that the chosen indicator to be audited was the Cancer Two-Week Wait

target. She stated that this is a sensible indicator and also one that has not been

previously chosen.

Dr Stefanou thanked Mrs W McFadden, SafeCare Team Facilitator, for her hard work in

the production of the Quality Account.

Mrs JEA Hickey, Chairman, reported that the Board of Directors had agreed at the Board

meeting earlier that morning to support that the proposed quality priorities for 2016/17

and to endorse the chosen indicator for audit for 2015/16. The target is a key national

target and external assurance would be greatly received.


RESOLVED: to agree the Cancer Two-Week Wait indicator as the local indicator on

which to gain assurance

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Agenda


Action

By

G/16/07 EXTERNAL AUDIT SERVICES TENDER:

Mr J Maddison, Director of Finance and Information, presented to the group an update

on the external audit services tender for approval.

He reminded the group that the appointment of the external auditor is power of the

Council of Governors, and explained that the appointment of KPMG was a three year

contract with the option of two additional years available to extend.

Mr Maddison stated that the contract was extended in 2015 for a further 12 months,

with a view to a review of the work by KPMG.

He stated that the recommendation to the Council of Governors is to extend the contract

for a further final 12 months with a formal tender process to be undertaken over the

summer period. This would be with a view of an appointment in September or October

2016 to ensure that the external auditors are in place for the 2017/18 financial year.

Mrs JEA Hickey, Chairman, stated that a timetable and proposals for the contract will be

brought to the Council of Governors’ meeting in May 2016 and the panel will have

governor representation.


RESOLVED: i) to approve a 12 month extension to the External Auditor’s

contract

ii) to begin a formal tender process for the contract

G/16/08 COUNCIL OF GOVERNORS’ 2015 APPRAISAL:

Mrs D Atkinson, Trust Secretary, presented to the group the results of the Council of

Governors’ 2015 appraisal questionnaire.

She reported that 25 questionnaires were sent out to the governors in place at the time

and 13 responded. She drew attention to the paper, agenda item 10, and the graphs

showing the results.

Mrs Atkinson reported that an action plan has been developed and some of the stated

actions are already in place.

She reviewed the action plan reporting on the progress and plans for each of the actions.

Mrs Atkinson stated that one of the actions is to promote governor only meetings either

before or after the full Council of Governors meetings and asked for any comments on

this.

After discussion, it was agreed to arrange an informal session before the next Council of

Governors meeting and review this again afterwards.

Mrs JEA Hickey, Chairman, highlighted the action regarding more informal meetings

between directors and governors. She suggested that lunch be organised after the

Annual General Meeting each year. This was agreed to be taken forward.

DA/JW

DA/JW

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Agenda


Action

By

Mrs Atkinson reported that work is beginning with staff governors to improve

communication with staff members, looking at new ways of working and improving this

engagement.

Mrs M Jobson, public governor, stated that visits are a good part of the training available

and the recruitment that she carries out in Outpatients is a good way to hear comments

first hand from patients.

Mrs JEA Hickey, Chairman, thanked those governors who had completed the

questionnaire and stated that an update on the action plan will be brought back to a

meeting later in the year.

After further discussion, it was:

RESOLVED: to receive the results and action plan for information

G/16/09 MEMBERSHIP DEVELOPMENT WORKING GROUP:

Mrs D Atkinson, Trust Secretary, gave an update on the work of the Membership

Development Working Group.

She highlighted the report, agenda item 11, and stated that an additional graph had been

included to show membership by age range as requested.

Mrs Atkinson stated that the slight rise in members aged 16 is due to work she has been

undertaking with local schools and the promotion of the Trust’s work experience

programme.

Professor P Dawson, appointed governor, stated that she asked for the age range graph

and gave thanks for the inclusion in the report. She stated that is it interesting to see a

peak in membership numbers at age 23-26 and suggested this could be from students.

She suggested that she could meet with Mrs D Atkinson, Trust Secretary, to discuss

further promotion of membership amongst Northumbria University students.

Ms J Doyle, appointed governor, also offered to meet with Mrs Atkinson to discuss

membership promotion with Gateshead College students.

Mrs Atkinson continued, reporting that she has been working with a number of local

schools to promote membership and careers at the Trust. She reported that a careers

open day will be held in July 2016 with five local schools attending to hear from various

staff on careers across the whole organisation. A further session has been arranged at

Lord Lawson of Beamish School in April 2016.

Mrs M Summers, public governor, stated that the ratio of members in the Western

constituency is quite low and asked if there was any reason for this. Mrs Atkinson replied

stating that due to the location, some patients choose to go elsewhere.

Mrs Atkinson concluded her report by informing the group that Mr M Loome, public

governor, has agreed to take over as chairman of the group.

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Agenda


Action

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After further discussion, it was:

RESOLVED: to receive the update for information

G/16/10 MEMBERSHIP FEEDBACK:

Mrs M Jobson, public governor, reported that an elderly friend had attended the ECC

recently and was in a treatment room alone from 10:15 am to 5:15 pm. She asked if this

patient should have been kept informed as to why he was waiting so long. Mr ID

Renwick, Chief Executive, agreed to discuss the issue with Mrs S Pearson, Associate

Director Medical Services and Mrs H Lloyd, Director of Nursing, Midwifery and Quality.

Mr S Connolly, public governor, reported that a neighbour had attended the hospital

recently for cardiac investigations. Staff at the appointment noticed that his breathing

was not too good so cancelled the appointment and recommended that he seek medical

attention. He passed on his praise for staff who noticed this and helped out.

Mr M Loome, public governor, stated that he has recently had discussions with Mr P

Harding, Deputy Chief Executive, regarding the signage to the hospital on the

surrounding roads. He reported that there are very few direction signs on the roads

leading to the hospital and no directions from the main A1 road. After discussions with

Mr Harding, the issue has been brought up again with the Council and the issue has been

acknowledged. Further updates will be provided to the group.

Mrs M Jobson, public governor, stated that from personal experience, the internal

signage had been vastly improved.

Mr J Holmes, public governor, reported that his wife recently had a fracture clinic

appointment. However, due to snow on the appointment day she was unable to attend

on time. He reported that she was treated well by staff and the appointment was re-

arranged. He also reported that his wife had attended the ECC and was seen and treated

within two hours.

Finally, he reported that he had raised an issue with Mr S Bowron, in his role of Senior

Independent Director, and this has been dealt with and completed.

Mrs J Todd, public governor, reported that she has recently joined the Safeguarding

Committee. She commented that the committee undertakes a great deal of work and it

is very interesting to see what is involved. Mrs JEA Hickey, Chairman, stated that

anything of importance could be fed back from committees to full Council of Governors’

meetings.

Mrs M Summers, public governor, reported that a friend’s husband had recently had

treatment at the hospital and was very happy. She reported that he is emailing his

comments direct to Mr ID Renwick, Chief Executive.

Mrs J Lockwood, public governor, asked what the impact the recent Junior Doctors strike

had caused. Mr K Godfrey, Medical Director, reported a one day strike was manageable

and work has been ongoing to reduce the backlogs of the cancelled appointments,

however the threat of a two day strike is more difficult.

