INTEGRATED PERFORMANCE REPORT Report... · INTEGRATED PERFORMANCE REPORT ... within 31 days of...

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North Bristol NHS Trust

INTEGRATED PERFORMANCE REPORT

February 2018 (presenting January 2018 data)

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CONTENTS

CQC Domain / Report Section Sponsor / s Page

Number

Performance Dashboard and Summaries

Director of Operations

5 Medical Director

Director of Nursing

Director of People and Transformation

Responsiveness Director of Operations 11

Safety and Effectiveness

Medical Director 25

Director of Nursing

Quality Experience Director of Nursing 39

Facilities Director of Facilities 45

Well Led

Director of People and Transformation 47

Medical Director

Finance Director of Finance 57

Regulatory View Chief Executive 62

3 3 Report Key

Target lines

Improvement trajectories

Performance improved

Performance maintained

Performance worsened

54

6

Unless noted on each graph, all data shown is for period up to,

and including, 31 January 2018.

All data included is correct at the time of publication.

Please note that subsequent validation by clinical teams can alter

scores retrospectively.

Abbreviation Glossary

ASCR Anaesthetics, Surgery, Critical Care and Renal

CCS Core Clinical Services

CEO Chief Executive

Clin Gov

GRR

Clinical Governance

Governance Risk Rating

HoN Head of Nursing

IM&T Information Management

Med Medicine

NMSK Neurosciences and Musculoskeletal

Non-Cons Non-Consultant

Ops Operations

RAP Remedial Action Plan

RCA Root Cause Analysis

WCH Women and Children's Health

NBT Quality Priorities 2017/18 QP1 Improving theatre safety

QP2 Reducing harm from pressure injury

QP3 Reduction of infections arising from indwelling

devices

QP4 Learning from deaths in hospital and improving

end of life care

QP5 Improving the care of patients whose condition

is at risk of deteriorating

QP6 Enhancing the way patient feedback is used to

influence care and service development

4 4 EXECUTIVE SUMMARY

January 2018

ACCESS

January’s position against the 4 hour standard was 75.11%, which although below trajectory, is an improved performance compared to December 2017

(70.26%). The majority of breach reasons were attributable to a wait for beds, with admissions higher than expected, not matched by discharge volumes. The

Trust continues to implement its emergency care improvement plan with a focus on reducing stranded patients and supporting the principle of ‘Home is Best’.

The Trust has not met the agreed recovery trajectory for Referral To Treatment (RTT) incomplete performance for January (86.30% vs trajectory of

87.77%). The waiting list backlog stands at 3758 vs a target of 3428. The Trust has experienced a decrease in patients waiting greater than 52 weeks from

Referral to Treatment (RTT) (55 in January vs 59 in December).

The Trust has achieved the national target (1.00%) for diagnostic performance with actual performance of 0.62% in January. This improvement from the

December position (2.06%) brings the Trust to the best reported performance since October 2015 and is reflective of the successful delivery of the DEXA Scan

remedial action plan.

The Trust has delivered 4 of the 7 national cancer targets in December. The 62 day standard was exceeded in December with performance at 85.71%

vs the 85.00% standard. Two Week Wait has achieved standard with performance of 94.50% confirming the successful delivery of the remedial action plan

and subsequent closure of the Contract Performance Notice.

SAFETY

Nursing staff levels continue to be monitored closely, but two wards triggered the Quality Effectiveness and Safety Trigger Tool (QuESTT) in January.

Recruitment to vacancies in these areas are underway and unfilled shifts are closely monitored to ensure safety is maintained.

Incidence of pressure ulcers in January were 15 reported Grade 2 pressure injuries, 4 reported Grade 3 and nil reported at Grade 4. The Trust remains

on target to achieve a 50% reduction of pressure injuries over the three year period, April 2015 - March 2018.

The Trust reported 1 Case of MRSA in January. This was a complex case colonised prior to admission. The Trust reported 2 cases of C. Difficile in

January.

PATIENT EXPERIENCE

The number of overdue complaints has risen in January to 39 from 27 in December. Friends and Family response rates have seen an increase in three

of the four areas with a decrease reported in inpatient response rates. NHS Choices ratings for both Southmead Hospital and Cossham Hospital are

both 4.5 stars.

WORKFORCE

The Trust vacancy factor increased from 6.8% in December to 7.00% in January. Agency expenditure increased in January to £700k and is above

NHSI target levels (£469k). The in-month sickness rate in December was 4.25%, remaining stable from November and remaining above the 4.05% target

submitted to NHSI for the month.

FINANCE

The Trust has planned a deficit of £18.7m for the year in line with the agreed control total with NHS Improvement. The financial position for the end of

January is £4.2m adverse to plan. The Trust is currently rated 3 by NHSI.

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Target

92% 86.30% 87.77% 6 87.10% (Q2 2017/18) - 87.68% (Q3 2017/18) 53758 3428 6 3719 (Q2 2017/18) - 3461 (Q3 2017/18) 5

90% 75.11% 5 76.28% (Q2 2017/18) - 77.32% (Q3 2017/18) 512 Hour Trolley Waits 0 107 5 3 (Q2 2017/18) - 47 (Q3 2017/18) 6

Neurosurgery and Epilepsy 0 5 0 5 5 (Q2 2017/18) - 2 (Q3 2017/18) 5MSK 0 32 15 5Ortho-Spinal 0 8 0 4Other 0 10 N/A* 5 66 (Q2 2017/18) - 13 (Q3 2017/18) 5

1% 0.62% N/A* 5 4.83% (Q2 2017/18) - 2.38% (Q3 2017/18) 5Same day - non-clinical reasons 0.8% 1.73% 6 1.45% (Q2 2017/18) - 1.97% (Q3 2017/18) 628 day re-booking breach 0 12 6 6 3 (Q2 2017/18) - 5 (Q3 2017/18) 6

95% 101.52% 6 98.85% (Q2 2017/18) - 98.66% (Q3 2017/18) 56910 6 6816 (Q2 2017/18) - 6971 (Q3 2017/18) 6

2.50% 5.04% 6 4.86% (Q2 2017/18) - 4.04% (Q3 2017/18) 593% 94.50% 6 91.52% (Q2 2017/18) - 94.64% (Q3 2017/18) 593% 93.15% 6 94.95% (Q2 2017/18) - 96.90% (Q3 2017/18) 596% 96.12% 6 97.72% (Q2 2017/18) - 97.18% (Q3 2017/18) 694% 87.18% 5 95.92% (Q2 2017/18) - 85.67% (Q3 2017/18) 698% 100.00% 4 100.00% (Q2 2017/18) - 100.00% (Q3 2017/18) 485% 85.71% 86.60% 6 90.18% (Q2 2017/18) - 87.00% (Q3 2017/18) 690% 86.96% 5 97.14% (Q2 2017/18) - 88.17% (Q3 2017/18) 6

0 0 4 1 (Q2 2017/18) - 1 (Q3 2017/18) 497.34% 6 97.71% (Q2 2017/18) - 98.04% (Q3 2017/18) 5

95% 97.20% 5 95.83% (Q2 2017/18) - 95.70% (Q3 2017/18) 695% 94.00% 6 97.67% (Q2 2017/18) - 96.37% (Q3 2017/18) 6

Grade 2 QP2218

2017/1815 6 39 (Q2 2017/18) - 39 (Q3 2017/18) 4

Grade 3 QP20

2017/184 6 2 (Q2 2017/18) - 1 (Q3 2017/18) 5

Grade 4 QP20

2017/180 4 0 (Q2 2017/18) - 0 (Q3 2017/18) 4

0 1 6 1.21 (Q1 2017/18) - 1.83 (Q2 2017/18) 660

2017/186 6 22 (Q2 2017/18) - 41 (Q3 2017/18) 6

432017/18

2 5 10.92 (Q1 2017/18) - 11.00 (Q2 2017/18) 619

2017/183 6 7.28 (Q1 2017/18) - 9.17 (Q2 2017/18) 6

95% 95.30% 5 95.40% (Q2 2017/18) - 95.19% (Q3 2017/18) 6Emergency Department QP6 88.42% 5 84.49% (Q2 2017/18) - 87.08% (Q3 2017/18) 5Inpatient QP6 92.62% 5 91.62% (Q2 2017/18) - 90.88% (Q3 2017/18) 6Outpatient QP6 93.78% 6 93.38% (Q2 2017/18) - 93.81% (Q3 2017/18) 5Maternity (Birth) QP6 95.12% 5 92.81% (Q2 2017/18) - 90.44% (Q3 2017/18) 6% Overall Response Compliance 100.00% 5 65.30% (Q2 2017/18) - 74.18% (Q3 2017/18) 5Complaints acknowledged in <3 days 95% 70.00% 6Overdue <10 39 6 26 (Q2 2017/18) - 29 (Q3 2017/18) 6

£469 £700 6 £507 (Q2 2017/18) - £469 (Q3 2017/18) 53.80% 7.00% 6 8.20% (Q2 2017/18) - 6.50% (Q3 2017/18) 51.10% 1.20% 5 1.50% (Q2 2017/18) - 1.40% (Q3 2017/18) 54.05% 4.25% 4 4.07% (Q1 2017/18) - 4.37% (Q2 2017/18) 6

85.00% 84.48% 5 82.27% (Q2 2017/18) - 85.06% (Q3 2017/18) 590%

Nov. 201766.43% 6 46.86% (Q2 2017/18) - 66.03% (Q3 2017/18) 5

£18.7m2017/18 6

5

Description

C. Difficile

Bed Occupancy

Patients seen within 2 weeks of urgent GP referral

Patients with breast symptoms seen by specialist within 2 weeks

Trust Wide Referral to Treatment Backlog

Diagnostic DM01 - % waiting more than 6 weeks

Patients receiving first treatment within 31 days of cancer diagnosis

Patients waiting less than 31 days for subsequent surgery

E. Coli

Access Standard

Re

spo

nsi

ven

ess

- C

ance

r (I

n a

rre

ars)

