Council of Governors Meeting - North Tees and Hartlepool ... · e presented at a future Council of...

Council of Governors Meeting

Thursday, 18 September 2014

Conference Room 1 Hartlepool College of Further Education

PG/CN 28 July 2014 Dear Colleague A meeting of the Council of Governors will be held on Thursday, 18 September 2014 at 10.00am in Conference Room 1, Hartlepool College of Further Education, Stockton Street, Hartlepool TS24 7NT. Refreshments will be served from 9.30am. Free car parking is available. Yours sincerely

Paul Garvin Chairman Agenda 9.30am Refreshments (1) 10.00am Welcome Chairman (2) 10.00am Apologies for Absence Chairman (3) 10.00am Declaration of Interests (4) 10.05am Minutes of the last meeting held on 17 July 2014 (enclosed) Chairman (5) 10.10am Matters Arising Chairman (6) 10.20am Chairman’s Report and Board Business Chairman (7) 10.30am Chief Executive’s Report Alan Foster (8) 10.40am Quality Report (enclosed) Cath Siddle (9) 10.50am Staff & Patient Experience and Quality Standards Report (enclosed) Cath Siddle (10) 11.00am Infection Prevention and Control Report (enclosed) Cath Siddle (11) 11.10am Compliance & Performance Report (enclosed) Julie Gillon (12) 11.20am Operational Resilience Report 2014/15 (enclosed) Julie Gillon

11.30am Comfort Break (13) 11.40am Momentum: Pathways to Healthcare Programme Update (enclosed) - New Hospital Update - Service Transformation Update Julie Gillon/Neil Atkinson (14) 11.50am Finance and Contract Performance Report as at 31 July 2014 (Month 4) (enclosed) Neil Atkinson (15) 12.00pm Human Resources and Education Quarter 1 Report April to June 2014 (enclosed) Alan Sheppard (16) 12.10pm Staff Survey Actions & Progress Report (enclosed) Alan Sheppard (17) 12.20pm 2015 Council of Governors Schedule of Meetings, including Sub Committees

(enclosed) Barbara Bright (18) 12.30pm Sub-committee Minutes (enclosed) (18.1) Travel and Transport Committee – 1 September 2014 John Cairns (18.2) Nominations Committee – 27 August 2014 Barbara Bright (18.3) External Audit Working Group – 14 July 2014 Neil Atkinson (18.4) Membership Strategy Committee – 18 August 2014 Wendy Gill (19) 12:40pm Non-Executive Director Re-appointment (enclosed) Barbara Bright (20) 12.45pm Any Other Notified Business Chairman Date and Time of Next Meeting The next meeting is scheduled to take place on Thursday, 15 January 2015, Londonderry Room, Wynyard Rooms

Governors Roles and Responsibilities Holding the Board of Directors to Account

1. Key Principles

1.1 The overall responsibility for running an NHS Foundation Trust lies with

the Board of Directors. 1.2 The Council of Governors is the collective body through which the

directors explain and justify their actions. 1.3 Governors must act in the interests of the NHS Foundation Trust and

should adhere to its values and Code of Conduct.

2. Standard Methods for Governors to Provide Scrutiny and Assistance

2.1 Receiving the Annual Report and Accounts. 2.2 Receiving the Quality Report and Account. 2.3 Receiving in-year information updates from the Board of Directors. 2.4 Receiving performance appraisal information for the Chair and other Non-

executive Directors. 2.5 Inviting the Chief Executive or other Executive and Non-executive

Directors to attend the Council of Governors meetings as appropriate.

3. Further Methods Available for Governors

3.1 Engagement with the Board of Directors to share concerns. 3.2 Employment of statutory duties. 3.3 Dialogue with Monitor via the lead Governor (if necessary and only in

extreme circumstances)

Glossary of Terms

Strategic Aims and Objectives

Strategic Aims

Putting Patients First – to create a patient centred organisational culture by engaging and enabling all staff to add value to the patient experience and demonstrated through patient safety, service quality and LEAN delivery.

Integrated Care Pathways – to develop and expand the portfolio of services to provide integrated care pathways for the people of Easington, Hartlepool, Sedgefield and Stockton providing equal access to acute care and care as close to home as possible in line with Momentum: Pathways to Healthcare.

Service Transformation – to improve and grow our healthcare services to continually review the needs of our healthcare community and transform services. In line with evidence based guidelines we will enhance quality, clinical effectiveness and patient experiences whilst improving clinical outcomes.

Manage our Relationships – to ensure our services, and the way we provide them, meet the needs of our patients, commissioners and other partners by proactively engaging with all appropriate stakeholders including our staff, through communications, engagement and partnership working.

Maintain Compliance and Performance – to maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business.

Health and Wellbeing – to embrace the health and well being of the population we serve and ensure that the health needs of the people of Easington, Hartlepool, Sedgefield and Stockton are reflected and catered for in the commissioning of services from the Trust.

Strategic Objectives Maintain Compliance and Performance – assurance around compliance with standards, performance indicators and requirements within the Terms of Authorisation. Requirement to provide Board regulation and self certification on a quarterly and annual basis in accordance with Monitors Terms of Authorisation. Seasonal Pressures – requirement to ensure preparedness for seasonal winter pressures. Reduce Hospital Acquired Infections – supports the Trust’s key strategic theme of; Maintain Compliance and Performance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of the Trust business. Effective Board Governance – corporate oversight and scrutiny will continue to be provided by key management structures; 1. Board of Directors, 2. Executive Team, 3. Trust Directors Group. Training – ensuring the workforce is appropriately trained.

Workforce – absence management, ensuring we have adequate staffing levels that provide safe and effective care to our patients. Momentum – Pathways to Healthcare – delivery of a new healthcare system for the people of Easington, Hartlepool, Sedgefield and Stockton. Putting Patients First / Patient Safety – to create a patient-centred organisation by engaging and enabling staff to add value to the patient experience, demonstrated through patient safety, service quality and LEAN delivery. Finance – to maintain our performance and compliance with required standards and continually strive for excellence by good governance and operational effectiveness in all parts of our business.

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North Tees and Hartlepool NHS Foundation Trust

Minutes of the Council of Governors’ Meeting held on Thursday, 18 September 2014

in Conference Room 1, Hartlepool College of Further Education Present: Paul Garvin, Chairman Hartlepool Elected Governors: Staff Elected Governors: Pauline Robson Pat Ferguson Maureen Rogers Manuf Kassem Thomas Sant Matt Wynne Roger Morrow Carol Alexander Chander Parkash Nina Bedding Deborah Gardener Stockton Elected Governors: Chris Clough Appointed Governors: Mary Morgan Gerard Hall, Hartlepool Borough Council Margaret Docherty Carol Ellis General Public: James Newton Laura Bradwell Patricia Upton Megan Greening Rebecca Hollingsworth Sedgefield Elected Governor: Danielle Mann Wendy Gill Michelle Wells Bill Keen Easington Elected Governors: John Cairns Mary King Denise Rowland In attendance: Alan Foster, Chief Executive Julie Gillon, Chief Operating Officer/Deputy Chief Executive David Emerton, Medical Director Cath Siddle, Director of Nursing, Patient Safety and Quality Brian Dinsdale, Non-Executive Director Michael Bretherick, Non-Executive Director Rita Taylor, Non-Executive Director Steve Hall, Non-Executive Director Ken Lupton, Non-Executive Director Neil Atkinson, Deputy Director of Finance and Commercial Opportunities Barbara Bright, Deputy Director of Human Resources/Company Secretary Alan Sheppard, Deputy Director of Education and Organisational Development Claire Young, Head of Communication Claire Nixon, Private Office Manager/ PA to Director of HR&E Nickola Graham, Private Office Assistant/ PA to Deputy Director of HR/Company Secretary CoG/510 Welcome The Chairman opened the meeting and thanked Governors for their attendance. CoG/511 Apologies for Absence Apologies for absence were received from Ann Burrell, Director of HR & Education, Lynne Hodgson, Director of Finance, ICT & Support Services, Ann Cains Elected Governor for Stockton, Kate Wilson Elected Governor

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for Stockton, Janet Atkins Elected Governor for Stockton, Shirley Erskine Elected Governor for Stockton, Robin Coningham, Appointed Governor for Durham University, Morris Nicholls, Appointed Governor for Durham County Council and Professor Tom Lennard, Appointed Governor for University of Newcastle. CoG/512 Declaration of Interest There were no declarations of interest received. CoG/513 Minutes of the Last Meeting held on 17 July 2014 The minutes of the last meeting were signed by the chairman as a true record. CoG/514 Matters arising a. CoG/ 505 Outline Business Case (OBC): Pathology Collaboration between North Tees &

Hartlepool NHS FT and South Tees Hospitals NHS FT & North Tees Out-Patient Pharmacy The Chief Executive provided an update on out-patients‟ pharmacy which is to be named Panacea. Out patients pharmacy was to relocate to the old George Hardwick Foundation centre, and was expected to be officially opened by Duncan Banatynne on the 6 October 2014. The Chief Executive advised that Out Patients pharmacy was an income generating venture and would generate VAT savings as well as being able to offer retail revenue similar to other pharmacies. The future plan was to apply for a licence to be able to process non hospital prescriptions. Following a query from a member the Chief Executive explained that staff had been fully involved with the process, and would rotate through both services. It was expected that the pharmacy would expand and recruit more staff therefore no redundancies were expected. Following a query from a member the Chief Operating Officer/Deputy Chief Executive advised that prescription waiting times were continually reviewed and it was hoped Panacea would ease waiting times further. It was agreed a report on discharge times would be presented at a future Council of Governors meeting. Following a members query the Chief Executive explained that he and Steve Hall, Non-Executive Director were the main Directors of the Optimus Commercial Company Board, and were accountable to the main Trust Board. Following discussion regarding how the revenue would be spent it was agreed to have a seminar session on the activities of the commercial panel at a future Council of Governors meeting.

Resolved: (i) A future seminar session, to include presentation from the Commercial panel, (ii) discharge report to be presented at a future Council of Governors meeting (iii) that, the information be noted.

CoG/515 Chairman’s Report and Board Business a. Consultants Appointments The Chairman reported on Consultant appointments that had taken place since the last meeting 2014: 1. Dr Tarkeshwari Mane, Consultant Anaesthetist in Anaesthetics appointed following interview on 21 July

2014; 2. Dr Maria Ahmad, Consultant Histopathologist, in Pathology appointed following interview on 25 July 2014; 3. Dr Catriona Lane, Consultant in Emergency Medicine appointed following interview on 1 August 2014; 4. Mr Robert Anderson, Consultant in Emergency Medicine appointed following interview on 1 August 2014; 5. Mr Richard Jeavons, Consultant Orthopaedic Surgeon - Upper Limb in Orthopaedics appointed following

interview on 11 August 2014; 6. Dr Graham Miller, Consultant in Respiratory Medicine appointed following interview on 1 September 2014;

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7. Mr Lanre Ajekigbe, Consultant Orthopaedic Surgeon - Hand & Wrist in Orthopaedics appointed following interview on 8 September 2014.

Following a query from a member the Chairman advised that the Trust had been able to successfully attract good candidates, with difficulties being in a minority of sub specialist areas.

b. New Hospital The Chairman reported that following a meeting between himself, the Director of Finance, ICT & Support Services, the Chief Executive and Chairman of Hartlepool and Stockton Commission Care Group and the Department of Health, it had been proposed that the Trust reviewed a further 4 areas to complete the business case submission to the department of Health and Treasury. This had now been completed and the Trust were awaiting a final decision from the Treasury. c. South Tees Collaboration The Chairman reported on a meeting between the Chief Executives and Chairs of the Trust and South Tees Hospitals NHS Foundation Trust. Opportunities for collaboration were being explored which could help both Trusts support each other. A three way meeting to include County Durham and Darlington FT was also to be arranged to discuss wider collaboration. d. Foundation Trust Network The Chairman reported that he had attended a North East Chairs‟ meeting for the Foundation Trust Network (FTN) members. Regional representation on the FTN Board was being sought so that there would be wider representation.

e. Westminster Briefing – The Future of NHS Leadership The Chairman reported that he had attended a conference the previous day on the future of NHS leadership. This had looked at how leaders could facilitate an improvement in patient care and move towards providing a fully integrated service across all sectors. f. Closure of Day Nurseries Following media coverage, the Chairman reported on the decision to close the Trust‟s day nurseries. The day nurseries had been set up many years ago to help staff return to work, however less than half of the current occupancy was children of Trust employees. Local Authority grants had been withdrawn and it was no longer acceptable for this service to be subsidised with support from frontline healthcare budgets. The Chairman advised that the Trust had undertaken a detailed financial affordability review and highlighted that the financial position of the nursery over the last 4 years showed that this was no longer a viable service to provide. Steve Hall Non-Executive Director, a member of the commercial panel, provided assurance that all commercial opportunities by way of outsourcing this service had been explored and exhausted. The Trust would continue to work with staff, parents and the unions and a further update would be provided at the next meeting of the Board of Directors. g. Haematology The Chairman reported that discussions were on-going with neighbouring organisations in collaboration to provide in patient haematology services in order to maintain the highest standard of delivery within the Tees-wide area. The MD explained that the Trust currently provided level 1, 2a and 2b services but that due to a shortage of Consultants the Trust would be unable to provide the level 2b service in the near future. The Trust had re-advertised for a substantive Consultant Haematologist post, however it was noted that even if the

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Trust were successful in recruiting to this post, this would not improve the current position and the Trust would still be unable to provide a sustainable level 2b service. Following a query from a member the chairman advised that patient transport services such as volunteer driver scheme and shuttle bus would be available for patients and relatives. h. Expenses The Chairman requested that all Governor mileage claims submitted to the Private Office for payment should be within the three month cut of period only.

Resolved: that, the information be noted. CoG/516 Chief Executive’s Report a. Tracy Noble & Mandy Forth The Chief Executive was pleased to report that the Trust had won first prize in a poster competition run by the International Society of Orthopaedic and Trauma Nurses, designed to reduce missed follow up appointments. b. Modern Apprentices The Chief Executive reported that the Trust had been shortlisted from over 1,300 entries in the workforce category of the Health Service Journal awards for the Trusts modern apprentice programme. As a Trust health care assistants are no longer recruited without them going through the Trusts modern apprentice programme, ensuring they develop the skills and behaviours, including literacy, numeracy and compassion in practice (6C‟s). Esther Blakey Nursing Resource Team Manager and her team were scheduled to present to the judges on 7 October 2014. c. Mealtime Companions The Chief Executive advised that the Trust was in the process of recruiting mealtime companions to support staff on the wards by encouraging patients to eat and drink in a calm and sociable atmosphere, helping to make mealtimes a more enjoyable and social experience. d. Tracey Cramond The Chief Executive reported that Tracey Cramond, Procurement, Contracts Support Officer for the Trust, had been the 1 millionth finisher of the Great North Run. He placed on record his congratulations to Tracey for this achievement. e. International Congress on Patient Safety The Chief Executive reported that Janet Alderton, Assistant Director of Clinical Governance was due to present on improving patient safety and quality at the International Congress on Patient Safety in Madrid. This promoted the Trust internationally and staff were commended for being selected to present at this prestigious event. f. Local Area Teams The Chief Executive reported that consultation was underway with regards to the organisation of Local Area Teams. Area teams currently provided oversight to the Clinical Commissioning Groups (CCG) and were responsible for commissioning primary and specialist care. A reduction in the number of Area Teams had been proposed, which would result in larger geographical area team management. It was likely that this would result in a North East and Cumbria Area Team. It was also proposed that the CCG co-commission primary care and that potentially specialist commissioning would return to their control. g. Cancer Services

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The Chief Executive reported that discussions were on-going with the CCG, Area Team and Public Health to address the current pressures being experienced in meeting cancer performance targets. h. Winter Planning The Chief Executive reported that the Chief Operating Officer/Deputy Chief Executive was leading on securing extra funding for additional resilience and capacity to ensure safe patient flow through the winter months. Following a query from a member the Medical Director confirmed that Dermatology services were available at North Tees, via visiting consultants.

Resolved: that, the information be noted. CoG/517 Quality Report

The Director of Nursing, Patient Safety and Quality presented the Quality Report and drew members‟ attention to key areas: The Trust‟s Care Quality Commission (CQC) priority banding for inspection remained at Band 4. The Director of Nursing, Patient Safety and Quality had met the CQC and other organisations which had already been inspected to gain information on the format and work required for the inspections. The overall relative risk for Hospital Summary Mortality Ratio (HSMR) from June 2013 to May 2014 had increased from 118.17 to 119.76 and continued to be outside the „as expected‟ range. The Trust‟s crude mortality rate for HSMR had reduced from 3.45 to 3.43. The latest Summary Hospital-Level Mortality Indicator (SHMI) value for the latest 12 month period ending December 2013 was reported at 112.78 compared to 113.08 the previous reporting period. This remained in the “higher than expected” range but demonstrated a slight reduction. The Trust‟s crude mortality rate for SHMI had reduced from 3.99 to 3.91. Since 1 April 2014 the Trust had received 505 complaints, of which 94 had progressed to formal stage 3 complaints. The highest number of complaints related to communication and insufficient information. The compliance in complaint turnaround times for stage 3 (formal response) for July 2014 was at 94%. The Friends and Family response rate for quarter 1 was 51.33% for inpatients and 17.17% for Accident and Emergency. These values met CQUIN‟s quarter 1 minimum target of 20% for inpatients and 15% for Accident and Emergency. The Trust used a token system in Accident and Emergency to record patient experience, however from April 2015 this would no longer be allowed. Plans were in place to re-introduce paper forms into Accident and Emergency later in the year. The Trust were an early adopter site and ran a two week trial in August 2014 for the new outpatients and day case Friends and Family Test. Outpatients had a net promoter score of 52, with 90% likely or extremely likely to recommend the Trust. Day cases had a net promoter score of 87, with 98% likely or extremely likely to recommend the Trust. A further two week trial would take place in September 2014 and would be carried out in different areas of the Trust. There had been no never events reported in quarter 1 of 2014/15.

Resolved: that, the information be noted.

CoG/518 Staff & Patient Experience and Quality Standards Report The Director of Nursing, Patient Safety and Quality reported that Liz Harris, Director of Nursing from Sunderland City Hospital shadowed a recent Staff & Patient Experience and Quality Standards visit, which proved to be successful and the Trust were exploring the possibility of further sharing. Patient Experience and Quality Standards (PEQS) had now been renamed Staff and Patient Experience and Quality Standards (SPEQS) to include the staff element of the reviews. From August 2014 the highest score achieved had been 100% by 10 wards/areas, which was up from 6 in July 2014. 3 wards scored under 90% and these would be re-assessed under an unannounced SPEQS visit at a later date with feedback being

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delivered to the relevant Senior Clinical Matrons with improvement plans put in place. The Trust‟s first impressions average in August 2014 was 93.59%, this had reduced from 96% the previous month. The Trust‟s nursing evidence average had increased from 85.68% to 87.61%. Following a query from a member the Director of Nursing, Patient Safety and Quality advised that early warning alerts were in place to ensure improvement plans were in place.

Resolved: (i) that a correlation of complaints against Staff & Patient Experience and Quality Standards Visits is undertaken.

(ii) that, the information be noted. CoG/519 Infection Prevention and Control Report The Director of Nursing, Patient Safety and Quality presented the Infection Prevention and Control Report for quarter 1, and drew members‟ attention to key areas: The Trust were reporting 8 Trust attributed cases of Clostridium Difficile (C-Diff) infection up to 18 September 2014. This was over trajectory for the month but with a total of 8 Trust attributable cases to date, the Trust were well within the year to date trajectory of 16 cases. There had been 12 Trust attributable cases of Methicillin Sensitive Staphylococcus Aureus (MSSA) bacteraemia for 1 September 2014 and 7 case of Escherichia Coli bacteraemia (E-coli) bacteraemia. There had been no Trust attributable cases of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia for the year to 31 August 2014. Resolved: that, the information be noted. CoG/520 Compliance and Performance Report The Chief Operating Officer/Deputy Chief Executive presented the Compliance and Performance Report and drew members‟ attention to the key points. In July, overall performance against key operational standards and trajectories remained relatively positive, though a number of in month challenges remained. In comparison to the same period last year, non-elective activity indicated a decrease of 4.7% and A&E attendances indicated a decrease of 1.9%, compared to the same period the previous year. The Trust achieved against the emergency care 4 hour target in July 2014. The Trust continued to demonstrate positive performance against the original 18 week Referral to Treatment (RTT) pathway standard, with all standards achieved at aggregate level. The Trust had experienced significant pressure in achieving the 14, 31 and 62 day cancer pathway standards during June, with both the June and final quarter 1 position reporting outside the required standard against three of the targets; breast symptomatic 2 week wait, cancer 2 week wait and 62 day urgent referral to treatment target. One of the key areas of impact continued to be the uptake of patient choice, causing delay in the diagnosis and treatment stages within the pathway. The Trust continued to work with local GPs and CCG leads to ensure continued support to encourage patients to take up appointments offered within the required timescales. The Chief Operating Officer/Deputy Chief Executive advised that the Trust was working with the CCG's to allow patients to be referred back to their GP if they failed to attend for an appointment more than twice. In addition, that where a patient chose to delay treatment at the diagnostic stage of the pathway, that they be removed from the 62 day standard. These recommendations were in-line with Department of Health guidance. The intensive Management Support Team (IMAS) had been invited into the organisation to review current practices and give an objective view of any further actions that could be implemented to improve the Trust‟s delivery against the cancer standards. The team would be on-site between 29 and 30 September 2014. Following a query from a member the Chief Operating Officer/Deputy Chief Executive reported that the decrease in activity at A&E was due to the case mix changing throughout the summer months as well as the population using the local centres such as Onelife in Hartlepool. Resolved: that, the information be noted.

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CoG/521 Operational Resilience Report 2014/15 The Chief Operating Officer/Deputy Chief Executive presented on operational resilience highlighting that the National Focus had changed to include elective care. The Trusts winter capacity and surge plan 2014/15 had been produced in line with the national context and requirements articulated by NHS England, now merging into an operational resilience plan. The Trust held a winter debrief session in March 2014, reviewing the organisations capacity and capability to manage the pressures faced last winter. The lessons learnt from this debrief session had been used to improve the planning process for 2014/15. The Chief Operating Officer/Deputy Chief Executive provided assurance with regards to readiness for winter resilience, this had been managed in a number of ways including;

Strong leadership and governance arrangements with active engagement throughout the Trust in planning for resilience to support potential surge in activity.

Action planning to manage the changes in profile of surges in emergency activity whilst continuing to deliver elective and urgent activity requirements.

Bids had been submitted to the clinical commissioning group for work streams to support operational resilience, elective and emergency access, patient flow and timely discharges.

Pathway reviews with the introduction of new plans to ensure that patients are streamed and seen in the most appropriate setting.

Continuous benchmarking including visits to other organisations to assess and manage ways of working in the future.

The Chief Operating Officer/Deputy Chief Executive also reported in addition, an action plan is to be developed to manage the demands on A&E and EAU and the changing profile of activity surges which will include proactive discharge preparations on the base wards as well as exploration of a GP resident.

Resolved: (i) the information be noted.

CoG/522 Momentum: Pathways to Healthcare Programme Update The Chief Operating Officer/Deputy Chief Executive provided a verbal update on the Momentum: Pathways to Healthcare Programme. The overall Momentum programme structure and governance arrangements continued to provide an effective mechanism for the management of the Momentum Programme. The portfolio approach was being progressed within the overall Momentum: Pathways to Healthcare programme taking forward the development of phase two of service transformation, co-ordinated with the planning for the Better Care Fund (BCF) and working towards the development of the single site hospital, and associated primary and community services, in addition to maintaining clinical, operational and financial sustainability. The Chief Operating Officer/Deputy Chief Executive reported that the next phase would include delivering the clinical services strategy with Respiratory, End of Life Care and Frail Elderly and Dementia to be priority pathways to be implemented in 2014/15 and 2015/16. The Chief Operating Officer/Deputy Chief Executive was working with the CCG‟s to look at streamlining practices by refocusing professional groups. The Chief Executive provided an update on the new hospital project and advised that a gateway review was planned for September 2014. The review would be undertaken by a team from the Office of Government Commerce, who would undertake a peer review of the new hospital scheme. This would be the second review to be undertaken on the scheme, and would review progress made since the last review in 2011. The Department of Health were concluding their review of the scheme and it was hoped a decision would be imminent. The Chief Executive was hoping for a public announcement of support for the scheme from the Government prior to engagement with bidders.

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Following a query from a member the Chief Operating Officer/Deputy Chief Executive advised work was on-going behind the scenes looking at a Onelife unit for Stockton as pathways would still require 30% of activity to move out into the community.

Resolved: (i) that, the information be noted.

CoG/523 Finance and Contract Performance Report The Deputy Director of Finance and Commercial Opportunities presented the Finance and Contract Performance Report to the period of 31 July 2014, and drew members‟ attention to the key points. Performance against the Continuity of Service Risk Rating demonstrated that the Trust had achieved a risk rating of 4. As at 31 July 2014, the Trust was reporting an operational deficit of £1.250m for the period, which was £2.064m behind the planned surplus for the period to date of £0.813m. There was under-recovery on income against the profiled plan of £447k at the end of July 2014. The Trust continued to over-perform with Hartlepool and Stockton CCG and under-perform against the planned contract value with Durham, Darlington, Easington and Sedgefield CCG. Other patient care income was under-recovered by £393k, primarily relating to the bariatric service commissioned through South Tees. Income from non-patient care (commercial income) was under-recovered by £81k which related to the reduction in car parking, occupational health, nursery and catering income. To date, pay budgets were showing an over-spend against plan of £536k. The main area of risk continued to be recourse to locum staff at premium rates and where appropriate, and subject to validation, these additional costs would be funded from the remainder of the locum contingency reserve approved by the Board of Directors‟ in April 2014. Non-pay budgets were £288k overspent for the period to the end of July 2014. The gross Service Improvement and Efficiency Programme (SIEP) target for 2014/15 of £15.548m had been reduced to £13.494m as a result of recurrent and non-recurrent schemes actioned during the month. When compared against the Monitor plan, the Trust was currently £1.002m behind its projected in-year plan. It was appropriate to continue to use slippage from reserves/contingencies and balance sheet flexibility non-recurrently on the challenging SIEP target. Further work on identifying and delivering recurrent SIEPs continued to ensure that the financial performance remained in line with plan to ensure that the earnings before interest, taxes, depreciation and amortisation (EBITDA) margin was not eroded. Due to the back-ended nature of the SIEP plan, it was imperative that schemes were in place and could be delivered in quarter 4. The net cash outflow for the period was £0.5m, resulting in a decrease in cash from £46.378m to £45.873m as at 31 July 2014. Net current assets at 31 July 2014 had decreased by £0.523m to £40.100m. Financial performance was behind plan for the first 4 months of the financial year. Operational pay budgets for Directorates were under pressure and SIEP delivery was behind plan. The Trust had implemented a financial recovery plan to address the reported deficit position and recover the shortfall in savings to ensure the Trust delivered a balanced outturn position. The Chief Executive reported that alongside the SIEP schemes the Trust was looking at further collaborations with South Tees Hospital NHS Foundation Trust including pathology, the Trust had won Community tenders , as well as IT projects being rolled out to allow efficiencies within administration, and back office reviews.

Resolved: that, the information be noted. CoG/524 Human Resources and Education Quarter 1 Report

The Deputy Director of Education and Organisational Development presented the Quarter 1 Human Resources and Education Report and highlighted the key points. At the end of quarter 1 the Trust employed 5,343 staff compared to 5,493 for the same period last year, a reduction of 150. This equated to 4528.84 whole time equivalent (wte) in June 2014 compared to 4503.04 wte in June 2013, an increase of 25.8 wte.

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156 employees commenced employment with the Trust in the first quarter of this year, an increase of 28 from Quarter 4 and an increase of 34 for the same period in 2013/14. Turnover steadily increased from July 2013 (8.24%) to March 2014 (10.61%). This trend had continued in quarter 1, increasing to 10.96% in June 2014. This had increased when compared to the previous year. The average sickness absence rate for quarter 1 was 4.09%, compared to 4.05% in 2013/14. At the end of quarter 1 the Trust was 97% compliant for mandatory training corporately, which represented a 2% increase compared with the position at the end of the previous quarter. 94% of the Trust‟s consultant job plans were entered onto the e-Job plan system. Implementation of the e-Rota software was now complete, enabling quick and easy identification of European Working Time Directive and New Deal compliance. There were no disclosure of concerns raised in Quarter 1 and no reported cases pertaining to failure to adhere to infection control procedures. The staff Friends and Family Test was launched during quarter 1 using an electronic platform to gather the data. A total of 456 responses were received which ran from 1 July 2014 to 31 July 2014. 25% of respondents stated that they were extremely likely to recommend the organisation to friends and family if they needed care or treatment, whilst 45% stated likely. 22% of respondents stated that they were extremely likely to recommend the organisation as a place to work, whilst 41% stated likely. The results of the survey would be used in developing action plans to address any areas of concern. In response to a member‟s query, it was reported that equality and diversity data was reported to Board and Council of Governors as a requirement of legislation and does not show personal identifiable information.