IDR

PH

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Agenda


Action

By

Miss L Ritchie, public governor, reported that she had recently attended the ECC with a

family member and stated that they were seen quickly and impressively.

Mr A Dougall, public governor, reported that the cold winds coming through the doors of

the Outpatient Department are causing distress. He is a Meet and Greet volunteer and

the winds are howling through the department when the automatic doors open. He

stated that recently the doors of the ECC had been closed and all patients were directed

in through the OPD doors. Mr Renwick noted that the closure of the ECC doors was for

safety reasons in abnormally high winds. In relation to the Outpatient doors he stated

that he will discuss this issue with Mr P Harding, Deputy Chief Executive.

Mr I Stafford, staff governor, added that the winds through the doors of the ECC were

causing a wind tunnel so had to be closed. A new break in the wall has been created so

that opposite doors can be open, thus stopping the tunnel effect.

IDR/PH

G/16/11 FINANCE AND ACTIVITY PERFORMANCE:

Mr J Maddison, Director of Finance and Information, presented the financial headlines at

month 10.

He explained that nationally at quarter 3 the provider deficit stands at £2.24bn and the

year-end figure could be as high as £2.8bn. significant efforts are being made to reduce

this, as a figure of over £1.8bn would exceed the NHS Parliamentary vote.

Mr Maddison reported that the Trust’s planned deficit was predicted at £9.9m originally.

Following reviews and investigations, this was re-forecasted to £7.5m and is on track at

month 10.

He reported that the Trust is delivering CRP targets and is on track for the full year with

any non-achievements recurrently being carried forward to 2016/17.

The Trust’s cash is at £6.5m and is ahead of plan.

He concluded his report by stating that the plan for 2016/17 is challenging and contains a

number of risks and caveats. He stated that contract negotiations are underway.

Mrs M Jobson, public governor, asked if the report is “good news”. Mrs JEA Hickey,

Chairman, reported that the Trust is in a better position than some other Trusts and the

reduction in the forecast deficit is a good result in a challenging environment. Work is

ongoing internally moving into the next financial year. She gave her thanks to all the

staff for their hard work.

Mr Maddison stated that if the Trust was one of few Trusts in a similar position then it

could be looked at as the Trust’s problem or fault. We always strive to improve efficiency

and cost effectiveness and the sector as a whole is in a similar position. There an issue of

sustainability longer term and the funding and availability of services with some decisions

to be made at a higher level.


RESOLVED: to receive the report for assurance and information

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Agenda


Action

By

G/16/12 MONITOR Q2 RETURN:

Mr J Maddison, Director of Finance and Information, presented Monitor’s Quarter 2

Return (30 September 2015).

He stated that the Trust’s ratings for Q2 were reported as:

• Financial sustainability risk rating – 2

• Governance risk rating – Green

Following further discussion, it was:

RESOLVED: to receive the report for assurance and information

G/16/13 PERFORMANCE REPORT:

Mr S Lawson, Acting Head of Performance, provided the Council of Governors with an

update on performance against national and local targets.

He reported that the cancer 2-week wait performance has improved and, after four

consecutive quarterly fails for this indicator, the Trust has delivered a sustained

performance since September 2015. He also reported that performance has been

delivered against all tumour sites for December and Quarter 3, with Quarter 4 also

looking encouraging.

Mr Lawson stated that the Trust has experienced pressure against the A&E 4 hour

waiting time indicator since October and throughout Quarter 3, resulting in a fail being

reported. The predicted position for Quarter 4 is also considered a risk. However, in the

national context the Trust has outperformed others over the winter period.

He stated that focus continues to be given to the A&E black breaches which are defined

as being an ambulance handover to A&E taking in excess of 60 minutes. The Trust

experienced some pressures but implemented a new Standard Operating Procedure in

November 2015, which has resulted in the January position of zero.

Mrs JEA Hickey, Chairman, reported that a development session for governors has been

arranged for later in the year and will look at the targets, key measures and performance

reporting.

Professor P Dawson, appointed governor, asked if the A&E breaches were due to bed

availability. Mr Lawson responded stating that the Trust reviewed the reasons for

breaches, which cover many factors including bed availability. Winter pressures also

contribute. He stated that processes and workstreams are being looked at to improve

the discharge process.

Mr ID Renwick, Chief Executive, reported that the Trust has opened additional winter

capacity beds. He stated that is it difficult to strike a balance between what is affordable

and what is needed. The position is similar in all hospitals around the country.

Mrs JEA Hickey, Chairman, stated that a difficulty is that whilst the level of attendances

are relatively stable, the number that have needed to be admitted has increased by

around 8%.

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Agenda


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Dr J Bryson, Non-Executive Director, reported that GP surgeries are seeing more complex

cases and therefore hospital attendance is required.

Mr S Bowron, Non-Executive Director, asked if there is a way of reporting the level of

delayed discharge for non-clinical reasons. Mr Lawson reported that this information is

available and agreed to report back at the next meeting.

Mrs J Todd, public governor, asked why the hospital is seeing more poorly patients. Mr

Renwick responded stating that the population is generally older and sicker, and this is

seen across the healthcare system.

Dr J Bryson, Non-Executive Director, commented that patients are living longer but

developing long term or chronic illnesses such as asthma and diabetes.

Professor Dawson, appointed governor, asked how the Trust’s performance against the

targets is in comparison with other Trusts in the region, in particular with South Tees who

appear to be performing very well. Mr Lawson responded stating that the Trust has been

in contact with South Tees to see what mechanism they have in place, however there is

nothing in particular that is being done differently by others.


RESOLVED: to receive the report as assurance against the management governance

indicators in the Compliance Framework and local supporting measures

of improvement management

SL

G/16/14 GOVERNOR REPRESENTATION ON TRUST COMMITTEES:

Mrs D Atkinson, Trust Secretary, presented a paper detailing the governor

representatives on the Trust’s committees.

She thanked the governors who responded for their interest and drew attention to the

table contained in the paper, agenda item 16.

She reported that the red text in the paper showed the new governor observers of the

committees. She stated that in addition to the list Mr S Connolly, public governor, has

joined the Infection Prevention and Control Committee and Mrs J Todd, public governor,

has joined the Safeguarding Committee.

Mrs Atkinson stated that the committees now have a good representation from

governors and any further interest will be recorded for vacancies that may arise.

Mrs JEA Hickey, Chairman, stated that the Infection Prevention and Control Committee

(IPCC) is an interesting but clinically focussed committee, and suggested that a briefing

session is arranged with the committee chair for Mr Connolly and Mrs Todd before

attending their first meeting.

Mrs J Todd stated that this would be helpful as it is interesting to have knowledge before

going to the meetings.

HL/AL

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Agenda


Action

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Dr F Ahmad, staff governor, asked how the number of governors is allocated to each

committee. Mrs Atkinson responded stating that it depends on the individual

committees; some are small committees, but it has been worked out over the years

which are best.

Mrs Hickey added that the 15 Steps Challenge consists of a list of interested governors

and Remuneration Committee is a governor only committee. She thanked Professor T

Waring, public governor, for taking on the chairmanship of the Remuneration

Committee.

Mr A Dougall, public governor, expressed an interest in joining the Equality and Diversity

Committee.