Cancelled Operations

ED 4 Hour Performance

Stranded Patients (LoS >7 days)

Delayed Transfers of Care (DToC)

Patients waiting less than 31 days for subsequent drug treatment

Patients receiving first treatment within 62 days of urgent GP referral

Patients treated within 62 days of screening

We

ll L

ed In Month Turnover

In Month Sickness Absence (In arrears)

Trust Mandatory Training Compliance

Non - Medical Annual Appraisal Compliance

Agency Expenditure ('000s)

Month End Vacancy Factor

Fin

ance Deficit (£m)

NHSI Trust Rating

Qu

alit

y P

atie

nt

Safe

ty a

nd

Eff

ect

ive

ne

ssQ

ual

ity

Exp

eri

en

ce

Pressure Injuries

FFT - % Would

recommend

Complaints

MSSA

Venous Thromboembolism Screening (In arrears)

Never Event Occurrence by Month

Safety Thermometer - Hospital Compliance

WHO Checklist Compliance QP1

Hand Hygiene Compliance

MRSA

Quarterly

performance

direction of travel

Re

sp

on

siv

en

es

s

Referral to Treatment - % incomplete pathways <18 weeks

Referral to Treatment

52 Week Waits

IPR

section

January 2018

Key Operational Standards Dashboard

Performance against

Target

Performance against

NBT Trajectory

Performance

direction of travel

from last month

Quarterly Performance

6 6 RESPONSIVENESS

SRO: Director of Operations

Overview Urgent Care

January’s position against the 4 hour standard was 75.11%, which although below trajectory, is an improvement to the reported performance of December

2017 (70.26%). The performance was directly attributable to the increase in emergency admissions experienced during the month with an inability to

discharge patients at the level required to meet the periods of surge. Occupancy therefore remained a significant impairment to supporting timely flow

through the hospital and resulted in a significant number of patients waiting over four hours for transfer into the admission unit. An emergency care

improvement plan is being revisited by the Trust and the System, focusing on reducing stranded patients through addressing unnecessary delays in a

patient’s pathway and also supporting the principle of ‘Home is Best’. This plan is expected to result in more effective flow through the hospital to support

sustained improvement against this target by Quarter 1 2018/19.

Referral to Treatment (RTT)

In month, the Trust has not achieved the Trust RTT trajectory of 87.77%, with actual performance at 86.30% which was impacted by the National directive

to cancel non-urgent operations as part of the winter resilience planning. The number of patients exceeding 52 week waits in January were 55 (the

majority of which (32) were due to capacity issues within MSK). The Trust is delivering against a remedial action plan specifically focusing on the

challenged sub-specialties within MSK.

Cancelled Operations

In month, there were twelve breaches of the 28 day re-booking target. Ten of these breaches were patients who were cancelled during December and

unable to be rebooked within 28-days.

Diagnostic Waiting Times

The Trust has achieved the 1.00% target for diagnostic performance for the first time this year in January with actual performance at 0.62%. This

improvement is the Trust’s best reported level since October 2015 and is reflective of the successful delivery of the DEXA Scan remedial action plan.

Cancer

Cancer performance in December has achieved four of the seven standards. The Trust has met and exceeded the 62 day standard at 85.71% (Target

85.00%). Two Week Wait urgent GP referrals standard has been met at 94.50%, Commissioners have closed the Contract Performance Notice in relation

to this standard. Two Week Wait Breast has exceeded standard in December with performance of 93.15%. The three standards that have missed the

national targets in December 2017 are: 31 days from diagnosis to first treatment; 31 day subsequent treatment (Surgery); and 62 day screening.

Areas of Concern

The system continues to monitor the effectiveness of all actions being undertaken, with daily and weekly reviews. The main risks identified to the Urgent

Care Recovery Plan (UCRP) are as follows:

• UCRP Risk: Lack of community capacity and/or pathway delays fail to meet bed savings plans as per the bed model.

• UCRP Risk: Length of Stay reductions and bed occupancy targets in the bed model are not met leading to performance issues.

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QUALITY PATIENT SAFETY AND EFFECTIVENESS

SRO: Medical Director and Director of Nursing

Overview

Improvements

The positive increase in incident reporting following the implementation of Datix is continuing with a decrease in serious incidents and an increase in

incidents resulting in minor or no harm.

Areas of Concern

There was an increase in hospital acquired pressure ulcers in January with an increase in grade 2 pressure ulcers and four grade 3 pressure ulcers

affecting three patients. This has reduced the harm free care rating for the trust.

Hand hygiene has fallen below the Trust standard (94% vs 95% requirement) for the first time in a year which may reflect the pressures on ward care during

January.

8 8 QUALITY EXPERIENCE

SRO: Director of Nursing

Overview

Improvements and Actions:

Overdue complaints remain of concern, work continues to bring the residual number overdue to ten or less. Additional resource is in place to support ASCR

and to address areas with high volumes of patients to ensure complaint responses are more timely. There is a new Director of Midwifery in post who is

already addressing their overdue complaints and working on a patient experience improvement plan.

A programme of work is underway to address poor performance in percentage that recommend. Our strategic aim is to achieve 95% would recommend and

some improvement is noted already for January’s data.

9 9 WELL LED

SRO: Director of People and Transformation

Overview Resourcing

Nurse / HCA Recruitment

Work continues between NBT and Cohesion on a proactive recruitment campaign for HCA and nurse vacancies. Since the start of the campaign the Trust

has offered and had accepted 193 HCA candidates’ and 26 registered nurse candidates.

Our prioritised activity is now focused on Band 5 experienced qualified nurses in terms of both recruitment and retention.

Sickness

Short term sickness due to “Anxiety/stress/depression/other psychiatric reason” saw a 24% reduction in reason for absence. It remains the top reason for

long term sickness with a slight increase in December. Our staff health and well being initiatives are in place to specifically support management of anxiety

and stress.

Agency Spend

Month three of the neutral vendor contract to supply nursing agency staff remains challenging and this remains under review to identify changes to improve

performance. The bank team continue to work closely with DePoel (neutral vendor) and have met with suppliers to work together to improve the fill rates.

Trends

Trust compliance in mandatory and statutory training remains on target during the period of postponed face to face training to support winter pressures.

In month turnover decreased in January 2018 compared with December, however the rolling 12 month position increased with the Trust seeing an increase in

voluntary turnover from 12.5% to 12.74%.

Areas of Concern

Worked WTE and pay expenditure increased in January. The largest increase was in bank usage which increased by 16.7% in terms of worked WTE and

14.3% in terms of expenditure. The biggest increase was in Medicine with an additional 50 WTE used in January. This represents over half of the Trust’s

increase for December. The additional usage is linked to the escalation areas currently open within Medicine. Our experienced Band 5 nurse workforce is an

area of concern.

10 10 FINANCE

SRO: Director of Finance

Overview

The Trust has a planned deficit of £18.7m for the year in line with the control total agreed with NHS Improvement.

• At the end of January, the Trust is reporting a deficit of £21.1m compared with a planned deficit of £16.9m, £4.2m adverse to plan.

• The adverse variance is wholly driven by loss of Sustainability and Transformation Funding (STF) of £2.7m related to non-delivery of A&E performance

trajectories. This does not preclude the Trust from receiving the element of STF dependent on financial performance as NHS Improvement measure

delivery of control total on the position excluding STF. However, this month the pre-STF position has deteriorated to £1.4m adverse to plan. The control

total excluding STF needs to be achieved.

• Non-pay (excluding finance costs) was £2.1m favourable, whilst pay is £5.5m adverse to plan and income excluding donations is £0.1m adverse to

plan..

• Savings delivery was £6m less than required in the year to date. The planned increase in savings each month has now been achieved but needs to be

sustained.

• The main areas of concern relates to the level of elective activity income against planned levels as well as savings delivery which is behind plan. This

is despite the fact that the overall financial plan profile reflected a savings profile that is lower in the first half of the year.

• The Trust has ended the month with £12.8m cash after receipt of £2.8m loan financing from the Department of Health to support the ongoing deficit.

• Capital expenditure was £10.4m for the year to date against a plan of £13.3m.

• The Trust is rated 3 by NHS Improvement (NHSI).

Key areas of concern:

• Continued focus on delivering the full savings required as well as full delivery of planned activity and income for the remainder of the year will be

crucial to ensure delivery of the Trust’s control total. Ongoing operational pressures continue to challenge the delivery of financial targets.

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RESPONSIVENESS

Board Sponsor: Director of Operations

Kate Hannam

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Responsiveness - Board Sponsor: Director of Operations

Overview of Urgent Care

Although overall ED attendances in

January were in line with the previous

three months, acuity remained high with

majors patients equating to 60% of all

ED attendances vs. an average of 54%

year to date.

Admissions for Medicine were higher

than predicted in January which

resulted in occupancy levels at above

100% for the majority of the month.

The inability to match discharges to the

surges in flow resulted in 25% of

patients waiting more than four hours in

ED and the challenges for timely

transfer from the ED to the wards

continued to be a major contributor to

the reasons patients were waiting in

excess of the four hours.

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Majors / Minors

The number of minors patients

treated within the four hour target in

January returned to above 95% at

97.09%, despite the overall pressure

on the department.

Majors performance for January was

61.14% and was directly attributable

to the surges in demand and the

inability to pull patients out of the

department in a timely way.