CoG/525 Staff Survey Actions & Progress Report The Deputy Director of Education and Organisational Development reported a full census had been undertaken in 2013 in order to ascertain the wider views and gain feedback to support a number of key activities including culture and values. In total 2455 surveys were completed resulting in a response rate of 49.65%. The Trusts five top scores in 2013 were

Percentage of staff experiencing discrimination at work within the last 12 months;

Percentage of staff experiencing physical violence from patients , relatives or the public in the last 12 months;

Percentage of staff working extra hours

Percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months; Percentage of staff believing the Trust provides equal opportunities for career progression or promotion. The bottom five being:

Percentage of staff agreeing that their role makes a difference to patients;

Percentage of staff reporting errors, near missus or incidents witnessed in the last month;

staff motivation at work;

Percentage of staff receiving Health and Safety training in the last 12 months.

Effective team working. The Deputy Director of Education and Organisational Development reported that action plans had been developed looking at the key themes. The NHS Staff Survey for 2014 was due to commence October 2014 and would again be a census.

Resolved: that, the information be noted. CoG/526 2015 Council of Governors Schedule of Meetings, Including Sub Committees

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The proposed meeting schedules were agreed with the Deputy Director of Human Resources/ Company Secretary highlighting the key dates as a reminder for 2015.

Resolved: that, the information be noted and meeting dates for 2015 approved. CoG/527 Sub-Committee Minutes a. Travel and Transport Committee John Cains Elected Governor for Easington presented the minutes of the Travel and Transport Committee, which was held on 1 September 2014 and highlighted the key points.

Resolved: that, the information be noted. b. Nominations Committee The Chairman and the Non-Executive Directors left the meeting. The Deputy Director of Human Resources/ Company Secretary highlighted the key areas, including the outcomes of the Chairman's and Non-Executive Directors appraisals. At the meeting it had been proposed that the Chairman and NEDs receive a 5% annual retention payment subject to the new hospital being built, the Nominations Committee had supported the proposal and Council of Governors were asked for agreement. Length discussions ensued which resulted in a vote, the outcome of which was 13 votes in agreement, 8 votes against, and 1 abstained vote, therefore the proposal was agreed.

Resolved: that, a 5% retention scheme be agreed for the Non-Executive Directors and Chairman,

to be paid 6 months following the successful opening of the new Hospital. c. External Audit Working Group The Deputy Director of Finance and Commercial Opportunities presented the minutes of the External Audit Working Group, which was held on 14 July 2014 and highlighted the key points including the agreement from the Committee that Price Waterhouse Cooper‟s (PwC) Contract would be extended for a further two years.

Resolved: that, the information be noted and PwC contract approved to be extended a further 2 years.

d. Membership Strategy Committee Wendy Gill, Elected Governor for Sedgefield presented the minutes of the Membership Strategy Committee, which was held on 18 August 2014 and highlighted the key points.

Resolved: that, the information be noted. CoG/528 Non- Executive Director Re-Appointment Brian Dinsdale Non- Executive left the meeting. The Deputy Director of Human Resources/ Company Secretary reported that Brian Dinsdale‟s term of office was due to end 30 November 2014, and proposed that his term be renewed for a further 3 years to ensure continuity going forward to the new hospital. Following a query from a member the Deputy Director of Human Resources/ Company Secretary explained the process for re-appointment of a Non-Executive Director. Resolved: that, Brian Dinsdale should be re-appointed for a further 3 years.

11

CoG/529 Any Other Business There was no any other business notified. CoG/530 Date and Time of Next Meeting The next meeting was due to be held on Thursday, 15 January 2015 in the Londonderry Room, Wynyard Rooms. The meeting closed at 13.05 pm Signed: Date: 15 January 2015

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Meeting of the Council of Governors

18 September 2014

Executive Summary

Quality Report

Report of the Director of Nursing, Patient Safety and Quality

Strategic Aim (the full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Putting Patients First

Strategic Objective (the full set of Trust Objectives can be found at the beginning of the Council of Governors Reports) Putting Patients First/Patient Safety

1. Introduction 1.1 Section 2 and 3 describes mortality data with Trust HSMR and all-cause mortality data as being

out of the ‘as expected’ range. Latest Trust SHMI data is reported as being also out of the ‘as expected’ range. This section provides additional information including benchmark data.

The HSMR value has increased to 119.76 (June 2013 to May 2014) from 118.17 (April 2013 to March 2014)

The Trust crude mortality rate for HSMR has reduced from 3.45 to 3.43 The SHMI value has decreased to 112.78 (January 2013 to December 2013) from 113.08

(October 2012 to September 2013) The Trust crude mortality rate for SHMI has reduced from 3.99 to 3.91 Significant work is outlined in this report through internal and external routes There are four other Trusts within the North East that also fall out of the ‘as expected’ range The Trust is collaborating regionally to reduce both values focusing the work on care and

coding 1.2 Section 4 describes the Care Quality Commissions (CQC) Intelligent Monitoring Update which

was produced in July 2014. The Trust priority banding for inspection (risk level) has increased from Band 5 to Band

4 (Band 1 being the highest risk and band 6 the lowest) The Trust previously had 0 indicators in the ‘Risk Category’ this is now 1 The Trust had 3 in the Elevated Risk category and this still remains at 3 Areas of concern continue to be around HSMR and SHMI values, the new risk element is

for staff sickness rates The next CQC Inteligent Monitoring Report is expected around near the end of the year

1.3 Sections 5 and 6 describes the Trusts Falls and Pressure Ulcer information

There have been 9 Falls with Fracture this reporting period of which zero have died whilst in our care

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These incidents have been investigated thoroughly and lessons learned are shared with the Trust falls group and across the organisation both formally and informally

Pressure Ulcers recording has changed for the 2014/2015 reporting year going forward. Previously there were only two categories, Pressure Sore Grade 2 or below and Pressure Sore Grade 3 and above.

The categories are now separated into Grade 1, Grade 2, Grade 3 and Grade 4. The reporting of Pressure Ulcers has improved over the years, this is why there is an

increase in the number of Pressure Ulcers year on year since 2012. Pressure Grades 1 and 2 have increased whilst Grade s 3 and 4 have decreased

1.4 Section 7 describes the Trust’s complaints data within the three new complaints streams; Stage 1

– concern, Stage 2 – Informal and Stage 3 – Formal. Since April 2014 the Trust has received 505 complaints, of which 94 are Stage 3 – Formal The highest complaints relate to Communication – insufficient information There are currently 94 open complaints, of which 48 are Stage 3 - Formal The provisional compliance rate for July 2014 is 94%, when the new process was

implemented in October 2013 the compliance rate was 20% 1.5 Sections 7 to 11 describes the Friends and Family Test

The Trust returns for A&E for quarter 1 was 17.17% and In-patients was 51.33%, both met the CQUIN response rate targets of 15% for A&E and 20% for in-patients

Tokens cannot be used from April 2015, therefore the Trust is putting an action plan in place to re-instate paper forms into A&E later in the year

As an early adopter site, the Trust ran a two week trial in August (4 to 22 August) for the new outpatients and day case Friends and Family Test

Trust outpatients has a Net Promoter Score of 52, with 90% of forms returning either extremely likely or likely

Trust day cases has a Net Promoter Score of 87, with 98% of forms returning either extremely likely or likely

1.6 Section 12 describes the current Patient Reported Outcome Measures (PROMS) The Trust is no longer an outlier for Hips, Knees or Groin Hernia using the latest data from

the Healthcare Evaluation Data (HED)

1.7 Section 13 describes the information on ‘Never Events’ Since the previous Board report there have been no further Never Events reported

2. Recommendation 2.1 The Council of Governors is asked to note the content of this report.

Cath Siddle Director of Nursing, Patient Safety and Quality 18 September 2014

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18 September 2014

Quality Report


1. Introduction/Background 1.1 This quality report aims to describe progress in relation to the following aspects of patient safety

and experience.

Mortality update Hospital Standardised Mortality Ratio (HSMR) Mortality update Summary Hospital-Level Mortality Indicator (SHMI) Care Quality Commission Intelligent Monitoring Report (IMR) Nursing and Midwifery Dashboard data Trust Complaints Breakdown Friends and Family Test Patient Reported Outcome Measures (PROMS) Never Events Recommendations

2. Mortality - Hospital Standardised Mortality Ratio (HSMR) 2.1 Data reported in this document is taken from the Healthcare Evaluation Data (HED) tool which

provides mortality data for HSMR up to May 2014. 2.2 The overall Relative Risk for HSMR from June 2013 to May 2014 is reported at 119.76, this value

continues to be outside the ‘as expected’ range, the national mean is 100. 2.3 The following chart demonstrates the Trust HSMR trend over the reporting period:

2.4 The Trust’s level of palliative care recording remains a concern as the months of February to May 2014 yielded the lowest numbers for over three years. These low numbers are having a direct

4

impact on the HSMR value, therefore, the Clinical Director for Integrated Care Services has taken this forward with the palliative care team to ensure that accurate, clear documentation is visible in the patient notes that the patient has been seen by a member of the specialist palliative care team.

2.5 The Trust has therefore undertaken a full review of the Palliative Care coding process to ensure that all patients that require palliative care are correctly coded as having this. A new process was rolled out with the palliative care team in July utilising the Trusts virtual ward for patients receiving specialist palliative care. This will be underpinned by a Trust policy for palliative care coding.

2.6 Additional work is ongoing to ensure that the Trust accurately captures all members of the specialist palliative care team, such as Lung Cancer Nurses. This comprehensive list will allow for more accurate capture of patients seen by the specialist palliative care team.

2.7 There are three other Trusts within the North East that also fall out of the ‘as expected’ range for

HSMR; they are South Tyneside NHS Foundation Trust, City Hospitals Sunderland NHS Foundation Trust and Northumbria Healthcare NHS Foundation Trust.

2.8 When the region is benchmarked against the crude mortality rate (number of discharges against

number of mortalities) for the reporting period of June 2013 to May 2014, North Tees and Hartlepool NHS Foundation Trust currently sits third lowest for crude mortality out of the eight North East Trusts.

2.9 The Trust crude mortality rate has reduced from 3.45 to 3.43 from the previous reporting period.

2.10 For the Trust to gain a greater understanding on its position on pneumonia cases, we have entered

into a collaborative pneumonia project with South Tees and Durham & Darlington Trusts. 2.11 The North East Quality Observatory System (NEQOS) have commissioned Clarity Informatics to

produce a set of measures which comply with the British Thoracic Society (BTS) audit and can be used to assess the treatment of the Trust’s community acquired pneumonia patients. This project is known as the Community Acquired Pneumonia (CAP) project which is also been run simultaneously with South Tees and Durham & Darlington Trusts.

2.12 The Trust’s newly appointed pneumonia specialist nurse will support patients from admission and

implement processes, national guidance and audit. Details from the project in relation to statistics will be provided in later Council of Governors reports when there is sufficient data.

2.13 Feedback will be provided to the Keogh Task and Finish Group in September and then will be reported in the next Council of Governors paper.

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3. Mortality - Summary Hospital-Level Mortality Indicator (SHMI) 3.1 SHMI provides mortality data relating to deaths within 30-days of discharge from hospital and does

not adjust for end of life care. The latest data available nationally is for the 12 month period ending December 2013 when the Trust SHMI was 112.78 from 113.08 the previous reporting period. This still remains in the ‘higher than expected’ range but demonstrates a slight reduction.

3.2 The following chart demonstrates the Trusts monthly SHMI values for the latest 12 month rolling

period (January 2013 to December 2013).

3.3 Similar to HSMR, there are three other Trusts within the North East that also fall out of the ‘as

expected’ range for HSMR; they are City Hospitals Sunderland NHS Foundation Trust, Northumbria Healthcare NHS Foundation Trust and South Tyneside NHS Foundation Trust.

3.4 When the region is benchmarked against the crude mortality rate (number of discharges against

number of mortalities) for the reporting period of January 2013 to December 2013, North Tees and Hartlepool NHS Foundation Trust currently sits fifth best out of the eight North East Trusts.

3.5 The Trust crude mortality rate has reduced from 3.99 to 3.91 from the previous reporting period. 3.6 The Trust acknowledges that the HSMR and SHMI values are higher than expected and is

implementing a number of processes/reviews to gain a greater understanding of the quality of care being given to patients.

3.7 The Trust now conducts a review of clinical documentation and the associated coding, both for

accuracy and the process itself, clinician led reviews of most deaths on a weekly basis and the introduction of an early warning mortality panel, recoding all relevant details and determining if the death was avoidable or unavoidable. This process has been running for weeks, therefore no trending data is currently available. Once there is sufficient data this will appear in this report and the percentage of avoidable versus unavoidable deaths will be reported.

3.8 A proposal for Audit North to undertake a review of compliance with the Mortality policy is currently

being discussed with the Medical Director and the Chief Operating Officer/Deputy Chief Executive. 3.9 The Trust is working with Healthcare Evaluation Data (HED), our benchmarking tool provider, to

produce a piece of work which would see what impact the HSMR/SHMI values would have if we

6

re-introduced the ambulatory care data back into the data upload. Currently, between 20% to 25% of the Trust’s activity comes through this route, with this activity not being taken into account.

4. CQC Intelligent Monitoring Report (IMR) 4.1 Since the last Council of Governors report, there have been no further Intelligent Monitoring

Reports from the Care Quality Commission (CQC); the next report is expected by the end of the year, therefore the following is a recap of the latest IMR report.

4.2 The Trust’s ‘Priority banding for inspection’ has reduced a level from Band 5 (March 2014 IMR) to

Band 4 (July 2014 IMR). The banding stated in the IMR relates directly to the 96 indicators and should not be confused with the CQC banding for the Trust when one is given.

4.3 National Comparison: The Trust has been banded as Band 4 along with 17 other Trusts. 4.4 The three ‘Elevated Risk’ indicators that are in the July 2014 CQC IM report for the Trust are

expected to remain the same going forward due to them relating to mortality. The three indicators were as follows; Summary Hospital-level Mortality Indicator (SHMI) (01-Oct-12 to 30-Sep-13), Dr Foster Intelligence: Composite of Hospital Standardised Mortality Ratio indicators (01-Oct-12 to 30-Sep-13) and Dr Foster Intelligence: Mortality rates for conditions normally associated with a very low rate of mortality (01-Oct-12 to 30-Sep-13)

4.5 The one new ‘Risk’ indicator that is in the July 2014 CQC IM report for the Trust is as follows;

Composite risk rating of ESR items relating to staff sickness rates (01-Apr-13 to 31-Mar-14) 4.6 The Trust is forecasting a slight shift downwards for the SHMI indicator, when the next period is

released in October 2014. 4.7 The Trust’s level of palliative care recording remains a concern as the months of February to May

2014 yielded the lowest numbers for over three years. To ensure that the palliative care coding improves in the future, there has been a new process for reviewing and recording of palliative care patients using the end of life virtual ward board. The work on this process commenced in early July, therefore the impact has not been demonstrated in the HSMR.

4.8 The Trust has started to roll out a mortality dashboard to directorates, thus enabling the directorates to view the data/trends and then if needed pull notes to see what has been influencing the values. The roll-out will conclude in September 2014.

5. Patient Falls 5.1 Since the last CoG report in July 2014, which data was for April to June 2014, there has been an

additional 189 falls with no Injury, 9 Falls with fracture and 64 Falls injury, no fracture.

5.2 The number of patient falls calculated per 1,000 occupied bed days (midnight bed count) are as follows:

Fall No Injury, 5.34 falls per 1,000 bed days Fall Fracture, 0.18 falls per 1,000 bed days Fall Injury, No Fracture, 1.48 falls per 1,000 bed days

5.3 The falls policy review has occurred and ratified with the following minor changes:

reduce the time to asses to 6 hours on admission and transfer

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enforce the principle that professional judgement to be utilised for patients who are deemed high risk that do not fit the age assessment for FRAT1 (over age of 65) assessment.

5.4 The falls risk assessment tool was revalidated in 2013 via the ‘fallsafe’ regional working group,

which is chaired by an older person physician.

5.5 The Stirling Environmental audit will be utilised to review wards 36 to 40 following the refurbishment work and the transfer of patients in 2013 as these areas have a high rate of falls and subsequent falls with fracture.

5.6 Following a Datix review of the 2013/2014 falls activity, advanced falls training continues to be delivered to identified wards for high risk falls areas. The training will be delivered by the clinical educators within the Educational and Organisational Directorate.

5.7 The Trust falls working group chaired by the general manager for orthopaedics will meet in September to discuss the concerns raised by the corporate team in relation to all falls, and develop a work programme, which will be governed through the Patient Safety and Quality Standards (PS &QS) meeting monthly

6. Pressure Ulcers

6.1 Pressure Ulcers recording has changed for the 2014/2015 reporting year going forward. Previously there were only two categories, Pressure Sore Grade 2 or below and Pressure Sore Grade 3 and above. The categories are now separated into Grade 1, Grade 2, Grade 3 and Grade 4.

6.2 The following data for pressure sores relates to Hospital Acquired only and not community. In future reports community data will be included.

Pressure Ulcers Category Pressure Ulcers

(Apr 14 to Aug 14) Pressure Ulcers

(Apr 13 to Aug 13)

Pressure Sore Grade 1 44 102

Pressure Sore Grade 2 96

Pressure Sore Grade 3 1 3

Pressure Sore Grade 4 0

6.3 The Trust’s reporting of pressure ulcers has increased since training was provided by the tissue viability nurses, therefore the increase is likely to be due to better reporting and awareness rather than an increase in incidents.

6.4 The governance process for the investigation of pressure ulcers is a root cause analysis is carried out on all grade 3 and 4 damage, which is then reviewed by the weekly pressure ulcer review group. Cases are then presented to the pressure ulcer assurance panel which includes commissioner representation. Each case is then classified as avoidable or unavoidable with appropriate actions/recommendations being agreed and disseminated. The Board of Directors receives the outcomes from the pressure ulcer assurance panel via the Patient Safety and Quality Standards (Ps&Qs) committee.

6.5 The one grade 3 pressure sore was deemed as unavoidable by the pressure assurance panel. A comparison with the grade 3 pressure ulcers in the previous reporting year is not possible as the process was not introduced until April 2014.

6.6 The result from the latest prevalence audit is not yet available at the time of this report, therefore these results will appear in the next Quality report.

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7. Trust complaints breakdown 7.1 Since April 2014, the Trust has received 505 complaints up to 01 September 2014;

Stage 1 329 (65.15%) Stage 2 33 (6.53%) Stage 3 142 (28.32%)

7.2 Of the 505 complaints received the Trust currently has 94 open;

Stage 1 28 (29.79%) Stage 2 18 (19.15%) Stage 3 48 (51.06%)

7.3 The Trust also monitors the type of complaints that are being reported. The top ten categories of complaint are as follows; to note, complaints can have multiple reasons.

7.4 All lessons learned from complaints are taken back into the teams and managed appropriately. 7.5 The compliance rates for April and July 2014 are as follows. July data is provisional and subject to

change.

9

Month Compliance

Rate

Increase or decrease

in rate

Apr-14 86.00% May-14 95.00%

Jun-14 96.00%

Jul-14 94.00%

7.6 To note; July 2014 compliance rate of 94% (provisional) continues to be an excellent achievement by the complaints team, maintaining constantly above the 90% rate since May 2014. These rates are a vast improvement from the lowest compliance rate of 20% in October 2013.

7.7 In September 2014 the Trust will commence the first complaint clinics within the Directorate of Medicine. These clinics will be piloted with subsequent feedback relayed and evaluated. Once this has occurred, a structured roll-out to other directorates will commence.

7.8 The aim of these clinics is to strengthen the governance and assurance that lessons and themes

from complaints are taken to relevant areas for action, reflection, improvement and an overall reduction in actual complaints.

8. Family and Friends Test 8.1 The image below is taken from the Nursing and Midwifery Dashboard, In-patient, A&E and

Maternity Friends and Family Test page and includes April and May data. – See Appendix 1

9 Family and Friends Test (FFT) – Inpatients and A&E

9.1 For 2014/2015, Friends and Family Test is a key indicator in the Commissioning for Quality and Innovation (CQUINs) measures.

9.2 To obtain the full value for the response rate indicators, the Trust must ensure that for Accident & Emergency the response rate is 15% at the end of Q1 and reached 20% by the end of Q4. For the in-patient response rate, the Trust must achieve a minimum of 20% at the end of Q1 and reach 30% by the end of Q4. An incentive payment for in-patients will be made to the Trust if in March 2015 the response rate reaches 40%.

9.3 The response rate for quarter 1 (April to June) was 51.33% for Inpatients and 17.17% for Accident & Emergency. These values met CQUIN’s Q1 minimum target of 20% for inpatients and 15% for Accident & Emergency.

9.4 From April 2015 tokens will no longer be allowed to be used by any Trust in capturing Friends and

Family returns, as this does not provide any qualitative information only quantitative, therefore, the Trust is putting a plan in place later this year to re-introduce the paper forms back into A&E.

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9.5 Accident and Emergency response rate for July was 12.79%. This falls below the minimum

required rate of 15% and, therefore, the Trust will need to ensure that August and September returns are improved. This was managed through the Friends & Family Test group and CQUIN board. The current average Accident & Emergency response rate for the year stands at 16.03%.

9.6 In-patient and Accident & Emergency Net Promoter Scores:

Friends and Family Test Net Promoter Score (NPS)

Area April May June July In-patient 67 72 73 72

Accident and Emergency 54 69 57 56 10. Family and Friends Test – Maternity 10.1 The Friends and Family Test (FFT) aims to provide a simple, headline metric which, when

combined with follow-up questions, can be used across the maternity pathway to drive a culture change of continuous recognition of good practice and potential improvements in the quality of the care received by NHS patients and service users.

10.2 To note; there has been a change to the response rate data collections for questions 1 (ante-natal care), 3 (post-natal) and 4 (post-natal community provision). The new guidance now states that we no longer need to provide this data, as providers have identified issues providing accurate eligible population for these questions. As a result, NHS England now only requires question 2 (birth) eligible population figures, as these will be based on hospital birth records.

10.3 To date there has been 309 returns for Question 2 (birth) from a possible 1,059; this equates to

29.18% return rate. 10.4 Maternity Net Promoter Scores:

Friends and Family Test Net Promoter Score (NPS)

Questions April May June July Q1 - Antenatal care 71 67 76 81 Q2 - Birth 71 70 78 68 Q3 - Postnatal 67 71 90 64 Q4 - Postnatal community provision

76

78

50

76

11 The NHS Friends and Family Test: Outpatient and Day Case

11.1 The NHS Strategic Projects Team is responsible for developing the implementation, publication and reporting guidance for the application of the NHS Friends and Family Test by providers and commissioners across outpatient and day case services.

11.2 To further inform the development of the Guidance, a number of early adopter sites have been

identified. These sites, which are represented on the Work Stream Group, will begin delivering the NHS Friends and Family Test prior to national roll-out. This pilot work is important as it means that the methodology can be thoroughly tested in the field, with revisions made based on direct feedback where appropriate, to ensure that when the national roll-out occurs the methodology is robust.

11.3 As an early adopter site, the Trust ran a two week trial in August (4 to 22 August) for the new

outpatients and day case Friends and Family Test.

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11.4 The Net Promoter Score for the Trusts Outpatients areas of Main Outpatients and Orthopaedics

Outpatients was 52. With 90% of returns stating either Extremely Likely or Likely on their forms. 11.5 The Trusts number of returns during this trial for the Outpatients areas of Main Outpatients and

Orthopaedics Outpatients was 719 from a total of 1,274 eligible patients able to respond, this equates to a 56% response rate

11.6 The Net Promoter Score for the Trusts Day Case areas of Main Day Case Unit and Leven Day

Case Unit was 87. With 98% of returns stating either Extremely Likely or Likely on their forms. 11.7 The Trusts number of returns during this trial for the Day Case areas of Main Day Case Unit at

both sites and Leven Day Case Unit was 195 from a total of 381 eligible patients able to respond, this equates to a 51% response rate.

11.8 An additional two week trial will continue in September and will run over a different four areas.

This will give good data and analysis which will allow for aligning the Trusts approach when the full roll out commences.

11.9 NHS England do acknowledge in their guidance for Friends and Family, that the ‘feedback should

be used alongside other measures of quality’. 12. Patient Reported Outcome Measures (PROMS)

12.1 The Trust was reported as being an outlier in the latest North East Quality Observatory System

(NEQOS) report for Patient Reported Outcome Measures (PROMS) for Hips and Knees. The data used for this report was for 2012/2013.

12.2 The latest data available for 2013/2014 shows the Trust is no longer an outlier in Hips and Knees

and is in a very positive position. Also to note, the Trust was highlighted in a previous Intelligent Monitoring Report (IMR) from the CQC as being an outlier for Groin Hernia, again, the latest data shows this is no longer the case and the position is positive.

13. Never Events 13.1 There have been no Never Events reported in this reporting year of 2014/2015. 13.2 The NHS England report can be accessed via:

http://www.england.nhs.uk/ourwork/patientsafety/never-events/ne-data/

The Never Event data from April 2014 will be published on the website at the end of May and then updated on a monthly basis.

14. Recommendation 14.1 The Council of Governors is asked to note the content of this report. Cath Siddle Director of Nursing, Patient Safety and Quality 18 September 2014

Appendix 1

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18 September 2014

Executive Summary

Staff & Patient Experience and Quality Standards Report


Strategic Aim (the full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Putting Patients First

Strategic Objective (the full set of Trust Objectives can be found at the beginning of the Council of Governors Reports) Putting Patients First/Patient Safety

1. Introduction 1.1 Section 2 describes the outcome of the monthly Staff and Patient Experience & Quality Standards

(SPEQS) reviews for August 2014. 25 areas were assessed

PEQS is now known as SPEQS, which is now including the staff element in the name

From the August visit, the highest score was 100% by 10 wards/areas, this is up from 6 the previous visit

There were only 3 wards that scored under 90% where a turn-around work programme has been delivered

Trust first impressions average in August was 93.59%, this has reduced from 96.00% the previous month

Trust nursing evidence average has increased from 85.68% to 87.61%

2. Recommendations 2.1 The Council of Governors is asked to note the content of this report.

Cath Siddle Director of Nursing, Patient Safety and Quality September 2014

2



18 September 2014

Staff & Patient Experience and Quality Standards Report


1. Introduction/Background 1.1 This report aims to describe progress in relation to the following aspects of patient safety and

experience.

Staff and Patient Experience & Quality Standards (SPEQS)

2. Staff and Patient Experience & Quality Standards (SPEQS)

2.1 The Staff and Patient Experience & Quality Standards proforma has been redesigned and July is the

second visit utilising this document. The aim of this review was to improve consistency, rigour and assurance of the results.

2.2 The four sections that are being assessed are:

First Impressions

Nursing Evidence

Patient Experience

Staff Involvement (new since June 2014)

2.3 The following data is for the Hospital SPEQS visits;

SPEQS Visit

Month

First Impressions %

2014/2015

Nursing Evidence % 2014/2015

Patient Experience %

2014/2015

Staff Involvement %

2014/2015

Q1 June 99.02 82.68 98.80 89.71

July 96.00 85.78 95.56 95.33

Q2 August 93.59 87.61 98.29 95.51

2.4 The number of toilets seen since June 2014 has been 246 of which 244 (99.19%) were clean, there

were also 170 commodes inspected of which 165 (97.05%) were clean. 2.5 The monthly average value for all ward areas has increased from 93.60% in July to 95.47% in

August. 2.6 The ward areas that returned low scores will be re-assessed under an unannounced PEQS visit at a

later date, with feedback being delivered to the relevant Senior Clinical Matrons (SCMs) with improvement plans put in place.

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2.7 From the 33 areas visited between June 2014 and August 2014, the following table demonstrates

the SPEQS average score breakdown:

SPEQS Average score (%) Number of wards/areas

100.00 3

98.89 1

97.78 8

97.04 2

96.30 1

95.56 4

94.81 1

94.07 1

93.89 1

93.33 2

92.59 3

92.22 1

91.11 3

88.15 1

82.22 1

2.8 The Trust has a plan to undertake ‘unannounced’ visits throughout the year and once these have

commenced data and trending of these will be included in future reports. 2.9 The ward areas that returned low scores will be re-assessed under an unannounced SPEQS visit at a

later date, with feedback being delivered to the relevant SCMs with improvement plans put in place.

2.10 The time of the SPEQS visits has been changed to an afternoon to allow the team to meet with the visitors of patients without capacity and take their view on the care of the family member or friend.

2.11 The integration of in hospital and out of hospitals SPEQS is now moving forward with both teams joining to undertake visits. Staff will be asked to confirm prior to the visit their attendance and will be allocated a location or base to visit, community staff will link with hospital staff as usual supported by our Governors

2.12 The first collective visit will occur in September.

3 Patient Experience and Quality Standards – Nursing and Midwifery Dashboard 3.1 The new Patient Experience and Quality Standards data has been incorporated into the Nursing and

Midwifery Dashboard, so that it can be trended along with other key indicators. 3.2 The following image is taken directly from the Nursing and Midwifery Dashboard. All ward areas have

access to this Dashboard and can continually monitor how their areas are progressing month-by-month. This will be displayed by ward alongside the staffing information boards.