Mrs Atkinson concluded her report by informing the group that dates and times for the

meetings will be distributed to individuals shortly.



G/16/15 GOVERNOR ACTIVITIES:

Mrs D Atkinson, Trust Secretary, presented to the group a report compiled from

governors’ attendance at meetings and events from 11th

November 2015 to 16th

February

2016 inclusive.

She reminded the group that the report is brought to each Council of Governors’ meeting

for information.

Mrs Atkinson drew attention to the paper, agenda item 17, and the attached appendix

which showed how governors are carrying out their role.



G/16/16 DATE AND TIME OF NEXT MEETING:

RESOLVED: that the next meeting of the Council of Governors will be held at 10.00

am on Wednesday 25th

May 2016 in the Education Centre, Queen

Elizabeth Hospital

G/16/17 EXCLUSION OF THE PRESS AND PUBLIC:

RESOLVED: to exclude the press and public from the remainder of the meeting due

to the confidential nature of the business to be discussed

Council of Governors

Report Cover Sheet Agenda Item: 6

Date of Meeting:

Wednesday 25th

May 2016

Report Title:

Chief Executive’s Briefing

Recommendations:

(Action required by Council

of Governors)

To provide the Council of Governors with a brief update on key issues and

events since the last meeting

Decision: Discussion: Assurance:

Information:

Brief summary to highlight key issues:

This paper provides a brief update on some of the key issues and events for the Trust since the last

Council of Governors meeting.

Author:

Mr ID Renwick, Chief Executive

Presented by:

Mr ID Renwick, Chief Executive

Paper for Council of Governors Meeting

25th

May 2016 Agenda Item: 6

G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T

CHIEF EXECUTIVE’S REPORT

This paper provides a brief update on some of the key issues and events for the Trust since the last Council

of Governors meeting.

2015/16

Subject to the completion of the audit of the final accounts, we can reflect on what has been a very

challenging, but overall a very successful year, for the Trust. We began the year under the cloud of

Monitor’s financial investigation, but managed to navigate that process without the regulator taking and

further regulatory action. This was largely a reflection of the work undertaken to develop the Trust’s

Recovery Programme, which resulted in us achieving our revised financial target for the year. It also leaves

us in a much better position with regard to the forward planning of CRP and efficiency plans.

Last year was another very challenging one in terms of activity and service pressures. In common with most

other acute providers, the Trust experienced the worst winter period that most clinical staff could

remember. In the face of this, it is a testament to our clinical teams that we managed to keep the hospital

open throughout, maintain patient flow, and achieve the majority of our service targets and standards.

My final reflection is of the ultimate recognition of our unrelenting focus on patients, and the quality and

safety of the care they receive. The CQCs inspection and report on the Trust has provided a fitting end to

the year and the efforts, commitment and dedication of staff across the organisation to our core vision and

values.

Financial Performance

Subject to the final audit, in a very difficult financial year for the NHS as a whole, the Trust has achieved its

revised financial plan for the year. More detail is provided in the Director of Finance’s update.

Service Pressures

In keeping with previous reports, levels of clinical pressure show no signs of relenting, with emergency

services having continued to experience some days of significant pressure over recent weeks, despite the

fact that we are well into May (although conversely there have been days when the Trust has achieved

100% compliance against the 4-hour wait target). Whilst we failed this standard across Quarters 3 and 4,

signs in the first two months are more promising, although it remains a daily challenge keeping the system

under a degree of control.

Community Services Tender Opportunity

As was reported ‘hot off the press’ at the last meeting, the Trust was successful in its tender submission for

Gateshead’s community based services. We will take full responsibility for these services in October, and

mobilisation discussions are already in place with staff and South Tyneside FT.

Junior Doctors Industrial Action

April saw two more periods of industrial action by Junior Doctors. With the support and input of senior

clinical staff, we were able to minimise the risk and impact on patients (although inevitably some non-

urgent elective operating and outpatient appointments suffered some disruption). At the time of writing,

the lines of discussion between the DoH and BMA remain open, and we are hopeful that the current

situation can be drawn to an amicable conclusion without any further disruption.

Sustainability and Transformation Plan

Work to develop the STP across Gateshead:Newcastle, and for the wider Northumberland, Tyne and Wear

area, continues. The ‘challenge’ meetings for the process have gone very well so far, and there has been a

view expressed from NHS England that our local work is an exemplar of good practice. This work will

continue with a final submission date for the wider STP of 30th

June 2016 uppermost in our minds as it does

so.

Spring Consultant Conference

Tuesday 17th

May saw the latest of our Consultant Conferences. Over 110 delegates, the majority of them

from the senior clinical community, came together for a full day at the Lancastrian Suite. The morning

provided an opportunity to develop clinical engagement and involvement in the work now underway under

the umbrella of the Recovery Programme, and in particular those workstreams relating directly to the

Consultant body.

The afternoon focused on opportunities for patient pathways and flows under the community services

tender, and culminated in a presentation from CCG colleagues on their view of the challenges facing the

Gateshead patch. Overall the day was very well received, and will form the basis for a follow-up event later

in the year.

Ian Renwick

Chief Executive

May 2016



Date of Meeting:

Wednesday 25th

May 2016

Report Title:

Quality Account Statement

Recommendations:


of Governors)

To approve the statement for inclusion in the Trust’s Quality Account

2015/16

Decision:

Discussion: Assurance:

Information:


This paper provides the Council of Governors’ formal response to the Trust’s Quality Account 2015/16

Author:

Dr Nichola Stefanou, Head of Quality

Presented by:

Dr Nichola Stefanou, Head of Quality


25th



Quality Account Feedback

Background:

As in previous years, the Council of Governors is required to provide a formal response to the Trust’s

Quality Account.

Governors were given a copy of the draft Quality Account 2015/16 in May 2016 and asked to forward any

comments on the document to prepare the response.

The response has been drafted and is below for approval.

Statement:

The following statement will be included in the Trust’s Quality Account 2015/16:

The Governors of Gateshead Health NHS Foundation Trust have been consulted on and been involved in the

formation of the Trust’s Quality Account in 2015/16. Governors have been continuously involved in

refreshing the Trust’s strategic plans with their involvement at various Trust committees and the Council of

Governors meetings throughout the year. At each of the Council of Governors meeting during 2015/16, a

range of reports have been presented, which enable Governors to receive and discuss quality and patient

safety matters and progress against our quality priorities. In January 2016 a Governor workshop was held

where Governors were consulted on the quality priorities for inclusion in the Quality Account 2015/16.

Overall the Quality Account clearly demonstrates the Trust’s ongoing commitment to delivering high quality

and safe patient care and improved health outcomes.

Comments received from Governor’s:

“It is obvious from the report that the Trust should be commended on its achievements, and the hard work

of staff. Also the Trust and its dedicated staff should be praised regarding the recent CQC inspection report,

in which it was shown as one of the best trusts in the country.

The residents of Gateshead should be justly proud that their local hospital is seen by CQC, in this way, and

that they know that they will receive a high standard of care when required.

I am sure that priorities will be achieved in the continual challenges that the trust will encounter”.

Recommendation:

The Council of Governors is asked to approve the above statement for inclusion in the Trust’s Quality

Account 2015/16.