4 Hour Breaches

The primary cause of delays

continues to be waiting for transfer to

the admission unit. This is directly

linked to the lack of flexibility to meet

surges in demand due to operating at

100%+ occupancy within the main

admission wards.

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12 Hour Trolley Waits

There were 107, 12 hour trolley

breaches in January. All breaches

have had the initial 24hr clinical

review with a follow up review at two

weeks to establish the harm levels.

The Trust’s governance process will

report on any findings. One of the

breaches in month was associated

with a wait for a specialist mental

health bed.

Ambulance Handovers

Ambulance attendances at NBT are

up 6.67% year to date when

compared to 2016/17. In month

surges in attendances has resulted in

delays against the 15 minute

handover target. There were no 60

minute breaches in month despite on-

going winter pressures.

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Attendances and Admissions

Attendances and admissions into the

Trust continue to rise when

compared to previous years. ED had

an additional 10 attendances per

day in January 2018 compared with

numbers seen in January 2017. In

spite of this, the conversion rate has

fallen in January in comparison to

last winter.

Monthly emergency admissions

remain above 2016/17 levels.

The number of patients who are

managed within our short stay

medical and surgical admission units

continues to meet National best

practice for the number of patients

treated in less than 48 hours.

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Occupancy, DToCs and North

Bristol Operational Standards

High occupancy levels (102.04%) in

the Trust remains the prime reason

for ineffective flow through the

hospital and remains the main area

targeted for improvements - both

from an internal and a system

perspective.

The number of patients recorded as

formal delays (DToCs) remains

above target levels (5.04%) with

particular pressure experienced for

Bristol patients.

Extra capacity in terms of D2A

pathway two beds and pathway one

support at home is planned for

February, but demand continues to

outstrip supply and further work is

needed across BNSSG to mitigate

against this position.

Opportunities to reduce internal

delays and therefore bed days (up to

2000 bed days Trust wide) are the

focus of patient flow improvement

plans.

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Referral to Treatment (RTT)

The Trust has failed to achieve the

RTT trajectory in month with

performance of 86.30% against

trajectory of 87.77%. The Trust did not

meet the RTT backlog trajectory,

reporting 3758 against trajectory of

3428.

Remedial action plans are in place for

Divisions where performance is an

issue - of particular concern is

Respiratory Medicine where

performance has not been delivered

at trajectory level since April 2017,

this is due to an ongoing demand and

capacity imbalance.

Plastic Surgery has failed to deliver

the national standard of 92% with

January performance of 87.09%. This

is mainly due to underperformance at

a sub-specialty level in Breast and

Hands resulting from staffing issues.

Return to standard in March 2018 is

now at risk, as it is dependent on

these staffing issues being resolved.

Urology has also failed to deliver the

national standard in January with

performance of 89.92%. This is the

first time in 2017/18 that the standard

has not been met. Reasons for

underperformance are multifactorial,

but in the main relate to the impact of

staff shortages, which are being

addressed. A return to standard is

anticipated in June 2018.

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Cancellations

The same day non-clinical cancellation

rate in January was 1.73% against the

national target of 0.8%. This is a 1.3%

improvement in the rate of

cancellations when compared to

December 2017, 2.79%.

There were twelve operations that

could not be rebooked within 28 days of

cancellation in January 2018. RCAs

have been completed for each of these

cases to understand the reasoning and

to ensure that there was no patient

harm. Patients were unable to be

rebooked within 28 days mostly due to

winter pressures and cancellation of all

non-urgent elective work throughout

January.

In month there were two urgent

operations cancelled for a subsequent

time. These were due to theatre list

overrun owing to a complex case and

incorrect anaesthesia requested at the

time of booking. RCAs are being

completed for these breaches.

The Theatres Board is overseeing the

monthly performance for the Trust

cancelled operations with an aim to

further reduce cancellations and is also

overseeing a delivery plan to improve

theatres productivity and to introduce

changes to scheduling.

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Referral to Treatment 52 Week

Waits

The Trust has reported a total of 55

breaches in January 2018. These

patients were within the following

specialties:

2 Neurosurgery;

3 Epilepsy;

8 Orthopaedic Spinal;

32 MSK;

10 Others, which include a small

number of patient choice (4).

Root Cause Analyses (RCAs) have

been completed for all patients, with

dates for patients’ operations being

agreed at the earliest opportunity and

in line with the patient’s choice.

A remedial action plan is in place for

MSK 52 week wait performance and

an improvement in performance has

been noted with a trajectory for

clearance at the end of Quarter 4.

The Trust has classed patient choice

as any patient choosing to wait

beyond 52 weeks when two

reasonable offers with three weeks

advance notice have been made prior

to week 28 in their pathway The

patient will have been clinically

reviewed as per best practice

guidance that the most appropriate

course of action is for them to

continue to wait as per their choice.

N.B. MSK 52ww performance is managed against the RAP agreed with the CCG

N.B. Epilepsy and Neurosurgery 52ww performance is managed against the RAP agreed with NHSE Specialised Commissioning

20


Diagnostic Waiting Times

The Trust has achieved the 1.00%

target for diagnostic performance in

January with actual performance at

0.62%, a 1.44% improvement to

December’s reported position of

2.06%. This improvement in

performance brings the Trust to the

best reported diagnostic performance

level since October 2015.

Endoscopy diagnostic tests continue to

be delivered in line with the recovery

trajectory. DEXA has achieved the six

week standard sooner than anticipated

with performance reported at 0.75%.

Plans remain in place to ensure this

improvement is continued in to the next

financial year.

There is an in month

underperformance in Colonoscopy and

Urodynamics.

Although the largest underperforming

diagnostic test type, Urodynamics is

also the most improved in month. At

4.03%, Urodynamics has improved

1.71% from the December reported

position of 5.74%.

The largest number of breaches was

reported for non-obstetric ultrasound

(20), which is 16 breaches under the

36 breach tolerance threshold for that

test type.

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Clinic Letter Typing

Four of the five Clinical Divisions’

average typing turnaround time

continues to report within the

contractual obligation of ten days.

ASCR have had an average increase

of eight working days to their typing

turnaround time. Taking an average of

89 days, Urology has the longest typing

turnaround time of the four

underperforming ASCR specialties.

The outsourcing of typing pilot has

commenced in General Surgery and

Urology has secured additional staffing.

Both of these actions should ensure

backlog clearance by the end of March

2018.

Medicine have the largest improvement

in month with a further two day

reduction in turnaround time from the

eight days reported in December.

Discharge Summaries

In January, 78.20% of discharge

summaries were available on ICE

within 24 hours.

January’s performance is a 2.30%

decrease to December’s reported

position of 80.50%, although year to

date performance remains improved

from 2016/17 at an average of 7.09%

more discharge summaries available

on ICE within 24 hours.

*Where data is unavailable, an average of the previous fortnight’s performance is calculated for chart purposes.

22 22

Cancer

The Cancer Waiting Times

Performance for December 2017

shows that the Trust achieved five of

the seven national standards.

The Trust continued to pass the TWW

standard with a performance of

94.50%.The Trust received 1,601

TWW referrals in December and there

were 84 breaches. The three

specialities with the highest number of

breaches were in ASCR. There were

18 Colorectal breaches, 29 in Breast

and 13 in Skin. All breaches were

either a result of capacity issues or

patients being unable to attend the

appointments offered.

The Trust has continued performance

against the Breast Non-Symptomatic

TWW standard with a performance of

93.15% against the 93% target. There

were five breaches against this

standard; Three due to capacity

issues and two due to patients not

being available to attend the

appointment offered.

The Trust continues to pass the 31

day first treatment standard with a

performance of 96.12% against the

96% target. There were nine breaches

against this standard, all in Urology.

Of these nine breaches; seven were

due to insufficient elective capacity,

one was a medical delay and one was

cancelled on the day due to consultant

sickness. All capacity related

breaches were patients who required

robotic surgery.

Responsiveness - Cancer - Board Sponsor: Director of Operations

23 23 Cancer

The Trust passed the 62 day national

standard for December 2017 with a

performance of 87.00% against target

of 85%. The Trust is now being

measured against the new national

breach reallocation policy; However

official monitoring of this will not

commence until April 2018. The Trust

reported a performance of 85.71%

against the new rules.

The Trust continues to meet the 62

There were 27 patients that breached

in November, 16 of which started their

pathway at NBT. Of these 16 patients,

15 had their first appointment at NBT

after day seven.

Delays in radiology contributed to four

of these breaches and delays in

pathology contributed to four others.

Eight Urology patients were

transferred in to the Trust from other

providers for treatment in November

beyond day 38 of their pathway. The

Urology department managed to treat

one of these patients within 24 days of

transfer, enabling the Trust to

reallocate a half breach back to the

referring providers. Capacity issues in

Oncology and Theatres continue to

limit the ability to treat these patients

within 24 days of referral.

The Trust transferred six patients to

treating providers later than day 38

which created the negative impact on

performance when applying the new

guidance for December.

NB: The charts show the breakdown of breach reasons for both

whole and shared 62 day breaches for the month. Breakdown of

breach reason may not match total published performance due to

time of which data was captured. Data is extracted from a live

system.


December

Brain 0.5 0.5 0 100.00%

Breast 17.5 17.5 0 100.00%

Colorectal 9 8 1 88.88%

CUP 0 0 0 0.00%

Gynaecology 2.5 1.5 1 60.00%

Haematology 6 6 0 100.00%

Head and Neck 0 0 0 0.00%

Lung 7 4.5 2.5 64.27%

Sarcoma 1 1 0 100.00%

Skin 33 31.5 1.5 95.45%

Upper GI 1.5 1.5 0 100.00%

Urology 51.5 39 12.5 75.73%

Total 129.5 111 18.5 85.71%

New National

Policy Applied

62 Day (Urgent GP) - Target 85 %

Total

treated

Total

treated in

target

Breaches% meeting

target

24 24

Cancer

The Trust failed the 31 day

subsequent treatment target in

December 2017 for patients requiring

surgery with a performance of

87.18% against the 94% standard.

