Agenda - swast.nhs.ukTrust Public Board of Directors Meeting 31 March 2016 Page 1 of 12 Minutes Trust Public Board of Directors Meeting Thursday 31 March 2015, 10.00hrs Boardroom,

Trust Public Board of Directors Meeting – 26 May 2016 Page 1 of 2

Agenda Trust Public Board of Directors Meeting

Date Thursday 26 May 2016 Time 10.00

Venue Boardroom, Trust HQ, Abbey Court, Eagle Way, Exeter EX2 7HY

Chair Mrs H Strawbridge OBE, Chairman

Members:

Mrs H Strawbridge OBE (HS), Mr K Wenman (KW), Mr T Fox (TF), Mr H Hood (HH) Mrs V James (VJ), Mr P Love (PL), Dr I Reynolds (IR), Baroness Watkins of Tavistock (MW), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AS), Mrs J Winslade (JW), Mrs E Wood (EW)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms L Bowden (LB), Mr N Le Chevalier (NLC)

Circulation Mr C Nelson, Joint Branch Secretary, Unison, Ms J Fowles Joint Branch-Secretary, Unison, Council of Governors

Administration Mr M McAuley (MM)

Opening business

No Topic Format Presenter

1 Welcome, Introduction & Apologies Verbal HS

2 Declarations of Interest Verbal All

3 Patient Story Presentation HS

4 Report from the Chairman Verbal HS

5 Report from the Chief Executive Verbal KW

6 Questions from the Public Verbal HS

7 Minutes of Previous Meeting – 31 March 2016 Paper 1 HS

8 Action Point Register Paper 2 HS

Trust Public Board of Directors Meeting – 26 May 2016 Page 2 of 2

Strategic Items for assurance

9 Integrated Corporate Performance Report Paper 3 KW

10 Corporate Risk Register and Board Assurance Framework – BAF to Follow

Paper 4 JW

11 Patient Safety and Experience Report Paper 5 JW

12 Information Governance Year to Date Report Paper 6 FG

13 Communications update Paper 7 LB

14 ACQIs Paper 8 AGS

Sub Committee reporting for assurance

15

Quality Committee Assurance Report – April 2016

Minutes from April 2016

Paper 9 VJ

16

Audit Committee Assurance Report – March 2016

Minutes from January 2016

Paper 10 PL

Closing business

17

Any Other Business

Identification of New Risks (incl. Health & Safety)

Identification of New Legislation

Verbal HS

Trust Public Board of Directors Meeting 31 March 2016

Page 1 of 12

Minutes Trust Public Board of Directors Meeting Thursday 31 March 2015, 10.00hrs Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Exeter EX2 7HY Chair Mrs H Strawbridge - Chairman Administration Mr M McAuley – Trust Secretary

Members: Mrs H Strawbridge HS Chairman Mr K Wenman KW Chief Executive Mr P Love PL Non-Executive Director Mr A Fox AF Non-Executive Director Mr H Hood HH Non-Executive Director Mrs V James VJ Non-Executive Director Mr I Reynolds IR Non-Executive Director Prof M Watkins MW Non-Executive Director Mr F Gillen FG Executive Director of IM&T Mrs J Kingston JK Deputy Chief Executive/Executive Director of

Finance Dr A Smith AGS Executive Medical Director Mrs J Winslade JW Executive Director of Nursing and Governance Mrs E Wood EW Executive Director of HR & OD Non Members: Lord P Tyler PT Advisor to the Board Mr M McAuley MM Trust Secretary Mr C Nelson CN Unison Mr J Fowles JF Unison Observers: Mr B Deed BD Public Governor - Devon Mr R Care RC Public Governor – Bristol & B&NES Mr T McInness TM Public Governor - Wiltshire


Page 2 of 12

No Agenda Item Action

1.0 Welcome, Introduction & Apologies

1.1 1.2

Apologies were received from Mary Watkins. Welcome to:

Rae Care, Torquil McInnes, Bob Deed – Public Governors

Ann Rees – Patient Story

Sara Coburn – Patient Engagement Manager

2.0 Declarations of Conflict of Interest

2.1 No declarations of interest were declared.

3.0 Patient Story

3.1

Ann Rees, patient, explained that she had accessed the Service through Patient Opinion but wanted to get in touch with the Ambulance service directly as they saved her life and she had used them on occasions in the past and without SWASFT she would not be there to tell the story. She shared the positive experience of how her allergic reaction was treated and could not thank staff enough. Ann was disappointed over the negative press coverage of the Trust so wanted to say thank you as the Ambulance service had supported her family on a number of occasions. KW thanked Ann for her feedback and explained how negative stories have an impact on staff, so stories like hers are very important for the Trust to hear. AGS asked what in her mind was the most important thing about the Ambulance service. Ann explained the crew who attended her and saved her life were amazing but they commented that it was nice to have a proper emergency so she was sad to hear how staff work so hard and often very late only to hear the negative side of things. She explained that Devizes can be a Bermuda Triangle when it came to emergency medical care. CN thanked Ann, explained his role and he said he would pass her feedback to the crews in the area. KW and HS thanked Ann for attending the Board and wished her well in the future.