Dr Nichola Stefanou

Head of Quality



Date of Meeting:

Wednesday 25th

May 2016

Report Title:

Membership Strategy Sub Group Update

Recommendations:


of Governors)

To receive the report for information


Information:


To provide the Council of Governors with an update on membership numbers and the current and future

work of the Membership Strategy Sub Group

Author:

Mrs J Williamson, Membership Co-ordinator

Presented by:

Mr M Loome, Chairman of the Group and Public Governor


25th



Membership Strategy Sub Group Update

1. Current Membership

Information on membership numbers is presented at each meeting and reviewed by the group.

This includes breakdowns by age, gender and ethnicity.

The total number of public members at 30th

April 2016 was 13,006. A graph showing membership

totals is overleaf as Appendix 1.

A table showing the population of the three public constituencies; Central, Eastern and Western,

and their membership ratio is attached as Appendix 2.

A breakdown of the age range of membership is attached as Appendix 3.

2. Recent Work

The group has met once since the last update and has continued to take part in the following

activities:

• discussed plans and ideas for Membership Week 2016

• discussed a careers event being held in July 2016 for local school sixth forms

• reviewed newly developed membership noticeboards

• discussed ways of promoting staff membership with the staff governors

• continued with recruitment and engagement in OPD

• continued to attend local community groups

3. Next Steps/Future Plans

The next steps/future plans for the group are to:

• encourage all members of the Council of Governors to become involved in recruitment

• continue to work with all governors towards the objectives and actions detailed in the

Membership Strategy

• continue to promote membership in the QE Outpatients department

• continue to attend local engagement events

• continue with plans and ideas for Membership Week 2016

Mr M Loome

Chairman of the Group and Public Governor

Appendix 1

2368

6531

3670

437

3148

0

1000

2000

3000

4000

5000

6000

7000

Eastern Central Western Out of Area Staff

Membership by Constituency(at 30th April 2016)

Appendix 2

Population and Membership Ratio by Constituency

Western Central Eastern Overall

Population 77,471 92,828 41,615 211,914

Membership 3,670 6,531 2,368 12,569

% 4.74 7.04 5.69 5.93

Ap

pe

nd

ix 3

104444

63686771

107173

145146

124105

11598

10389

118133

124125

117126

103121

115151

148163

157185

139196

176182

202199

174200

181201

182212

237184

214239

201248

275248

318342

361256

270278

253239

222272

264236

219203

178185

175163161

116108

9491

6953

402425

1219

810

75

182

0

50

10

0

15

0

20

0

25

0

30

0

35

0

40

0161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899

100+Unknown

Number of Members

Ag

e

Me

mb

ersh

ip b

y A

ge



Date of Meeting:

Wednesday 25th

May 2016

Report Title:

Monitor Q3 Return

Recommendations:


of Governors)

To receive the report for assurance and information


Information:


The Trust submits quarterly returns to Monitor and receives from Monitor an executive summary of the

results. Attached are the results and correspondence for Quarter 3.

Author:

Mr J Maddison, Director of Finance and Information

Presented by:

Mr J Maddison, Director of Finance and Information

1 March 2016 Mr Ian Renwick Chief Executive Gateshead Health NHS Foundation Trust Education Centre Queen Elizabeth Hospital Queen Elizabeth Avenue Sheriff Hill Tyne and Wear NE9 6SX Dear Mr Renwick Q3 2015/16 monitoring of NHS foundation trusts Our analysis of your Q3 submissions is now complete. Based on this work, the trust’s current ratings are:

• Financial sustainability risk rating: 2 • Governance rating: Green

These ratings will be published on Monitor’s website later in March. The trust has been allocated a financial sustainability risk rating of 2, which has triggered consideration for further regulatory action. Monitor uses the measures of financial robustness and efficiency underlying the financial sustainability risk rating as indicators to assess the level of financial risk at foundation trusts. A failure by a foundation trust to achieve a financial sustainability risk rating of 3 or above could indicate that the trust is providing health care services in breach of its licence. Accordingly, in such circumstances, Monitor could consider whether to take any regulatory action under the Health and Social Care Act 2012, taking into account, as appropriate, its published guidance on the licence and enforcement action including its Enforcement Guidance1 and the Risk Assessment Framework2. Monitor has decided not to open an investigation to assess whether the trust could be in breach of its licence at this stage. The trust’s governance rating has been reflected as ‘Green’. Should any other relevant circumstances arise, Monitor will consider what, if any, further regulatory action may be appropriate. A report on the aggregate performance of all NHS providers (Foundation and NHS trusts) from Q3 2015/16 will be available in due course on our website (in the News, events and publications section), which I hope you will find of interest. 1 www.monitor-nhsft.gov.uk/node/2622 2 www.monitor.gov.uk/raf

For your information, we will be issuing a press release in due course setting out a summary of the report’s key findings. If you have any queries relating to the above, please contact me by telephone on or by email ([email protected]). Yours sincerely Yours sincerely

Richard Schofield Senior Regional Manager cc: Mrs Julia Hickey, Chair Mr John Maddison, Director of Finance

1



Date of Meeting:

Wednesday 25th

May 2016

Report Title:

Trust Performance Report

Recommendations:


of Governors)

The Council of Governors is requested to receive this report as assurance


Information:


National Access targets measured in the Risk Assessment Framework can be demonstrated as having

generally good performance. The target with significant risk is the maximum waiting time of 4 hours in

A&E which has a target threshold of 95%. The Trust has experienced pressure against this indicator since

October 2015 and throughout quarters 3 and 4. The Trust has reported two quarterly fails in the last

four quarters for this indicator. This will mean Monitor, as the regulator, is required to investigate the

Trust position and determine if any additional action is required.

Having reported four consecutive quarterly fails for the cancer 2 week wait standard, the Trust

implemented a number of changes/processes which have successfully delivered sustained performance

since September 2015. The Trust can also report that performance has been delivered against all tumour

sites from December with the exception of head and neck in January.

Cancer 62 day performance has been excellent until quarter 4, where breaches against the indicator for

screening patients caused a fail in the quarter. The analysis has shown that the breaches were attributed

to capacity issues in the lower gastrointestinal pathway, and this service has been placed in escalation.

The service has developed an action plan and will be monitored against delivery of this into 2016/17.

National Outcome targets measured in the Risk Assessment Framework can be demonstrated as having

generally excellent performance. The target with highest risk is against the C-Difficile trajectory. This is

determined by the number of cases where a lapse in care is evident. There are currently 12 cases

reported in quarter 4, but the appeals to determine if lapses in care were evident are outstanding. If the

trust is successful in making these appeals the C-Difficile target will be delivered.

On 16 May 2016 the trust held its quarterly review call with NHS Improvement (formerly Monitor) and

this focused on A&E performance and 62 day cancer screening performance. Assurance was given that a

number of actions were in hand to improve performance. NHSI will be monitoring this.