This is an improvement on November

2017.

Of the ten breaches, one was in

Sarcoma, two were in Urology and

seven were in Skin. All ten breaches

were due to capacity in theatres.

The Trust also failed the 62 day

screening target with a performance

of 86.96% against the target of 90%.

There were three breaches in total, all

in Breast. Of the three breaches; two

were due to medically appropriate

delay and one was patient initiated

delay due to being on holiday.

The Trust passed the 31 day

subsequent treatment for patients

receiving anti-cancer drugs with a

performance of 100%.

The Trust also passed the 62 day

consultant upgrade target with a

performance of 90.70%, however this

standard is only monitored internally

and not nationally reported.


25 25

Safety and Effectiveness

Board Sponsors: Medical Director and Director of Nursing

Chris Burton and Sue Jones

26 26

Safe Staffing - Board Sponsor: Director of Nursing

QuESTT

The areas not submitted have been

individually reviewed by the Head of

Nursing for each Division to ensure

that any triggers are reviewed.

Two wards have triggered for action in

January.

Gate 34b- Recruitment to vacancies &

unfilled shifts monitored closely to

ensure safety maintained. HR

investigations have now concluded..

Gate 34a- Recruitment to vacancies is

underway, the ward transferred to

Medicine in January 2018 and

received an increase in establishment

to reflect enhanced care requirements.

Unfilled shifts monitored closely to

ensure safety maintained.

Safe Care Live

(Electronic Acuity tool)

The acuity of patients is measured

three times daily and reviewed at the

twice daily safe staffing meetings .

Staff are moved between Divisions to

ensure safety is maintained where a

significant shortfall in required hours is

identified. Rostered hours were above

in all Divisions than required in

January and reflected the additional

staffing required for escalation areas. .

Professional judgement is also utilised

to maintain safe staffing levels. It has

been recognised that staff require on

going education to complete and data

validation is continuing to ensure

consistency of patient assessments.

More detailed work on implementation

and full utilisation of the SafeCare tool

is being planned in order that the tool

can be used to its maximum benefit.

27 27 Nursing Workforce

January saw a sustained increase in

the over establishment of both RNs and

HCAs due to volume of new starters in

January requiring supernumerary time

and the staffing of additional escalation

areas and enhanced care.

NMSK

Increases in HCA requirements to

cover enhanced care in Neuro and

increased requirements for acuity of

care for medical patients in MSK.

Medicine

Significant escalation areas in January

required additional staffing with both

RN’s and HCA’s. Increased

requirement for HCAs and RMNs to

provide enhanced care above plan due

to higher acuity and occupancy on

wards.

ASCR

Increased HCA for enhanced care

across Surgical wards where there has

been an increase in Medical patients.

Escalation areas requiring additional

staffing of both RNs and HCAs in

January.

Women and Children’s

Increase due to staffing additional

capacity beds on Cotswold and

covering maternity leave.

Actions in place: HCAs in the pipeline

due to start over the next two months to

support shortfall. Cross Trust working

to support areas where vacancies are

increased. The agency expenditure in

January increased to 4% due to

increased requirement for escalation

areas and higher use of Non framework

high cost agency use to ensure patient

safety.


Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Agency 28.44 31.65 34.69 40 51 45 41 31 32 45

Bank 165.31 168.61 167.4 165 166 167 172 179 146 198

Substantive 1959.7 1958.3 1929.2 1924 1918 1945 1995 2025 1988 1974

Total 2153.4 2158.5 2131.3 2129 2136 2158 2208 2235 2166 2217 0 0

Agency 0 0 0 0 0 0 0 0 0 0

Bank 234.34 240.83 251.61 266 269 243 241 242 231 259

Substantive 881.41 894.09 889.58 891 889 867 881 913 916 938

Total 1115.8 1134.9 1141.2 1157 1158 1110 1122 1155 1147 1197 0 0

Worked WTEs

N&M

HCA

28 28 Southmead Nursing Fill Rate and CHPPD

RN fill rates are up this month in line with the skill mix

review and the winter planned staffing for increased

escalation. Care assistant (CA) fill rates for January have

fallen slightly as some ward have now been adjusted to the

planned number from the skill mix review. This should

continue as the new levels are absorbed fully into the

planned numbers within the roster build.

CHPPD has increased again this month by 0.2 to 8.6

despite an increase of over 2399 patients within the

midnight census however this is reflective of the increased

RN fill rates.

Wards below 80% fill rate are:

Mendip: The reduced number of Midwives on both day and

night on Mendip ward occurred again this month due to

continued high acuity on CDS.

NICU: Reduced fill for CA day and night; NICU continues to

work to a reduced cot base where possible and staffing is

closely monitored each shift. In order to maintain safety,

practice development staff and the Clinical Matron have

supported the unit. The staff have successfully recruited

5.5 WTE to the unit which with induction and

supernumerary status start to impact on the March fill rates.

Wards over 200% fill rate are:

33A CA fill rate both day and night. This is due to support

for the burns clinic on days and a patient requiring

enhanced care at night for most of the month.

IR: CA fill rate both day and night. This is the first month

reporting on the IR escalation beds as part of the winter

plan. The anticipated requirement for 2RN and 1CA has

been increased as required for the acuity, dependency and

actual patient numbers.

Cossham Midwifery Fill Rate and CHPPD:

Cossham Birth Suite continues to show a slight increase in

midnight census to 48. With decreased fill rate of RMs on

days the CHPPD is down 2.8 on last month. The RN fill rate

decrease this month is due to vacancy and 11% long term

sickness. The planned phased return to work will improve

this slowly but may impact until March. There is an increase

in the CA hours to support the unit and the supervisory

sister covered clinically as required to maintain safety.

The numbers of hours Registered Nurses (RN) / Registered Midwives (RM) and Care Assistants (CA), planned and actual, on both day and night shifts are collated . CHPPD for Southmead hospital includes ICU, NICU and the Birth Suite where 1:1 care is required. This data is uploaded on UNIFY for NHS Choices and also on our Website showing overall Trust position and each individual gate level. The breakdown for each of the ward areas is available on the external webpage.


29 29

Maternity Staffing

In January 2018 the unit closed on

one occasion due to a lack of beds.

The unit was closed for a total of 11.5

hours.

The Midwife to birth ratio remains at

1:30 in December and has been a

constant since April 2016.

The Birth Rate Plus report continues

to be used to inform business

planning for the future workforce plan,

alongside the introduction of

integrated working between the birth

centres and the community. The

midwife to birth ratio is currently

being re-evaluated in accordance

with updated acuity tools.


Dec-17 Jan-18Direction of Travel

last month - current

513 542 5

01:30 01:30 4

56.3% 56.7% 5

30.3% 28.9% 6

17.2% 20.4% 5

Cossham BC 6.4% 6.2% 5

Mendip BC 10.4% 13.3% 5

Home 1.0% 1.7% 5

CDS 81.8% 77.9% 6

97.2% 98.6% 5

Birth

Total births

Midwife to birth ratio

Normal birth rate

Caesarean birth rate

Total births in midwife led environment

Birth

Location

One to one care in labour

30 30 Serious Incidents (SI)

Four serious incidents were reported

to STEIS in January 2018:

3 x Delayed Treatment

1 x Fall

One serious fall identified for

externally reporting through the

SWARM process.

One serious fall was identified for

Internal QI investigation through the

SWARM process.

Never Event Description - None

SI and Incident Reporting Rates

Incident reporting has slightly

decreased to 45.0 per 1000 BD, still

well above the national median, which

indicates a positive reporting culture.

The serious incident reporting rate is

now at 0.15 per 1000 BD, below

national median.

Divisions:

SI rate by 1000 Bed Days:

CCS* - 1.53

ASCR - 0.38

Med - 0.27

WCH - 0.26

NMSK - 0.22

*CCS Bed Base Intentional Radiology

only

Quality and Patient Safety - Board Sponsor: Director of Nursing

31 31

Incident Reporting Deadlines for

RCA submission

Two serious incidents breached their

January 2018 reporting deadline to

commissioners.

One SI remains a breach:

1x (CCS) Delayed cancer diagnosis.

Top SI Types in Rolling 12 Months

Serious falls (either by SWARM, or

as STEIS reportable) are the most

prevalent of reported SI’s, followed

by delayed treatment.

*Other Categories:

1 Unintended Damage to Organ

1 Wrong Site Surgery

1 Lost to Follow Up

1 Adverse Media Event

1 Screening Issues

1 Equipment Failure

1 Transfusion Error

1 Operating without Valid Consent

1 Delayed Treatment of Deteriorating

Patient

Data Reporting basis

The data is based on the date a serious incident is

reported to STEIS. Serious incidents are open to being

downgraded if the resulting investigation concludes the

incident did not directly harm the patient i.e. Trolley

breaches. This may mean changes are seen when

compared to data contained within prior Months’ reports.

Central Alerting System (CAS)

Eight new alerts reported, none breaching alert target

dates. One previously issued alert patient safety alert

remains in breach of its deadlines.

PSA/2016/008: Restricted Use Of Open Systems For

Injectable Medication - Specialty: Pharmacy still remain

open.

32 32 Harm Free Care

The ‘harm free’ care reporting now

includes both overall harm free care

and the new harm rates which are

reflective of ‘hospital acquired harm’.