4

4. Recommendation 4.1 The Council of Governors is asked to note the content of this report.

Cath Siddle Director of Nursing, Patient Safety and Quality September 2014

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18 September 2014

Executive Summary

Infection Prevention and Control Report

Report of the Director of Nursing, Patient Safety and Quality/

Director of Infection Prevention and Control Strategic Aim (the full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Putting Patients First Strategic Objective (the full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Reduce Hospital Acquired Infections 1. Executive summary 1.1 To date in 2014-15 there have been

zero cases of Trust attributed MRSA bacteraemia

12 cases of Trust attributed MSSA bacteraemia

7 cases of Trust attributed E coli bacteraemia

7 cases of Trust attributed C difficile infection

*information correct at time of writing 1st September 2014

1.2 This means that the Trust is within trajectory for MRSA bacteraemia and C difficile but has seen an increase in the number of MSSA bacteraemia. The cases are all being reviewed and it seems there are no recurrent themes or linked cases but the increase is nonetheless of concern

1.3 An outbreak of Ebola Virus Disease has been reported in West Africa and regularly

updated guidance has been released by Public Health England. As a result an updated guideline has been provided and protective equipment ordered for use in the unlikely event that the trust receives a patient suffering from this infection.

2. Recommendation 2.1 The Council of Governors is asked to note the work underway to reduce the incidence of

Clostridium difficile and MRSA bacteraemia acquired by patients in our care and the recent improvements in performance for these infections

Cath Siddle Director of Nursing, Patient Safety and Quality/ Director of Infection Prevention and Control September 2014

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18 September 2014

Infection Prevention and Control Report

Report of the Director of Nursing, Patient Safety and Quality/ Director of Infection Prevention and Control

Introduction This report will describe the progress to date relating to:

1. Methicillin resistant Staphylococcus aureus (MRSA) bacteraemia 2. Methicillin Sensitive Staphylococcus aureus (MSSA) bacteraemia 3. Clostridium difficile diarrhoea 4. Escherichia coli bacteraemia 5. Hand Hygiene 6. Ebola Virus Disease 7. Recommendation

1. MRSA bacteraemia 1.1.1 There have been zero cases of Trust attributed MRSA bacteraemia in August 2014 and

zero during this reporting year at all. The national approach for 2014-15 remains one of zero tolerance. Figure 1 shows the quarterly reporting of trust attributed MRSA bacteraemia since 2006 including the current quarter and demonstrates a sustained reduction.

Figure 1 – Trust attributed MRSA bacteraemia (by quarter)

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1.2 The Trust is required to report all MRSA bacteraemia cases as the organisation processing the sample, including those attributed to the Clinical Commissioning Group (CCG). There has been one such case since April 2014 attributed to the commissioners. The investigation into this case showed no learning points for the Trust.

2 Methicillin sensitive staphylococcus aureus (MSSA) bacteraemia 2.1 Staphylococcus aureus is a bacterium commonly found on human skin which can cause

infection if there is an opportunity for the bacteria to enter the body. In serious cases it can cause blood stream infection. MSSA is a strain of these bacteria that can be effectively treated with many antibiotics.

2.2 There have been 3 cases of trust attributed MSSA bacteraemia reported in August 2014.

This means a total of 12 cases have been reported for the year to date which means the Trust has almost reached its internal trajectory of 13 cases. Figure 2 shows the cases of Trust attributed MSSA bacteraemia since 2012. A review of cases over the last two years has been carried out. Some earlier themes such as contaminated samples have already had a significant amount of work completed and do not feature in the more recent cases. A cluster of cases on one ward was investigated and genetic typing found the cases to be unrelated. Although a clear theme has not emerged from the investigations, many of which show the infection to have been unavoidable, additional focus will be placed on hand hygiene compliance, environmental cleanliness and line care as each of these things will reduce the risk of an infection occurring.

Figure 2 – Trust attributed MSSA bacteraemia (by month)

2.3 Two community attributed MSSA bacteraemia cases were reported in September 2014.

3 Clostridium difficile diarrhoea 3.1 Clostridium difficile is a bacterium that is found in the gut of around 3% of healthy adults. It

seldom causes a problem as it is kept under control by the normal bacteria of the intestine. However certain antibiotics can disturb the bacteria of the gut and Clostridium difficile can then multiply and produce toxins which cause symptoms such as diarrhoea.

3.2 There were 5 Trust attributed cases reported in August 2014 (Figure 3). The trajectory for 2014-15 remains at 40 cases and the Trust is well within this with 7 cases reported for the year to date against a trajectory of 16 cases. This represents a reduction of 59% on the same period last year.

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Figure 3 – Trust attributed C difficile cases (by month)

3.3 Seven cases of community attributed Clostridium difficile were reported in June 2014. 3.4 All of the previously reported work undertaken to reduce the risk of Clostridium difficile infection in our patients continues in this reporting year. Additional cleaning on high risk wards has continued to be funded and the implementation of an internal mattress decontamination service, which a number of governors have visited, can only have reduced the risk of infection further 4 Escherichia coli (E coli) bacteraemia 4.1 Escherichia coli is a very common bacterium found in the human gut which can cause

serious infections such as blood poisoning. 4.2 In August 2014 there was one case of Trust attributed E coli bacteraemia and 9 community

attributed cases. Figure 4 shows the number of hospital and community attributed cases since April 2011. Each Trust case is subject to root cause analysis

Figure 4 – E coli bacteraemia

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4.3 It should be noted that the figures currently published by Public Health England do not

segregate the hospital and community cases of infection. The Trust uses the same criteria applied to other bacteraemia to assign cases to Trust or community for internal purposes.

5 Hand Hygiene

5.1 The Trust uses a combination of independent assessment by the Infection Prevention and

Control Team (IPCT) and self assessment by wards where observation by IPCT is difficult due to the needs of the service to calculate directorate and overall trust average scores for hand hygiene. Directorate and individual ward scores are displayed on the nursing and midwifery dashboard, which is reviewed at the Senior Clinical Matron meeting. The Trust score for August 2014 was 94.97, just 0.3% below the Trust target of 95%. This score was accurate at the time of writing but may change as additional self assessment scores are received in the first week of September.

5.2 Where staff are noted to be non compliant with policy they are reminded of their

responsibility under the hand hygiene policy on the first occasion. If subsequent non compliance is noted their name is forwarded to the Clinical Director and General Manager of the directorate for action, which may include disciplinary proceedings.

5.3 The hand hygiene group established in June 2014 continues to meet and has agreed a

logo to go onto the uniform sleeves of hand hygiene champions (Figure 5). This will be launched as part of International Infection Prevention Week in October.

Fig 5

6 Ebola Virus Disease 6.1 Following the outbreak of Ebola Virus Disease in West Africa, which commenced in March

2014, the Trust has reviewed its guideline and policy for management of viral haemorrhagic fevers and an updated guideline based on the most recent advice from Public Health England is available to staff. Emergency stocks of protective equipment are available in the event of the Trust receiving a patient at risk of having this infection. It must be noted however that the risk assessment for the UK remains very low and it is unlikely, based on the current situation, that the Trust will see any patients with Ebola.

7 Recommendation

7.1 The Council of Governors is asked to note the work underway to reduce the incidence of

infections acquired by patients in our care and the recent improvements in performance for Clostridium difficile and MRSA bacteraemia particularly.

Cath Siddle Director of Nursing, Patient Safety and Quality/ Director of Infection Prevention and Control September 2014



18 September 2014

Executive Summary

Compliance and Performance Report

Report of the Chief Operating Officer/Deputy Chief Executive

Strategic Aim (the full set of Trust Aims can be found at the beginning of the Board Reports) Maintain Compliance and Performance Strategic Objective (the full set of Trust Objectives can be found at the beginning of the Board Reports) Maintain Compliance and Performance 1. Introduction 1.1 The Compliance and Performance Report highlights performance against a

range of indicators, including Monitor’s Risk Assessment Framework and the Everyone Counts: Planning for Patients 2014/15 indicators, for July 2014

2. Key issues and Planned Action 2.1 In July, overall performance against key operational standards and

trajectories remains relatively positive, with a number of in month challenges, highlighted and contextualised in this report.

2.2 Non elective activity in July indicated a decrease in comparison with the same period last year, 4.7% (n=168); This included 620 patients who were treated via Ambulatory care, 18.4% of the total emergency admissions.

2.3 July reported a decrease in A&E attendances reporting 1.9% (n=155) lower than the same period last year.

2.4 The Trust achieved the emergency care 4 hour target in July. 2.5 The Trust continues to demonstrate positive performance against the original

18 week Referral to Treatment (RTT) pathway standards, with all standards achieved at aggregate level.

2.6 The Trust has experienced significant pressures in achieving the 14, 31 and 62 day cancer pathway standards during the June period (latest validated position), with both the June and final quarter 1 position reporting outside the required standards against three of the targets, Breast symptomatic 2 week wait, Cancer 2 week wait and the 62 day urgent referral to treatment target.

2.7 With regard to Health Care Associated Infections (HCAI), the Trust has reported within the monthly trajectory for both MRSA and C-Diff, with zero cases reported against both standards.

2.8 Key Challenges 2.8.1 The Trust is facing significant challenges in the delivery of consistent

performance against the key cancer standards. A recovery plan has been

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developed, covering pathway management, governance, capacity and demand and patient tracking processes.

2.8.2 Further objective support has been requested from the DoH ‘Intensive Management and Support Team’ (IMAS), who will be on site on the 29th and 30th September to review the Trust’s current processes and procedures and provide a view of the organisation’s position and any future required developments.

2.8.2 The impact of patient choice continues to be a main contributing factor in the delivery of the cancer standards. Included within the main report are a number of implementation requirements, in line with the Department of Health (DoH) ‘Going Further with Cancer Waits’ guidelines, to address the patient choice issue in the outpatient and diagnostic stages of the pathway.

3. Recommendations 3.1 The Council of Governors is asked to note performance against key indicators

and the contextual challenges, contained in the attached Compliance and Performance report, in line with Monitor Risk Assessment Framework and the Everyone Counts: Planning for Patients 2014/15 requirements.

3.2 The Council of Governors is also asked to note that the cancer standards

recovery plan, as outlined in this report, was approved by the Board of Directors in July 2014.

Julie Gillon Chief Operating Officer/Deputy Chief Executive September 2014

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18 September 2014

Compliance and Performance Report

Report of the Chief Operating Officer/Deputy Chief Executive 1. Introduction 1.1 The Compliance and Service Performance Report highlights performance

against a range of indicators, including Monitor’s Risk Assessment Framework and the Everyone Counts: Planning for Patients 2014/15 indicators, for July 2014.

1.2 The Corporate Dashboard has been updated to reflect the revised

performance frameworks for 2014/15 and the additional internal reporting requirements.

1.3 Appendix 1 illustrates the monthly trend and variance analysis against

targets/trajectory profiles; with due consideration given to both positive and negative variances and progress against monthly, annual and in year improvement targets.

1.4 Appendix 2 illustrates a high level view of the Corporate Dashboard and

progress against key performance indicators. 1.6 This report must be read in conjunction with the additional information as

detailed in the Quality Report and the Human Resources (HR) report. 2. Performance Overview 2.1 In July the overall performance against key operational standards and

trajectories remains challenging. 2.2 Non elective activity in July indicated a decrease in comparison with the same

period last year, 4.7% (n=168); with the main decreases evident in General Medicine, indicating a 4.8% (n=105) reduction, Orthopaedics a decrease of 17% (n=39), General Surgery a decrease of 2.5% (n=14) and Gynaecology a 24.1% (n=19) reduction.

2.3 The overall emergency activity included 620 patients who were treated via

Ambulatory care, 18.4% of the total emergency admissions, a positive move to avoid unnecessary emergency inpatient admissions, where appropriate.

2.4 July A&E attendances have also seen a decrease in comparison with the

same period last year, reporting 1.9% (n=155) lower. 2.5 Performance against the emergency care target reported at 95.86% against

the national standard of 95% in July. The Trust position against the supporting emergency care quality indicators is reported in section 3.9.

2.6 The Trust continues to demonstrate positive performance against the 18

week Referral to Treatment (RTT) pathway standards and the supporting

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median waits at aggregate level, however is reporting outside the national target for the 95th percentile waits for admitted care.

2.7 The Trust has experienced significant pressures in achieving the 14, 31 and

62 day cancer pathway standards during the June period (latest validated position), with both the June and final quarter 1 position reporting outside the required standards against three of the targets, Breast symptomatic 2 week wait, Cancer 2 week wait and the 62 day urgent referral to treatment target.

2.8 With regard to Health Care Associated Infections (HCAI), the Trust reported

within trajectory in July for MRSA and C-Diff. Shadow monitoring of HCA Infections to include Methicillin Sensitive Staphylococuss Aureus (MSSA) and E Coli continues through 2014/15.

3. Compliance Indicators 3.1 The position against key performance indicators for July 2014 is outlined

below: 3.2 Referral to Treatment (RTT) Pathways 3.2.1 The Trust continues to perform well against the RTT standards, reporting at

98.61% for non admitted pathways, within the tolerance of 95%, 91.94% for admitted pathways, against the target of 90%, and 96.96% for incomplete pathways against the target of 92%.

3.2.2 The Trust also performed within standards against two out of the three

supporting RTT measurements of ‘95th percentile waits’, reporting at 13 weeks for non admitted pathways against the target of 18.3 weeks, and 16.7 weeks for incomplete pathways, against the target of 28 weeks, however reported outside the admitted pathways target of 23 weeks, at 24 weeks.

3.2.3 The July position against the additional measure of ‘median waits’ reported

within required standards, reporting at 4.4 weeks for non admitted pathways, against the target of 6.6 weeks, 9.4 weeks for admitted pathways against the target of 11.1 weeks, and 5 weeks for incomplete pathways, against the 7.2 week target.

3.2.4 A zero tolerance approach to any incomplete RTT unadjusted pathways over

52 weeks remains within the Everyone Counts: Planning for Patients 2014/15 document. This standard has been assigned a £5000 penalty within the National Standard Contract. The Trust reported no over 52 week waits in July and continuously monitors this position on a weekly basis via the Patient Tracking List (PTL).

3.2.5 National RTT data, June position (latest published data), indicates the Trust is

performing above national average for admitted, non-admitted and incomplete pathways. The table below gives an indication of the Trust’s position against the national performance. The national reports are provided at both aggregate and specialty level, with the ability to compare with other individual organisations. These are shared monthly with the directorates for monitoring and management purposes.

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Table 1: June RTT Benchmarked Position RTT Measure National

Position

Trust

Position

Trust v

National

Incomplete Pathways waiting < 18 wks 93.8% 97.40% + 3.6%

Half of patients wait less than 6 weeks 4 weeks - 2 weeks

Admitted Pathways within 18 weeks 89.7% 93.5% + 3.8%

Half of patients wait less than 9 weeks 10 weeks -1 week

Non admitted Pathways within 18

weeks

96.30% 98.30% + 2%

Half of patients wait less than 5 weeks 4 weeks - 1 week

3.2.6 A particular focus is now being placed upon those specialties whereby

median and 95th percentile waits are rising/outlying to manage process delays, and reduce waits to support performance management and improve patient experience. These include Orthopaedics, General Surgery, Pain Management and Rheumatology.

3.2.7 In June, NHS England announced a waiting list initiative to reduce national

RTT waits, in the first instance patients waiting over 18 weeks on the RTT pathway, and then also progress toward 16 weeks to build additional resilience into the system for winter. The funding is intended to ensure that:

• all three RTT standards are achieved at both local and National level. • this is achieved in the publication of September RTT data for the three

standards of admitted 90%, non-admitted 95% and incomplete 92% at aggregate level for both providers and CCGs.

The directive is to achieve this through:

• Reducing backlog by focusing additional activity on patients that are

waiting more than 18 weeks for treatment. • Reducing the total number of patients waiting over 16 weeks by 115,000

nationally, bringing the level of over 18 week waiters back to the numbers seen in January 2013.

• Maintaining the balance of the RTT waiting list.

3.2.8 The Trust was successful in bidding for an allocation of the RTT funding and is in the process of delivering additional admitted and non admitted activity to reduce the RTT backlog and overall waiting times.

3.3 Diagnostic Waiting Times 3.3.1 Diagnostic pathways continue to be monitored closely to ensure maximum

contribution to RTT pathway management and to reduce waiting times. In line with the national trend, the Trust is experiencing increased pressures for the provision of MRI and CT scanning services.

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3.3.2 The maximum 6 week diagnostic wait indicator remains within the Everyone Counts: Planning for Patients 2014/15 document. The Trust achieved 99.92% against the target of 99% in July.

3.4 Health Care Associated Infections 3.4.1 MRSA 3.4.2 There were no cases of MRSA bacteraemia reported in July 2014. 3.4.3 The Trust target for 2014/15 remains at zero cases, in line with the national

target of zero tolerance for MRSA. 3.5 Clostridium Difficile (CDI) 3.5.1 There were no cases of Clostridium Difficile reported in July, against the

month end target of 3 cases, with the cumulative position reporting 2 cases against the target of 13.

3.5.2 A full health economy governance approach to management has been

investigated according to national directive and continues to develop in line with local requirements.

3.5.3 The Trust target for 2014/15 remains at 40 cases, in line with the Department

of Health methodology. 3.6 MSSA and E Coli 3.6.1 The DH introduced the requirement to shadow monitor hospital acquired

MSSA and E Coli cases from 2011 onwards; a reduction in cases is expected. In July the Trust reported 4 cases of MSSA, against the monthly internal target of 1 case, and 1 case of E Coli against the monthly internal trajectory of zero cases. Full root cause analysis is carried out of each MSSA and E Coli cases to identify any emerging themes and trends.

3.7 Cancer Standards (June final position) 3.7.1 The Trust has experienced significant pressures in achieving the 14, 31 and

62 day cancer pathway standards during the June period (latest validated position), as initially highlighted to the Council of Governors in the July report, which included detailed supporting information and reported to Monitor thereafter.

3.7.2 The final June validated position reported an underachievement against three

of the cancer standards, Breast symptomatic 2 week wait, Cancer 2 week wait and the 62 day urgent referral to treatment target for both the monthly position and the quarter 1 position.

3.7.4 The Trust has experienced increasing pressures across the cancer services,

compounded by significant increases in referrals as a result of multiple national cancer awareness schemes. The increase in referrals has had a significant impact on the outpatient and diagnostic services, as each 2 week wait referral has to be seen and diagnosed within the required timescales, which can include multiple appointments and diagnostic tests.

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3.7.6 The Trust has implemented a robust recovery plan which covers mitigation actions across the key areas of pathway management, governance, capacity and demand and patient tracking processes.

3.7.7 One of the key areas of impact continues to be the uptake of patient choice,

causing delay in the diagnosis and treatment stages within the pathway, affecting the delivery of the cancer standards.

3.7.8 In response to the patient choice issue, the Trust continues to work with local

GPs and CCG leads, to ensure continued support to encourage patients to take up appointments offered within the required timescales, to improve patient information and ensure a continued focus on patient information at referral.

3.7.9 In April 2014, the DoH ‘Intensive Management Support Team’ (IMAS)

released additional guidance on improving delivery against the cancer standards, NHS ‘Delivering Cancer Waiting times’. The Trust has reviewed the documentation to assess current internal practices and how improvements can be made to ensure best practice is being followed. The key recommendations have been built into the Trust’s Internal Cancer Standards Recovery Plan and expedited where appropriate.

3.7.10 This work has supplemented the on-going review of pathways, breaches and

governance. 3.7.11 In addition to the agreed internal actions, the IMAS team has been invited into

the organisation to review current practices and give an objective view of any further actions that could be implemented to improve the Trust’s delivery against the cancer standards. The team will be on site on the 29th and 30th September to work with key stakeholders.

3.7.12 Intensive work is on-going to deliver against the key actions already identified. 3.8 Emergency Care Standards 3.8.1 The Trust achieved 95.86% for the month of July against the emergency care

‘4 hour arrival to discharge or admission’ standard of 95%. July reported a 95th percentile wait of 03:59.

3.8.3 For the month of July, the Trust achieved a median wait of 50 minutes against

the 60 minutes indicator for ‘waiting time to initial treatment. 3.8.4 ‘Time to initial assessment (ambulance arrivals)’ reported at 16 minutes in

July, against the standard of 15 minutes. 3.8.5 ‘Unplanned returns within 7 days’ reported within the 5% tolerance in July, at

4.72%. 3.8.6 Patients who ‘left before being seen’ reported at 2.62 % in July against the

5% standard. 3.8.7 Work is on-going to improve resilience during periods of high impact service

pressure, such as high throughput and/or case mix within the A&E Department. A Rapid Process Improvement Workshop has resulted in a number of pathway and workforce changes to support resilience and ensure a service fit for the future. This work will continue across emergency care pathways to improve flow and outcomes.

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3.8.8 In addition, work continues within the department to improve the data completeness position by ensuring the timeliness and accuracy of data entry at source, to ensure consistency in delivery. Revised systems have been developed to ensure data is valid, complete and therefore fit for the purpose of central measurement.

3.8.9 These quality outcome indicators are published each month, where

benchmark comparisons can be found (for those Trusts that publish). 3.8.10 Ambulance handovers greater than 30 and 60 minutes are monitored within

the commissioner reports on a monthly basis. In July the Trust reported two ambulance handover greater than 30 minutes and none greater than 60 minutes. Overall performance in July indicated 98.01% of ambulance handovers (valid) within 15 minutes.

3.8.11 Given the recent national publicity around delays in emergency access, the

delivery of efficient ambulance turnaround times is currently high profile across the health economy. The Trust reported 93.2% ambulance turnaround times within 30 minutes during June.

3.8.12 In line with operational resilience requirements (as outlined in the Operational

Resilience Board Report 2014/15), the Trust has developed plans and submitted a bid to support resilience funding, in addition to a supportive infrastructure to improve the service position going into the winter months.

3.9 Community Information Dataset (CIDS) (June Final) 3.9.1 Performance indicators for Community Services, with data completeness

used as a measure for the three elements of Referral to Treatment (RTT), referral and activity information, with a target of 50% completeness set for achievement from Q1 2012/13 remain in the 2014/15 Risk Assessment Framework.

3.9.2 Monitor indicated two further data completeness measures would be

introduced within 2012/13, End of Life Pathway and Patient Identifiable Information, however these were subsequently removed from the Risk Assessment Framework. The Trust continues to monitor these indicators in shadow format.

3.9.3 June position (latest available data) indicated the Trust had achieved all three

CIDs targets for the period. 4. Human Resource / Productivity Indicators 4.1 Cancelled Operations 4.1.1 In July, non-medical cancelled operations reported at 0.69% (n=26), which is

within the Care Quality Commission target of 0.8%. All patients have been readmitted within the required 28 day period.

4.1.2 In July, the national press reported that between the April 2014 to June 2014

period, 15,661 scheduled operations were cancelled on the day due to non-medical reasons, the highest number for nine years. Reasons included staff shortages, failed equipment and a lack of beds. This equated to approximately 0.8% of all planned procedures. In comparison, the Trust reported 0.52% (56/10871) in the same period, the key issue being out of theatre time. No procedures were cancelled due to lack of beds.

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4.1.2 The Department of Health introduced a new indicator within the Everyone

Counts: Planning for Patients 2013/14 document, with no ‘urgent’ operation to be cancelled more than once, this target remains in the revised 2014/15 document.

4.1.3 July position reported no ‘urgent’ procedures had been cancelled. 4.2 Outpatient Attendance Indicators 4.2.1 The Trust continues to report progressive positive performance against the

national comparative benchmarks for outpatient attendance efficiency indicators. These benchmarks were reviewed in April 2014 to ensure they reflected the current national position. Three year stretch targets have been set for each indicator.

4.2.2 The aggregate New to Review ratios in July are reported at 1.50 below the

2014/15 target of 1.73, however additional individual targets have been agreed with Commissioners for monitoring at specialty level. Further work continues with Clinical Commissioning Groups (CCGs) to develop pathways to support further reduction/exemption, where possible.

4.2.3 The Trust’s performance against New Outpatient DNA rates reported above

the agreed target of 5.80%, reporting at 7.09%, with Review DNA rates reporting at 10.20% against the 10% target. Reductions to date have been achieved via automated reminder services and the introduction of partial booking processes, however work is on-going to further reduce DNAs.

4.3 Choose and Book Appointment Slot Issues (ASIs) 4.3.1 The Trust reported an overall monthly position of 4.56% with regard to ASIs in

July (latest final position), slightly under-achieving against the commissioner target of 4%. Capacity issues across a number of specialties during June has resulted in an increase in unsuccessful CaB appointment bookings, however the main areas of pressure being respiratory and spinal. In comparison, the latest national Choose and Book report (May position) indicated the North East position was reporting at 18% and the national average at 16%. The Trust reported at 2nd position within the region.

4.4 Sickness Absence 4.4.1 The Trust reported an aggregate Sickness Absence rate of 4.06% during

June (latest final position) against the set target of 3.5%. 4.4.2 The Trust focus remains on adherence to policy and management support to

deliver a reduction in sickness. The Trust has reviewed and updated the Absence Management Policy, with guidance distributed to all managers. Further work is on-going within the Task and Finish Group to tackle main causative factors contributing to sickness.

5. High Level Quality Indicators

5.1 Several new indicators have now been added to the dashboard for continuous

monitoring and improvement. This analysis is supported by the Quality Report.

5.2 HSMR and SHMI

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5.2.1 The Trust is reporting higher than expected at 119.76 against the HSMR in

the most recent HED rolling 12 month period (June 2013 – May 2014). 5.2.2 SHMI is also reporting higher than expected at 112.78 in the most recent

Health and Social Care Information Centre rolling 12 month period (January 2013 to December 2013).

Note: SHMI includes deaths outside of hospital, within 30 days of discharge.

5.2.3 Early investigations immediately upon raw data analysis indicate no areas for clinical concern however the Trust has undertaken a number of mortality reviews of clinical records for conditions that were reported as having a higher than expected SHMI.

5.2.4 Internal work is on-going to review both the HSMR and SHMI position via the

Keogh Task and Finish Group. A number of key areas are being reviewed including accurate documentation, clinical coding and weekly clinical led reviews of all in-hospital mortalities. In addition, to addressing the eight key recommendations in the Professor Keogh report (July 2013)

5.2.5 A comprehensive clinically led Pneumonia Mortality Project is underway to

improve clinical pathway management, data collection and documentation. 5.3 Readmissions 5.3.1 The Trust recognises that emergency readmissions are an area requiring

further work, in line with national drivers to reduce inappropriate admissions. The Trust is currently reporting emergency readmission rates at 3.15% post elective admission and 12.70% post emergency admission, slightly above target. However the aggregate readmission rate reports at 8.36% against the target of 8.30%.

5.3.2 A working group has been reviewing the baseline position, to identify key

issues in pathway management, stakeholder ownership and expectations, issues with coding, documentation and funding flows to support service change and development. This programme of work aims to reduce avoidable emergency readmissions. Medical and surgical clinical leaders have been identified and further engagement sought at the Trust Directors Group.

5.3.3 Work streams have been developed with agreed metrics in place to set out

the delivery expectations. These will be supported by clinical audit and clinical debate to inform discussions and negotiation with the Clinical Commissioning Groups. Appropriate governance structures via the Better Care Fund Working will be put in place to ensure that the responsibility of readmissions is shared across the acute, community, primary and social care providers to tackle the key themes associated with avoidable readmissions

5.4 Unplanned Hospitalisation and Emergency Admissions 5.4.1 The Everyone Counts: Planning for Patients 2014/15 Framework includes a

number of measures aimed at reducing unnecessary hospital admissions for a defined set of acute conditions. These are:

• Unplanned hospitalisation for chronic ambulatory care sensitive conditions

(adults) • Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

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• Emergency admissions for acute conditions that should not usually require hospital admission

• Emergency admissions for children with lower respiratory tract infections (new measure for 2013/14)

5.4.2 Although no set target has been set, there is an expectation that acute

providers will deliver a year on year reduction against these key areas. The Trust has set a baseline against 2013/14 outturn and will monitor delivery on a month on month basis, in addition to continuing joint work with GPs and CCGs to develop pathways to avoid admission where inappropriate.

5.4.3 Two out of the four standards reported a slight increase in the rate of

admissions in June (latest coded position), indicating a rise in unexpected emergency admissions across the defined set of conditions.

5.4.4 The key areas of pressure included adult emergency admissions for lobar,

atypical or viral pneumonia and kidney and urinary tract infection, and Paediatric admissions for lower respiratory tract infections.

5.5 Venous Thromboembolism (VTE) 5.5.1 This target measures the Trust’s compliance with the assessment for VTE on

admission for all appropriate admissions. The Trust reported at 96.01% in June (final validated position), above the 95% target.

5.6 Grade 3 & Grade 4 Pressure Sores 5.6.1 The monitoring of hospital acquired grade 3 and grade 4 pressures sores has

been added to the quality section of the Corporate Dashboard. In July no grade 3 or grade 4 hospital (in hospital) acquired pressures sores were reported.

5.7 In Hospital Falls 5.7.1 Two new measures of total ‘in hospital falls’ and ‘in hospital falls resulting in a

fracture’ are now included in the Corporate Dashboard. 5.7.2 The performance for total ‘in hospital’ falls will be monitored against last

year’s position for the comparative period, with an expected improvement. In July the Trust reported 114 falls in hospital, a 12.97% (n-17) reduction on the July 2013 position, which reported 131 falls.

5.7.3 In July, 8 of the in hospital patient falls resulted in a fracture, 7% of total falls. 5.8 NHS Choices 5.8.1 The Trust’s current score against the NHS Choices section relating to patient

experience and recommendation of provider is reported within the Quality section of the Corporate Dashboard. Patient experience and choice is high on the Trust’s quality agenda, therefore this measure has been added as a guide to the patient’s perception of the care the two hospital sites are providing.