Author: Steve Lawson – Acting Head of Performance

Presented by: Susan Watson – Director of Strategy and Transformation

3

Report structure:

1. Risk Assessment Framework – Access Measures (Monitor)

1.1 Referral To Treatment 18 Weeks

1.2 Maximum Waiting Time 4 Hours in A&E

1.3 Cancer 2 Week Wait Waiting Times

1.4 Cancer 31 Day Waiting Times

1.5 Cancer 62 Day Waiting Times

2. Risk Assessment Framework – Outcome Measures (Monitor)

2.1 Clostridium Difficile

2.2 Mental health Delayed Transfers of Care

2.3 Mental health Data Completeness

2.4 Community Services Data Set

3. Junior Doctors Strike Impact

4

Risk Assessment Framework:

5

1. Risk Assessment Framework – Access Measures (Monitor)

1.1 Referral to Treatment 18 weeks

Referral to Treatment 18 Weeks – Year End Position

The Trust has successfully delivered against the referral to treatment standard in the Risk Assessment

Framework for each month in 2015/16. The yearend position was reported as 93.1% against the 92%

standard

Referral to Treatment 18 Weeks – Forecast Position

Performance against the incomplete pathway standard remains an area of achievement for the Trust.

1.2 Maximum Waiting Time 4 Hours in A&E

Maximum Waiting Time 4 Hours in A&E – Year End Position

The Trust did not achieve the 95% threshold between October 2015 and March 2016. The yearend position

was reported as 93.7% against the 95% standard.

The underperformance of this indicator in quarter 4 may result in Monitor assigning a governance risk. This

is a result of having not delivered performance in two of the last four quarters.

A breakdown of activity by month and quarter is given below.

Figure 1. A&E performance in last 12 months

The performance of neighbouring Trusts is illustrated below and indicates that the pressure experienced by

QE is being experienced across that patch and nationally.

The Trust developed and implemented an action plan in conjunction with the CCG to recover performance

to a sustained level against the 95% standard.

Maximum Waiting Time 4 Hours in A&E – Forecast Position

Performance against the A&E standard into 2016/17 is demonstrating that efforts made by the Trust are

having the desired effect. Performance in April 2016 was 98.5%.

The Trust does anticipate that this indicator will be pressured in 2016/17 during the winter period.

Trajectories made for performance across the year identify January and February as the most likely times

for pressure.

The Trust is continuing to develop the action plan and work with the wider health economy to address

issues that impact on the waiting times in A&E.

6

1.3 Cancer Two Week Waiting Times

Cancer 2ww – Year End Position

The yearend position was 93.9% for 1st

outpatient appointment and 94.9% for Breast Symptomatic

referrals. This demonstrates delivery against the 93% standard set out in the Risk Assessment Framework.

The Trust experienced significant pressures for this indicator in the first 5 months of year as a result of

significant demand increases in Breast referrals in conjunction with pathway delays in Urology and Upper

Gastrointestinal services. The Trust adhered to the performance management framework and placed these

services in escalation.

This process has successfully turned performance around and the Trust has sustained delivery of the 2

week wait for 1st

Outpatient appointment indicator since September 2015. The Trust has also delivered

sustained delivery for 2 week wait for Breast Symptomatic referrals since June 2015.

Cancer 2ww – Forecast Position

The Trust expects that performance across the 2 week wait standards will be delivered throughout

2016/17. Evidence to date in April and May shows the Trust is on track with this forecast with performance

above the 93% threshold.

1.4 Cancer 31 Day Wait Times

Cancer 31 Day Waiting Times – Year End Position

The Trust has achieved all three standards for 31 day waiting times for each month in 2015/16.

Cancer 31 Day Waiting Times – Forecast Position

The Trust has successfully delivered on the 31 day standards throughout 2014/15 and 2015/16. On this

basis the expectation is that performance will be maintained throughout 2016/17.

1.5 Cancer 62 Day Wait

Cancer 62 Day Waiting Times – Year End Position

The yearend position for 62 day wait for 1st

definitive treatments was 86.1% against the target threshold of

85%. The Risk Assessment Framework determines delivery based on a quarterly basis and the Trust

delivered in quarter 2, 3 and 4.

The yearend position for 62 day wait for treatment (screening patients) was 95.3% against the target

threshold of 90%. The Risk Assessment Framework determines delivery based on a quarterly basis and the

Trust delivered in quarter 1, 2 and 3.

The under performance in quarter 4 for screening patients was the result of 6.5 patients whose treatment

was received after 62 days. Analysis of the breaches has identified that the primary issue is a shortfall of

capacity in the lower gastrointestinal screening pathway. The service has been placed in escalation as per

the Trust performance management framework and an action plan has been created.

7

In accordance with national good practice, root cause analysis of reasons for patients breaching is routinely

undertaken. Root cause analysis themes indicate:

• Delay in receiving diagnostic test and delay in reporting for diagnostic test, including EBUS

(Endobronchial Ultrasound) and PET (Positron Emission Tomography).

• Subsequent delay to treatment at other neighbouring Trusts.

• Multi part pathways –patient being investigated in more than one cancer site

• Medical delays due to patient health

Actions being taken to address these issues include, recruiting to vacant posts, outsourcing testing and

reporting. Increasing capacity with WLI sessions and mobile diagnostic vans where appropriate. Ongoing

pathway review, internally and liaison with other Trusts to ensure the patient is treated as soon as possible.

Cancer 62 Day Waiting Times – Forecast Position

The Trust expects that performance across the 62 day standard will be strong throughout 2016/17.

However this indicator is historically pressured and with the small numbers of treatments at the Trust this

compounds the risk for delivery with each single breach. Quarter 1 of 2016/17 is at risk and should this

materialise then this will assign a service score point for the Trust. The performance of other indicators in

the Risk Assessment Framework is expected to be delivered and thus it is forecast that despite the risk in

the 62 day indicator it is not expected to assign a governance risk to the Trust.

Cancer 62 Day Waiting Times (Screening) – Forecast Position

Due to the delivered performance in February and March this indicator is to be considered at risk until the

improvement plan for Lower GI Screening is completed and assurances delivered around sustained

performance.

8

2 Risk Assessment Framework - Outcome Measures (Monitor)

2.1 Clostridium Difficile

The yearend position is still to be confirmed. The Trust has successfully delivered against the trajectory in

the Risk Assessment Framework in quarters 1, 2 and 3. The unconfirmed position for quarter 4 is 12 cases,

with 4 pending appeal. The expectation is that these will be successful.

The Trust will not achieve the quarterly trajectory of 5 in quarter 4, but can still deliver against the annual

trajectory of 19 providing that at least 3 cases are upheld. This will deliver the criteria set out in the Risk

Assessment Framework.

2.2 Mental Health Delayed Transfers of Care

The Trust continues to report no patients delayed or awaiting transfer of care.

2.3 Mental Health Data Completeness

The Trust continues to meet Monitor’s Data completeness levels in Q3.

2.4 Community Services Information Data-Set

The Trust continues to meet Monitor’s Data completeness levels in Q3.

9

3. Junior Doctors Strike Impact

To date there have been 6 days where a junior doctor’s strike has taken place. The Trust has a dedicated

group with a clinical lead to plan for strike days. The impact on patient services is identified below for each

of the strike periods and is split by Outpatients, Inpatients, Daycases and A&E Performance.