This month shows 97.34% for harm

free care compliance (adjusted for

hospital acquired harm). The

reduction in harm free care remains

a reflection of an increase in

pressure ulcers with harm. The

tissue viability team continue to

support the validation of pressure

ulcers on the day and further

education on assessment of

pressure ulcers has taken place.

Overall Falls

There were 223 falls recorded for

January with two recorded as

serious. Following a review of the

second national inpatients falls audit,

three areas have been identified to

build into the clinical audit action plan

and triangulation with the NICE

guidelines. These actions will inform

a revision of the Inpatients falls

policy, the monthly questionnaire and

Datix incident reporting questions.

The action plan is due to be finalised

following the February 2018 group

meeting.

Safety - Board Sponsor: Director of Nursing

33 33

Pressure Injuries

Pressure injury incidence per

thousand bed days observed an

increase this month at 0.53 per 1000

bed days.

Grade 4: Nil reported

Grade 3: Four reported, on three

patients within NMSK (3) and

Medicine Division (1). All located on

heels, learning from SWARMs

related to re-assessment of risk

following transfer and / or

deterioration in clinical condition.

Grade 2: Fifteen reported, 63% were

validated on heels - the clinical

teams are completing local level

reviews to look for themes and

trends.

The Trust is part of the BNSSG

Multi-agency strategy for the

prevention and management of

pressure injuries.

VTE Risk Assessment

Timely VTE Risk Assessments

above the 95% national standard

have continued.

The emphasis on broader quality

improvement work in relation to

cases of Hospital Acquired

Thrombosis continues, overseen by

the Thrombosis Committee and in

line with the approach endorsed

within the ward of VTE Exemplar

Centre status in October 2017.

QP2 QP2

QP2


34 34

Malnutrition

Malnutrition compliance for January

was 78.67%, December was

81.33%. All Divisions were non

compliant with the 90% target.

Targeted work being undertaken

within the divisions to address poor

compliance

WHO Checklist Compliance

Measured compliance with the WHO

checklist was 97.20% in January

2018.

The WHO checklist compliance

improvement programme continues

to be overseen by the Theatre

Board. WHO safer surgery list

compliance through is being

reviewed by a sub group to report

into Theatre Board focusing on

clinical governance. This outcome of

this is a process to validate all non-

compliant cases and the removal of

patients whose surgery has been

cancelled from the data.

QP1


35 35 Medicines Management

Severity of Medication Error

Reporting will be highlighted in

Pharmacy staff briefings over the

coming month and with additional

training sessions from the Datix team

as we would want increased reporting

of low harm events.

High Risk Drugs

Moving to Datix has provided an

opportunity to review how to report on

high risk drugs. A new category has

been added to the chart for

Chemotherapy. Due to resources

being focused to support patient flow

and winter pressures, data is shown a

month in arrears.

Themes of Medication Error

Omitted doses remains the top theme

in January but data shows

improvement compared to the

previous month and is now below

target.

Missed Doses

Currently both nursing and pharmacy

undertake missed doses audits and

this is in the process of being

rationalised.


36 36

Safety - Board Sponsor: Medical Director

MRSA

There was one reported case of

MRSA bacteraemia in January.

The Trust position is four in 2017/18 ,

the previous reported case was in

August. The Trust MRSA remedial

action plan has been submitted to the

CCG Quality committee for closure,

we await their decision.

C. Difficile

There were two reported cases in

January, occurring within the Medical

Division. The graphs now include

reported lapses in care. Lapses are

nationally defined as evidenced care

not meeting an expected standard

which would enable transmission of

C. Difficile within the hospital

environment - whether or not there

was evidence the ‘lapse’ was a

specific risk factor in the individually

reported cases.

Public Health England (PHE)

Benchmarks

Data from the latest published report

is shown.

Influenza

The increase in influenza within the

organisation reflects the position

within the community, and having an

impact on hospital admissions, with

an increase in patients admitted with

respiratory symptoms. Daily flu

submissions are being submitted by

the Trust

37 37 E. Coli

There were six cases of E. Coli

bacteraemia reported in January

and the total is within our planned

trajectory. There is a BNSSG

system action plan in place to

address this infection to which NBT

is contributing.

MSSA

There were three reported cases of

MSSA bacteraemia in January. The

RCAs for cases are reviewed and

presented at a bi-monthly Steering

Group chaired by the Trust Infection

Control Doctor. Good management

of indwelling devices is the focus of

the Trust improvement action plan.

Norovirus

During January there were two bays

placed under restricted access due

to norovirus. No bed days were lost.

Hand Hygiene

Hand Hygiene compliance reported

at 94%, this is below the required

95% target for the first time in a

year. The information is being

reviewed by ward teams to ensure a

rapid return to the Trust standard.

Safety - Board Sponsor: Medical Director

38 38 Learning from Deaths

All deaths should be reviewed (either screened or full case note review)

within three months of the death. For this reason, the data for the IPR is

shown up to 31 October 2017 to allow for allocation of cases, pulling of

notes and notes arriving with clinicians.

The completion rate of SCRs has remained at 62% whilst the screening

process continues to improve. Specific work is being undertaken with

teams that are struggling to meet the review requirements.

In this report time period (October 2017) there have been no new cases

where problems in care were thought to have contributed to death.

There have been 3 cases in the year to date where problems in care

were initially thought to be contributory to death. One has completed

Root Cause Analyses (RCA), one is awaiting RCA completion and the

remaining case has been reviewed in the Executive led Incident Review

Group where it was agreed that the identified care problems were not

contributory to the death.

Quality Improvement work has started to improve the processes for

completion of death certification by medical staff.

QP4

Effectiveness - Board Sponsor: Medical Director

39 39

Quality Experience

Board Sponsor: Director of Nursing

Sue Jones

40 40

Caring - Board Sponsor: Director of Nursing

Friends and Family Test Actions

Root cause analysis into reasons for

low response rates is near completion.

The aim is to:

Reduce the errors in telephone

numbers in the data feed.

Explore ways to reduce survey fatigue

protection whilst remaining within

budget.

To re-promote FFT across NBT during

March, April and May with staff and to

patients.

Inpatients

A relaunch of FFT is planned as above.

NICU to commence FFT surveys.

Planning a three month pilot of

business cards handed to parents with

web address and QR code for online

completion.

Maternity

National maternity survey improvement

actions will feed into the improvement

of response rate and % recommend.

Work is also underway to follow the

delivery and administration process of

FFT in the antenatal clinics to identify

issues with poor response rates and

identify actions to deliver improvement.

Outpatients

Gate 5 MDC, are exploring ways with

PEX team to increase response rate.

The Brain Centre, at their request, are

being supported to relaunch their FFT

programme. Learning will be applied

elsewhere. Exploration work identified

that FFT card responses had been sent

to a previous company that managed

the FFT reporting, this now rectified.

N.B. NHS England FFT Official stats publish data one month behind current data presented in this IPR.

QP6 QP6

QP6 QP6

Owing to technical issues, NHS England have not published maternity FFT data for November 2017.

41 41

Inpatient Friends and Family Test

Actions

Would recommend percentage rate

has increased by one percentage

point to 93% whilst those who would

not recommend have decreased to

3%. The response rate has increased

by two percentage points of all who

were asked and by one percentage

point of all patients.

The user survey sent to staff who

should be using FFT has been

progressed. Results are expected by

the end of February 2018 and will help

inform the re-promotion of FFT, the

relaunch campaign for FFT continues

in planning stages to commence in

March.

Emergency Department

Continuing overall trend of increasing

the percentage who would

recommend. Support continues to be

given to those carrying out local

surveys within the Trust and systems

to register the projects and capture

their output

Outpatients

The patient experience team are

continuing to support the outpatient

review project with FFT being a

source of data.

Maternity

The patient experience team are

continuing to support the maternity

services team with activities to

improve the national survey results

which will in turn influence the

percentage recommend.

N.B. NHS England FFT Official stats publish data one month behind current data presented in this IPR.

QP6

Caring - Board Sponsor: Director of Nursing

Owing to technical issues, NHS England have not published maternity FFT data for November 2017.

QP6

QP6 QP6

42 42

.

Key: Would you recommend? 1. Extremely Likely 2. Likely 3. Neither Likely nor Unlikely 4. Unlikely 5. Extremely Unlikely 6. Don’t know

Friends and Family Test

“Please tell us the main reason for the answer you chose.”

Waited 3.5 hours

to get an injection that could

have been given earlier avoiding

the distress of being sick and

occupying a bed in AMU.

5 - ED

Excellent,

professional and

polite help when I

needed help, a bit of

a long wait but

otherwise excellent.

1 - ED

All staff so kind and caring.

In particular the theatre staff

and assigned nurse

practitioner. Treated as an

individual and not rushed.

1 - Gate 21

Too much

hanging around to decide

they were cancelling my

procedure, could of been

dealt with in a better way.

4 - Gate 21

All the staff are very helpful

and friendly. Nothing is ever

too much trouble.

1 - Gate 6B

I was moved six times in

eight days which did not help

with me getting better.

3 - Gate 9B

The reception staff at Gate

36 were non-attentive and

preferred to continue their personal

conversation before checking me

in. My appointment was late by

90mins, where I was sat waiting in

considerable pain as well as

running up parking charges

4 - Gate 36

I had excellent care

throughout the birth. The

midwives doctors and

students were very

attentive. I felt safe at all

times.

Birth - Southmead

I feel being made to travel

to Southmead hospital to get

my new baby weighed at a

clinic three days after a

C-Section pretty unreasonable, never

seen the same health professional

twice, not one of the people I have seen

have asked to check section wound

since the day after hospital discharge.