5.8.2 The July report indicated Hartlepool hospital at 5* and North Tees hospital at

4*. In comparison, the average score across the hospitals within the North East region was 4*.

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5.8.3 This will be supplemented by the Friends and Family Indicator report in the Quality Report to Board, with July scores for Wards, A&E and Maternity (births element) now reported on the quality section of the Corporate Dashboard.

6. Contract Key Performance Indicators 6.1 The Trust agreed a significant number of key performance measures for

2014/15 within the NHS standard and local contract negotiations. In line with the NHS England Commissioning Board structure, these are reported to multiple commissioning bodies including:

• Clinical Commissioning Groups • Area Team • Local Authority

6.2 The KPIs cover quality requirements across both acute and community

services, with financial penalties attached against non compliance. The Trust reports performance to the commissioners on a monthly basis.

6.3 The Trust performed well across the majority of the contract KPIs during the

July period. The main areas of pressure currently being the RTT admitted pathways and Cancer targets at commissioner level.

6.4 The performance against the contract KPIs for all commissioners are

monitored and managed robustly. 7. Conclusion/Summary 7.1 The Trust has, in the main, performed well against the majority of key

operational standards during July, notwithstanding the considerable challenges associated with on-going operational pressures across both elective and emergency pathways. The Trust continues to develop the performance reporting framework to ensure it meets the needs of both corporate and directorate level delivery, reflecting the multiple internal and external performance requirements and principles of Service Line Management.

8. Recommendations 8.1 The Council of Governors is asked to note the detail in the Corporate

Dashboard and performance against the Risk Assessment Framework and the key national indicators, for July 2014, in the context of Monitor’s Terms of Licence and the Everyone Counts: Planning for Patients 2014/15 document.

8.2 The Council of Governors is also asked to note that the cancer standards

recovery plan, as outlined in this report, was approved by the Board of Directors in July 2014.

Julie Gillon Chief Operating Officer/Deputy Chief Executive September 2014

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Return to CDB menuProfile 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%Actual 93.64% 92.65% 93.46% 91.94% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Variance 3.64% 2.65% 3.46% 1.94%Profile 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%Actual 98.65% 98.09% 98.33% 98.61% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Variance 3.65% 3.09% 3.33% 3.61%92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92%

Actual 97.05% 97.34% 97.39% 96.96% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

5.05% 5.34% 5.39% 4.96%Profile 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1 11.1Actual 9.9 9.0 10.0 9.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Variance -1.2 -2.1 -1.1 -1.7

Profile 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6Actual 4.1 4.6 4.6 4.4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Variance -2.5 -2.0 -2.0 -2.2

Profile 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2 7.2Actual 5.4 5.1 4.9 5.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Variance -1.8 -2.1 -2.3 -2.2

Profile 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0 23.0Actual 24.1 23.1 22.0 24.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Variance 1.1 0.1 -1.0 1.0

Profile 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3Actual 12.9 14.1 13.9 13.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Variance -5.4 -4.2 -4.4 -5.3

Profile 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0 28.0Actual 16.3 16.6 16.4 16.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Variance -11.7 -11.4 -11.6 -11.3

Profile 0 0 0 0 0 0 0 0 0 0 0 0

Actual 0 0 0 0

Variance 0 0 0 0

Profile 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Actual 100.0% 100.0% 100.0% 100.0%

Variance 5.0% 5.0% 5.0% 5.0%

Profile 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3 18.3

Actual 7.0 6.0 6.0 6.0

Variance -11.3 -12.3 -12.3 12.3

Profile 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 95.66% 95.89% 94.87% 95.86% 0.00%

Variance 0.66% 0.89% -0.13% 0.86%

Profile 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00 15:00Actual 18:00 18:00 16:00 16:00 00:00 00:00 00:00 00:00 00:00 00:00 00:00 00:00

Variance 03:00 03:00 01:00 01:00

Profile 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00 01:00Actual 00:43 00:46 00:48 00:50 00:00 00:00 00:00 00:00 00:00 00:00 00:00 00:00

Variance 00:17 00:14 00:12 00:10

Profile 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%Actual 4.75% 5.05% 5.13% 4.72% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Variance -0.25% 0.05% 0.13% -0.28%

Profile 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%Actual 2.06% 2.07% 2.17% 2.62% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Variance -2.94% -2.93% -2.83% -2.38%

Profile 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%Actual 97.29% 98.04% 97.70% 98.01%

Variance -2.71% -1.96% -2.30% -1.99%

Profile

Actual Variance

* Data collection, validation and reporting processes prevent these standards from achieving a more timely result

% Ambulance Handover (Valid) within 15 minutes

A&E left without being seen

A&E 4 hr target (excludes walk-in centres)

Audiology non admitted wait (95th percentile)

A&E Time to Initial Assessment -Ambulance arrivals (95th percentile)

RTT incomplete pathways >52 week wait

A&E Time to Initial Treatment (Median)

A&E unplanned returns within 7 days

RTT non admitted wait (Median)

RTT incomplete pathways wait (Median)

RTT incomplete pathways wait (95th percentile)

RTT non admitted wait (95th percentile)

RTT admitted wait (95th percentile)

The % patients treated within 18 weeks of referral to audiology (Hpool site)

Appendix 1 - Compliance Monitoring Framework

RTT admitted wait (Median)

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The % of patients whose clock is still running waiting less than 18 weeks

The % of patients whose clock stopped within 18 weeks during the month with an admission (Part1a)

The % of patients whose clock stopped within 18 weeks during the month - non admitted (Part 1b)

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Trust Performance

(1)

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Return to CDB menuProfile 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0%

Actual 100.0% 100.0% 100.0%

New Cancer 31 days subsequent Treatment (Drug Therapy) * Variance 2.0% 2.0% 2.0%

Profile 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0% 94.0%Actual 94.7% 100.0% 100.0%Variance 0.7% 6.0% 6.0%Profile 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0%Actual No patients 100.0% 100.0%

Variance 0.0% 15.0% 15.0%Profile 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%Actual 100.0% 95.5% 90.5%Variance 10.0% 5.5% 0.5%Profile 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0%Actual 85.8% 86.5% 73.5%Variance 0.8% 1.5% -11.5%Profile 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0% 96.0%Actual 96.4% 98.3% 100.0%Variance 0.4% 2.3% 4.0%Profile 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0%Actual 89.9% 93.6% 92.2%Variance -3.1% 0.6% -0.8%Profile 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0% 93.0%Actual 83.9% 95.2% 92.0%Variance -9.1% 2.2% -1.0%Profile 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0Variance 0 0 0 0Profile 3 6 10 13 16 20 23 26 30 33 36 40Actual 0 1 2 2Variance -3 -5 -8 -11Profile 3 4 5 6 7 8 9 10 11 12 13 13Actual 4 5 5 9Variance 1 1 0 3Profile 0 1 3 3 4 4 7 9 14 18 20 22Actual 0 3 5 6Variance 0 2 2 3Profile 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00%Actual 78.95% 93.75% 87.18%Variance -1.05% 13.75% 7.18%Profile 60.00% 60.00% 60.00% 60.00% 60.00% 60.00% 60.00% 60.00% 60.00% 60.00% 60.00% 60.00%Actual 100.00% 100.00% 100.00%Variance 40.00% 40.00% 40.00%Profile 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4% 4%Actual 2.82% 2.85% 6.42% 4.56%Variance -1.18% -1.15% 2.42% 0.56%Profile 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0Variance 0 0 0 0Profile 100 100 100 100 100 100 100 100 100 100 100 100Actual 68 72 73 72

Variance -32 -28 -27 -28Profile 100 100 100 100 100 100 100 100 100 100 100 100Actual 60 69 57 56

Variance -40 -31 -43 -44Profile 100 100 100 100 100 100 100 100 100 100 100 100Actual 71 70 78 67

Variance -29 -30 -22 -33Profile 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 99.65% 99.67% 99.61% 99.55%Variance 4.65% 4.67% 4.61% 4.55%


** Mandatory from 2013

Outcome Compliance

Friends & Family - (A&E) [National Score based on % ‘extremely likely’ to recommend to F&F]

Friends & Family - (Ward) [National Score based on % ‘extremely likely’ to recommend to F&F]

New Cancer 31 days subsequent Treatment (Surgery) *

Breast Symptomatic Two week Rule (New Rules) *

TAL's - (No SLOT analysis)

Friends & Family - (Birth) **[National Score based on % ‘extremely likely’ to recommend to F&F]

New Cancer GP 62 Day (New Rules) *

New Cancer 62 days (screening) *

New Cancer Two week Rule (New Rules) *

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Stroke admissions 90% of time spent on dedicated Stroke unit

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Clostridium Difficile Patients - diagnosed after 72 hours all ages (Cumulative)

New Cancer 62 days (consultant upgrade) *

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MRSA - Bacteraemia (Cumulative)


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Trust Performance

(2)

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New Cancer Current 31 Day (New Rules) *

Delivery of Mixed Sex Accommodation

High risk TIAs assessed and treated within 24 hours

E-Coli (Cumulative)

Methicillin Sensitive Staphylococcus Aureus (MSSA) (Cumulative)

Return to CDB menuProfile 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0Variance 0 0 0 0Profile 0 0 0 0 0 0 0 0 0 0 0 0Actual 2 0 1 0Variance 2 0 1 0Profile 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80% 0.80%Actual 0.42% 0.28% 0.81% 0.69%Variance -0.38% -0.52% 0.01% -0.11%Profile 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%Actual 100.00% 100.00% 100.00% 100.00%Variance 5.00% 5.00% 5.00% 5.00%Profile 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00% 99.00%Actual 99.98% 99.98% 99.96% 99.92%Variance 0.98% 0.98% 0.96% 0.92%Profile 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 1 0Variance 0 0 -1 0Profile 0 0 0 0 0 0 0 0 0 0 0 0Actual 0 0 0 0Variance 0 0 0 0Profile 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5%Actual 1.29% 1.66% 0.89% 1.33% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%Variance 2.21% -1.84% -2.61% -2.17%

Profile 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00% 80.00%Actual 97.00% 97.00% 97.00% 97.00%Variance 17.00% 17.00% 17.00% 17.00%Profile 50.0% 50.00% 50.00% 50.00% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0% 50.0%Actual 93.90% 92.43% 93.06%

CIDs -Referral to Treatment information * Variance 43.90% 42.43% 43.06%Profile 50.0% 50.00% 50.00% 50.00% 50.0% 50.0% 50.0% 50.0% 50.0% 50.00% 50.0% 50.0%Actual 87.52% 89.53% 91.32%Variance 37.52% 39.53% 41.32%Profile 50.0% 50.00% 50.00% 50.00% 50.0% 50.0% 50.0% 50.0% 50.0% 50.00% 50.0% 50.0%Actual 70.92% 70.64% 70.97%Variance 20.92% 20.64% 20.97%Profile 50.0% 50.00% 50.00% 50.00% 50.0% 50.0% 50.0% 50.0% 50.0% 50.00% 50.0% 50.0%Actual 70.92% 70.64% 70.97%Variance 20.92% 20.64% 20.97%Profile 50.0% 50.00% 50.00% 50.00% 50.0% 50.0% 50.0% 50.0% 50.0% 50.00% 50.0% 50.0%Actual 98.15% 93.10% 95.16%Variance 48.15% 43.10% 45.16%Profile

Actual

Variance

Profile

Actual Variance


Readmission within 28 days of non medical cancelled operation *

Cancelled Operations for non medical reasons

Cancelled Urgent Operations for second time

Number of patients waiting under 6 weeks for diagnostic procedures

A & E 12 Hour Trolley waits

End of Life measure *

Delayed Transfers of Care

CIDs - Referral information *

Treatment Activity Information *

Mandatory Training

Patient Identifier Indicator *


Number of patients waiting over 26 weeks for an inpatient or daycase admission

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Number of patients waiting over 13 weeks for an outpatient appointment

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Return to CDB menuProfile 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Actual 96.69% 99.52% 99.56% 98.98%

Variance 1.69% 4.52% 4.56% 3.98%

Profile 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Actual 97.98% 98.70% 99.40% 98.85%

Variance 2.98% 3.70% 4.40% 3.85%

Profile 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Actual 100.00% 100.00% 100.00% 100.00%

Variance 5.00% 5.00% 5.00% 5.00%

Profile 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Actual 94.74% 90.00% 92.68% 91.11%

Variance 4.74% 0.00% 2.68% 1.11%

Profile 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Actual 103.32% 106.32% 107.67% 105.74%

Variance 8.32% 11.32% 12.67% 10.74%

Profile

Actual

Variance

Profile

Actual

Variance

Profile

Actual

Variance

Profile

Actual

Variance

Profile

Actual

Variance

Profile

Actual

Variance

Profile

Actual

Variance

Profile

Actual

Variance

Profile

Actual

Variance


Diabetic Retinopathy Screening

March

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Octo

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Feb

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18 week RTT admitted Community Dental

18 week RTT Non admitted MSK North Tees

18 week RTT Non admitted ENT

Appendix 1 - Community Monitoring Framework

18 week RTT Non admitted MSK Hartlepool

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Trust Performance

(4)

July 14

Appendix 2Published's Date & Time28/08/2014 15:12

ID MeasureMonthly Target

Annual Target

Act Cum ID Measure Monthly Target

Annual Target

Act Cum

1 A&E 1 New to Review ratio (cons led) 1.73 1.502 A&E 4 hr target (excludes walk-in centres) 95.00% 95.86% 95.57% 2 Outpatient DNA (new) 5.80% 7.09%3 3 Outpatient DNA (review) 10.00% 10.20%

4 Cancer The June 14 Position 4 Average depth of coding 3.01 4.025 New Cancer 31 days subsequent Treatment (Drug Therapy) 98.0% 100.0% 100.0% 5 Length of Stay Elective 3.23 2.806 New Cancer 31 days subsequent Treatment (Surgery) 94.0% 100.0% 98.0% 6 Length of Stay Emergency 4.45 4.547 New Cancer 62 days (consultant upgrade) 85.0% 100.0% 100.0% 7 Day case Rate 68.48% 75.77%8 New Cancer 62 days (screening) 90.0% 90.5% 95.4% 8 Pre - Op Stays 7.75% 4.13%9 New Cancer GP 62 Day (New Rules) 85.0% 73.5% 81.6% 9

10 New Cancer Current 31 Day (New Rules) 96.0% 100.0% 98.4% 10 Bed Occupancy11 New Cancer Two week Rule (New Rules) 93.0% 92.2% 91.8% 11 Revised Occupancy Hartlepool 82% 79.08%12 Breast Symptomatic Two week Rule (New Rules) 93.0% 92.0% 90.2% 12 Revised Occupancy North Tees 82% 84.95%13 13

14 RTT Milestones 14 Theatre Activity15 RTT admitted wait (90%) 90.00% 91.94% 15 Late Start % 34.27% 22.67%16 RTT non admitted wait (95%) 95.00% 98.61% 16 Early Finishes % 48.88% 55.28%17 RTT incomplete pathways wait (92%) 92.00% 96.96% 17 Session overuns (>30 minutes) 14.20% 12.42%18 18 Operation Time Utilisation 95.00% 73.11%

19 Community Information Dataset 19 Run Time Utilisation 95.00% 88.92%20 Referral to Treatment information 50.00% 93.06% 20 Cancelled Sessions 3 2521 Referral information 50.00% 91.32% 21 Cancelled on day of operation 5.87% 7.71%22 Treatment Activity Information 50.00% 70.97% 22 Cancelled (Non medical) 0.80% 0.69%23 23

24 HCAICumulative YTD Target 24 HR

25 MRSA 0 0 0 0 25 Staff in post (wte) 4528.3726 C.Diff (diagnosed after 72 hours) 3 13 0 2 26 Staff turnover ratio 10.00% 10.96%27 27 Sickness absence % 3.50% 4.06%28 Eliminating Mixed Sex Accommodation 0 0 28 Mandatory Training 80.00% 97.00%29 Access to Healthcare for People with Learning Disabilities 2930 3031 CQC Registration 3132 3233 Health Visitor numbers 62.22 60.15 3334 3435 35

ID MeasureMonthly Target

Annual Target

Act ID Measure Revenue Position

CIP Delivery

Strategic CIP

Delivery1 Mortality rate (HSMR) 100.00 119.76 1 ACCIDENT AND EMERGENCY2 Mortality rate (SHIMI) 100.00 112.78 2 ANAESTHETICS3 Mortality rate (SHIMI) - {High relative risk CCS's} TBA 15 3 CHIEF EXECUTIVE4 Readmission rate 30 days (Emergency admission) 9.73% 12.70% 4 CLINICAL SERVICE & COMPLIANCE5 Readmission rate 30 days (Elective admission) 0.00% 3.15% 5 COMMUNITY SERVICES CLINICAL6 Readmission rate 30 days (Total) 8.30% 8.36% 6 EDUCATION,LEARNING & DEVELOPMENT7 7 ENDOSCOPY8 Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) 72.60 55.34 8 ESTATES9 Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s 23.36 15.57 9 FINANCE

10 Emergency admissions for acute conditions that should not usually require hospital admissio 122.47 138.36 10 HUMAN RESOURCES11 Unplanned hospitalisation for respiritory tract infections in under 19s 2.22 5.56 11 MEDICINE12 12 NURSING AND PATIENT SAFETY13 Patient Safety Incidents (All Grades) {per 100 admissions} 6.80 8.98 13 OBS AND GYNAE14 Patient Safety Incidents that resulted in Serious Harm - {% of total PSIs} 0.60 0.20 14 ORTHOPAEDICS15 Complaint response times 79.00% 95.83% 15 PAEDIATRICS16 16 PATHOLOGY17 Corporate & Departmental Risks (Red) 14 17 PHARMACY18 Electronic Discharge Summaries within 24 hours 95.00% 90.00% 18 RADIOLOGY19 Grade 3 Pressure sores (Hospital only) 0 0 19 SURGERY AND UROLOGY20 Grade 4 Pressure sores (Hospital only) 0 0 20 TOTAL DIRECTORATE21 Total Falls (Hospital Only) 131 114 21

22 Falls with Fracture (Hospital only) 0 8 22

23 VTE 95.00% 96.01% 23 PORTFOLIO ARRAGEMENTS FOR 14/15 SIEP DELIVERY

24 Hand washing Compliance 100.00% 92.00% 24 DELIVERY PROGRAMME (BASED ON PHASING OF SAVINGS DELIVERY)

25

Cumulative YTD Target 25 ENABLING PROGRAMME (BASED ON PHASING OF SAVINGS DELIVERY)

26 Methicillin Sensitive Staphylococcus Aureus (MSSA)-(profile-2012-13 actual) 1 6 4 9 26 RESERVES SLIPPAGE / UTILISATION

27 E-Coli - (profile-2012-13 actual) 0 3 1 6 27 UNALLOCATED CIP

28 NHS Choices 28 OVERALL PORTFOLIO TOTAL29 % Patients recommending University Hospital of Hartlepool 4.0 5.0 29

30 % Patients recommending University Hospital of North Tees 4.0 4.0 30 CONTINUITY OF SERVICES RISK RATING31 31 CAPITAL SEVICING CAPACITY (50%) 332 Friends & Family - (Ward)-[National Score based on % ‘extremely likely’ to recommend to F&F] 70 -100 72 32 LIQUIDITY RATIO (50%) 433 Friends & Family - (A&E)-[National Score based on % ‘extremely likely’ to recommend to F&F] 70 -100 56 33 OVERALL FINANCIAL RISK RATING 434 Friends & Family - (Birth)-[National Score based on % ‘extremely likely’ to recommend to F&F] 70 -100 67 34

35 35

Compliance Monitoring

Quality Report Financial Position

HR - Productivity & Process



18 September 2014

Executive Summary

Operational Resilience Report 2014/15

Report of the Chief Operating Officer/Deputy Chief Executive

Strategic Aim (the full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Maintain Compliance and Performance Strategic Objective (the full set of Trust Objectives can be found at the beginning of the Council of Governors Reports) Maintain Compliance and Performance 1. Introduction 1.1 Significant pressures have been witnessed across the whole health economy

both locally and nationally and therefore it is essential that robust plans are in place to not only manage the increased predicted pressures placed on the Trust through the course of increased all year round surges in activity, particularly during the winter period, but to successfully focus on patient safety, quality and experience.

1.2 Guidance published by NHS England and Monitor, Operational Resilience

and Capacity Planning 2014/15, incorporates elective care and has therefore been considered in the System Resilience Group (SRG), formerly Urgent Care Working Group (UCWG), planning process.

1.3 The Trusts Winter Capacity and Surge Plan 2014/15 has been produced in

line with the national context and requirements articulated by NHS England; now merging into an Operational Resilience Plan.

1.4 In March 2014 the Trust held a winter debrief session, reviewing the

organisation’s capacity and capability to manage the pressures faced last winter. The lessons learnt from this debrief session have been used to improve the planning process for this year 2014/15.

2. Summary 2.1 This report describes the arrangements planned by the Trust to maintain

effective access to services and strengthen emergency preparedness and resilience specifically for winter 2014/15 but also to ensure on-going resilience during a period of inevitable increase in emergency activity. The paper informs and provides a level of assurance of the scale of planning for

1

2014/15 which has taken into account the lessons learned from the challenges of previous years.

2.2 Although work is ongoing to support assurance and further refine the plan in readiness for the expected winter surge 2014, positive assurance with regard to winter resilience has been managed in a number of ways including:

• Strong leadership and governance arrangements with active engagement throughout the Trust in planning for resilience to support a potential surge in activity.

• Action planning to manage the changes in profile of surges in emergency activity whilst continuing to deliver elective and urgent activity requirements.

• Staff engagement in planning and preparation meetings, especially with regard to debriefing, learning lessons and simulation.

• Pathway reviews with the introduction of new plans to ensure that patients are streamed and seen in the most appropriate setting

• Management of a robust stakeholder engagement and communications strategy together with the commissioners around winter planning has served to provide extensive consultation and operational ownership of required changes to support future resilience delivery.

• Plans have been tried and tested in practice and customised to manage clinical and managerial feedback

• Bids have been submitted to the Clinical Commissioning Group for work streams to support operational resilience, elective and emergency access, patient flow and timely discharge.

• The winter plan and revised North East Escalation Plan (NEEP) have been shared at a winter planning meeting with key staff providing both an opportunity for amendments and to ensure the plan is understood.

• Continuous benchmarking including visits to other organisations to assess and manage ways of working into the future.

• Assurance meetings with the Clinical Commissioning Group and the North East Clinical Support Unit with the Trust graded as low risk “self assessment” status.

2.3 The organisation continues to contribute to the Tees wide urgent care agenda and resilience planning to ensure a full systems approach to surge management.

2.4 The Trust is proactively engaged in the Better Care Fund planning with the

main Stakeholder Clinical Commissioning Group, Local Authorities and Tees, Esk and Wear Valley Mental Health Trust to improve admission avoidance and timely discharge including the provision of nursing home beds in Hartlepool.

2

2.5 The Trust continues to engage in the assurance review requirements across the Area Team span of authority and has participated in local Peer Review Programmes.

3. Recommendations 3.1 The Council of Governors is asked to note the contents of the report, to

acknowledge the challenges that the Trust is currently experiencing and will face, the progress that has been made to improve escalation actions and flexibility in management and service delivery approaches synonymous with sustainable surge and resilience management requirements.

Julie Gillon Chief Operating Officer / Deputy Chief Executive September 2014

3



18 September 2014

Operational Resilience Report 2014/15

Report of the Chief Operating Officer/Deputy Chief Executive 1. Introduction 1.1 Year on year effective winter planning and surge management has been a

key priority within both the NHS and the Trust with this year being no exception. Whilst the Trust is well rehearsed in planning for winter and surge, needless to say each year is different bringing with it individual and unexpected challenges from which the Trust reflects and plans for the future, working collaboratively with commissioners and other key stakeholders. There is also a renewed national drive to ensure additional assurance in the system with regard to emergency departments and system resilience.

1.2 Following the pressure experienced during the winter of 2012/13, NHS

England published the A&E Recovery Plan in May 2013. The plan called for the creation of Urgent Care Working Groups (UCWGs). There is now a need for the UCWGs to expand their remit to include elective care and become a forum where capacity planning and operational delivery across the health and social care system is coordinated, and will subsequently be known as System Resilience Groups (SRG). Guidance for the planning process has been published by NHS England and Monitor (Operational Resilience and Capacity Planning for 2014/15).

1.3 Last winter, albeit relatively mild in comparison to previous years, tested the

effectiveness and resilience of emergency care provision locally and nationally; this year has seen pressure continue through the spring and summer months and data trends would suggest that despite there not being a significant increase in activity, there has been an increase in the level of patient acuity and complexity. Additional challenges have also been overcome following service transformation and the relocation of acute medicine and critical care on to a single site with reduced bed flexibility. Further challenges will be faced throughout the implementation of clinical pathway plans in service transformation, requiring additional risk mitigation and robust patient safety planning.

1.4 Whilst winter is clearly a period of increased pressure, establishing

sustainable year-round delivery requires system planning to be on going and robust. Whilst the Trust has maintained focus on overall resilience there is no doubt that concentrated emergency activity evident through service transformation in addition to patient acuity and increased elective activity and complexity is placing a new pressure on the system. Working with partners in local authorities, the Trust needs to be in a position to move away from what is becoming a reactive approach to managing operational challenges towards a proactive system of year round operational resilience.

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1.5 In addition, the independent regulator Monitor relies on robust governance arrangements and self-regulation with regard to the requirement for Boards of Foundation Trusts to declare compliance with healthcare standards such as emergency preparedness and surge resilience.

1.6 The following report provides an overview of the historical context of winter

pressures, the relative status of operational resilience with regard to the previous winters, the lessons learnt, the current pressures across the system, the status of planning contingency for 2014/15, current risks and plans for future operational resilience during periods of high activity and additional operational measures all year round.

1.7 The report was received by the Board of Directors at a meeting in July 2014

and provided a level of assurance as to the readiness and resilience of the Trust to respond to a surge in activity, and to address access issues in an on-going manner but particularly during the winter months.

2. Historical Context and Background 2.1 Historical evidence signifies a recurrent, significant and exceptional pressure

upon healthcare resources during the conventional five month winter period (November – March).

2.2 Local Context 2.3 Winter 2013/14 (November to March period) indicated reduced emergency

pressures to the previous year, with overall emergency admissions reducing by 10.09% (n=1,462) in comparison to the same period in 2012/13. A&E attendances showed a slight increase of 0.49% (n=169), however within this activity the Trust reported a 2.67% (n=190) decrease in admissions via A&E. The decrease in admissions is potentially a result of changes in practice. Following service transformation, some pathways for patients with chest pain or respiratory disorders, who would have previously been admitted via A&E, have been developed for direct admission to Emergency Assessment Unit (EAU) by the North East Ambulance Service (NEAS). The Trust also treated patients via ambulatory care, providing diagnosis, treatment and discharge in the ambulatory care setting and reducing unnecessary admissions to base wards, the number being consistent with the previous year.

2.4 The first quarter of 2014 indicates that overall emergency admissions have

decreased by 5.66% (n=481), compared to the same period last year. Ambulatory Care admissions continue to be consistent.

2.5 A&E attendances have seen a slight increase of 0.15% (n=34), however the

significant pressures evident at front of house have been due to daily surges in activity later in the day. Admissions via A&E are reporting a decrease during this period of 5.56% (n=237).

2.6 Nationally the health economy sees a trend of year on year pressures in

emergency admissions and the Trust data shows alignment with national trends. The evidence to date would suggest that 2014/15 will see similar pressures to previous years, with increases in surge patterns and acuity already evident through both A&E and areas of emergency care delivery.

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2.7 National Context 2.8 The initial winter plan has been produced in line with the national context and

requirements articulated by NHS England. The Trust held a winter debrief session in March 2014, reviewing the organisation’s capacity and capability to manage pressures faced last winter, utilising lessons learnt to improve the planning process for this winter.

2.9 With increased media interest and the challenges faced nationally by

emergency care in particular accident and emergency units it was essential that the Trust adequately review all areas impacting on the potential effectiveness of managing winter to ensure optimum resilience.

The plan focuses on:

• Planning and support (planning process for 2014/15). • key pressures that arose from previous winters (planning key areas of

learning from last year’s winter experience). • demand and capacity modelling • risks and mitigations to capacity constraints • operational response and monitoring • governance and assurance

3. Operational and Capacity Resilience Planning 2014/15 3.1 The System Resilience Group (SRG)), formally the UCWG, is chaired by a

senior leader from the Clinical Commissioning Group (CCG). All provider, commissioner and social care organisations have membership on the group. The SRG was required to submit a multi-agency plan to the Area Team by 30th July 2014, signed off by all membership organisations, including the mandatory elements of good practice, wider considerations, governance and building on existing work. Key dates for planning and assurance are detailed in figure 1.

3.2 In line with the operational resilience approach now advocated nationally

each membership organisation has submitted plans to the SRG for collation. The Trusts submission demonstrates core aspects of good practice for both elective and non-elective care pathways, additional innovation plans and associated costs for delivery over the winter of 2014/15.

3.3 In previous years access to urgent care monies has been sporadic and

allocations released in an untimely manner resulting in the inability to make optimal use of available funding to manage the winter pressures. The guidance for 2014/15 gives specific timelines for organisations to plan accordingly (figure 1). It was anticipated that the plans would have been agreed, and organisations would have been informed which initiatives had been funded, by July 30th 2014 to allow adequate time for implementation in November 2014. The deadline has now been extended to facilitate negotiation until the Trust is assured that sufficient funding will be released to support its resilience plans.