Date of Strike Outpatient slots

cancelled

Inpatient

procedures

cancelled

Daycase

procedures

cancelled

A&E

Performance

against 4hr

target (95%)

12th

January 78 5 6 93.42%

10th

February 115 15 0 96.08%

9th

March 174

2 7 89.10%

10th

March 3 6 90.26%

6th

April 105

13 32 98.65%

7th

April 15 16 98.37%

26th

April 103 12 20

100.00%

27th

April 131 99.63%

Total 706 65 87



Date of Meeting:

Wednesday 25th

May 2016

Report Title:

CLIP Report

Recommendations:


of Governors)

To receive a summary presentation on the Complaints, Litigation, Incident

and PALS report


Information:


The attached presentation will be given at the meeting.

This has been distributed to the Council of Governors prior to the meeting to enable discussion at the

meeting.

Author:

Dr N Stefanou, Head of Quality and Mrs S Winn, Head of Risk

Presented by:

Dr N Stefanou, Head of Quality and Mrs S Winn, Head of Risk

18/05/2016

1

Governors Quality Report

Q3: October 2015 – December

2015

Presented by: Sue Winn and Nichola Stefanou

25th May 2016

PRESENTATION PURPOSE

• To trial a new interactive format, following the

workshop with Head of Quality Nichola Stefanou.

• Provide up to date information and an overview of

the work in the key domains of quality.

• Allow question to be answered throughout the

presentation.

18/05/2016

2

STRUCTURE

Share the quantity, themes, and learning from;

• Complaints

• PALS (Patient experience and information centre)

• Incidents

• Litigation (claims)

COMPLAINTSQ3 – 50 complaints received (reduced from Q2 – 60)

• Medicine – 19 complaints

Highest in General medicine (6) and Emergency Care (9)

• Surgery – 27 complaints

Highest in surgery (9) and trauma (8).

• Clinical Support & Screening– 4 complaints.

Radiology 3 and Planned Care 1

A total of 20 complaints were closed in this quarter taking an average of

36 days to complete investigations and respond

18/05/2016

3

COMPLAINT THEMES

Top three themes in Q3 were;

• Communication

• Clinical Assessment

• Staff Attitude

COMPLAINT LEARNINGConcerns where raised over the communication between staff and relatives

of a patient. There were also concerns over the discharge process.

• Communication – workshops are to be held for ward staff to increase

their confidence when dealing with patients.

• Discharge process - again communication failure and this will be

improved with training.

Concerns were raised over the care of a gentleman who had developed a

pressure sore.

• Focus of improvement and clinical supervision on the ward.

• Clinical audit to be carried out to patients, carers and relatives following

discharge, to improve patient experience.

• Pressure damage to always be monitored by senior ward staff.

18/05/2016

4

PATIENT EXPERIENCE (PALS)Medicine

77 concerns and enquiries and 78 informal complaints.

Top three themes: Clinical Assessment(Inpatient) 16, Clinical Assessment(Outpatient) 15 and

Communication 7.

Top three areas: Emergency Care, General Medicine and Older Persons Medicine.

Surgery 73 concerns and enquiries and 73 informal complaints.

Top three themes: Communication 16, appointment issues 14 and staff attitude 11.

Top three areas: Surgical Specialities, Trauma and Theatres.

Clinical Support and Screening63 concerns and enquiries and informal complaints.

Top three themes: Appointment issues 18, communication 16 and staff attitude 12.

Top three areas: Emergency Care, General Medicine and Older Persons Medicine.

COMPLIMENTS

37

6

5

3

2

2

2

2

1

0 10 20 30 40

Gynae-Oncology

Surgical Specialties

Gynaecology/Maternity

Theatres

Trauma &Orthopaedics /…

Emergency Care

General Surgery

Planned Care

Screening &Diagnostic Imaging

Surgical Business Unit (71)

50

16

2

2

1

0 20 40 60

Screening &Diagnostic Imaging

Planned Care

Radiology

Emergency Care

Support Functions(Non Clinical)

Clinical Support and Screening

Business Unit (70)

28

15

10

9

5

1

1

0 10 20 30

Paediatrics &Specialist Medicine

Emergency Care

General Medicine

Older PersonsMedicine

Old Age Psychiatry

Support Functions(Non Clinical)

Medical Specialties

Medical Business Unit (60)

The below charts show the number of compliments received by area.

18/05/2016

5

PATIENT EXPERIENCE (PALS) LEARNING

A patient travels 35 miles to attend an outpatient appointment and was

disappointed to find that Quenellies now closes early and she cannot buy

refreshments.

• Catering Manager has extended the opening to allow patients to buy refreshments.

Family member unhappy with mother’s care plan on discharge.

• Communication with this family should have been better and staff will be trained

accordingly.

Patient attend clinic with a hearing dog and security asked him to leave.

• Apologies given to patient. Briefing has been given to security staff regarding

assistance dogs to ensure this incident doesn’t happen again.

INCIDENTS1476 patient safety incidents reported. This represents a 16 % (236) decrease in the number of patient safety

incidents reported when compared with quarter two.

The following chart (left) shows the number of patient safety incident reported between April 2012 and

September 2015. The overall trend in incident reporting has gradually increased since the start of quarter one

of the of the 2012/13 period.

The table on the right shows the number and type of patient safety incidents for Q3.

900950

100010501100115012001250130013501400145015001550

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

2012/13 2013/14 2014/15 2015/16

Patient Safety Incidents Apr 2012-Dec 2015

0%

10%20%

30%40%

50%60%

70%80%

90%100%

0

50100

150200

250300

350400

450500

Pa

tien

t falls

Me

dica

tion

Disch

arg

e o

r tran

sfer issu

e

Ap

po

intm

en

t / list issue

s

Blo

od

tran

sfusio

n

De

lay / fa

ilure

to tre

at /…

Pre

ssure

da

ma

ge

Pa

tho

logy sam

ple

issue

s

Pa

tien

t info

rma

tion

Staffin

g / re

sou

rce issu

e

Eq

uip

me

nt

Ma

tern

ity / foe

tal / n

eo

na

tal

Re

sults / in

vestig

atio

ns issu

es

Co

mm

un

icatio

n fa

ilure

Pa

tien

t accid

en

t (no

n-fa

ll)

Op

era

tion

s / pro

ced

ure

s

Infe

ction

pre

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tion

& co

ntro

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Info

rma

tion

gove

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Ima

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e

Vio

len

ce, a

bu

se a

nd

…

Safe

gu

ard

ing

Pa

tien

t em

erg

en

cy

Facilitie

s issue

Q3 Patient Safety Incidents 2015/16

18/05/2016

6

INCIDENTS

0

50

100

150

200

250

Jan

20

14

Fe

b 2

01

4

Ma

r 20

14

Ap

r 20

14

Ma

y 20

14

Jun

20

14

Jul 2

01

4

Au

g 2

01

4

Se

p 2

01

4

Oct 2

01

4

No

v 2

01

4

De

c 20

14

Jan

20

15

Fe

b 2

01

5

Ma

r 20

15

Ap

r 20

15

Ma

y 20

15

Jun

20

15

Jul 2

01

5

Au

g 2

01

5

Se

p 2

01

5

Oct 2

01

5

No

v 2

01

5

De

c 20

15

Falls, Medication & Pressure Damage Incidents (Jan 2014 - Dec 2015)

Medication Patient falls Pressure damage

Three of the top patient safety incidents that were reported are shown below:

Falls, medication and pressure damage.