4 - Post

Natal Community

Another wait of over an hour.

When you have you leave work

to get there in good time, to find

published delays of 45 minutes,

rising to 50, but actually closer to

70 minutes, that is three hours

out of a working day. It highlights

the ridiculously short targets for

consultancy window (time with

the patient) Doctors are given.

3 - Cossham OP

Very friendly and

professional service by

all staff I came into

contact with.

2 - Cossham

Ultrasound

No communication of

ward rules. Had to find

out myself by mistakes.

3 - CDS

43 43 Complaints and Concerns

In January there were 58 complaints,

an increase of 13, and 70 concerns

received.

Compliments

The number of compliments returned to

ACT for recording for January

decreased in this month. This will be

monitored moving forward. Work is

also being undertaken to see how

teams can log their compliments via the

new Datix system.

NHS Complaints National Guideline

Targets

The three day acknowledgment was

met for all complaints (100%).

Overdue Cases

The number of overdue cases slightly

increased in January from 27 to 39.

Actions - DoN meeting two weekly with

HoN. Divisions addressing

sustainability in the change to SLM.

Monthly overdue complaints on

Safeguard system reported to Divisions

by ACT Overdue complaints entered

into Datix can be tracked by Divisions

independently. New complaints and

patient experience manager due to start

in April 2018. A workshop with each

Division will be held to identify barriers

they are encountering with meeting the

performance target and to help facilitate

participants to seek solutions to

minimise the risk of reoccurrence. Work

is also being undertaken with the

Urology team who have the highest

activity.

. Caring - Board Sponsor: Director of Nursing

44 44 Further detail of Final Response

Compliance (overdue complaints)

Of the cases closed in January 2018 (to

account for over due responses), 47

(70%) were completed within the

agreed timescale. The exceptions

were:

Nine were 1-10 days overdue

Two were 10-20 days overdue

Eight were greater than 20 days

overdue.

Complaint Handling

The top three categories of complaints

in October reflect the ongoing trend of

clinical care, communication (including

staff attitude), delays and

cancellations. This correlates with FFT

data.

The advice and complaints team work

closely with divisions to inform good

practice in responding to complainants.

NHS Choices Web posts

Southmead Hospital has an overall star

rating of 4.5 out of 5 from 239 reviews,

an increase 0.5. Cossham Hospital has

a rating of 4.5 out of 5 from 16 reviews.

In January, the star ratings given were:

1x 1 star, 1x 3 star and 11x 5 stars. The

advice and complaints team provide

feedback comments to each reviewer,

usually within a day of receipt.

Ombudsman Cases

No new cases were referred to the

Ombudsman in January 2018, Two

were closed; one case was not upheld

by the Ombudsman and one case was

upheld with a financial penalty of £500.

N.B. If all avenues for complaint resolution have been exhausted and the complainant is still

dissatisfied with the Trust’s response, the complainant has the right to take their complaint to the

PHSO. Cases can take many Months from ‘new’ to ‘decision’ which means the volumes shown

represent differing time periods and will not therefore ‘add up’ within any given period.

Caring – Quality Experience - Board Sponsor: Director of Nursing

Q1 17/18 Q2 17/18 Q3 17/18 Jan-18

New Cases referred to PHSO 5 2 2 0

No. of cases fully upheld 0 0 0 1

No. of cases partially upheld 1 0 0 0

No. of cases not upheld 1 2 2 1

Fines levied £350 0 0 £500

Corrective Actions Compliant

within timescales0 0 0 0

Non- compliant 0 1 0 0

Parliamentary Health Service Ombudsman (PHSO) Cases

45 45

Facilities

Board Sponsor: Director of Facilities

Simon Wood

46 46

Very High Risk Areas

Target Score 98%

Audited Weekly

Include: Augmented Care Wards and areas such as ICU, NICU,

AMU, Emergency Department, Renal Dialysis Unit

High Risk Areas

Target Score 95%

Audited Fortnightly

Include: Wards, Inpatient & Outpatient Therapies, Neuro Out

Patient Department, Cardiac/Respiratory Outpatient Department,

Imaging Services

Significant Areas

Target Score 90%

Audited Monthly

Include: Audiology, Plaster rooms, Cotswold Out Patient

Department

Low Risk Areas

Target Score 80%

Audited Every 13 weeks

Include: Christopher Hancock, Data Centre, Seminar Rooms,

Office Areas, Learning and Research Building (non-lab areas)

Operational Services Report on

Cleaning Performance against

the 49 Elements of PAS 5748

v.2014 (Specification for the

planning, application,

measurement and review of

cleanliness in hospitals)

Cleaning scores have remained

high throughout January with only

a minor dip in Very High Risk

Areas due to staff shortages and

winter pressures.

Mandatory training compliance for

December still exceeds the 85%

target, currently at 91% and 89% of

staff appraisals have been

completed against the 90% target.

Facilities is the highest performing

Division for appraisal completion.

There were a significant number of

additional deep cleans throughout

January - approximately 50 extra

per week against average months.

Our rapid response teams showed

resilience reporting only a 5%

breach rate overall.

Facilities Management - Board Sponsor: Director of Facilities

47 47

Well Led

Board Sponsors: Medical Director and Director of People and Transformation

Chris Burton and Jacolyn Fergusson

48 48

Well Led - Board Sponsor: Director of People and Transformation

Workforce Utilisation Trust

position

Worked WTE and pay expenditure

increased in January. The largest

increase was in bank usage which

increased by 16.7% in terms of

worked wte and 14.3% in terms of

expenditure.

87% of the increased use is

registered and unregistered nurses.

The biggest increase was in

Medicine with an additional 50 WTE

used in January. This represents

over half of the Trust’s increase for

December. The additional usage is

linked to the escalation areas

currently open within Medicine.

49 49 Bank and Agency

Winter pressures and additional capacity

has driven the bank’s expenditure to the

second highest point for this financial year,

along with an increase in agency

expenditure and reliance of non framework

agencies.

Month three of the neutral vendor contract

to supply nursing agency staff remains

challenging and this remains under review

to identify changes to improve performance

e.g. a change in our booking processes and

the early release of shifts to be filled by

agencies.

The bank team continue to work closely

with DePoel (neutral vendor) and have met

with suppliers to work together to improve

the fill rates.

Recruitment activity for bank staff remains

a high priority for all staffing groups and

includes Facebook campaigns, specialist

areas of recruitment for nursing staff, whilst

ensuring our Health Care Assistant and

Registered Nursing pipeline continues to

have a consist flow of candidates.


50 50

ESR - Finance System Alignment

Alignment between ESR and the Trust’s

Financial System is a recommendation of

the Carter Review. A 95% minimum

alignment is required.

Compliance with this metric continues to

remain steady; not dropping below 98%.


51 51

Vacancy Factor

The vacancy factor overall has

increased very slightly from 6.8% in

December to 7.0% in January. The

majority of the increase mostly came

from the registered nursing and

midwifery staff group.

Nurse/HCA Recruitment

Cohesion

HCA recruitment continues with 193

offers accepted to date since

September 2017.

Experienced Band 5 nursing

recruitment has seen 26 offers

accepted to date through the

cohesion approach.

SLA

Time to recruit continues to perform

below the SLA of 17 working days.

The Resourcing team maintained the

below 17 working days position since

October 2017. Work continues on

reducing the total end to end

recruitment time with shortlisting

delays being the highest priority.

Nurse Recruitment Open Day

The latest open day was held on

Saturday 27 January 2018 and was

a success with 55 offers made in

total, with the majority of these as

newly qualified nurses. Our next

open day is on 21 April 2018.

Vacancy Factor by Staff Group


Staff Group

Vacancy

Factor Dec-

17

Vacancy

WTE Dec-

17

Vacancy

Factor Jan-

18

Vacancy

WTE Jan-

18

Variance

Add Prof Scientif ic and Technic 6.2% 10.1 3.5% 5.8 -2.6%

Additional Clinical Services 7.2% 104.4 6.4% 94.3 -0.8%

Administrative and Clerical 8.3% 120.3 8.7% 125.9 0.4%

Allied Health Professionals 7.4% 26.8 6.3% 22.8 -1.1%

Estates and Ancillary 11.0% 81.5 11.1% 82.7 0.2%

Healthcare Scientists 4.1% 14.2 4.0% 13.7 -0.2%

Medical and Dental 2.4% 22.6 3.0% 28.2 0.6%

Nursing and Midw ifery Registered 6.5% 137.2 7.5% 158.3 1.0%

Trust 6.8% 517.0 7.0% 531.7 0.2%

52 52

Turnover

Turnover decreased in January 2018

and there were less leavers

compared with December 2017.

Registered nursing and midwifery

saw a reduction in leavers in January

but still an overall net loss of staff.

Unregistered nursing and midwifery

saw the number of leavers in January

reduced by 10 WTE compared with

December and a net gain of staff

overall with an increased number of

starters in January.

Work life balance and relocation

remain the first and largest reason for

voluntary leavers with little change in

number of leavers attributed to these

reasons compared with December.

Turnover Summary

In Month Turnover by Staff Group


Staff GroupTurnover

Dec-17

Leavers

WTE

Dec-17

Turnover

Jan-18

Leavers

WTE

Jan-18

Variance

Add Prof Scientific and Technic 1.75% 3.7 0.00% 0.0 -1.75%

Additional Clinical Services 1.86% 25.6 0.99% 13.8 -0.87%

Administrative and Clerical 2.05% 28.0 1.89% 25.5 -0.15%

Allied Health Professionals 1.95% 7.0 0.34% 1.2 -1.61%

Estates and Ancillary 1.39% 9.1 1.59% 10.5 0.21%

Healthcare Scientists 0.58% 2.0 1.36% 4.7 0.78%

Medical and Dental 0.62% 3.0 0.28% 1.3 -0.34%

Nursing and Midwifery Registered 1.68% 34.0 1.16% 23.2 -0.52%

Trust 1.65% 112.4 1.18% 80.2 -0.46%

Rolling 12 Months Dec-17 Jan-18 Variance

Total Turnover 15.99% 16.28% 0.29%

Voluntary Turnover 12.50% 12.74% 0.23%

Stability 85.47% 85.48% 0.02%

53 53

Sickness

The percentage of sickness absence

remained the same in December,

however the number of FTE days lost

to increased compared with November.