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Figure 1: Planning Process Timeline

4. Reflection and Lessons Learnt in Surge (Winter) Management and

Planning

4.1 Year on year early and sustained planning, systematic evaluation of surge resilience and operational readiness, a drive to achieve quality initiatives and to see a reduction in delayed discharges, a renewed focus on vaccination programmes and a strong governance and leadership infrastructure has resulted in a positive and managed impact upon performance standards, patient safety and clinical outcomes within the organisation.

4.2 Access and waiting time standards have been consistently achieved, patient

boarding minimised, and a low level of non-medical surgical cancellations maintained.

4.3 Last year the national target to vaccinate eligible staff was set at 75% with

many Trusts falling short of achieving this. This Trust achieved only 54.33% vaccination of all eligible staff; this was a disappointment and places a greater emphasis on this year’s planning and preparation. This year’s target has again been set at 75%.

4.4 Evaluation and historical intelligence have been fundamental in assessing the

approach to the planning requirements for the winter of 2014/15 and a number of key factors have influenced and altered plans for the future. However, there are a number of additional recognised factors falling outside the direct influence of the Trust which place additional pressures on the Trust, not least the requests for mutual aid by neighbouring Trusts.

4.5 Whilst the Trust is committed to placing the needs of the patient at the

forefront of any requests for mutual aid by neighbouring organisations it does need to be noted across the regional health economy that going forward this is not a sustainable solution for recurrent problems and a protocol has been revised in 2014, following lessons learnt during the winter months of 2013/14, to involve clinical and operational staff in decision making in the interests of patient safety and quality provision.

4.6 As outlined in section 2, it is evident that the Trust has had a period of

consistent pressure during the spring and early summer months which has certainly tested resilience but also impacted upon the relative position moving into winter surge.

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4.7 Key Pressures Faced by the Trust in the Winter of 2013/14 4.7.1 The key, but not exhaustive, list of pressures faced by the organisation last

winter included:

• Increase in attendances via A&E and a tendency for a more complex / dependent case mix leading to extended in lengths of stay and a subsequent reduction in capacity

• Changes in the profile of daily surges in emergency activity • Reductions in timely discharge of patients due to increased demand from

the Trust and primary care for capacity in community / social care and responsiveness of external organisations during weekends and bank holidays.

• Bed closures due to infection (e.g. Norovirus) outbreaks • Increase in medical outliers due to the above issues • Demand for mutual aid from neighbouring Trusts. • Recruitment to high risk areas (both medical and nursing)

4.7.2 In addition, it is inevitable that the health and social care economy face

challenges in meeting the increased demands made on services, therefore to strengthen planning an attempt is always made to predict some of these challenges to improve the Trust’s state of readiness. This includes:

• An aging population • Increased numbers of patients with long term conditions • Limited nursing assessment, rehabilitation and nursing home capacity • Delayed discharges • Reduction in surge capacity • Ambulance turnaround times.

4.8 Key Learning from Winter 2013/14 4.8.1 Whilst the pressures posed by winter are predictable, it is essential that, in

planning, lessons are taken on board, from previous experiences. A winter debrief, involving Trust and other agencies and partners, served to provide a rich source of learning to aid planning, including:

• the norovirus campaign worked well, the Trust witnessed a decrease in

bed closures as a result of infection compared to the previous year, but more work could be done to ensure timeliness of decision making around such

• there was a decrease in the uptake of flu vaccination by front-line staff; • the need for a review of the escalation process to ensure greater

sensitivity, in mobilising resources • the need to minimise patient movement between wards, to review the

boarding policy to ensure, during periods of intense surge, when boarding is required, that patients are cohorted and managed appropriately.

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4.9 Key pressures in 2014/15 4.9.1 As indicated (Section 2) operational challenges have remained in the system

during the first quarter of 2014/15 with Medical inpatient lengths of stay remaining high (average 5.1 days), increased ambulatory care activity (approximately 20% of emergency activity), requiring efficient diagnosis, treatment and discharge, the impact of a dearth in consultant recruitment, extended cancer campaigns, changes in clinical pathways between the two hospital sites to ensure clinical safety and quality, impacting upon the theatre resource, to name but a few.

4.9.2 Nationally 38% of non-specialist Trusts (n=99) are suffering from late winter

pressures and 27% with larger deficits due to continued pressures. Risks are compounded by the non-recurrent nature of winter funding which leads to temporary structures at premium cost.

4.9.3 The challenge this year is to maintain clinical, financial and service

performance and focus on overarching system resilience and transformation for the future. This is no longer a one dimensional ‘winter’ challenge.

4.9.4 The learning from winter 2013/14 and previous winters and the current

challenges facing the Trust has been incorporated into the plans for operational resilience and specifically for the winter of 2014/15.

4.9.5 The remainder of this report presents an assessment of the potential state of

readiness with regard to managing resilience and specifically the winter of 2014/15. Therefore, for the purposes of assurance several themes are explored.

5 Winter Preparedness and Resilience 2014/15 5.1 Leadership 5.1.1 Firm leadership arrangements have been instated to ensure that planning,

preparation and potential resilience is prevalent throughout the organisation. 5.1.2 The Chief Operating Officer / Deputy Chief Executive is supported by Senior

Managers and Clinical Directors who are responsible for communicating key messages, testing resilience and supporting tactical responses to key challenges.

5.1.3 All other Directors have a stake hold not only in supervising planning,

preparation and response tactics but also in the expertise required for decision making in the event of a sustained surge and process change.

5.1.4 It is imperative that the Trust has identified leaders who have clearly defined

roles and responsibilities, therefore, during the expected persistent winter surge, senior decision makers will remain at the forefront of operational services to make timely and appropriate decisions. Directors, Senior Managers, Matrons and Senior Nurses will provide continuous support to this infrastructure; co-ordinating and controlling the patient flows within the clinical and non-clinical services.

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5.1.5 This will be demonstrated with a senior on call rota, a bed management capacity and patient flow structure and a well embedded electronic bed management system, supported by robust processes.

5.1.6 During periods of sustained escalation the on call response will extend to

operational teams from Estates, Human Resource and Communications to support appropriate organisational responses.

5.1.7 Policies and operational guidelines further support the leadership

infrastructure with the expectation of standardised practices and procedures. 5.2 Command and Control 5.2.1 The Trust has contributed to the wider reviews of leadership and governance

supporting the Clinical Commissioning Groups and Area Team, in testing assurance around surge and emergency resilience.

5.2.2 The successful and tested implementation of the Resilience Command and

Control Centre function will serve to support escalation during potential unexpected surges, whereby the operational leads will be supported with regard to coordination of advice, guidance and logistics. The Resilience Command and Control Centre will continue to provide the hub of daily leadership functions; twice daily meetings of operational leads, representing managerial, clinical and support services across the organisation, will be held with the prime responsibility for ensuring robust leadership in represented areas of expertise and sustaining appropriate levels of communication and escalation during daily challenges.

5.2.3 Clinical leadership and timeliness of senior decision making is vital to, not

only successful surge management, but also for overall capacity management. Rota changes will ensure senior clinical cover at peak times in both EAU and A&E, and improved medical infrastructure on base wards, offered by the service transformation last year, will contribute to timely management and patient flow. The focus on timely decision making and proactive discharge planning will be continued through senior clinician board and ward rounds.

5.2.4 The effective functioning of the Resilience Command and Control Centre will

be further tightened with a rota to support round the clock Senior Manager and Director Responsibilities.

5.3 Winter Planning in Practice

5.3.1 Inherent to the Trust’s approach to winter and emergency preparedness is the on-going review of systems, processes and structures and not ad hoc planning. Therefore a number of project groups/schemes have been managed/established to ensure a structured and robust approach to improving patient flow pathway/service redesign and surge management. Each project group is led by an appropriate senior manager or lead clinician, and accountable to the director leads via the management team. Areas identified to focus efforts, based on lessons learnt from last year were:

• Staffing • Discharge liaison

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• Triggers for escalation • Immunisation campaign • Resilience capacity

5.3.2 The Trust has been working in partnership with social care and commissioner

colleagues over the past year on a number of schemes to reduce the need for a hospital admission by ensuring that patients at recognised risk of admission (e.g. those with long term conditions) receive timely interventions in the community.

5.3.3 In addition to a number of enabling planning processes that have been put into place to support change management, business continuity work has continued.

5.3.4 Business Continuity Planning – on-going development and testing of clinical and non-clinical service plans to manage and maintain core business during sustained disruption, including the ability to recover normalised activity /business in a timely manner. The Trust has contributed to the effective mechanism for planning, coordinating and responding to major incidents. The Trust is participating in plans developed by the Local Health Resilience Partnership (LHRP), ensuring the requirement to meet the statutory obligation placed upon the Trust as a Category 1 Responder as defined in the Civil Contingencies Act 2004 as well as having valid representation at local Emergency Planning Resilience and Response strategy forums. The Trust continues to maintain a strong focus on testing and improving resilience plans through a robust training and exercise programme.

6. Operational Readiness

6.1 As with previous years a key activity in managing system wide demand and capacity during winter is the participation in whole health economy and social care conference calls led by the existing commissioners. The daily calls provide almost real time opportunity to ensure any additional pressures placed on the Trust by local agencies and health organisations are dealt with promptly.

6.2 Access 6.2.1 Any increase in emergency admissions during the winter period will place

pressure on front line ambulance services and ultimately could have a significant impact on the ability to deliver quality patient care.

6.2.2 As a result, the Trust continues to actively engage with Hartlepool and

Stockton-on-Tees Clinical Commissioning Group to develop a system wide response to the urgent and emergency care challenges supported by a robust and coherent strategy with a focus that is measurable and deliverable.

6.2.3 Direct paramedic admission pathways have been identified to maximise the

success of the pathways implemented at University Hospital of North Tees in October 2013, following service transformation and continue to be reviewed and monitored for effectiveness.

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6.3 Front of House – Accident and Emergency (A&E), Ambulatory Care (AC) and Emergency Assessment Unit (EAU)

6.3.1 Both as a result of service transformation and winter planning, capacity and

patient pathways have been reviewed. Increased capacity in the ambulatory care facility has been created.

6.3.2 Senior clinical decision makers are improving patient flow in the See and

Treat element of the A&E service. 6.3.3 Improved nurse resource allocation according to peaks and troughs in activity

is underway. 6.3.4 In addition an action plan is being developed to manage the demands on A&E

and EAU and the changing profile of activity surges. This will include:

• Proactive discharge preparation on the base wards • Classification/triage of patients in EAU • Changes in medical and nursing staff allocations to meet the changing

demand profile • Exploration of a resident GP

6.4 Bed Capacity 6.4.1 Following on from the successes and lessons learnt from 2013/14, 5

additional beds will be opened across four wards from November 2014 to March 2015. Following reconfiguration of the medical base wards, an additional 13 beds will be made available. In addition, there is the potential to open a further 16 beds if required and only upon escalation to NEEP level 4. It also allows the organisation to employ dedicated staff for this facility. Recruitment will commence early to reduce the requirement to employ agency staff. There is a risk that recruitment is unsuccessful and insufficient funding is received from the CCG to cover the cost of agency staff.

6.5 Elective Activity 6.5.1 The Trust remains committed to ensuring effective plans are in place to

manage capacity to ensure elective activity can continue. It is anticipated that additional theatre lists will be provided prior to November 2014 to enable front loading of activity to maintain referral to treatment (RTT) standards in the event of cancellations due to limited capacity. A policy and protocol has been developed which will ensure a standardised approach is followed when making the decision to consider any cancellations.

6.6 Admissions Avoidance and Enhanced Patient Flow

6.6.1 The Trust continues to use and expand the Ambulatory Day Unit facility to

reduce admissions. In addition to this the following actions to avoid admissions or enhance patient flow are being undertaken:

• Senior clinical review in ambulatory care, EAU and A&E • Emergency Care Therapy Team model on base wards.

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• Community services teams supporting discharge through Community Integrated Assessment Team (CIAT) and Single Point of Access (SPA)

6.7 Estate Infrastructure and Support 6.7.1 The Estates Department have a planned process of maintaining the grounds

of the Trust when icy and snow laden. The plan conforms to best practice in maintaining the access and egress of emergency vehicles and main pathways.

6.7.2 Access to 4x4 vehicles has been gained and agreed with the voluntary sector

to assist in the transportation of staff in the event of extreme weather. 6.8 Infection Control 6.8.1 A full fogging programme has been commissioned to ensure all the medical

wards have had a complete deep clean prior the anticipated winter surge. Spot cleaning will continue as and when necessary.

6.8.2 Staff absence in relation to Norovirus will be reported via the Senior Clinical

Matrons and Infection control at the daily capacity meetings, to ensure proactive management.

6.8.3 Following the reconfiguration of beds in August additional side wards have

been made available. 6.9 Staff Vaccination

6.9.1 An early campaign and additional planning to improve compliance has

commenced. 6.9.2 Each ward and department has identified vaccinators to provide staff with the

opportunity to receive their vaccination within their work area. 6.9.3 The occupational health department share lessons learnt and best practice

from previous years vaccination programmes with neighbouring Trusts in an attempt to increase the uptake from staff.

6.10 Winter Staffing 6.10.1 A recruitment campaign will commence to recruit a dedicated resource to staff

the winter bed capacity. Plans are currently being developed to ensure a formal framework exists to utilise staff currently not employed in front line areas to provide assistance at times of surge. Specialist nursing rotas have been reviewed to ensure the provision can be made to assist ward staffing.

6.10.2 Training and orientation programmes are being developed to ensure staff are

fully supported to undertake work in ward areas. 7. Governance Arrangements 7.1 There is a governance accountability framework in place both internal and

external to the organisation. Local partnerships, specifically with the existing

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commissioners, have been engendered throughout the year, to share emergency care strategic and tactical plans including the further development of local escalation plans and communication arrangements during the required winter reporting period to the CCG, Area Team and Department of Health.

7.2 The contribution of staff to the command and control structure and internal

departmental escalation, to underpin the governance framework in the event of a sustained surge have been tested in desk top simulation exercises carried out this year including externally led exercises.

7.3 Risks to service and financial performance, quality and service sustainability

have been highlighted in the Annual Plan and discussed at Board of Director meetings. The Board signed off the Annual Plans and submission to Monitor in June of this year.

7.4 The Executive Team considers a weekly update on emergency services resilience and the Board of Directors also receive regular updates on the emergency services pressures, associated risks and actions. The Assurance Framework provides evidence of review and regular assessment of controls to aid mitigation.

7.5 The governance accountability arrangements within the Trust are currently supported by the timely analysis of patient flow information on a weekly basis to support responsive tactics and this will be supplemented with an infrastructure of situation reporting through the Area Team from early November. These reporting arrangements and the sharing of information internally have proved effective in supporting local response.

7.6 The organisation has an audit trail of all communications, meetings and action plans relating to the Trust’s preparedness in relation to the winter plan.

7.7 The Board of Directors receive an annual report to provide a level of

assurance as to the readiness and resilience of the Trust to respond to a surge in activity, and to address access issues in an on-going manner but particularly during the winter months.

8. Risks and Mitigation 8.1 A huge level of planning is involved each year to ensure the organisation is

prepared to face the oncoming winter with this year being no exception. However, factors which are outside the control of the organisation can pose a risk and must be taken into consideration to ensure that a level of assurance can be given that the organisation will make every effort to mitigate against the risks.

• HCAI - Norovirus outbreaks and infection control. Systematic deep

cleaning of all wards has continued. Additional side rooms have been made available following the reconfiguration of wards and the Operational Policy has been reviewed to support timely decision making.

• Delayed Discharges - Maintaining minimum numbers of delayed transfers of care through co-ordinated planning and monitoring.

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• Community Capacity – Supporting patient flow through community bed capacity and use of Community Matrons in admission and readmission avoidance projects.

• Deflect Policy - sustaining good performance on ambulance handover times, particularly if deflect policy initiated by NEAS. Weekly handover meetings with NEAS to monitor performance. Departmental Escalation Plans (DEEP) and North East Escalation Plan (NEEP) in place.

• Pandemic Influenza- last year the organisation experienced low levels of flu related admissions or sickness. An incentivised proactive plan is in place.

• Excess Demand- maintaining elective activity to deliver Referral to Treatment (RTT) targets.

• Staffing – Increased levels of sickness and absence. Sickness and absence continues to be proactively managed within directorates. Innovative solutions in the planning phases.

• Mutual Aid - Escalation to winter and surge group as well as weekly multi agency conferencing.

• Severe Weather. Cold weather plan in place in line with national guidance, working in collaboration with Local Resilience Forum with proactive use of Meteorological Office weather alerts. Estates plan robust. Mutual aid agreements are in place with the voluntary sector which will enable the use of 4x4 vehicles.

• Emergency Care Standard and Clinical Indicators – on-going work to monitor and improve standardised practice and risk mitigation to ensure an acceptable governance risk rating (Monitor returns).

• The Trust Business Continuity Plan will be used to escalate and plan for service disruption recovery relating to reduced staffing which cannot be addressed primarily by Departmental Business Continuity Plans.

• Delayed turnaround of ambulances (as per Department of Health SITREP Definitions, 2008) will be reported via the Trust Daily SITREP and acted upon immediately

9. Financial Consideration

9.1 Plans to increase winter bed capacity have been costed within the Trusts

winter reserve financial envelope. This year, national allocations at £250 million for RTT delivery and £400 million for Operational Resilience have been allocated. The Trust has submitted bids in an effort to secure the maximum additional funding. These centre around capacity management, resource protection, discharge planning and readmission avoidance in addition to patient safety initiatives to manage an expected escalation in case mix.

10. Summary of Resilience

10.1 Assuring the resilience of the Trust to respond effectively to surge is a key challenge. Work is on-going to support assurance and further refine the operational resilience plan in readiness for the next phase (winter) November 2014; however, positive assurance can be taken of the winter resilience in a number of ways including:

• Strong leadership and governance arrangements with active engagement throughout the Trust in planning for resilience to support a potential surge in activity.

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• Action planning to manage the changes in profile of surges in emergency activity whilst continuing to deliver elective and urgent activity requirements.

• Staff engagement and response in planning and preparation meetings, especially with regard to debriefing, learning lessons and simulation, has been explicit.

• Pathways are being reviewed with the introduction of new plans to ensure that patients are streamed and seen in the most appropriate setting

• Management of a robust stakeholder engagement and communications strategy together with the commissioners around winter planning has served to provide extensive consultation and operational ownership of required changes to support future resilience delivery.

• Plans have been tried and tested in practice and customised to manage clinical and managerial feedback

• Bids have been submitted to the CCG for work streams to support operational resilience, elective and emergency access, patient flow and timely discharge.

• The winter plan and revised NEEP plan will be shared at a final winter planning meeting at the beginning of October with key staff providing both a final opportunity for amendments and to ensure the plan is understood.

• Continuous benchmarking, including visits to other organisations to assess and manage ways of working fit for the future.

• The report was received by the Board of Directors at a meeting in July 2014 and provided a level of assurance as to the readiness and resilience of the Trust to respond to a surge in activity, and to address access issues in an on-going manner but particularly during the winter months.

10.2 The organisation is contributing to the Tees wide urgent care agenda and resilience planning to ensure a full systems approach to surge management.

10.3 The Trust is proactively engaged in Better Care Fund planning to support the infrastructure required in patient pathway management.

10.4 The Trust continues to engage in the assurance review requirements across the Area Team span of authority and has participated in local Peer Review Programmes.

10.5 Despite continuous planning and focus on operational resilience there is a

recognition and a drive to focus on overarching system resilience and transformation to support clinical, operational and financial sustainability evidenced in the Momentum Pathways work.

11. Recommendations 11.1 The Council of Governors is asked to note the contents of the report, to

acknowledge the challenges that the Trust is currently experiencing and will face, the progress that has been made to improve escalation actions and

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flexibility in management and service delivery approaches synonymous with sustainable surge and resilience management requirements.

Julie Gillon Chief Operating Officer / Deputy Chief Executive September 2014

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18 September 2014

Executive Summary

Momentum: Pathways to Healthcare Programme Update

Report of the Chief Operating Officer/Deputy Chief Executive and Director of Finance, ICT and Support Services

Strategic Aim (the full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Integrated Care Pathways Service Transformation Strategic Objective (the full set of Trust Objectives can be found at the beginning of the Council of Governors Reports) Momentum: Pathways to Healthcare Programme 1. Introduction 1.1 The purpose of this report is to provide the Council of Governors with an

update on the progress of the Momentum: Pathways to Healthcare Programme, in line with key milestones, as identified in the Critical Path and the most recent update reported to the Council of Governors in July 2014.

As outlined in the July report, portfolio management has been adopted by the Trust to support clinical, operational and financial sustainability within the delivery of the Momentum Pathways to Healthcare Programme. The programmes within the portfolio are:

• Delivery Programme • Enabling Programme • Directorate Programme • New Hospital Programme

2. Key Issues and Planned Actions

2.1 The overall Momentum Programme structure and governance arrangements continue to provide an effective mechanism for management of the Momentum Programme with Portfolio Management now integrated into the overall governance structure.

2.2 The programmes within the portfolio are aligned within the overall Momentum: Pathways to Healthcare Programme taking forward the development of phase two of Service Transformation coordinated with the planning for the Better Care Fund and working toward the development of the New Hospital and associated Primary and Community services in addition to maintaining clinical, operational and financial sustainability. As the programmes of work within the portfolio are developed the individual plans are reviewed, interdependencies and key milestones determined to inform the development of the next stage of the overall plan, along with the revised procurement process for the New Hospital as outlined in the submitted Outline Business Case.

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2.3 The Momentum Programme risk register is reviewed and updated monthly

with reports on all risks to the Programme Overview Group and on high and significant risks to the Programme Board. The schedule for the on-going external assurance with Audit North and Deloittes will be adjusted once the decision on the new hospital is known. In addition the Gateway review initially scheduled for July will now be conducted in September to better align with on-going new hospital work and pending decisions.

2.4 The Delivery Programme builds on the successful implementation of Service

Transformation Phase 1 which saw the centralisation of Critical Care, Acute Medical, Complex Surgical and associated support services onto the University Hospital of North Tees site, and the establishment of the Holdforth Unit at the University Hospital of Hartlepool. A full evaluation of Service Transformation Phase 1 has been completed, with a summary presented to a joint overview group set up as a result of the recommendations made by the joint scrutiny committee, with membership from the local councils and healthwatch.

2.4.1 Planning for the next phase of Service Transformation continues within the

framework of the Clinical Services Strategy to continually improve and develop services and will encompass integrated pathway development spanning hospital and community and integration with primary and social care. These initiatives will also form the basis of the Trust’s participation in the planning for the implementation of the Better Care Fund.

2.5 The Enabling Programme was established with the aim of overseeing service improvement and efficiency projects/schemes that are Trust wide or cross directorate boundaries.

2.5.1 The projects managed within the Enabling Programme are corporate

schemes that enable sustained service improvement and efficiencies in the wider Trust. Benefits are wide reaching and include financial performance, improved quality and supporting the organisations strategic direction.

2.6 The Directorate Programme consists of all the Operational and Corporate

plans for Service Improvement and Efficiency. The Operational and Corporate Directorates report progress against plans and collectively work to identify further schemes to minimise the gap against plans and allocated target. A review of the Directorate plans has commenced which will support the alignment of the interdependencies across the projects and programmes to ensure that these are reflected within the portfolio structure.

2.7 The New Hospital Programme continues to progress the business case. The

Trust met with DH, Monitor, the CCG and NHS England and as a result of that meeting the Trust has been reviewing the current scheme, and the size of the new build to ensure alignment with other recently agreed schemes. In addition the CCG was requested by DH to provide a letter of support in relation to the scheme to ensure commitment going forward. This will further reduce the risks to the Trust of the PF2 scheme. NHS England were requested to provide written commitment to the New Hospital and provide assurance to DH that this is the required solution for future healthcare across the area.

2.8 The programmes of work within the portfolio include inputs from workforce,

organisational development, human resources, change management, finance and communications. While these aspects are integral to the programmes of work the overarching principles and strategies ensure consistency across the programmes and broader organisation.

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3. Recommendations 3.1 The Council of Governors is asked

• To receive this report and note the governance activities, progress against the key milestones and the management and mitigation of challenges.

• To note the development of Portfolio Management and the programmes

therein and to note the on-going work to ensure capacity and capability is aligned to deliver the strategic and operational objectives.

• To accept the assurance around governance and implementation. • To note the final review of Service Transformation phase one and the

development of Service Transformation phase two underpinned by the Clinical Services Strategy.

• To note the on-going work with DH and Monitor on the review of the

Outline Business Case for the New Hospital. Julie Gillon Lynne Hodgson Chief Operating Officer/ Director of Finance, ICT and Support Services Deputy Chief Executive Technology September 2014

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North Tees & Hartlepool NHS Foundation Trust


18 September 2014

Momentum: Pathways to Healthcare Programme Update

Report of the Chief Operating Officer/Deputy Chief Executive and Director of Finance, ICT and Support Services

1. Introduction and Background 1.1 The purpose of this report is to provide the Council of Governors with an update on

the progress of the Momentum: Pathways to Healthcare Programme, since the most recent update reported to the Council of Governors in July 2014.

1.2 The Momentum: Pathways to Healthcare Programme was established to lead the

transformation of the local healthcare system. It was established in partnership with local stakeholders, specifically North Tees and Hartlepool NHS Foundation Trust, Stockton Teaching Primary Care Trust and Hartlepool Primary Care Trust, closely aligned with County Durham Primary Care Trust and the North East Strategic Health Authority. These bodies have now evolved to become the Hartlepool and Stockton-on-Tees Clinical Commissioning Group (HAST CCG), Durham Dales Easington and Sedgefield Clinical Commissioning Group (DDES) and the Local Area Team (LAT).

1.3 As outlined in the July report, portfolio management has been adopted by the Trust to support clinical, operational and financial sustainability within the delivery of the Momentum Pathways to Healthcare Programme.

2. Progress Report 2.1 This report gives an update on progress within the overall Momentum Programme

since the time of the last report (July 2014) namely on:

• Governance, assurance and risk management • Portfolio

o Delivery Programme o Enabling Programme o Directorate Programme o New Hospital Programme

2.2 The programmes within the portfolio comprise of sub programmes, which have

workforce, human resource, organisational development, financial and communications as integral components.

3. Governance, Monitoring, Reporting and Assurance


3.2 The reporting framework within the Portfolio Management structure is now operational in line with the governance structure, enabling effective reporting and escalation as and where appropriate.

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3.3 The overall programme plan continues to be updated monthly identifying the key milestones and interdependencies.

3.4 The Trust is committed to a comprehensive integrated Trust wide approach to the

management of risk and ensuring that risks in the delivery of services and care to patients are minimised and the well-being of patients, staff and visitors is optimised. The programme risk register has been fully reviewed and revised to reflect the portfolio and programmes of work, the risks continue to be reviewed monthly by the Portfolio Management Group (formerly the project and workstream leads) to ensure a consistent approach, in accordance with Trust Policy and that all risks are not only relevant, but assessed correctly and control measures initiated.

3.5 External assurance of the programme continues with Audit North and Deloittes; the

next assurance review to be scheduled once the way forward for the new hospital is determined.

3.6 The Office of Government Commerce (OGC) will be carrying out a Gateway review of

the New Hospital Project, it was reported to the last meeting as expecting to take place in July. The Review team met the Trust for a pre planning meeting and it was agreed that the timing of the Gateway review be re-scheduled for September to better align with on-going New Hospital work and pending decisions.

4. Portfolio Delivery Programme 4.1 The Delivery Programme has been established within Portfolio Management to

oversee the key strategic changes in patient pathways both through the Long Term Conditions Integrated Care Pathways and the wider implementation of the Clinical Services Strategy in Service Transformation Phase 2.

4.2 This programme builds on the successful implementation of Service Transformation

Phase 1 which saw the centralisation of Critical Care, Acute Medical, Complex Surgical and associated support services onto the University Hospital of North Tees site, and the establishment of the Holdforth Unit at the University Hospital of Hartlepool.

4.3 A full evaluation of Service Transformation Phase 1 was undertaken, with a summary

being presented to a joint overview group set up as a result of the recommendations made by the joint scrutiny committee at the conclusion of the public consultation, with membership from the local councils and healthwatch. This utilised a combination of a set of existing corporate key performance indicators and a range of ad-hoc reviews covering the use of isolation rooms, implementation of the Holdforth Unit at the University Hospital of Hartlepool, Transport, staff feedback, patient safety incidents and patient and public feedback.

4.4 Further work to ensure full implementation and management of key change

requirements following evaluation, is underway. 4.5 The Long Term Condition Integrated Care Pathways under development within the

Delivery Programme are:

Priority Pathways (to be implemented in 2014/15 and 2015/16):

• Respiratory • End of Life Care • Frail Elderly and Dementia

Other Pathways (to be implemented commencing 2015/16):

• Diabetes 2

• Cardiology • Rheumatology • Stroke • Long Term Neurological Conditions

4.6 Service Transformation Phase 2 will oversee the implementation of pathway and

service changes in the following areas:

• Unplanned Care: • Planned care: • Women’s and Children’s: • Clinical Support Services:

4.7 Each project has a managerial and a clinical lead, and in the case of the Integrated

Care Pathways, an executive sponsor. 4.8 Planning and implementation of each element of the Delivery Programme will ensure

that all workforce, finance and HR implications are identified at the earliest stages and appropriately managed, alongside critical interdependencies with hospital and primary care estate. Also key to the successful implementation of the pathway changes will be full engagement with commissioners, primary care and social care service providers as well as continuing dialogue with the public and local councils.