INCIDENT REPORTING RATE

26.73

31.89 32.40

28.56 28.32 27.0829.37 30.76

33.88

24.0626.40

0.000

5

10

15

20

25

30

35

40

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

REPORTING RATE PER 1000 BED DAYS

14181224

1466

827

0

500

1000

1500

2000

APR 15 -JUN 15 JUL 15 - SEP 15 OCT 15 - DEC 15 JAN 16- MAR 16

INCIDENTS

18/05/2016

7

SEVERITY OF HARM

0

100

200

300

400

500

Oct-15Nov-15

Dec-15

339 (23%)

351(24%)

423(29%)

No Harm

0

5

10

15

Oct-15Nov-15

Dec-15

12(0.85)

1(0.07%)

8(0.5%)

Moderate harm

0

1

2

3

4

5

Oct-15Nov-15

Dec-15

2(0.14%)

1(0.07%)

5 (0.3%)

Severe Harm

SERIOUS INCIDENTSSlips/trips/falls meeting SI criteria (fractured neck of femur/broken hip) 7

Pressure ulcer meeting SI criteria (grade 3 or 4) 2

Apparent/actual/suspected self-inflicted harm meeting SI criteria 1

Medication incident meeting SI criteria 1

Total 11

Learning

Incident 1:

Patient who was 7 days post-operative after Proctectomy bowel surgery.

While recovering on ITU the patient underwent the insertion of a bowel management system (BMS) to control diarrhoea.

This caused an internal tear as the correct procedures had not been followed.

The patient was required to return to theatre to have the tear repaired.

Action Taken: Prompt assessment was undertaken and surgical treatment to repair the damage caused.

Learning: Staff should always check with medical staff if a BMS can be used on patients prior to the use of such a system.

The BMS checklist that was produced as part of the action plan for this incident must always be completed prior to using the

system.

18/05/2016

8

SERIOUS INCIDENTS

Incident 2:

Patient who was usually mobile with a stick and had a history of confusion and falls at home, sustained an

unwitnessed fall and was found on the floor next to the toilet.

The patient had remained confused since admission and was being treated for possible pneumonia.

They had been advised to remain mobile throughout the hospital stay.

The correct falls prevention measures had not been put in place for the patient.

Action Taken: Post fall observations were recorded.

Medical staff reviewed the patient who sustained a laceration to their right arm.

Non-slip socks were subsequently issued to patient and a bed/chair alarm used.

Learning:

Staff have been made aware of the critical importance of falls prevention measures and work is ongoing in

the ward.

Staff recognize this may have prevented the fall if put in place when the patient was admitted to the ward.

Zone nursing is now being implemented to improve visibility when cohort nursing is not possible.

DUTY OF CANDOUR23 incidents in the Trust required the Duty of Candour process to be carried out in Q3.

The chart below shows a breakdown of severity of harm and clearly shows that the necessary

guidelines we followed for the verbal notification as part of the Duty of candour, in all cases.

Month 2015

Total Duty of

Candour

Incidents

Severe Harm Moderate Harm

Duty of Candour

carried out on

time

% Compliance

October 13 2 11 13 100%

November 2 1 1 2 100%

December 9 5 4 9 100%

In order to improve the recording of Duty of Candour documentation, an audit will be carried out by

the Risk Team. The intention is to validate the level of documentation that is currently recorded

against Datix incidents.

The Risk Team will then identify service improvements and relevant process changes to ensure

that the trust achieves a high standard for the entire process.

This will entail liaising with business units to discuss the service improvements once the audit has

been completed.

18/05/2016

9

LEGAL– CLINICAL NEGLIGENCEThe chart on the left shows the number and type of claims that have been by quarter

The pie chart on the right shows the breakdown of the business unit these were sent to.

No admissions have been made in relation to the 21 claim notifications received Oct to Dec 2015.

None of the claims received in Oct to Dec 2015 are deemed to be of a high litigation risk to the Trust.

1720

25

18

31

2

21 1

0

5

10

15

20

25

30

Jan to Mar2015

Apr to June2015

Jul to Sept2015

Oct to Dec2015

Requests for records Letter of claim Proceedings

Medicine(3)

Surgical(8)

Clinical Support

and Screening

(1)

Medicine Surgical

(3)

MedicineClincal

Support(1)

TSS(2)

Unknown(3)

LEGAL– CLINICAL NEGLIGENCEMaternit

y(3)

A&E(3)

General Surgery

(3)

Orthopaedics(2)

Bowel Screenin

g (1)

GastroCardiolo

gy(1)

A&E Gynae

(1)

A&E Physio(1

)

Gynae A&E

Radiology (1)

TSS (2)

Unknown (3)

The pie chart to the left shows the Trust’s

proportion/percentage of claims open with the NHSLA in

respect of the specialties with the highest percentage of

claims.

The spilt for the Trust reflects the spilt nationally i.e. the

highest percentage of claims nationally are for maternity,

general surgery and A and E as these areas are

considered to be high risk.

Damages £9,511,336.87

Claimant's costs

£160,401.44

Defence Costs£130,262.04

9350000

9400000

9450000

9500000

9550000

9600000

9650000

9700000

9750000

9800000

9850000

Total amount paid (£)

The graph to the right shows the

amounts paid by the NHSLA in

respect of Clinical Negligence

Scheme for Trusts (CNST) claims

from Oct to Dec 2015.

18/05/2016

10

LEARNINGLegal Services continues to encounter issues in relation

health records. Records issues include:

• Incorrect filing of patients’ notes within records

• Filing of legal responses within records

• Lost/missing/incomplete records

• Failure to track records

• Failure to note dates and times within the records

• Illegible signatures

INQUESTS

5

12

15

5

0

5

10

15

20

Jan to Mar 2015 Apr to June Jul to Sept 2015 Oct to Dec 2015

Notification of inquests recevied per quarter

Learning from Inquests

Inquest hearings for the inquests the Trust was notified of between Oct to Dec 2015 are yet to be listed.

Focus has therefore been placed on inquest hearings, pre-inquest review hearings that took place in the

quarter and themes more generally.

Issues arising for Inquests

• Lack of/poor communication with family as to decisions as to care of those without capacity,

especially in relation to DNACPR

• Lack of/poor communication with family as to the condition and prognosis of the patient

• Poor quality/re-writing of RCA investigations and reports

• Length of time taken to produce information to the coroner

18/05/2016

11

INQUESTS

Issues arising for Inquests

• Lack of/poor communication with family as to decisions

as to care of those without capacity, especially in relation

to DNACPR

• Lack of/poor communication with family as to the

condition and prognosis of the patient

• Poor quality/re-writing of RCA investigations and reports

• Length of time taken to produce information to the

coroner

EMPLOYEE AND PUBLIC LIABILTY CLAIMS

The charts show the amount of new (non clinical) claim notifications (4) that

have been received during the period of October to December 2015.

1

4

131 1

1

012345

Jan toMar

2015

Apr toJune2015

Jul toSpet2015

Oct toDec

2015

Employee Liability Public Liability

Liability has been admitted in relation to one Employee

Liability claim received within this quarter, chart to the

left.