Short term sickness increased in

December compared with November

with a 62% increase in FTE days lost to

“Cough/cold/influenza” and a 68%

increase in FTE days lost to

“Gastrointestinal problems”.

Short term sickness due to

“Anxiety/stress/depression/other

psychiatric reason” saw a 24%

reduction in reason for absence,

although it remains the top reason for

long term sickness with a slight

increase in December.


54 54

In Month Sickness Absence by Staff Group


Staff Group Variance Nov-17 Dec-17

Add Prof Scientific and Technic -0.53% 5.06% 4.52%

Additional Clinical Services -0.14% 5.69% 5.55%

Administrative and Clerical 0.09% 5.07% 5.16%

Allied Health Professionals -0.77% 3.08% 2.31%

Estates and Ancillary 0.64% 5.67% 6.31%

Healthcare Scientists -1.37% 2.38% 1.02%

Nursing and Midwifery Registered 0.16% 4.30% 4.46%

Medical and Dental 0.18% 0.66% 0.83%

Trust 0.00% 4.25% 4.25%

Rolling 12 Month Sickness Absence Nov-17 Dec-17 Variance

Total Absence 4.46% 4.39% -0.07%

55 55

Essential Training

The proactively planned reduction of

face-to-face MaST sessions will

cease at the end of February.

Current figures show that the

percentage compliance has

remained on track thanks to the

available eLearning and in situ

options available during this time.

The L and D team are working with

subject matter experts to review

training delivery and format. Options

for reducing staff absence from

clinical areas to undertake training is

being encouraged.


Training Topic Variance Dec-17 Jan-18

Infection Control 0.6% 84.8% 85.4%

Health and Safety 0.6% 87.7% 88.2%

Waste 0.3% 88.0% 88.3%

Information Governance 1.1% 81.9% 83.0%

Child Protection 0.1% 85.7% 85.7%

Equality and Diversity -0.4% 85.4% 85.0%

Fire -0.1% 82.1% 82.0%

Manual Handling -1.2% 79.3% 78.2%

Total 0.1% 84.4% 84.5%

56 56

Medical Appraisal and Revalidation The fifth appraisal and revalidation year started on 1 April 2017.

91% of the appraisals that were due between April 2017 and January 2018 have been

completed. In 2016 this figure stood at 90% for the same timescale.

The August 2017 doctors changeover saw the number of clinical fellows employed by

the Trust increase by 18. As these individuals are not in recognised training posts with

Health Education England, they are required to appraise and revalidate with NBT.

The Trust has currently deferred 25% of all revalidation recommendations due over the

past 12 months. This number has been slowly decreasing since August 2017 when it

reached its peak of 43%. The overall number of revalidation recommendations have

been low in 2017 with the vast majority of them being clinical fellows.

The number of doctors going through revalidation will rise sharply in 2018 and the

deferral rate is expected to continue to drop as more consultants go through their

second revalidation since the process began in 2012. One non-engagement

recommendation was made to the GMC in May 2017. This is the only non-engagement

recommendation made at NBT since the introduction of revalidation in 2012.

The Trust’s revalidation support team have continued to provide medical appraiser CPD

update training in 2017 with a further session available to appraisers in 2018. The PReP

system remains the mandatory system for medical appraisals for all non-training grade

doctors employed by the Trust. The current contract for PReP is in place until November

2018 which is currently under review by the revalidation support team.

An annual report representing the 2016/17 appraisal year was returned to NHS England

in May 2017. An annual Trust Board report was presented to the Trust Board on 27 July

2017 and a statement of compliance signed and submitted to NHS England on 30 July

2017. This will all be due again in 2018.

Well Led - Board Sponsor: Medical Director

36

57 57

Finance

Board Sponsor: Director of Finance

Catherine Phillips

58 58

Assurances

The financial position at the end of January shows a

deficit of £21.1m, £4.2m adverse to the planned

deficit of £16.9m. The position excluding STF is

£1.4m favourable to plan.

Key Issues

• Contract income is £0.2m adverse to plan

reflecting under-performance in electives offset by

significant increases in non-elective. Other income

is £0.1m favourable including an increase in

overseas income.

• Pay is £5.5m adverse to plan mainly due to under-

delivery of savings and significant escalation costs

• Non pay is £2.1m favourable to plan with lower

independent sector and drug usage along with a

non-recurrent benefit of £0.6m partially offset by

higher consumable costs

• Delivery of savings was £6m less than required to

date (£4.1m less than revised profile submitted as

part of financial special measures).

Actions Planned

Continued focus on identification of the full savings

required as well as full delivery of planned activity

and income for the year will be crucial to ensure

delivery of the Trust’s control total.

Finance

Statement of Comprehensive Income Board Sponsor Director of Finance

Prior year

actual to 31

January 2017 17.18 Plan Actual

Variance

(Adverse) /

Favourable

£m £m £m £m

Income

378.1 Contract Income 395.1 394.9 (0.2)

65.0 Other Operating Income 62.4 62.5 0.1

0.1 Donations income for capital acquisitions 0.0 0.9 0.9

443.2 Total Income 457.5 458.3 0.8

Expenditure

(278.3) Pay (275.0) (280.5) (5.5)

(149.7) Non Pay (151.7) (149.6) 2.1

(4.7) PFI Operating Costs (5.1) (4.8) 0.3

(432.7) (431.8) (434.9) (3.1)

10.5 Earnings before Interest & Depreciation 25.7 23.4 (2.3)

2.4% 5.1%

(19.4) Depreciation & Amortisation (21.3) (19.1) 2.2

(27.5) PFI Interest (28.2) (28.0) 0.2

0.0 Interest receivable 0.1 0.0 (0.1)

(3.2) Interest payable (3.6) (4.7) (1.1)

0.0 PDC Dividend 0.0 0.0 0.0

0.0 Other Financing costs 0.0 0.0 0.0

0.0 Impairment 0.0 0.0 0.0

(39.6)Operational Retained Surplus /

(Deficit)(27.3) (28.4) (1.1)

(8.9%) (6.2%)

Add back items excluded for NHS

accountability

(0.1) Donations income for capital acquisitions 0.0 (0.9) (0.9)

0.6 Depreciation of donated assets 0.0 0.6 0.6

0.0 Impairment 0.0 0.0 0.0

(39.1)Adjusted surplus /(deficit) for NHS

accountability (excl STF)(27.3) (28.7) (1.4)

STF 10.4 7.6 (2.8)

Adjusted surplus /(deficit) for NHS

accountability (incl STF)(16.9) (21.1) (4.2)

Position as at 31 January 2018

59 59

Assurances

The Trust received new loan financing in

January of £2.8m. This is £24.5m compared

with the £18.7m planned for this year, which

takes the total Department of Health

borrowing to £159.1m.

The Trust ended the month with cash of

£12.8m, £10.3m higher than plan. The

higher balance is required in order to meet

contractual payments prior to receipts being

received from commissioners in January.

Concerns & Gaps

The level of payables is reflected in the

Better Payment Practice Code (BPPC)

performance for the year which is below the

required 95% with 73% by volume of

payments made within 30 days.

Actions Planned

The focus continues to be on maintaining

payments to key suppliers, reducing the

level of debts and ensuring cash financing is

available.

Finance

Statement of Financial Position Board Sponsor Director of Finance

31 March

2017 £m

Statement of Financial Position as at

31st January 2018

Plan

£m

Actual

£m

Variance

above /

(below) plan

£m

Non Current Assets

518.0 Property, Plant and Equipment 509.9 510.8 0.9

15.8 Intangible Assets 10.6 14.4 3.8

20.0 Non-current receivables 19.0 14.0 (5.0)

553.9 Total non-current assets 539.5 539.2 (0.3)

Current Assets

10.2 Inventories 9.7 10.9 1.2

36.0 Trade and other receivables NHS 24.1 20.7 (3.4)

26.7 Trade and other receivables Non-NHS 30.8 31.4 0.6

4.7 Cash and Cash equivalents 2.5 12.8 10.3

77.5 Total current assets 67.1 75.7 8.6

1.6 Non-current assets held for sale 0.0 0.0 0.0

632.9 Total assets 606.6 614.9 8.3

Current Liabilities (< 1 Year)

18.3 Trade and Other payables - NHS 18.3 12.7 (5.5)

71.8 Trade and Other payables - Non-NHS 55.1 65.2 10.1

40.1 Borrowings 11.5 40.1 28.7

130.1 Total current liabilities 84.8 118.1 33.3

(51.1) Net current assets/(liabilities) (17.7) (42.4) (24.7)

502.8 Total assets less current liabilites 521.8 496.8 25.0

9.9 Trade payables and deferred income 18.4 9.3 (9.0)

514.3 Borrowings 545.5 529.6 (15.8)

(21.4) Total Net Assets (42.1) (42.2) (0.1)

Capital and Reserves

241.7 Public Dividend Capital 241.7 241.7 0.0

(312.4) Income and expenditure reserve (375.8) (363.5) 12.4

(51.1)Income and expenditure account - current

year(16.9) (20.8) (3.9)

100.4 Revaluation reserve 108.9 100.4 (8.6)

(21.4) Total Capital and Reserves (42.1) (42.2) (0.1)

60 60

The overall financial position was

£4.2m adverse against plan at the end

of January.