5. Portfolio Enabling Programme 5.1 As part of the Trust wide Portfolio Management approach, the Enabling Programme

was established with the aim of overseeing service improvement and efficiency projects/schemes that are Trust wide or cross directorate boundaries.

5.2 The projects managed within the enabling programme are often corporate schemes

that enable sustained service improvement and efficiencies in the wider Trust. Benefits can be wide reaching and include financial performance, improved quality and supporting the organisations strategic direction.

5.3 A wide range of projects/schemes form part of the enabling programme including:

• Electronic Document Management (EDM) – the aim of this project is the implementation of an electronic patient record which will benefit both staff and patients due to ease and speed of access to patient records by trained professionals from multiple secure locations. The project aims to achieve financial savings through greater efficiencies whilst helping to improve patient outcomes.

• Procurement – this programme of work forms a large part of the enabling work and is made up of multiple projects with the aim of identifying financial savings via improved contracts with suppliers and efficiencies through improved procurement of essential supplies.

• Workforce Information System (Allocate) – this project aims to remove waste and duplication from the processes needed to manage management information across the Trust. The development and introduction of a single point of contact for vital process e.g. staff amendment forms, payroll processes, training data and staff rota information will lead to efficiencies across multiple departments.

• Local Improvement System (LIS) – This work builds on the Trusts commitment to implement Lean management into everyday working practices. Benefits will include increased staff empowerment to implement change, increased efficiency leading to more patient facing time for clinical staff.

5.4 An enabling project group has been established comprising primarily the individual

project leads, finance representatives and Executive sponsor.

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5.5 The enabling programme lead meets regularly with the Directorate and Delivery programme leads to ensure maximum efficiency is gained whilst minimising duplication of resources.

6. Directorate Programme 6.1 The Directorate Programme consists of all the Operational and Corporate plans for

Service Improvement and Efficiency. 6.2 To support the identification of further schemes to reduce the gap against plans and

allocated target the Executive Team held a Clinic session with each Directorate. Further schemes were agreed and have been added to the Directorate Programme schedule.

6.3 A review of the Directorate plans in light of recent discussions has commenced which

will support the alignment of the interdependencies across the projects and programmes to ensure that these are reflected within the portfolio structure.

6.4 The finance deliverables have been realigned against new schemes to ensure that

these are accurately reflected in future portfolio reports. A portfolio finance meeting will take place each month to validate delivery against plans.

6.5 The Service Improvement and Efficiency Board will continue to meet and will report

using a RAG rating system to the Finance committee on a monthly basis. 6.6 Appendix A outlines a summary of the efficiency schemes for each of the

directorates.

7. New Hospital Programme 7.1 The Trust met with the Department of Health (DH), Monitor, the HAST CCG and NHS

England in July. As a result of that meeting the Trust has been reviewing the current scheme, as the size of the new build was not fully aligned with other recent schemes given the activity expected in the Trust.

7.2 Work has been undertaken by the Trust, supported by external Technical and

Financial advisors to review the scheme in detail, area by area. As a result a new set of technical documentation has been prepared and presented to DH regarding the potential future size and cost of the scheme. The changes suggested are mainly in relation to technical adjustments such as an assessment of risk associated with the scheme, an assessment of the space needed within each Area for Corridors and other “non clinical” services, and ensuring the space built into the current design is in line with other recently agreed schemes.

7.3 As a result of the reviewed scheme the Trust has worked with Financial advisors to

review the impact the resized scheme will have on the cost of running the New hospital and the costs related with PF2. This work is still underway however the Trust is confident that the reworked model will reduce the annual cost by £4-£5m per annum, which significantly reduces the risks of the scheme as identified to date by DH and Monitor.

7.4 At the meeting noted in section 7.1, the CCG was requested by DH to provide a letter

of support in relation to the scheme and to ensure commitment to support the New Hospital. The Trust and the CCG are meeting at the end of August to agree this position. This will further reduce the risks to the Trust of the PF2 scheme.

7.5 NHS England was requested to provide written commitment to the New Hospital and

provide assurance to DH that this is the required solution for future healthcare across the area.

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8. Workforce and Organisational Development Summary 8.1 The workforce monitoring tool has been presented to the Programme Overview

Group (POG) populated with data captured from the workforce projection meetings that took place in quarter 1 2014/15. Minor amendments were requested and this will be presented at the next POG meeting in September.

9. Human Resource Summary 9.1 The team continues to support activities in the development of further service

transformation during 2014-15, working closely with Strategic Planning to understand and have early involvement in the developmental stages. This will enable each element of the organisational change programme to be planned accordingly and resources identified and deployed within timescales.

9.2 Working in conjunction with communications in the development of a staff

communication and engagement strategy, and action plan, which will include a template for use in future organisational change, encompassing lessons learnt from transformation phase1.

10. Finance Summary 10.1 The work carried out regarding the New Hospital scheme will reduce the risks and

provide an affordable and deliverable solution. 10.2 A key risk that remains in relation to the overall programme is delivery of SIEP (CIP)

and two to one site savings. Progress is being made through the portfolio approach however there remains a risk regarding current and future year’s delivery. The Trust has a recovery plan in place for this financial year, to support slippage of schemes which will now be expected to deliver next year. A full review of the SIEP plan is underway with schemes for next year being confirmed as part of the Trust’s Business planning cycle.

11. Communications and Engagement Summary 11.1 Work has continued to raise awareness of the transport arrangements following

transformation in October 2013. This awareness raising has included:

• reminding staff through chief executive’s briefing • producing posters for GP surgeries and an article in the quarterly GP bulletin • advertising on the cross site shuttle bus • information in the outpatient and coming into hospital booklet • details on the trust website • stories in the trust magazine and the media • details on the franking stamp of outgoing mail

12. Conclusion


12.2 The programmes within the portfolio are aligned within the overall Momentum: Pathways to Healthcare Programme taking forward the development of phase two of Service Transformation coordinated with the planning for the Better Care Fund and working toward the development of the New Hospital and associated Primary and

5

Community services in addition to maintaining clinical, operational and financial sustainability. As the programmes of work within the portfolio are developed the individual plans are reviewed, interdependencies and key milestones determined to inform the development of the next stage of the overall plan, along with the revised procurement process for the New Hospital as outlined in the submitted Outline Business Case.

12.3 The Momentum Programme risk register is reviewed and updated monthly with

reports on all risks to the Programme Overview Group and on high and significant risks to the Programme Board. The schedule for the on-going external assurance with Audit North and Deloittes will be adjusted once the decision on the new hospital is known. In addition the Gateway review initially scheduled for July will now be conducted in September to better align with on-going new hospital work and pending decisions.

12.4 The Delivery Programme builds on the successful implementation of Service

Transformation Phase 1 which saw the centralisation of Critical Care, Acute Medical, Complex Surgical and associated support services onto the University Hospital of North Tees site, and the establishment of the Holdforth Unit at the University Hospital of Hartlepool. A full evaluation of Service Transformation Phase 1 has been completed, with a summary presented to a joint overview group set up as a result of the recommendations made by the joint scrutiny committee, with membership from the local councils and healthwatch.

12.4.1 Planning for the next phase of Service Transformation continues within the framework

of the Clinical Services Strategy to continually improve and develop services and will encompass integrated pathway development spanning hospital and community and integration with primary and social care. These initiatives will also form the basis of the Trust’s participation in the planning for the implementation of the Better Care Fund.

12.5 The Enabling Programme was established with the aim of overseeing service improvement and efficiency projects/schemes that are Trust wide or cross directorate boundaries.

12.5.1 The projects managed within the Enabling Programme are corporate schemes that

enable sustained service improvement and efficiencies in the wider Trust. Benefits are wide reaching and include financial performance, improved quality and supporting the organisations strategic direction.

12.6 The Directorate Programme consists of all the Operational and Corporate plans for

Service Improvement and Efficiency. The Operational and Corporate Directorates report progress against plans and collectively work to identify further schemes to minimise the gap against plans and allocated target. A review of the Directorate plans has commenced which will support the alignment of the interdependencies across the projects and programmes to ensure that these are reflected within the portfolio structure.

12.7 The New Hospital Programme continues to progress the business case. The Trust

met with DH, Monitor, the CCG and NHS England and as a result of that meeting the Trust has been reviewing the current scheme, and the size of the new build to ensure alignment with other recently agreed schemes. In addition the CCG was requested by DH to provide a letter of support in relation to the scheme and to ensure commitment going forward. This will further reduce the risks to the Trust of the PF2 scheme. NHS England were requested to provide written commitment to the New Hospital and provide assurance to DH that this is the required solution for future healthcare across the area.

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12.8 The programmes of work within the portfolio include inputs from workforce, organisational development, human resources, change management, finance and communications. While these aspects are integral to the programmes of work the overarching principles and strategies ensure consistency across the programmes and broader organisation.

13. Recommendations 13.1 The Council of Governors is asked

• To receive this report and note the governance activities, progress against the key milestones and the management and mitigation of challenges.

• To note the development of Portfolio Management and the programmes therein

and to note the on-going work to ensure capacity and capability is aligned to deliver the strategic and operational objectives.

• To accept the assurance around governance and implementation. • To note the final review of Service Transformation phase one and the

development of Service Transformation phase two underpinned by the Clinical Services Strategy.

• To note the on-going work with DH and Monitor on the review of the Outline

Business Case for the New Hospital. Julie Gillon Lynne Hodgson Chief Operating Officer/ Director of Finance, ICT and Support ServicesDeputy Chief Executive September 2014

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Appendix A

Directorate Overview of Schemes

A&E Review of patient flows/pathways and skill mix within the department

Anaesthetics Reviewing service models and operational efficiencies for example: Theatre

Scheduling

Chief Executive Review skill mix/staffing

Compliance Review of structures/skill mix to meet corporate requirements

Community includes a number of service reviews including management restructure.

EOD Review of skill mix / workforce

Endoscopy Includes more efficient ways of working to allow increased productivity as well

as reviewing procrurment opportunities

Estatesincludes a number of schemes which includes: energy savings, maintenance

contracts, review of services to ensure best model to meet service needs

Finance and ICT Reviewing service models and skill mix in line with the workforce information

systems and process redesign HR review of skill mix in line with information systems and process redesign

Medicine Several service reviews which include patient pathways, efficient use of

medicines and reviewing roles and skill mix for example, patient flow, length of stay, specialist nursing roles

Nursing Reviewing the support service and skill mix

Obs and Gynae Reviewing service models for example case load management for midwifrey

Orthopaedics Review of service models and operational efficiencies

Paediatrics Review of Paediatric pathway underway

PathologyReview of contracts and better use of technology, for example Point of Care

Testing in the Community

Pharmacy Implementing trust wide initiatives for example roll out of Omnicell

RadiologyReview and rationalisation of service models and operational efficiencies to

allow more productivity whilst maintaining an efficient service Surgery and urology Review of workforce model for example introdution of surgical practitioners

Directorate Programme - Overview of schemes

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18 September 2014

Executive Summary

Finance and Contract Performance Report as at 31 July 2014 (Month 4)

Report of the Director of Finance, ICT and Support Services Strategic Aim (The full set of Trust Aims can be found at the beginning of the Board Reports)

Maintain Compliance and Performance

Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Board Reports) Finance

1. Introduction 1.1 The purpose of this report is to inform the Council of Governors of the financial and

contract performance position of the Trust for the period to 31 July (month 4).

2. Key Issues & Planned Actions

Financial Risk Rating

2.1 Performance based on month 4 delivers a continuity of service risk rating of 4.

2.2 Month 4 performance - as at 31 July the Trust is reporting a deficit of £1.250m for the

period, which is £2.064m behind the planned surplus for the period to date of £0.813m.

Income

2.3 Total income is behind plan by £447k for the period, which is due predominately to

the Bariatric Service (commissioned through South Tees) and income from non-patient care (commercial income).The overall level of performance reported takes account of actioning internal trading adjustments to reflect the marginal cost of any over- performance.

The Trust’s income is showing an under recovery of £447k (0.49%)

Expenditure 2.4 To date pay budgets are showing an over spend against plan of £536k (after the

phased element of the £1.25m non-recurring CIP target for vacancies is taken into account). The main area of risk continues to be recourse to locum staff at premium

2

rates and where appropriate, and subject to validation, these additional costs will be funded from the locum contingency reserve approved by the Board in April 2014.

2.5 In addition, to elevated locum expenditure directorates are utilising significant levels of bank and agency. Finance is working with service teams to develop appropriate action plans to ensure corrective action is taken.

2.6 Non pay budgets are £288k over-spent for the period to the end of 31 July 2014.

Service Improvement & Efficiency Programme 2.7 The gross Service Improvement & Efficiency Programme (SIEP) target for 2014/15 of

£15.548m has been reduced to £13.494m as a result of recurrent and non-recurrent schemes actioned during the month.

2.8 The Trust has delivered £2.053m of its in-year SIEP, of which £1.447m (70%) was

recurrent and £0.606m (30%) non recurrent. When compared against the Monitor plan, the Trust is currently £1.002m behind its projected in-year plan. It is appropriate for the Trust to continue to use slippage from reserves / contingencies and balance sheet flexibility non-recurrently on the challenging SIEP target.

The Trust’s expenditure is showing an over-spend of £1.826k (2.09%)

Working Capital

2.9 Net cash outflow for the period was £0.5m, resulting in a decrease in cash from

£46.378m to £45.873m as at 31 July 2014. This is mainly as a result of an increase in an accrued income.

2.10 Net current assets at 31 July 2014 have decreased by £0.523m to £40.1m overall.

Summary

2.11 Financial performance is behind plan for the first 4 months of the financial year.

2.12 Pay and non-pay budgets continue to experience pressure; however corrective

action is in place to manage this position.

2.13 The Trust is implementing a financial action plan to address the reported position and recover the shortfall in SIEP to ensure the Trust delivers a balanced outturn position.

3. Recommendation 3.1 The Council of Governors are requested to note the financial position as at month

4, July 2014.

Lynne Hodgson Director of Finance, ICT and Support ServicesSeptember 2014

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18th September 2014

Finance and Contract Performance Report as at 31 July 2014

Report of the Director of Finance, ICT and Support Services 1. Introduction / Background 1.1 The purpose of this report is to inform the Council of Governors of the financial and

contract performance position of the Trust for the period to 31 July 2014.

2. Main content of report Summarised below is a brief commentary on the key income and expenditure, balance sheet, cash flow and financial risk rating issues for the first four months of 2014/15.

Income and Expenditure

Month 4 performance - As at 31 July 2014 the Trust is reporting an operational deficit of £1.250m for the period, which is £2.064m behind the planned surplus for the period to date of £0.813m.

There is an under-recovery on income against the profiled plan of £447k at the end of July 2014.

Income from CCG agreements is marginally over-recovered by £28k. Income of £130k has been released from the deferred government grant in-line with the conditions of the deferral. The Trust continues to over-perform with Hartlepool & Stockton CCG and under-perform against the planned contract value with Durham, Darlington, Easington & Sedgefield CCG.

Other patient care income is under-recovered by £393k, this primarily relates to the Bariatric Service commissioned through South Tees. The demand plan and budget setting assumptions were predicated on the pathway being in operation for the start of the financial year. The pathway and anticipated activity has subsequently changed and resulted in reduced referrals. In addition, the enhanced accident recovery scheme activity is below plan by £66k.

Income from non-patient care (commercial income) is under-recovered by £81k which relates to the reduction in car parking, occupational health, nursery and catering income. The Parking Eye system has been introduced from 1st August to capture both staff and patient car parking revenue and is anticipated to improve the position.

The Trust’s income is showing an under recovery of £447k (0.49%)

To date pay budgets, are showing an over spend against plan of £536k (after the phased element of the £1.5m non-recurring SIEP target for vacancies is taken into account). The pay position continues to display pressure as a result of an over

4

reliance in some areas on NHSP and agency. Conversely, the continuation of vacancies (specifically in community) continues to support the pay position.

The main area of risk continues to be recourse to locum staff at premium rates and where appropriate, and subject to validation, these additional costs will be funded from the remainder of the locum contingency reserve approved by the Board in April 2014.

Non pay budgets are £288k over-spent for the period to the end of July 2014 and

reflect activity under and over performing adjustments for months 1 to 4.

Non pay budgets will continue to be closely monitored throughout 2014/15 and Directorates that report a prolonged deterioration in non-pay will be escalated to the Director of Finance, Chief Operating Officer/Deputy Chief Executive and the Director of Nursing.

Service Improvement & Efficiency Programme

The gross Service Improvement & Efficiency Programme (SIEP) target for 2014/15 of £15.548m has been reduced to £13.494m as a result of recurrent and non-recurrent schemes actioned during the month. The Trust has delivered £2.053m of its in-year SIEP, of which £1.447m (70%) was recurrent and £0.606m (30%) non recurrent.

When compared against the Monitor plan, the Trust is currently £1.002m behind its projected in-year plan. It is appropriate for the Trust to continue to use slippage from reserves/contingencies and balance sheet flexibility non-recurrently on the challenging SIEP target.

Further work on identifying and delivering recurrent SIEP’s continues in order to ensure that financial performance remains in line with plan and to ensure that the EBITDA margin is not eroded.

The CIP continues to be the Trusts key risk and will continue to be the primary focus.

The Trust’s expenditure is showing an over-spend of 1.826k (2.09%)

EBITDA

The Trust has generated an EBITDA of £937k at month 4, £2.272m behind plan and an EBITDA margin of 1.8%.

Balance Sheet and Cash Flow

There has been a net cash outflow this period, resulting in an increase of cash from £41.109m at the start of the year to £45.873m as at 30 July 2014. This is mainly as a result of £7.134m Public Dividend Capital received in connection with EPR funding from the Safer Hospitals / Safer Wards initiative.

Net current assets at 30th July have decreased by £0.523m to £40.100m overall.

Financial Risk Rating

The overall risk rating driven by the month 4 performance is a 4. This consistent with the annual plan submitted to Monitor.

Financial performance against the risk rating:

5

Summary

Financial performance is considerably behind plan for the first 4 months of the financial year.

Operational pay budgets for the Directorates are under-pressure and SIEP delivery is behind plan.

The Trust has implemented a financial action plan to address the reported deficit position and recover the shortfall in savings to ensure the Trust delivers a balanced outturn position.

Recommendation

The Council of Governors are requested to note the financial position as at month 4, July 2014.

Lynne Hodgson Director of Finance, ICT and Support ServicesSeptember 2014

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Original Budget Setting Annual Budget Budget to Date Actual to Date Variance Variance Last

Month

Income £000 £000 £000 £000 £000 £000

Commissioning Agreements (242,032) (244,634) (81,078) (81,106) 28 18

Other Income from Patient Care (3,219) (3,502) (1,199) (806) (393) (280)

Other Income from Non Patient Care (19,180) (19,215) (9,088) (9,007) (81) (39)

Total Income (264,431) (267,350) (91,365) (90,919) (447) (301)

Expenditure

Pay 180,408 185,534 62,225 62,762 (536) (738)

Non Pay 58,191 66,333 26,313 26,601 (288) 76

Passthrough Reserve / Deferred Govt Grant 13,483 8,475 0 0 0 0

Reserves 16,193 8,792 0 0 0 0

Hosted Services - Audit North (251) (245) (82) (82) 0 0SIEP (15,548) (13,494) (1,002) 0 (1,002) (1,063)

Total Expenditure 252,476 255,396 87,455 89,281 (1,826) (1,725)

EBITDA 11,955 11,955 3,911 1,638 (2,272) (2,026)

Depreciation 5,858 5,858 1,952 1,819 133 100

Interest Payable Loans & Leases 162 162 54 47 7 5

PDC 3,425 3,425 1,142 1,075 67 50

Interest Receivable (150) (150) (50) (52) 2 (3)

Total Surplus/(Deficit) 2,660 2,660 813 (1,250) (2,064) (1,874)

Income & Expenditure Summary as at July 2014

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Human Resources and Education Report Quarter 1: April - June 2014

Meeting of the Council of Governors 18 September 2014

Report of the Director of Human Resources and Education

Executive Summary

Strategic Aim: (The full set of Trust Aims can be found at the beginning of the Council of Governor reports) Maintain Compliance and Performance Strategic Objective: (The full set of Trust Objectives can be found at the beginning of the Council of Governor reports) Effective Board Governance 1. Introduction

This is the quarter 1 report (2014/15) from the Human Resources and Education Directorate. Where applicable this data will be compared with that of the same period in 2013/14.

2. Workforce Statistics

The key issues for consideration are:

At the end of quarter 1 the Trust employed 5,343 staff (headcount). This compares with 5,493 at the end of the same period last year, a reduction of 150. The equivalent wte figures are 4528.84 in June 2014 compared to 4503.04 in June 2013, an increase of 25.8 wte. (Note: ESR wte figures do not include staff on zero hour contracts).

A total of 156 employees (headcount), equating to 119.43 WTE commenced employment with the Trust in quarter 1 of 2014/15, an increase of 28 from quarter 4 and an increase of 34 for the same period in 2013/14.

Turnover steadily increased from July 2013 (8.24%) to March 2014 (10.61%). This trend has continued in quarter 1 2014-15, increasing to 10.96% in June 2014. The chart shows that turnover in quarter 1 2014-15 has been higher than the same period in 2013-14.

The quarter 1 sickness absence average is 4.09%, compared to 4.05% in 2013-14. Monthly rates throughout the quarter for 2014-15 compared to 2013-14 are shown below:

2013-14 2014-15 April 4.46% 4.36% May 3.94% 3.84% June 3.77% 4.08%

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The cumulative absence rate for the quarter is 4.09% with a salary based sickness cost of £1,094,635 compared to 4.05% and £1,135,760 for the same period in 2013-14. Although the sickness absence rate for the quarter in 2014-15 is slightly higher than for the same period last year, the salary based cost of sickness is lower by just over £41,000.

The salary based cost of absence for quarter 1 2014-15 was £132,167 less than quarter 4 2013-14.

The sickness rate dropped to 3.84% in May 2014 before increasing again to

4.08% in June 2014.

3. Workforce Development At the end of quarter 1 the Trust is 97% compliant for mandatory training

corporately, which represents a 2% increase compared with the position at the end of the previous quarter.

The Annual Deanery Quality Monitoring (ADQM) visit took place on 8 April 2014. The Trust was commended for the presentation of the paperwork for the visit.

4. Workforce Productivity

94% of the Trust’s Consultant job plans are entered onto the eJob Plan system.

Implementation of the e-Rota software is complete, enabling quick and easy identification of European Working Time Directive (EWTD) and New Deal compliance.

The pre-requisite for rostering medical staff is the completion of eJob planning

for Consultants and SAS Doctors and population of eRota for juniors. The Trust made a decision to be the national beta test site for Version 10 of

eExpenses, which will ultimately result in a product that is quicker and easier for staff to use.

5. Workforce Relations

There were no disclosures of concern (whistleblowing) in quarter 1 2014/15 and no reported cases pertaining to failure to adhere to infection control procedures in this quarter.

The staff friends and family test was launched during quarter 1 using an electronic platform to gather the data (with an option for staff to complete a paper questionnaire if they preferred). A total of 456 responses were received for the quarter1 staff friends and family test which ran from 1 July 2014 to 31 July 2014.

6. Recommendation

The Council of Governors are asked to note the content of and accept this report. Mrs Ann Burrell Director of Human Resources and Education 9 September 2014

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Our Values Our Direction

Our foundation


Human Resources and Education Report Quarter 1: April - June 2014


18 September 2014


1. Introduction

This is the quarter 1 report (2014/15) from the Human Resources and Education Directorate. Where applicable this data will be compared with that of the same period in 2013/14.

This report focuses upon the current workforce profile and activities aimed at ensuring the staff profile is fit for purpose, enabling the Trust to meet all legislative requirements and targets set by the Trust and other Health agencies whilst maintaining good employee relations and staff engagement. In addition, it considers future activities, plans and processes required to ensure continued success.

2. Workforce Statistics 2.1 Workforce Profile At the end of quarter 1 the Trust employed 5,343 staff (headcount). This compares

with 5,493 at the end of the same period last year, a reduction of 150. The equivalent wte figures are 4528.84 in June 2014 compared to 4503.04 in June 2013, an increase of 25.8 wte. (Note: ESR wte figures do not include staff on zero hour contracts).

Staff Group Headcount F M White/ British Other P/T F/T

Add Prof Scientific and Technical 89 66 23 81 8 31 58

Additional Clinical Services 1,034 943 91 972 62 561 473

Administrative and Clerical 1,091 921 170 1,046 45 459 632

Allied Health Professionals 401 341 60 377 24 179 222

Estates and Ancillary 577 366 211 549 28 367 210

Healthcare Scientists 131 91 40 124 7 39 92

Medical and Dental 403 146 257 186 217 65 338

Nursing and Midwifery Registered 1,598 1,489 109 1,394 204 639 959

Students 19 19 NULL 19 0 NULL 19

Total 5,343 4,382 961 4,748 595 2,340 3,003

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Our foundation

The workforce profile for the previous 12 months is shown below:

Workforce Profile Headcount WTE

Jul-13 5524 4538.87

Aug-13 5474 4480.35

Sep-13 5509 4515.36

Q2 5509 4515.36Oct-13 5495 4508.43

Nov-13 5374 4508.14

Dec-13 5308 4496.12

Q3 5308 4496.12Jan-14 5307 4488.78

Feb-14 5316 4507.96

Mar-14 5313 4505.90

Q4 5313 4505.90Apr-14 5311 4494.58

May-14 5336 4524.91

Jun-14 5343 4528.84

Q1 5343 4528.84

2.2 Recruitment A total of 156 employees (headcount), equating to 119.43 wte commenced employment with the Trust in quarter 1 of 2014/15, an increase of 28 from quarter 4 and an increase of 34 for the same period in 2013/14. The table below provides an overall summary of recruitment activity by staff group during quarter 1 2014/15 and quarter 1 2013/14:

It should be noted that an on-going recruitment drive has been in existence to support the number of RN vacancies across the organisation; therefore it is expected that this particular staff group would see an increase due to the targeted recruitment project.

New Starters by Staff Group

Q1 2013/14 Q1 2014/15 Staff Group Headcount Headcount Add Prof Scientific and Technical 4 3 Additional Clinical Services 23 36 Administrative and Clerical 32 15 Allied Health Professionals 9 16 Estates and Ancillary 8 7 Healthcare Scientists 2 1

Medical and Dental 10 10 Nursing and Midwifery Registered 34 68 Students 0 0 Total 122 156

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There is a notable decrease (53%) in the number of Administrative & Clerical appointed during this quarter compared to the same quarter last year. This reduction is likely to be linked to the current non-clinical vacancy freeze process the Trust has in place in support of the SIEP agenda.

The activity in respect of Additional Clinical Services relates to the recruitment of

Medical Laboratory Assistants and the intake of the Pre-registered Nurses at band 2 level. Total recruitment activity for the previous 12 months is shown below:

New Starters Headcount WTEJul-13 71 60.10Aug-13 64 45.46Sep-13 92 76.09Q2 2013/14 227 181.65Oct-13 45 31.26Nov-13 35 26.08Dec-13 29 21.13Q3 2013/14 109 78.47Jan-14 38 26.17Feb-14 52 44.08Mar-14 38 32.21Q4 2013/14 128 102.47Apr-14 52 36.19May-14 60 49.39Jun-14 44 33.85Q1 2014/15 156 119.43

2.3 Equality and Diversity

In order to analyse aspects of equality and diversity within the workforce it is helpful to consider staff in post split by protected characteristics (ethnicity, religion and belief, age, gender, sexual orientation, disability). Ethnicity At the end of quarter 1, 88.9% of the Trust’s workforce was of White/British ethnic origin or other White ethnic group, with Asian being the next largest ethnic group at 5.4%. An ethnic origin of mixed race accounted for 0.6% of the workforce, while 0.6% stated their ethnic origin as Black/Black British. A further 0.3% of the workforce was Chinese and 1.7% of staff stated they were from another (or undefined) ethnic group. A total of 2.5% did not state their ethnic origin. These figures are consistent with those of previous quarters.

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Religion and Belief 57.5% of our workforce has not informed the Trust or not stated their religion or belief whilst 33% defined their religion as being Christianity. The next largest group is Atheism at 5%, with 0.9% of the workforce stating their religion as Hinduism with Islam at 0.8%. A further 0.2% stated another minority religion (Buddhism, Sikhism and Jainism) and 5.6% of the Trust workforce simply stated they followed another religion, giving no further details. These figures are consistent with those of previous quarters.

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Age Almost 78% of Trust staff fell into the age range 31 – 60 at the end of quarter 1. Staff 30 and under account for just over 17% of staff, while just less than 5% of staff are aged 61 or over.

Gender At the end of quarter 1, 82% of the workforce was female and 18% male. Of our female staff, 50% are in part-time posts compared to only 15% of male employees. These figures are consistent with those of previous quarters.

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Sexual Orientation 43% of Trust staff have not stated their sexual orientation and 10% have indicated that they did not wish to disclose their sexual orientation. A further 46.4% stated they were heterosexual and 0.6% bisexual, gay or lesbian. These figures are consistent with previous quarters.