Damages£75,089.40

Claimant's costs

£53,438.50

Defence Costs

£11,430.85

0

20000

40000

60000

80000

100000

120000

140000

160000

Total amount paid (£)

The chart to the right shows the

amounts paid by the NHSLA in respect

of LPST claims from Oct to Dec 2015.

18/05/2016

12

EMPLOYEE AND PUBLIC LIABILTY CLAIMS

Learning

Manual Handling

• Fitness risk assessments for tasks.

• Up to date training for all business units.

• Adequate risk assessments and training.

DISCUSSION POINTS

18/05/2016

13

EVALUATION AND FEEDBACK

• Was the data included adequate?

• Did you feel able to engage?

• Suggestions for improvement?



Date of Meeting:

Wednesday 25th

May 2016

Report Title:

Governor Activities

Recommendations:


of Governors)

To receive the report for information


Information:


The report details governor activities from 17th

February 2016 to 17th

May 2016 inclusive including

attendance at events and meetings and information from the online feedback form.

Author:

Mrs J Williamson, Membership Co-ordinator

Presented by:

Mrs D Atkinson, Trust Secretary


25th



Governor Activities

1. Introduction

Data for the report has been compiled from attendance at events and meetings and from the

online feedback form.

The time period of the activities below covers 17th

February 2016 to 17th

May 2016 inclusive.

2. Governor Activities

During the period, 16 survey responses were received from governors after attending an event or

meeting. The feedback was as follows:

2

6

3

4

1

0

1

2

3

4

5

6

7

8

A p

ub

lic

ev

en

t

(in

tern

al

to t

he

Tru

st)

Re

cru

itm

en

t/E

ng

ag

em

en

t

A m

ee

tin

g o

r

con

fere

nce

(in

tern

al)

A t

rain

ing

se

ssio

n

(in

tern

al)

A m

ee

tin

g o

r

con

fere

nce

(ext

ern

al)

What are you providing feedback about?

6

45

1

76

2

0

2

4

6

8

10

12

14

Ta

lke

d t

o p

eo

ple

ab

ou

t th

e T

rust

info

rma

lly

Re

cru

ite

d n

ew

me

mb

ers

Co

ntr

ibu

ted

yo

ur

vie

ws

to a

dis

cuss

ion

or

con

sult

ati

on

Lea

rne

d m

ore

ab

ou

t

the

ro

le o

f F

T

go

ve

rno

rs

Lea

rne

d m

ore

ab

ou

t

the

Tru

st

Lea

rne

d u

sefu

l n

ew

skil

ls/k

no

wle

dg

e

Oth

er

Please let us know if you did any of the

following

3. Recommendation

The Council of Governors is asked to note this summary and the activities report attached as

Appendix 1.

Debbie Atkinson

Trust Secretary

1 1

4

0

1

0

1

2

3

4

0-5 6-10 11-20 21-50 More than 50

If you were able to recruit new members, how

many did you recruit?

0 2 4 6 8 10 12

I learned a lot

It was worthwhile to me personally

I was able to contribute usefully

I was clear about why I was there

I enjoyed myself

I think my being there was of benefit to the Trust

Potentially, my being there was of benefit to patients

I would be happy to do this again

N/A Strongly Agree Agree Not Sure

Appendix 1

Governor Activities

Public and Staff

Governor Name Activity Date

Eileen Adams

Medicine for Members – Prostate Cancer 17/02/2016

Visit to Jubilee Wing and Medical Wards 01/03/2016

Governors’ Workshop – Quality Governance 09/03/2016

Patient Experience Group 14/03/2016

OPD Recruitment 17/03/2016

OPD Recruitment 05/04/2016

Medicine for Members – Dementia 20/04/2016

Membership Strategy Sub Group 12/05/2016

Sue Begg Membership Strategy Sub Group 12/05/2016

John Bolam Membership discussion with Margaret Jobson and Michael Loome 23/03/2016

Membership Talk – Ellison Road Methodist Church 06/04/2016

Joanne Coleman

Staff Governors’ Meeting 07/03/2016

Board of Directors’ Meeting 23/03/2016

NHS Providers Governor Focus Conference 20/04/2016

Corporate Induction Marketplace 03/05/2016

Steve Connolly

Visit to Emergency Care Centre 25/02/2016


Meeting with Phil Pugh re Infection Control Committee 04/04/2016

Corporate Induction 05/04/2016


Alan Dougall




Andrea Hayward Staff Governors’ Meeting 07/03/2016


Jim Holmes


PLACE 02/03/2016

PLACE 08/03/2016


PLACE 10/03/2016

PLACE 23/03/2016


Theatre Users Group 30/03/2016

Human Resources Committee 12/04/2016

SafeCare Council 13/04/2016

PLACE 20/04/2016


SafeCare Council 11/05/2016


Observational Visits Workshop 16/05/2016

Margaret Jobson


Recruitment at OPD 02/03/2016


Governors’ Noticeboard Photo, Discussion and Recruitment at OPD 23/03/2016






Patient Experience Group 16/05/2016


Michael Loome


Visit to Emergency Care Centre 25/02/2016

Visit to Maternity 03/03/2016


Visit to Pathology 17/03/2016

Membership discussion with Margaret Jobson and John Bolam 23/03/2016


PQRS Meeting 15/04/2016




Jackey Lockwood


Visit to Jubilee Unit and Medical Wards 01/03/2016



Paula MacGregor Staff Governors’ Meeting 07/03/2016


Lynn Ritchie

NHS Providers Training – Governor Accountability 15/03/2016


Governor Accountability – presentation preparation 22/04/2016

Mental Health Committee 13/05/2016

Mary Summers

Equality and Diversity Steering Group 17/02/2016

Visit to Jubilee Wing and Medical Wards 01/03/2016

Visit to Maternity 03/03/2016

PLACE Audit QEH 08/03/2016


PLACE Audit QEH 10/03/2016

PLACE Audit ICAR 16/03/2016

PEAG Meeting 07/04/2016

Safeguarding Committee Meeting 08/04/2016


PLACE Inspection 27/04/2016

PLACE Inspection 04/05/2016

Equality and Diversity Training 09/05/2016

Ian Stafford Staff Governors’ Meeting 07/03/2016

Corporate Induction Marketplace 03/05/2016

Janice Todd

Meeting with Phil Pugh re Infection Control Committee 04/04/2016


Safeguarding Committee 08/04/2016

Teresa Waring Governors’ Workshop – Quality Governance 09/03/2016


In addition, appointed governors have also been able to attend the following events:


Pam Dawson Governors’ Workshop – Quality Governance 09/03/2016

Judith Doyle Corporate Induction Marketplace 02/03/2016

Meeting to discuss Membership with Trust Secretary 03/05/2016



Date of Meeting:

Wednesday 25th

May 2016

Report Title:

Feedback from NHS Providers Governor Focus Conference 2016

Recommendations:


of Governors)

To receive the presentations and verbal update for information


Information:


To provide the Council of Governors with the presentation slides and a verbal update from the recent

NHS Providers Governor Focus Conference

Author:

Mrs J Coleman, Staff Governor

Presented by:

Mrs J Coleman, Staff Governor

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