Capital expenditure was £10.4m

compared to a plan of £13.3m for the

year to date. The plan for the year is

£21.8m.

Available capital funding for the year

has reduced by £3.7m from the

planned level largely due to lower

forecast depreciation. This is reflected

in forecast expenditure of £18.1m.

Assurances and Actions Planned

• Ongoing monitoring of capital

expenditure with project leads.

• Cash for our planned deficit for the

year to date has been made

available to the Trust via DH

borrowing

Concerns & Gaps

The Trust is rated at 3 (a score of 1 is

the best) in the finance and use of

resources metric. This means the

financial position remains a concern

but is no longer the highest score of 4.

Finance Rolling Cash Forecast, In-year Surplus/Deficit, Capital Programme Expenditure and Financial Risk

Ratings Board Sponsor Director of Finance

0

5

10

15

20

£m

2017/18 Cumulative capital expenditure and forecast

Plan Actual Forecast

(150)

(125)

(100)

(75)

(50)

(25)

0

25

50

£m

Rolling cash flow forecast

Forecast including support Forecast excluding support

Weighting MetricYear to

dateForecast

0.2 Capital service cover capacity 4 4

0.2 Liquidity rating 4 4

0.2 I&E margin rating 4 4

0.2I&E margin: distance from

financial plan2 2

0.2 Agency rating 1 1

Overall finance and use of

resources risk rating 3 3

61 61

Assurances

£36.8m of the £39.4m efficiencies required have

been identified at the end of January. This has

reduced by £0.7m in month mainly due to slippage

into 2018/19.

Concerns & Gaps

Under-delivery of £6m year to date against the

original target of £32.2m. A revised profile was

submitted to NHSI as part of financial special

measures against which the shortfall is £4.1m.

The graphs show forecast delivery of £39.4m.

£35.2m is rated as green or amber.

Actions Planned

Continued monitoring of actions required to deliver

required savings in 2017/18 and catch up the year to

date shortfall.

Finance

Savings Board Sponsor: Director of Finance

62 62

Regulatory

Board Sponsor: Chief Executive

Andrea Young

63 63

Regulatory View - Board Sponsor: Chief Executive Officer

The Governance Risk Rating (GRR) for ED 4 hour performance continues to be a challenge through 2017/18, actions to improve and sustain this

standard are set out earlier in this report. A recovery plan is in place for RTT incompletes and long waiters (please see Key Operational Standards

section for commentary). In quarter, monthly cancer figures are provisional therefore, whilst indicative, the figures presented are not necessarily

reflective of the Trust’s final position which is finalised 25 working days after the quarter.

We are scoring ourselves against the Single Operating Framework (SOF). This requires that we use the performance indicator methodologies and

thresholds provided and a Finance Risk Assessment based upon in year financial delivery.

Board compliance statements - number 4 (going concern) and number 10 (ongoing plans to comply with targets) warrant continued Board consideration

in light of the in year financial position (as detailed within the Finance commentary) and ongoing performance challenges as outlined within this IPR. The

Trust is committed to tackling these challenges and recovery trajectories are scrutinised on an ongoing basis through the Monthly Integrated Delivery

Meetings.

CQC reports history (all sites)

* These services are no longer provided by NBT.

Location Standards Met Report

date

Overall Requires Improvement

Apr-16

Child and adolescent mental health wards (Riverside) *

Good Feb-15

Specialist community mental health services for children and young people *

Requires Improvement

Apr-16

Community health services for children, young people and families *

Outstanding Feb-15

Southmead Hospital Requires Improvement

Apr-16

Cossham Hospital Good Feb-15

Frenchay Hospital Requires Improvement

Feb-15

Regulatory Area Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18Finance Risk Rating

(FRR)Red Red Red Red Red Amber Amber Amber Amber Amber Amber Amber

Board non-compliant

statements2 1 1 1 1 1 1 1 1 1 1 1

Prov. Licence non-

compliant statements0 0 0 0 0 0 0 0 0 0 0 0

CQC Inspections RI RI RI RI RI RI RI RI RI RI RI RI

64 64

Monitor Provider Licence Compliance Statements at January 2018

Self-assessed, for submission to NHSI

Ref Criteria Comp

(Y/N) Comments where non compliant or at risk of non-compliance

G4

Fit and proper persons as

Governors and Directors (also

applicable to those performing

equivalent or similar functions)

Yes

A Fit and Proper Person Policy is in place.

All Executive and Non-Executive Directors have completed a self assessment and no issues have been

identified. Further external assurance checks have been completed on all Executive Directors and no issues

have been identified.

G5 Having regard to monitor Guidance Yes The Trust Board has regard to Monitor guidance where this is applicable.

G7 Registration with the Care Quality

Commission Yes

CQC registration is in place. The Trust received a rating of Requires Improvement from its inspection in

November 2014 and again in December 2015. A number of compliance actions were identified, which are

being addressed through an action Plan. The Trust Board receives regular updates on the progress of the

action plan through the IPR.

G8 Patient eligibility and

selection criteria Yes Trust Board has considered the assurances in place and considers them sufficient.

P1

Recording of information Yes

A range of measures and controls are in place to provide internal assurance on data quality. Further

developments to pull this together into an overall assurance framework are planned through strengthened

Information Governance Assurance Group.

P2

Provision of information Yes

Information provision to Monitor not yet required as an aspirant Foundation Trust (FT). However, in

preparation for this the Trust undertakes to comply with future Monitor requirements.

P3 Assurance report on

submissions to Monitor Yes

Assurance reports not as yet required by Monitor since NBT is not yet a FT. However, once applicable this

will be ensured. Scrutiny and oversight of assurance reports will be provided by Trust's Audit Committee as

currently for reports of this nature.

P4

Compliance with the National Tariff Yes

NBT complies with national tariff prices. Scrutiny by CCGs, NHS England and NHS Improvement provides

external assurance that tariff is being applied correctly.

P5 Constructive engagement

concerning local tariff modifications Yes Trust Board has considered the assurances in place and considers them sufficient.

C1 The right of patients to make choices Yes Trust Board has considered the assurances in place and considers them sufficient.

C2 Competition oversight Yes Trust Board has considered the assurances in place and considers them sufficient.

IC1 Provision of integrated care Yes Range of engagement internally and externally. No indication of any actions being taken detrimental to care

integration for the delivery of Licence objectives.


65 65

Board Compliance Statements at January 2018

Self-assessed, for submission to NHSI

No. Criteria Comp

(Y/N) No. Criteria

Comp

(Y/N)

1

The Board is satisfied that, to the best of its knowledge and using its own

processes and having had regard to the TDA’s oversight model (supported

by Care Quality Commission information, its own information on serious

incidents, patterns of complaints, and including any further metrics it

chooses to adopt), the Trust has, and will keep in place, effective

arrangements for the purpose of monitoring and continually improving the

quality of healthcare provided to its patients.

Yes 8

The necessary planning, performance, corporate and clinical risk management

processes and mitigation plans are in place to deliver the annual operating plan,

including that all audit committee recommendations accepted by the Trust Board

are implemented satisfactorily.

Yes

2 The board is satisfied that plans in place are sufficient to ensure ongoing

compliance with the Care Quality Commission’s registration requirements. Yes 9

An Annual Governance Statement is in place, and the Trust is compliant with the

risk management and assurance framework requirements that support the

Statement pursuant to the most up to date guidance from HM Treasury

(www.hm-treasury.gov.uk).

Yes

3 The board is satisfied that processes and procedures are in place to ensure

all medical practitioners providing care on behalf of the Trust have met the

relevant registration and revalidation requirements. Yes 10

The Trust Board is satisfied that plans in place are sufficient to ensure ongoing

compliance with all existing targets (after the application of thresholds) as set out

in the relevant GRR; and a commitment to comply with all known targets going

forwards.

No

4 The board is satisfied that the Trust shall at all times remain an ongoing

concern, as defined by the most up to date accounting standards in force

from time to time. Yes 11

The Trust has achieved a minimum of Level 2 performance against the

requirements of the Information Governance Toolkit. Yes

5

The board will ensure that the Trust remains at all times compliant with

regard to the NHS Constitution.

Yes 12

The Trust Board will ensure that the Trust will at all times operate effectively. This

includes maintaining its register of interests, ensuring that there are no material

conflicts of interest in the Board of Directors; and that all Trust Board positions

are filled, or plans are in place to fill any vacancies.

Yes

6 All current key risks have been identified (raised either internally or by

external audit and assessment bodies) and addressed – or there are

appropriate action plans in place to address the issues – in a timely manner. Yes 13

The Trust Board is satisfied that all Executive and Non-executive Directors have

the appropriate qualifications, experience and skills to discharge their functions

effectively, including: setting strategy; monitoring and managing performance

and risks; and ensuring management capacity and capability.

Yes

7 The board has considered all likely future risks and has reviewed

appropriate evidence regarding the level of severity, likelihood of it occurring

and the plans for mitigation of these risks. Yes 14

The Trust Board is satisfied that: the management team has the capacity,

capability and experience necessary to deliver the annual operating plan; and

the management structure in place is adequate to deliver the annual operating

plan.

Yes

Comment where non-

compliant or at risk of

non-compliance

As the Trust has not yet achieved a sustainable position in relation to delivery of the 4

Hour A&E and RTT standards due to a reliance on external system changes/factors,

the Trust is unable to confirm compliance with this statement

Timescale for

compliance: Q4 2017/18 – for RTT


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