Disability 68% of staff did not disclose whether they have a disability, whilst 31% declared that they did not have a disability and 1% had disclosed a disability. As with other protected characteristics, these figures are consistent with previous quarters.

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2.4 Staff Turnover and Leavers Turnover steadily increased from July 2013 (8.24%) to March 2014 (10.61%). This

trend has continued in quarter 1 2014-15, increasing to 10.96% in June 2014. The chart below shows that turnover in quarter 1 2014-15 has been consistently higher than the same period in 2013-14.

The turnover by staff group is shown below. The medical and dental staff group have the largest turnover (30.40%); this is due to the junior doctor changeovers which are included in these figures. This is reflective of the same period last year when the turnover figure for Medical and Dental was 30.75%. The second largest turnover figure in quarter 1 2014-15 is attributed to Healthcare Scientists at 14.11%, closely followed by Add Prof Scientific and Technical at 13.99%. These figures are higher than that of quarter 1 2013-14 when Healthcare Scientists had the third largest turnover at 8.97% and Add Prof Scientific and Technical had the fourth at 8.44%. Turnover for the Nursing and Midwifery staff group during quarter 1 2014-15 is 10.97% which is higher than the same period in 2013-14 when the turnover rate for this staff group was 9.29%. (Note: ESR turnover calculations do not include staff on zero hours contracts).

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Flexi retirements account for the highest proportion of the reasons for leaving in quarter 1 2014-15 at 22.70 wte. This is higher than the same period last year when 13.02 WTE left due to flexi retirement. Voluntary resignation accounts for the second highest amount of leavers in quarter 1 2014-15 at 18.62 wte.

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2.5 Sickness Rates

The quarter 1 sickness absence average is 4.09%, compared to 4.05% in 2013-14. Monthly rates throughout the quarter for 2014-15 compared to 2013-14 are shown below: 2013-14 2014-15 April 4.46% 4.36% May 3.94% 3.84% June 3.77% 4.08%

The cumulative absence rate for the quarter is 4.09% with a salary-based sickness cost of £1,094,635 compared to 4.05% and £1,135,760 for the same period in 2013-14. Although the sickness absence rate for the quarter in 2014-15 is slightly higher than for the same period last year, the salary-based cost of sickness is lower by just over £41,000. The salary-based cost of absence for quarter 1 2014-15 was £132,167 less than quarter 4 2013-14.

The chart below compares the monthly percentage sickness rates for 2014-15 with

those for 2013-14 and with the Trust target rate.

The chart shows that sickness rates continued to decrease across the first two months of quarter 1 2014-15, following the trend from quarter 4 2013-14. The sickness rate dropped to 3.84% in May 2014 before increasing to 4.08% in June 2014. Although the rates in the first two months of the quarter were lower than in the same period last year, the rate for June 2014 was higher when compared to June 2013 (3.77%).

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Stress/anxiety (22.63%) and musculoskeletal/back problems (23.23%) typically account for large proportions of staff sickness as shown in the chart below. This is reflective of the same period in 2013-14 with stress/anxiety accounting for 28.92% and musculoskeletal/back problems accounting for 22.83%. Other Known Causes (15.01%) also accounted for a large proportion of sickness absence in quarter 1 2014-15.

The days lost to sickness in wte for 2014-15 compared to 2013-14 are shown below. The chart corresponds with the sickness rate information which shows a decrease in the number of wte days lost for the first two months of the quarter, increasing again in June. The total number of wte days lost in quarter 1 2014-15 was 173.14 higher, at 16776.45, compared to quarter 1 2013-14 at 16603.31.

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The salary-based cost of sickness over the same periods is presented below. The

cost of sickness follows the same trend as the sickness absence rate and was consistently lower for the first two months of the quarter when compared to the same period in 2013-14, with a slight increase in June. It should be noted that this is an ESR-estimated figure, and does not include employer on-costs. Overall the salary-based cost of sickness for quarter 1 2014-15 was £132,167 lower than in quarter 1 2013-14.

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Sickness costs by directorate are detailed below. Finance, Integrated Care Services and Medicine account for the largest amount of sickness costs across the quarter, however, these are also the largest directorates in the Trust.

Costs by staff group are presented below. The staff group which consistently

accounts for the greatest share of costs is nursing and midwifery. This is followed by Additional Clinical Services and Administrative and Clerical.

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Regional sickness absence data for quarter 1 2014-15 is not currently available. 2.6 Occupational Health

The table below details the top 10 reasons for referral to Occupational Health up to and including quarter 1 2014/15:

Reason for Referral Apr-Jun 2014

Jul-Sep 2014

Oct-Dec 2014

Jan-Mar 2015 Total 2014-15

Mental Health Problems 51 51 Musculoskeletal - other 46 46Neurological 27 27 Musculoskeletal - back and neck 25 25 Post-Surgery 18 18 Infections 13 13 Short Term Sickness Absence 9 9 Fitness for Interview 7 7 Fracture 7 7 Other GI 6 6

Following national Occupational Health re-categorisation of reasons for referral, the above categories differ slightly from previous years.

‘Mental Health Problems’ include stress, both work and non-work related and anxiety and depression. These reasons will be separated for future reports.

‘Neurological’ collates all previous neurological reasons in to one category, e.g. Epilepsy, MS, Migraine etc.

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3. Workforce Development

3.1 At the end of quarter 1 the Trust is 97% compliant for mandatory training corporately, which represents a 2% increase compared with the position at the end of the previous quarter. The improved position is due to a number of factors including close monitoring of individual directorate compliance levels, a review of all training requirements including frequencies, the establishment of a task and finish group and improved communication between E&OD and other directorates.

The table below shows the compliance levels quarter by quarter for ‘key’ topics:

Topic Target

compliance % Q2

2013/2014 % Q3

2013/2014 % Q4

2013/2014 % Q1

2014/2015 Infection Control 95 100 100 100 100 Information Governance

95 91 91 97 90

Medicines Management

80 97 97 95 96

Corporate Induction

100 100 100 100 100

Appraisal 95 88 92 96 95

Patient Handling 80 91 89 89 86

Resuscitation 80 85 83 83 82

Dementia 50* - 58 79 85 Enhanced infection control

80 50 53 92 N/A***

Safeguarding Children (combined levels)

80 93 95 98 97

Safeguarding Adults (combined levels)

80 92 93 94 94

Human Factors 80 48 60 89 N/A*** Patient falls (advanced)

80 54 66 84 24**

Pressure sores 80 82 89 89 21** Overall Trust compliance

95 94 95 97

Dementia target of 50% set by CCG – newly added to RAG for 2013/2104 period ** Target staff group changed from 2013/2014 period *** Topic was specific to 2013/2014 training schedule and is not included in the 2014/2015 TNA

Although the ‘effective management of mandatory training’ (HR45) policy was reviewed 18 months ago, a further review is underway to investigate methods of enhancing the effect that mandatory training has on patient safety by concentrating resources on evidence-based training. The aim is that specific training related to Serious Untoward Incidents (SUI), Datix’s and claims can be quickly incorporated into the training plan to ensure rapid improvement in patient outcomes. The robust audit process to ensure resources are directed to where they will be most effective continues to be monitored by the E&OD quality group and will continue as part of any review of policy. As part of the Trust’s commitment to improving patient safety and driving up standards, a number of additional targeted training topics are included in the annual Training Needs Analysis (TNA) as a result of analysing a number of data sources

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such as Datix, SUIs and claims data. After discussion with key stakeholders, the following topics will be added from the 2014/2015 Q1 report:

1. Pressure Sores 2. Patient Falls – enhanced 3. Conflict resolution

Compliance levels for these topics have been incorporated into the table above. The Trust continues to invest in clinical simulation as a way of improving patient safety. Following a successful bid to Health Education North East (HENE) the Trust purchased a number of state of the art manikins including a birthing simulation manikin that will further strengthen the Trust’s simulation agenda. This equipment will allow realistic scenarios to be developed and assist in individual and team training, placing specific emphasis on the human factors element.

3.2 Medical Education 3.2.1 Visits

The Annual Deanery Quality Monitoring (ADQM) visit took place on 8 April 2014. The Trust was commended for the presentation of the paperwork for the visit. A number of areas were identified as Notable Practice including: SUIs used to inform future training (including simulation) Engagement of trainees via College Tutor surgeries and the remuneration of

trainers Improvements to rotas and EWTD compliance The way the red outliers for Paediatrics on the 2013 GMC Trainee survey have

been addressed and improvements made The following area was recognised as strengths: Educational and Clinical supervisors appraised against AME standards There were 7 minor action points from the visit, with 4 actions for the Trust to take forward.

3.2.2 Exams

The Undergraduate Department held medical student exams on behalf of the Medical School at Newcastle University. These were the Final year OSCE on Tuesday 3 June 2014 and the MOSLER exams on Tuesday 10 June 2014.

3.2.3 ARCP for Foundation Doctors The ARCP panels were held the first week in June for 86 Foundation doctors. Panel members included those Consultants who have been supported by E&OD to undertake their Cert / Dip / Masters in Clinical Education.

3.2.4 Funding New funding arrangements have been put in place for training posts from 1 April 2014.

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3.2.5 Surveys

The GMC survey opened on 26 March and closed on 8 May 2014. The response rate was 100%.

3.3. Leadership Development

During Q4, the last of the four 2013/2014 leadership programme cohorts completed their final presentations to invited guests including many of the Trust’s Executive and non-Executive members. Feedback by both participants and the audience was extremely positive. The programme has helped equip the leaders of today as well as the leaders of tomorrow to shape the services we deliver in a way that focuses on improving patient outcomes whilst ensuring maximum efficiency is achieved. The Trust continues to recognise the need for developing leaders at all levels of the organisation and therefore continues to invest in building leadership capacity. Following on from the successes of the previous leadership programmes, an event for 200 Trust staff (primarily AfC bands 2-5) took place in May at the Wynyard Rooms. The event was the induction day for the eight cohorts of staff due to undertake a comprehensive leadership programme over the coming months. As with last year’s event, this programme is being jointly delivered with our training partner, Teesside University. Feedback so far has been overwhelmingly positive. North Tees and Hartlepool NHS Foundation Trust’s sustainability and success is dependent on having the right people with the right skills in the right roles – with the right behaviours and values. Consequently the Trust’s approach to talent management is aimed at maximising the potential talent which exists in the Trust to address the inherent complexities and meet the challenges faced The Trust has recently participated in a national talent management pilot facilitated by the National Leadership Academy. The outcome of this pilot will not only influence our own internal process but talent management regionally and nationally. Following evaluation, the expected outcome is to integrate talent management into the Trust’s appraisal process. Following our involvement in the national pilot, North Tees & Hartlepool NHS FT has worked with the National Leadership Academy to further develop the tool and the modified talent tool was launched at an event in Leeds in June.

4.0 Workforce Productivity 4.1 eJob Planning for Consultants and SAS Doctors

94% of the Trust’s Consultant job plans are entered onto the eJob Plan system. Within directorates, job plans are at varying stages of review either by the General Manager and/or Clinical Director and/or individual Consultants. Over the coming months work will take place with the directorates to increase the percentage of job plans ‘signed off’ on the system. To promote consistency across the Trust and align NHS, Trust, team and individual objectives during the job planning cycle to support delivery of high quality patient care, a job planning policy is in the process of being introduced together with a job planning review group led by the Trust’s Medical Director.

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4.2 eRota for Junior Doctors

Implementation of the software is complete, enabling quick and easy identification of European Working Time Directive (EWTD) and New Deal compliance. Benefits realisation of the software will take place over the coming months, maximising the efficiency of the rotas, which will then be used to populate the eRostering software. This includes plans to establish regular meetings with rota co-ordinators from directorates to promote shared learning and embed best practice.

4.3 eRostering for Medical Staff

Electronic rosters are currently live for the consultant on call roster in Medicine. In addition, rosters are now populated electronically using the Health Roster system for junior doctors in Medicine, following an initial pilot in June and July 2014. We are also in the early stages of populating electronic on-call rosters for the middle grades in Medicine. The roster contains real time information and is updated on a daily basis with annual leave, study leave and sickness by the roster administrators in Medicine, and Consultants/Medical Secretaries can view the live rosters on the system. Following the pilot, we will share our learning by introducing the system across all the remaining directorates. This will enable juniors to effectively rotate through the Trust, with full staff visibility within the system, allowing easy and efficient re-allocation of staff.

4.4 eRostering for Nursing Staff

The pilot in medicine to decentralise nurse rostering in line with the model used for medical staff has been completed and the evaluation concluded that having the Roster Administrators on / near the ward areas was beneficial for the Hartlepool site.

However, the overall conclusion was that being situated in the Resource Office: enhanced accessibility for Ward Managers to the Roster Administrators gave heightened collaboration due to 1:1 discussions improved communication through uninterrupted review meetings to discuss

rosters improved communication between all RAs when covering each other during

annual leave or other absences

The first electronic roster for community Hartlepool District Nursing is due to be released in September 2014. Electronic rostering has been completed and is live for the Chemotherapy Department and preliminary work has commenced for the, Antenatal Day Unit, Rutherford Morrison, Endoscopy and the Medical Rehabilitation Unit on the North Tees and Hartlepool sites. The next areas to go live are still to be decided.

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4.5 eExpenses The Trust made a decision to be the national beta test site for Version 10 of eExpenses, which will ultimately result in a product that is quicker and easier for staff to use. Current users of eExpenses continue to use version 9.5, until version 10 of eExpenses can be tested. Version 10 of eExpenses is ready for general release. The ‘kick off’ meeting to start the project and establish a Project team took place on 22nd July 2014. We are currently in the data gathering and project implementation planning stage.

4.6 Management of Flexible Workers Following the TUPE transfer of 700 non-medical bank/zero hours/casual contract holders to NHS Professionals (NHSP) during November and December 2013 and implementation of a new additional hours process for substantive AfC staff via NHSP, a decision was made to allow part-time staff the option of working additional hours via NHSP or via Trust payroll. The management of booking agency staff for all areas (excluding medical and some specialist areas) is now also managed via the NHSP booking platform. The ‘Golden Key’ to control shifts automatically cascading to agency is now fully implemented and a further control called ‘Two Tier’ is planned to be implemented in August/September 2014 which will introduce a requirement for second level authorisation. Finance are undertaking analysis of all current NHSP expenditure across the various staff groups to review the levels of savings in each area and a report is due to be presented to the Executive Management Team in August 2014. A post implementation governance structure has been developed to monitor the quality and performance of the NHSP service and to ensure benefits are fully realised.

4.7 NHSP – Nurse Rostering Interface The software interface enables shifts to be sent from the electronic nursing rosters to NHSP, therefore improving efficiency, control and governance. It is now being tested and is currently being piloted in Critical Care.

4.8 Lean Activity

The Trusts approach to implementing Lean management has the core values of: quality; safety; focus on the customer/patient; total commitment to staff and increased satisfaction for all, while reducing costs. The benefits of this approach include: A relentless focus on the patient experience provides value added time with care

providers, and Lean tools and processes help care providers deliver the best possible care with zero defects.

Patients benefit from greater safety, less delay in getting to see their doctors and other professionals for care and more timely results and treatments.

Staff benefit by having less rework and greater opportunities to care for patients — the reason they chose health care as a profession.

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The organisation benefits by operating more efficiently and improving processes that are a part of any health care experience thereby reducing cost.

Following the closure of the NHS Institute of Innovation & Improvement and the subsequent demise of the productive series, a paper was agreed by the Trust’s Executive Team to re-brand the activity under the name of North Tees & Hartlepool FT Local Improvement System (LIS). The creation of a North Tees & Hartlepool NHS FT Local Improvement System (LIS) which encompasses Lean methodology and other improvement tools and methods would support the Trust as it reviews its culture and values and we consider the new hospital and transformation developments. The LIS gives the possibility of integrating Lean with all our activities whether service, operational, developmental or strategic. The LIS would enable the Trust to build upon the good work already done and create greater flexibility for future change and transformation. LIS has been implemented in the following areas during quarter1:

Wards 26,37 and 40, UHNT Holdforth Unit, UHH

5.0 Workforce Relations

5.1 Employee relations case summary

The table below summarises the number of employee relations matters raised within the Trust during this reporting period and carried forward from previous reporting periods:

Category Cases commenced in Q1

Cases commenced and concluded in Q1 (with outcome)

Cases carried forward from previous quarters

Carried forward cases concluded in Q1 from previous quarters (with outcome)

Total on-going cases to carry forward to Q2 2014/2015

Disciplinary & Capability

14

4 – No further action

23

2 – dismissed 1 - first written warning 1 – final written warning 1 – no case to answer 8 – no further action

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Grievance 2 0 8

1 – not upheld 2 – upheld

7

B&H 2 0 2

4

Mediation 4 1 – resolved successfully

3 2 – resolved successfully 1 – mediation did not proceed

3

Absence dismissals

1 1 - - -

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5.2 Disclosure of Concerns (Whistleblowing)

There have been no disclosure of concerns raised in quarter 1 of 2014/15. 5.3 Disciplinary cases relating to infection control

There have been no reported cases pertaining to failure to adhere to infection control procedures in this quarter.

5.4 Staff Friends and Family test

The staff friends and family test was launched during quarter 1 using an electronic platform to gather the data (with an option for staff to complete a paper questionnaire if they preferred). A total of 456 responses were received for the quarter 1 staff friends and family test which ran from 1 July 2014 to 31 July 2014. As per nationally published requirements, the following 2 questions were included in the questionnaire: 1. How likely are you to recommend this organisation to friends and family if they

needed care or treatment? ''

25% of respondents stated extremely likely and 45% stated likely. 2. How likely are you to recommend this organisation to friends and family as a

place to work?''

22% of respondents stated extremely likely and 41% stated likely. A section for free text comments was also included. A summary of the results is shown below:

Figure 1 - How likely are you to recommend this organisation to friends and family if they needed care or treatment?

0%5%

10%15%20%25%30%35%40%45%50%

Extremelylikely

Likely Neitherlikely nor

unlikely

Don't know Unlikely Extremelyunlikely

%age of respondents

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Figure 2 - How likely are you to recommend this Organisation to friends and family as a place to work?

The quarter 2 survey was launched in July 2014 and a communication plan is being implemented to ensure that actions are taken forward to increase the response rate. A review of online solutions will also be undertaken to scope out alternative ways of capturing a response. With respect to next steps, the results of the survey will be used, working with directorates, in developing action plans or interventions to address any areas of concern. Groups already in place, such as the Improving Working Lives group, will review responses and include as part of their ongoing work. From a clinical persepctive, information will be fed into relevant forums/groups to ensure this can be review, assessed and processed.

6.0 Recommendation

The Council of Governors are asked to note the content of and accept this report.

Mrs Ann Burrell Director of Human Resources and Education 9 September 2014

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Meeting of the Council of Governors 18 September 2014

Staff Survey Actions & Progress Report


Executive Summary

Strategic Aim: (The full set of Trust Aims can be found at the beginning of the Council of Governors reports) Maintain Compliance and Performance Strategic Objective: (The full set of Trust Objectives can be found at the beginning of Council of Governors reports) Effective Board Governance 1. Introduction The Trust took part in the NHS National Staff Survey 2013. This paper is to provide the Council of Governors with an executive summary of the key findings. The Trust as in past years took part in the eleventh NHS National Staff Survey 2013. The Trust has historically asked a sample of staff (850) to complete a survey; however, a full census was undertaken in 2013 in order to ascertain fully the wider views and gain feedback to support a number of key activities, not least, the culture and values work. In total, 2455 surveys were completed resulting in a census response rate of 49.65%. Nationally, reported figures are based on a sample size of 850 giving the Trust a response rate of 49.09%, which equates to a total of 407 staff. The Trust response rate was less than 2012 (57%) and was average for acute Trusts in England. 2. Key Findings The Trust was ranked in comparison to other acute trusts nationally in relation to each of the 28 key findings contained within the 2013 staff survey. The full survey outcomes can be provided if the Board would wish to receive a personal copy. This report provides a summary of the findings. 2.1 Top Scores The Trusts five top scores in the 2013 Staff Survey were in the following key findings:

Percentage of staff experiencing discrimination at work in last 12 months;

Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months;

Percentage of staff working extra hours;

Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months;

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Percentage of staff believing the Trust provides equal opportunities for career progression or promotion.

2.2 Bottom Scores The Trust’s five bottom scores were in the following key findings:

Percentage of staff agreeing that their role makes a difference to patients;

Percentage of staff reporting errors, near misses or incidents witnessed in the last month;

Staff motivation at work;

Percentage of staff receiving health and safety training in last 12 months;

Effective team working 3. Census Report key themes Given the Trust decision to undertake a full census staff survey, analysis of the outcome report has been underway and provides the following early indicators. 3.1 Areas where staff have indicated satisfactory outcomes

I am trusted to do my job

I feel that my role makes a difference to patients / service users

My organisation encourages us to report errors, near misses or incidents

I always know what my work responsibilities are

My organisation does not blame or punish people involved in errors near misses or incidents.

These areas of improvement have been included in the action plan and will be addressed as part of the overarching staff survey plan. 3.2 Areas where staff have indicated a need for improvement

I would recommend my organisation as a place to work

If a friend of relative needed treatment, I would be happy with the standard of care provided by this organisation.

Senior managers act on staff feedback

Senior managers here try to involve staff in important decisions

Communication between senior management and staff is effective

There are enough staff as this organisation for me to do my job properly

My level of pay 4. Recommendation Following a programme of consultation and engagement meetings with staff, and local directorate meetings, the action plan at appendix one has been produced for 2013/2014. The Council of Governors are asked to note the contents of this report. Mrs Ann Burrell Director of Human Resources and Education 9 September 2014

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18 September 2014

Staff Survey Actions & Progress Report


This action plan and progress report identifies the key findings where as a Trust we have been benchmarked as poor in relation to other acute Trusts regionally. It is important to note that these have been identified via a sample of staff. Due to the fact that as a Trust we decided to ask all staff to complete a survey in 2013, this action plan and progress report also includes areas where, from a census perspective, required action has been identified.

Issue Action/Progress Update Target date

Relevant to Measured Outcome

Next Steps

KF2 Percentage of staff agreeing that their role makes a difference to patients Trust Score: 86% National Average: 91% Lead: Michelle Taylor / Tracy Minns

During 2013 a programme of engagement events have been implemented as part of the “Your part in our future” engagement plan. Outcomes have been evaluated and triangulated with appropriate action plans to ensure a consistent response to any identified areas for improvement. Results of the staff survey census report indicate this is one the trust‟s most improved areas; suggesting the wider workforce feels this is an area of good practice within the Trust. However as we fair low compared to

Sep 2014

Francis IIP Engagement Strategy

Staff Friends & Family Test Directorate Staff Survey Action Plans

Further engagement events are planned for 2014 which will primarily focus on the outcomes of the feedback sessions together with other key information taken from staff related surveys. A project team has been established which is focussing on the Trust‟s approach to implementing the 6Cs. Feedback from this programme of work is being received into key staff engagement groups around the trust to ensure that measures, where needed, are implemented.

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other acute Trusts, work will be on-going to reflect on this key finding.

An evaluation of the recent transformation programme is currently being undertaken to identify any learning lessons for future change models and local ways of working



Next Steps

KF14 Percentage of Staff reporting errors near misses or incidents witnessed in the last month Trust score 2013: 87% National average: 90% Lead: Janet Alderton

Work has been underway during 2013 to review and revise the Disclosure of Concerns Policy. This revised policy has now been ratified and is being promoted at every available opportunity. The Trust Patient Safety team have undertaken various initiatives to promote the reporting of incidents and the importance of raising concerns through the most appropriate route. A patient safety “message of the week” has been introduced which again highlights the importance of reporting errors, near misses and incidents. The patient safety team have undertaken directorate visits raising awareness of the policy and providing advice where necessary. The team also ensure this is a key agenda item at meetings. Sessions have been scheduled with Managers in the form of training days to promote incident reporting and investigation.

September 2014

Francis Berwick CQC IMR

Increased incident reporting – NRLS / Datix data. Improvement on scoring within staff survey in 2014. Directorate Staff Survey Action Plans

Continuation of the raising awareness of incident reporting and the need to investigate issues identified. Plans are in place to review the provision of training on this topic with a view to designing some generic and bespoke training facilitated by the patient safety team.

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Next Steps

KF10 Percentage of staff receiving health and safety training in the last 12 months Trust Score: 69% National Average: 76% Lead: Ian Clough

Compliance figures of Health & Safety Training remain consistently high at 93%. As a result of the 2012 staff survey, amendments were made to the wording of the H&S question to explain the portfolio of health & safety training in order to articulate the definition of what is within the scope of H&S training.

September 2014

IIP Health & Wellbeing strategy IIP People & Organisational Strategy

Rag Report improved outcomes Directorate Staff Survey Action Plans

A response paper is currently being drafted around mandatory training including Health & Safety topics. A re-branding model is considered the most appropriate approach to ensure staff are aware of the linkage of the different training sessions

KF25 Staff motivation at work Trust Score: 3.76 National Average: 3.86 Lead: Michelle Taylor / Gary Wright / Claire Young

The Trust has invested heavily in the development of staff during 2013 with the roll out of the Leadership and Management course in conjunction with Teesside University. Due to its success this course has been extended to all staff with the intention of providing tools, awareness and understanding to assist and understand the impact of motivation levels throughout the organisation. The Trust continues to hold the annual Shining Stars event, in order to celebrate excellence and good practice across the organisation at all levels. This event is very well received by staff, with excellent feedback year on year.

September 2014

Francis Engagement Strategy IIP People & Organisational Strategy

2014 Staff Survey outcomes Cultural Assessment outcomes Performance Dashboard Sickness Levels & Turnover Directorate Staff Survey Action Plans

A Trust engagement strategy is currently being developed in order to enhance the good work already being undertaken across the organisation. As part of the People and Organisational Strategy a key outcome is the review and re launch of the Reward and Recognition. Strategy. This review will include engaging with staff through various communication channels that exist within the Trust, asking for their views and opinions. A re-design of the approach of reward and recognition will then be considered, with the aim of meeting the needs of staff by listening to their views and acting accordingly

6



Next Steps

KF4 Effective Team Working Trust Score: 3.68 National Average: 3.74 Lead: Michelle Taylor / Gary Wright

The Trust has invested heavily in the development of Trust staff during 2013 with the roll out of the Leadership and Management course in conjunction with Teesside University. A number of organisational development interventions have, and continue to be embedded across the Trust to measure, evaluate and improve the Trust‟s approach to team working. These will continue into 2014/15. The Education & OD department continue to support staff through organisational change. In addition to the many team building methods/tools used (e.g. Myers Briggs, Belbin) bespoke team building events are organised to support specific needs The Trust celebrates excellent team work as part of the annual Shining Stars event, with many of the categories being open to team nominations as well as a Team of the Year category.

September 2014


2014 Staff Survey outcomes Cultural Assessment outcomes Performance Dashboard Directorate Staff Survey Action Plans

Due to its success this course has been extended to all staff with the intention of providing tools, awareness and understanding of effective team working and how to role model this throughout the organisation. A cultural analysis will be concluded within 2014, outcomes of this analysis will inform necessary interventions needed to support the cultural change leading to improved team working in areas where this is deemed to be an improvement area.

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Next Steps

Q12c I would recommend my organisation as a place to work Trust Score: 53% National average: 59% Lead: Tracy Minns

Given the infancy of the staff friends and family test, information that will be used to monitor improvements will be collated throughout 2014. Initial response from our first quarter staff friends and family test has now been received and provides a positive response rate. 456 staff responded to the survey providing a useful benchmark of staff opinion in the first month of the launch.

September 2014


Staff Friends & Family Test 2014 Staff Survey outcomes / Directorate action plans Cultural Assessment Turnover

Following the launch of the nationally driven Staff Friends and Family Test results from the first quarter are currently being collated and analysed, outcomes of which will seek to address any lagging indicators through local intelligence, benchmarking against the national data set and regional tends. Set outcomes will then be built into the corporate IWL plan with progress and triangulation of learning embedded. through appropriate channels The review and re-launch of the Trust Reward and Recognition Strategy, will take into consideration the views and opinions of staff across the organisation.

Q12d If a friend of relative needed treatment, I would be happy with the standard of care provided by this organisation. Trust Score: 57% National average: 64% Lead: Tracy Minns

The Trust launched the Staff Friends and Family test which will seek to address this area supported by the work of the 6cs project team with any learning triangulated into the relevant action plans. This supports the Patient Friends and Family Test which is something that is being closely monitored by the Trust Workforce plans are measured and monitored against a strict set criterions Robust workforce planning is in place across the organisation to monitor performance and provide assurance that the organisation is appropriately resourced to deliver high quality levels of patient care.

October 2014

Francis

Staff Friends & Family Improved patient experience outcomes Directorate Staff Survey Action Plans

Work with the 6Cs project team will continue across the trust with the aim of embedding the 6Cs across the organisation. Following the launch of the SFFT national data set, plans are in place to allow a level of regional and national benchmark in order to assess progress against set outcomes. This will be reported regularly via appropriate channels ensuring that the trust continues to place patient care at the forefront of business planning.

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Next Steps

Q7g There are enough

staff as this organisation for me to do my job properly Lead: Lesley Pritchard

A review of the workforce projections is in place to ensure the organisation has in place the right design and development in order to support the workforce strategy.

April 2015

Francis Workforce Strategy People & Organisational Strategy CQC

Workforce Projection outcomes CQC outcomes 2014 Staff Survey outcomes

A number of workshops are in the planning stages and will be implemented to appropriate cohorts of staff across the organisation equipping them with the knowledge and tools needed to design a structure that will be sustainable, meet demands and provide the strategic direction needed to implement the trust‟s business and operating models

Q8h My level of pay Lead: Tracy Minns

The Trust adopts national terms and conditions and has robust checking mechanisms in place to ensure any variance from national terms, utilising manager discretion is fair, balanced and is a direct service requirement A vacancy control system is in operation which operates a hierarchical approval process. This method of analysis informs a detailed check of salaries across the organisation to ensure transparency, equity and compliance of terms and conditions across the trust.

Dec 2014

Workforce Strategy People & Organisation Strategy

Outcomes Equal Pay Audit 2014 Staff Survey outcomes

An equal pay audit is planned for 2014 which will seek to highlight any variances by protected characteristic ensuring good practice is adopted in respect of the Equality Act. This review allows a measurable approach to equal pay.

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Next Steps

Q11d Senior managers

act on staff feedback Lead: Michelle Taylor / Gary Wright / Claire Young

During 2013 a programme of engagement events have been implemented as part of the “Your part in our future” engagement plan. Outcomes have been evaluated and triangulated with appropriate action plans to ensure a consistent response to any identified areas for improvement. A project team has been established within the Trust which focuses on the Trust‟s approach to implementing the 6cs values. Feedback from this programme of work is being received into key staff engagements groups around the Trust to ensure that measures, where needed are implemented. The Education & OD team have supported staff through transformation phase 1 and have worked on over 21 wards/areas and „trained‟ over 560 staff

Sep 2014 Francis Engagement Strategy IIP People & Organisational Strategy

2014 Staff Survey outcomes Cultural Assessment outcomes Directorate Staff Survey Action Plans

Further engagement events are planned during 2014, which will primarily focus on the outcomes of the feedback sessions together with other key information taken from staff related surveys. An evaluation of the recent transformation programme is currently being undertaken to identify any learning lessons for future change models.

Q11c Senior managers

here try to involve staff in important decisions Lead: Michelle Taylor / Gary Wright / Claire Young

The Trust has invested heavily in the development of Mangers during 2013 with the roll out of the Leadership and Management course in conjunction with Teesside University. Following feedback from staff, a management development programme (MDP) has been developed to support line managers with the practical aspects of managing staff and their department. This programme will equip line managers with key skills needs to operate on a day to day basis i.e. budget management, attendance management, risk analysis etc…

Dec 2014 Francis Engagement Strategy IIP People & Organisational Strategy


Due to its success the Leadership and Management course has been extended to all staff with the intention of providing tools, awareness and understanding to assist with motivation levels throughout the organisation. A key aspect of the course is leadership and management styles and in particular effective communication. Managers are expected to embed learning from this course into operational practice.

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Next Steps

Q11b Communication

between senior management and staff is effective Lead: Michelle Taylor / Gary Wright / Claire Young

The trust recognises the importance of communication between senior managers and staff. To aid this and in addition to the staff appraisal process managers are encouraged to hold regular 1:1 meetings with their staff to aid 2 way communication. All departments and teams have team briefings/meetings. In addition to the chief executives briefing, the communication department forwards regular communications via the trusts e-mail system To aid open and honest two way communication, the trust works to develop a culture of candour.

Review September 2014



The Trust is currently undertaking a cultural assessment the aim of which is to test the cultural barometer of the organisation, which includes how we communicate across the organisation. Outcomes of this assessment will inform any future interventions needed to support and enhance communication.

North Tees and Hartlepool NHS Foundation Trust 2015 Council of Governors’ and Governor Sub-Committee Meetings

21 May 2014

CoG Meetings (All Board members to attend) Formal Meeting (Morning) Development Session (Afternoon)

Membership Strategy Committee 11.00am – 12.30pm Chair – Wendy Gill ED/Company Secretary – Barbara Bright

Travel and Transport Project Committee 10am-12 noon Chair - Peter Mitchell

Service Development and Quality Committee 2.00pm-4.00pm Chair – Rita Taylor ED – Julie Gillon

Strategy Committee Meetings 2.00pm-4.00pm Chair – Ken Lupton ED – Julie Gillon

Thursday, 15 January 2015 Londonderry Room, Wynyard Rooms

Monday, 9 February 2015 Boardroom, UHNT

Thursday, 12 March 2015 Boardroom, UHNT

Monday 2 March 2015 10.00am until 12.00noon Tees Meeting Room, Ground Floor, UHNT

Thursday, 19 March 2015 Boardroom, UHNT

Thursday 16 April 2015 Conference Rooms 1 & 3, Hartlepool College

Monday, 8 June 2015 Boardroom, UHNT

Thursday, 25 June 2015 Boardroom, UHNT

Thursday, 16 July 2015 Londonderry Room, Wynyard Rooms

AGM & CoG Thursday, 1 October 2015 Conference Rooms 1, 2 & 3, Hartlepool College

Monday, 14 September 2015 Boardroom, UHNT

Monday 7 September 2015 10.00am until 12.00noon Tees Meeting Room, Ground Floor, UHNT

Thursday, 22 October 2015 Boardroom, UHNT

Thursday, 8 October 2015 Boardroom, UHNT

Monday, 23 November 2015 Boardroom, UHNT

North Tees & Hartlepool NHS Foundation Trust

Notes of Travel & Transport Project Team Meeting

Monday 1 September 2014

Present Peter Mitchell Deputy Director of Support Services (Chair)

Sharon Pounder Financial Services Co-ordinator Ian Fraser IT Estates/Car Park Administrator

John Cairns Trust Governor (Easington) Claire Bedford Communications Officer

Reg Ramsden Linen Services Manager Paul Robson Consultant Integrated Transport Unit Manager (Hartlepool Borough Council) Barbara Carr Associate Director of Nursing, Quality and Patient and Experience Brian Christelow Portering/Security/Transport Manager

In attendance Tracy Priestman Note Taker (PA to Deputy Director of Support

Services)

1 Apologies for absence Action

Apologies for absence were received from Linda Bartlett,

Roger Morrow, Michael Kirtley (Deputised by Sharon Pounder)

2 Notes of the last meeting held on 3 March 2014

a) Matters arising

Patient Representative PM attended Healthcare User Group to provide an update of the new Parking Eye system and it was agreed BCa would forward the name of Patient Representative from the Group. BCa asked the Group to consider representation, as members from various meetings BCa attended had expressed an interest to attend future Travel & Transport Project Team meetings. PM agreed to discuss representation as Agenda item at next meeting.

BCa

TP

Fleet Review Report from Energy Savings Trust

End of year mileage report was tabled by SP which was discussed and it was agreed half yearly figures would be tabled at next meeting.

Car Sharing

To be discussed under Item 6.

Volunteer Driver Scheme


Shuttle Service Update


b) Acceptance

The notes of the meeting held on Monday 3 March 2014 were accepted as an accurate record of the meeting.

2

Action

3 Terms of Reference

PM went through Terms of Reference, which had been agreed by the Chairman.

PM requested IF/RR attend meetings due to their expertise in certain areas which were due to be on the Agenda for the foreseeable future.

It was agreed Membership of the Group should include Deputy Director of Support Services, as Chair of the Group. TP to advise Private Office of update to Terms of Reference. Updated Terms of Reference to be circulated to the Group. PM requested a review of dates of future meetings. To be discussed at next meeting.

TP

4 New Hospital Update – Section 106 Agreement

New Hospital Update The Trust met with DH Senior representatives, Monitor, Treasury, NHS England and CCG representatives on 22nd July to discuss and seek a clear view on progressing the scheme. A meeting also took place with DH representatives on the 26th August 2014. The DH Estates team are reviewing the amended OB forms and feedback is expected during September 2014. PM gave update of a similar scheme at another Trust which had recently received approval. Section 106 Agreement PM gave an update on the Section 106 agreement, which provides measures to support transport regarding the OBC to the new hospital. One meeting has taken place and a second meeting is scheduled for mid-September 2014 which is Chaired and led by Hartlepool Borough Council (HBC). It is hoped this will be approved as soon as possible. Guidance is being provided regarding bus provision. The Highways Authority are progressing work on A19 which will avoid the Trust’s obligation to be done in the future, but work will still be required on the A689 junctions. Wynyard/Cameron Hall Estates have submitted planning applications for housing developments, should the new hospital project not go ahead the Section 106 will fall upon the housing developers.

5 ParkingEye

ParkingEye went live on 1 August 2014. It is a very rigid system and has progressed to agreed plans and timescales. There is a cost of £70 for a CPN notice, discounted to £40 if paid within 14 days. First two weeks ParkingEye had people on site for 12 hours per day. Leaflets have been distributed, roadshows, radio interview, local articles in the Hartlepool Mail and Evening Gazette. ParkingEye have agreed to install 3 further pay on foot machines at UHNT. Warning letters have been issued to staff by ParkingEye if parked in the incorrect car park or details have not been registered.

3

Action

A number of staff/volunteers have received CPN notices which have hopefully all now been resolved. Visitors have received CPN notices due to their own errors or mistakes made by the Security Office, which are being resolved. Teething problems have been experienced, but work is constantly being undertaken to improve systems and help visitors/patients and staff. ParkingEye have been asked to uphold any appeals for Emergency A&E/Maternity/Paediatrics/End of Life/Cancer admissions, which the Trust would support. People are being encouraged to write back and appeal if they believe they have appropriate grounds for appeal. ParkingEye have not charged for the installation of the system, which has avoided a £400,000 capital spend for the Trust and a reduction in staffing costs. Increase in staff car parking charges was raised. PM responded that if staff are in the salary sacrifice scheme this should still be cheaper than, for example, using the car park opposite UHNT hospital. Staff are using the car park at UHH and using the shuttle bus. IF advised those staff involved in transformation of services from UHH to UHNT do receive free parking at UHH. BCa advised patient leaflets now include Parking Eye information. PM has attended a number of meetings to provide information regarding ParkingEye. IF commented there is a good relationship with ParkingEye and have been excellent in helping to address issues. The car park opposite the University Hospital of North Tees has been granted formal planning approval.

Barbara Carr left meeting

6 Car Sharing

Only a dozen people using the scheme. Not been as much interest as hoped.

7 Taxi Review

Taxi Policy has been approved. Approval required by Band 8’s for use of taxi’s has been rigorously applied and has seen a significant reduction in the use of taxis for staff.

8 Volunteer Drivers Scheme

RR circulated a schedule of volunteer journeys undertaken to date for 2014. Posters have been placed around the hospital promoting the service and posters have also been sent to GP practices. RR advised volunteers are unable to take people to Endoscopy appointments as drivers do not have first aid experience.

4

Action

It is hoped to expand the Volunteer Driver Service from 9.00am until 5.00pm in the near future and next year it is hoped drivers can deal with work remotely from Outpatients. Controlled envelopes are being looked at for Volunteer Drivers, as passengers are wishing to make donations to the drivers directly. Advantages from the scheme include the Discharge Lounge being freed up and more appointments are being attended by patients. Recruitment process is slow when trying to recruit Volunteer Drivers. RR to look at possibility of ways of contacting staff who are due to retire to see if interested in becoming a volunteer driver. RR to speak to CB regarding further communications. IF asked about Patient Transport Service and BCa to be asked to speak about this at the next meeting.

RR

PM

9 Shuttle Service Update

IF circulated report of shuttle service usage to date. Generally service working very well, however, there are pressures to meet demand. Shuttle service provides transportation for those involved in transformation of services from UHH to UHNT. The service, therefore, reduces inter-site travel mileage claims. PM reviewed inter-site journeys compared to last year which saw a reduction of 300,000 miles. Nurses are planning to standardise start/finish times, so looking to simplify and co-ordinate shuttle bus with those start/finish times. Staff self-booking system working very well. PR said this would be a good time to evaluate both the Volunteer Driver Scheme and the Shuttle Service. If required, there is a Travel Club facility available to get people to UHH. PM asked if the group had any integrated travel information could this be brought to the next meeting. Tees Valley Connect is trying to establish a central database system through monies received from the Sustainable Trust to collate what travel information is available. LJ still to provide an update for an end date for free parking for transformation staff for the Park and Ride at UHH, which had been queried by AB at the meeting in March 2014, which had been agreed at another meeting. To be c/fwd to next meeting.

All

LJ

5

Action

10 Any other business

Bus Services JC advised the new telephone number for Patient Transport Service/East Durham Hospital Link to book transport is 03000 269999 (Option 1).

11 Date/Time of future meetings

Monday 2 March 2015 - 10.00-12:00 Tees Meeting Room, Ground Floor, UHNT Monday 7 September 2015 - 10.00-12:00 Tees Meeting Room, Ground Floor, UHNT

Signed: …………………………………………….. (Chair) Date: ………………………………………….. PM/TP/05.09.2014

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In Confidence


Minutes of the Nominations Committee

held on 27 August 2014

in the Seminar Room, University Hospital of North Tees Present: Paul Garvin, Chairman Pat Upton, Elected Governor for Stockton Professor Tom Lennard, Appointed Governor (Newcastle University) Maureen Rogers, Elected Governor for Hartlepool In attendance: Barbara Bright, Deputy Director of Human Resources / Company Secretary

Nickola Graham, Private Office Assistant/ PA to Barbara Bright The Chairman welcomed members to the meeting. 1. Apologies for Absence Apologies for absence were received from Rita Taylor Senior Independent Director; Pat Ferguson Staff Governor. 2. Minutes of the Last Meeting Resolved: that, the minutes of the last meeting were accepted as a true record. 3. Declaration of Interests Pat Upton elected governor for Stockton joined the Nomination Committee, following a review of the membership in early 2014. 4. Matters Arising The Chairman reported that Steve Hall had been re-appointed as Non-Executive Director 1 March 2014. Resolved: that, the information be noted. 5. Outcome of Non- Executive Director Appraisal The Chairman presented a paper on the outcome of the Non-Executive Directors’ appraisals for 2013/14 and explained that all Non-Executive Directors (Brian Dinsdale, Rita Taylor, Steve Hall, Ken Lupton and Michael Bretherick) had participated in an annual appraisal which included self-appraisal against the following criteria:

Strategy;

Performance (including financial);

Assurance/Risk management;

People;

Patient Safety and Quality;

External Links.

2

The Chairman reported that there were no significant, or critical development needs or skill shortages identified. A number of common objectives in addition to specific objectives had been set for the forthcoming year for each individual, and the Chairman confirmed that the Non-Executive Directors continued to make a major contribution to the work of the Trust and the Board.


6. B Dinsdale, Non-Executive Director Re-appointment Proposal

The Chairman presented a paper regarding the reappointment of Brian Dinsdale, Non-Executive Director and outlined the process for reappointment. Brian’s term of office, was due to expire on 30 November 2014. The Chairman reported that Brian’s appraisal demonstrated he had made an outstanding contribution to the work of the Trust; he fulfilled the term of independence of the NHS 2006 Act and Monitors Code of Governance; and had steered the Trust towards meeting its financial and performance targets which is attributable to the Trust meeting its year end position in line with Monitor’s Compliance Framework. This was evidenced when the Chief Operating Officer/Deputy Chief Executive confirmed at the Board of Directors’ meeting on 24 April 2014 that the Trust declared a Green risk rating for Governance and an overall financial risk rating of 4 in relation to the Risk Assessment Framework (RAF) monitoring for the financial year 1 April 2013 to 31 March 2014.

Resolved: that, the Committee agreed the re-appointment of B Dinsdale for a further 3 years, the proposal would be presented for approval at the Council of Governors meeting on 18 September 2014.

The Chairman left the meeting. 7. Outcome of Chairman’s Appraisal

Barbara Bright, Deputy Director of HR/Company Secretary presented a paper on the outcome of the Chairman’s appraisal for 2013/14. The DDoHR/CS outlined the process for the appraisal explaining that 43 questionnaires had been distributed to Board and Council of Governors members, with 29 being returned. The DDoHR/CS explained that the responses had been very positive overall, with last years’ comments being taken on board. The DDoHR/CS highlighted the areas below as objectives for the following year:

Review Board and Council of Governor reports/papers and the frequency of meetings;

Visibility of the Board to Ward to continue. There were no significant development needs or skill shortages identified.

Resolved: that, the report be noted. 8. Chairman and Non-Executive Director Remuneration Review Barbara Bright presented a paper regarding the annual review of remuneration for the Chairman and the Non-Executive Directors, highlighting that the bench mark was looked at locally due to no national comparable being available. However the Chairman had proposed that there should not be an increase in Non-Executive Director remuneration. In view of the progress made in respect of the New Hospital programme it was recognised that it was vitally important to maintain the Non-Executive Director team to effectively overview and

3

challenge delivery against the scheme and day to day Trust performance. In order to reflect this additional workload and to ensure continuity a retention scheme had been proposed. The DDoHR/CS proposed that the retention scheme should be based on 5% pa with effect from 2014/15 to be accumulated and paid 6 months after the successful delivery of the new hospital. It was also proposed that this would be subject to the individual’s satisfactory appraisals and to their remaining with the Trust for the full term. Funding for the scheme should be from the new hospital budget and therefore have no impact on day to day revenue. After an in depth debate it was agreed to support the proposal.

Resolved: that, the report proposal was agreed and supported 9. Any Other Business There was no other business reported. The meeting closed at 10.25am.


Minutes of the External Audit Working Group Meeting

14 July 2014

Seminar Room 4th Floor North wing

Present: Brian Dinsdale, Non-Executive Director / Vice Chairman (Chair) Lynne Hodgson, Director of Finance, Information & Technology

Barbara Bright, Deputy Director of HR/Company Secretary Wendy Gill, Elected Governor for Sedgefield Patricia Upton, Elected Governor for Stockton

Chris Clough, Elected Governor for Stockton Shirley Erskine Elected Governor for Stockton Pat Ferguson, Elected Staff Governor In attendance: Nickola Graham, PA to Barbara Bright/ Private Office Assistant

1. Welcome

BD opened the meeting by welcoming those in attendance and gave a brief explanation as to the purpose of the meeting in that the group were required to review options and put forward recommendations in respect to the appointment of the Trust’s external auditors.

2. Apologies for absence None reported

3. Minutes of the meeting held on 16 July 2010 The minutes of the meeting held on 16 July 2010 were discussed. The members of

the committee had changed since that meeting but it was felt they reflected the current position and previous decisions made to appoint the external auditors.

4. Matters arising There were no matters arising from the minutes.

5. Proposal to extend the appointment of the Trust’s external auditors LH advised that the external audit service was last tendered in 2010/11, with Price

Waterhouse Coopers (PWC) being awarded the contract. The contract was initially for 3 years, but permitted a two year extension of the arrangement, up until audit of the 2015/16 accounts had been completed. At that point, under the Monitor Audit Code, a full contract re-tender exercise will be required.

It was reported that the 3 year contract with PWC will be coming to an end during

2014/15 and LH outlined the options that are available to the Trust as follows:

Formally re-tender and market test audit services during 2014/15;

2

Extend the existing contract until completion of the 2014/15 financial year audits, 1 year extension;

Extend the existing contract until completion of the 2015/16 financial year audits, 2 year extension, with a formal re-tendering exercise undertaken in the final year.

It was reported that the Audit Committee have reviewed the performance of the incumbent external auditors on an on-going basis and would propose that the External Audit Working Group recommend to the Council of Governors that the contract is extended for a further period of 2 years.

The group considered the options put forward and discussions were held around the work of PWC; their performance in delivery of outcomes; their continued excellent working relationships with senior management; their relationship with internal audit and annual work plans; value for money and continuity of service.

The group after due consideration agreed to support and propose a 2 year extension to contract to the Council of Governors for approval at the next meeting scheduled for 18 September 2014.

6. Any other business

There was no any other business.

1


Minutes of the Membership Strategy Committee

Held on Monday 18 August 2014

University Hospital of North Tees Present: Wendy Gill, Elected Governor (Sedgefield) (WG) Chair

Janet Atkins, Elected Governor (Stockton) (JA) Carol Ellis, Elected Governor (Stockton) (CE) Mary Morgan, Elected Governor (Stockton) (MM) Mary King, Elected Governor (Easington) (MK) Pauline Robson, Elected Governor (Hartlepool)

Maureen Rogers, Elected Governor (Hartlepool) (MR) Barbara Bright, Deputy Director of HR/Company Secretary (BB)

Claire Young, Head of Communications (CY)

In Attendance: Janet Clarke, Private Office Support Secretary, Note Taker (JC) Samantha Sharp, PA to Chief Executive (SS)

1. Welcome WG welcomed members to the meeting.

2. Apologies for Absence

Apologies for absence were received from Ann Cains, Elected Governor

(Stockton), Roger Morrow, Elected Governor (Hartlepool) and Nina Bedding, Staff Governor

3. Minutes of the last meeting held Monday 09 June 2014

The minutes of the last meeting were confirmed as an accurate record.

4. Matters Arising Private Office BB reported that Claire Nixon had been seconded to cover the Private Office

Manager role until the return of Sarah Hutt which was expected to be in January 2015.

Displaying of Reports It was noted that in the last Membership Committee meeting figures highlighted in

blue were proving difficult to read. This had now been rectified with an additional block colour background, which the Governors agreed was easier to read.

It was noted that Capita had changed the line graph on the previous year’s report to only include details for the three months being reported for the current year, helping members to follow and read the graph with ease.

2

Governor Figures SS explained the discrepancy in Governor figures for the Norton West catchment area raised at the last meeting which was due to Margaret Docherty not being recorded as a Governor on her personal data page. All Governor details had been checked and SS confirmed that records were now correct.

Recruitment of Members JC had received dates for when the National Blood Transfusion Service held their clinics in the area. It was anticipated that the Trust could recruitment members at these clinics and JC was awaiting confirmation that this was acceptable.

Membership Recruitment (5.1, 5.3, 5.4 and 5.5) BB confirmed that Hartlepool College of Further Education was holding an Open Day on Wednesday, 10 September 2014. It was suggested that members of the Membership Committee hold a membership stand at the event with the aim of recruiting younger members. Members of the event agreed and offered their availability for this event. It was also noted that East Durham College were holding a Fresher’s Fayre at their Peterlee campus on Monday, 8 September 2014 and again, Governors agreed to hold a stand. CY reported Health Trainers from the Trust had attended a health and wellbeing event on 23 June 2014; unfortunately no new members had been recruited.

CY reported that the Hartlepool Mayors fun day was to be held on Saturday, 23 August 2014 and that the Trust’s Health Trainers would be attending the event and it was hoped that they would recruit new members for the Trust. MR reported that no town centre events were scheduled to be held in the near future. BB suggested getting in touch with the Town Council for forthcoming events. Due to Ann Cains not being present at this meeting, it was suggested that recruitment of members at residential coffee mornings be discussed at the next Membership Committee meeting.

Simon Stevens’ Announcement (5.2) It was noted that a further announcement from Simon Stevens, Chief Executive, NHS England relating to small and community hospitals had been circulated.

5. Membership Statistics

5.1 Membership Breakdown Report & Comparison

BB gave an overview of the report which showed a decrease in public members of 13. The main reduction was seen in males aged between 70 and 79 years. BB reported an increase in staff members of 64 which was largely due to the intake of new Junior Doctors in August, the recruitment to nursing vacancies and an increase in fixed term contracts within the Trust. Following a members’ query regarding the socio economic grade highlighted on reports, BB agreed to send information on this to Committee members.

Action:

3

BB to send socio economic information to members of the Committee.

5.2 Eligibility Report & Comparison

BB gave an overview of the report which provided a breakdown of members and Governors in each catchment area. Following a query from a member, BB explained that staff appointed Governors were included in the Governor report. BB reported that there had been a slight decrease in members from Easington, with a slight increase in members from Stockton and Hartlepool. It was previously agreed at the last Membership Committee in June, that future reports would highlight public membership including non-core public members and public membership, not including non-core public members. JC was waiting for Capita to confirm that this was possible.

Action:

JC to contact Capita.

5.3 Membership Representation Dashboard Reports

BB gave an overview of the membership presentation dashboard reports. It was reported that 26 members had joined, 11 of these had been online recruitments.

5.4 Membership Recruitment by Age Report (March to June)

BB gave an overview of the membership recruitment by age report. It was reported that between April 2013 and March 2014, 379 new members had been recruited. The overall membership target was being maintained.

BB suggested contacting Supermarkets to see if it was possible to hold membership stalls to recruit members.

Action:

CY to speak with Ann Burrell regarding contacts to approach Supermarkets.

6. Membership Recruitment

6.1 Membership Data and Recruitment to 7 August 2014

BB gave an overview of the report which provided an update on new members. BB reported that the current public membership was 6,130, which included 198 non-core public members (those members out of the catchment areas). There were 5,545 staff members. It was reported that in total 12 members were recruited between June and August 2014, 6 being recruited at a member event on Saturday, 19 July 2014. BB explained that it was the Trust’s aim to maintain membership numbers.

6.2 Peterlee Show

At the last Membership Strategy Meeting held in June there were discussions to hold a membership stand at the Peterlee Show, however, it was agreed that this was to prove too costly on this occasion.

7. Feedback from Member Event – 26 April 2014

CY provided an overview of the Member Event held on Saturday, 19 July 2014, which focused on Gynaecology Services and Chemotherapy Services. CY

4

reported that the event had been well attended and feedback had been positive with many members impressed with the presentations.

CY had reported that some members had once again commented on the use of microphones especially for quiet speakers. BB confirmed that IT was looking into the possibility of a portable PA system.

BB confirmed that the next event was scheduled to take place on Saturday, 18 October 2014 at the University Hospital of North Tees.

8. Any Other Business

New Trust Website

The HoC reported that the new Trust website had gone live earlier that morning.

9. Date and Time of the Next Meeting

The next meeting was scheduled to take place on Monday, 24 November 2014 at 11:00am, in the Board Room, University Hospital of Hartlepool.



18 September 2014

Report of the Deputy Director of Human Resources/Company Secretary

Non-Executive Director Re-appointment Strategic Aim (The full set of Trust Aims can be found at the beginning of the Council of Governors Reports) Maintain Compliance and Performance Strategic Objective (The full set of Trust Objectives can be found at the beginning of the Council of Governors Reports) Maintain Compliance and Performance 1. Introduction The purpose of this report is to provide evidence in support of the re-appointment of Brian Dinsdale, Non-Executive Director whose term of office is due to end on 30 November 2014. The proposed re-appointment is in line with the process for Chair/Non-executive Director Recruitment/Re-appointment that was approved in February 2009 by the Nominations Committee. 2. Background The Nominations Committee is a sub-committee of the Council of Governors which can agree in principle and make recommendations to the Council of Governors on whether appointments should be advertised or whether existing Chair/Non-executive Directors should be considered for further terms of office (subject to legislative requirements of the NHS 2006 Act, the Trust’s Constitution, satisfactory appraisal and Monitor’s Code of Governance). The Nominations Committee at its meeting on 18 February 2009 agreed a systematic approach to appointments and re-appointments for the Chair/Non-executive Directors. Legislative requirements of NHS Foundation Trusts state that terms of office can be offered for a maximum of 3 years followed by two periods of re-appointment to a maximum of 9 years. Thereafter appointments are required to be considered annually in line with legislative and governance best practice guidelines. 3. Re-appointments Chairs and Non-executives are eligible to be considered for uncontested re-appointment, provided they have a record of consistently good performance. However, there is no automatic right to be re-appointed. All candidates wishing to be considered for re-appointment after a first term should advise the Nominations Committee (through the Company Secretary) that this is the case.

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Confirmation was received from Brian Dinsdale that he wished to be considered for re-appointment from 1 December 2014. 4. Process The Nominations Committee will make a recommendation to the Council of Governors on whether a candidate should be considered for a further term based on the following:

A recommendation by the Trust Chairman;

Non-executive Director’s performance appraisal;

Confirmation that they fulfil the term of independence of the NHS 2006 Act and Monitors Code of Governance;

The organisation’s performance as measured externally. 4.1 The Chairman advised the Nominations Committee that Brian Dinsdale should be considered

for a further term of office on the following grounds: 4.1.1 That his appraisal demonstrated he has continued to make a considerable contribution to

the work of the Trust, the Board of Directors and Council of Governors to help drive the Trust forward and hold the Executive Directors to account for Trust performance and delivery against the strategy;

4.1.2 His contribution to the Trust has assisted meeting all of the financial risk rating targets and

all of the governance risk rating targets for the financial year ending 31 March 2014. This was evidenced when the Chief Operating Officer/Deputy Chief Executive confirmed at the Board of Directors’ meeting on 24 April 2014 that the Trust declared a Green risk rating for Governance and an overall financial risk rating of 4 in relation to the Risk Assessment Framework (RAF) monitoring for the financial year 1 April 2013 to 31 March 2014;

4.1.3 The Trust has achieved excellent performance over the last financial year which is

evidenced in the Annual Report which was submitted to Parliament and Monitor in June 2014;

4.1.4 Brian brings a plethora of experience and understanding of the strategic, finance and audit

agendas of the Trust, chairing the Finance Committee, Audit Committee, Investment Committee, Charitable Funds Committee and the External Audit Working Group.

5. Recommendation The Nominations Committee recommend that the Council of Governors approve a further term of office for Brian Dinsdale, Non-executive Director, with effect from 1 December 2014. Barbara Bright Deputy Director of Human Resources/Company Secretary 9 September 2014

Council of Governors Meeting - North Tees and Hartlepool ... · e presented at a future Council of...

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