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4.0 Report from the Chairman

4.1 4.2

HS explained there had been a lot of media coverage and the resultant pressure on staff had been immense and was pleased to see how staff had responded. HS highlighted a couple of key things that had happened since the last Board meeting:

Meeting with Neil Parrish, MP, at the Tiverton Urgent Care Centre.

Trust Research Show Case, which included national speakers and the Trust had won Awards.

Student Paramedic Conference at UWE.

Health Watch Engagement Day

Council of Governors Induction Day.

Derek Greatorex of South Devon and Torbay CCG had visited the Clinical Hub.

5.0 Report from the Chief Executive

5.1 5.2 5.3

KW, JK and AGS had a meeting with Gloucester Commissioners regarding the pressure on staff. They shared concerns and looked for solutions to the system-wide pressure that the NHS is facing locally. Concerns were raised that demand is not sustainable for staff or performance and demands within the control of the CCG to manage. KW spoke with Rob Webster, the Chief Executive Director of the NHS Confederation, to hear our perspective. Rob arranged for KW and two AACE colleagues to meet Simon Stephens. JF noted that because of the engagement with Directors, the Union was able to ensure appropriate messaging to its members.

6.0 Questions from the Public

6.1 6.2

BD asked the question about PTS in Devon due to the performance of the current provider. KW explained we would not be proceeding with the contract as the funding level is inadequate; the Trust has commercial principles around margins but the Trust could step in locally to support Commissioners locally. RC asked about demand, noting that it had been a mild winter. KW explained winter pressures didn’t really exist as a peak anymore and that the peak was more constant throughout the year due to the increased demand on the Service.


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6.2.1 6.2.2 6.2.3

CN noted on behalf of the staff the Trust’s recognition of the pressures that demand was causing. The Union also receiving feedback regarding the existing PTS provider, and the uncertain future of the contract, is an area of concern for some staff. CN was pleased to report that there had been good engagement from the Directors around the topics and changes are noticeable in staff, such as in recent SOPs. CN noted the increase in demand and the effort in the Trust to respond appropriately, including the ARP, DoD and the positive and innovative work being done, but staff were not impressed by the CCGs lack of funding for the Service.

7.0 Minutes of the Previous Meeting – 26 November 2015

7.1 The Minutes of the previous meeting of 28 January 2016 were approved as a correct record of proceedings.

8.0 Action Point Register

8.1 30/07/2015 9.3.3 Update – to be delivered in second quarter of 16/17. 28/01/2016 20.2 Action completed and has been added to the Risk Register The following actions were noted as completed:

30/7/15 9.38

24/9/15 12.4

28/1/16 5.2

28/1/16 5.3

28/1/16 6.3.3

28/1/16 14.6

28/1/16 20.4


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9.0 Integrated Corporate Performance Report

9.1 9.2 9.3 9.4 9.5 9.6

KW introduced the ICPR and explained that activity was up by 5% on last year with a significant number of hours lost to hand-over delay. KW explained he would answer any questions associated to the storyboard regarding performance presentation, but note should be taken that for the last 6 days the Trust had achieved the best performance it had in the last 2 to 3 years. This was due to the recovery measures in place which had been agreed to the end of April 2016. KW introduced the storyboard on the screen adding narrative which had been used at the Commissioners’ meeting where Jonathan Benger had been present. The storyboard covers a 4-week period and shows peaks and troughs linked to key activities. Paul Quick joined the Board meeting to talk through the storyboard and highlighted where performance measures, IT changes, staff changes, trials and the consequential drops and improvements in performance occurred. PQ had also factored in where additional changes had occurred on a national scale, such as guidance changes. The Board considered 111 to 999 call referral rates. FG confirmed we are over-triaging 111 calls in the North. KW shared with the Board that a recent survey of the A&E staff showed that over 75% staff would like to see the origin of their call. CN explained how calls are evaluated, and post-call notifications, as to whether the call was appropriate or not and that this was also being discussed with Dave Partlow to be incorporated in the ECPR. KW added that this pressure also existed with the GPs through the OOHs service. IR thanked the Trust for the presentation which was informative and well-received by the Board. HH summarised that despite more productivity demand is just too high. JK introduced the Finance Section of the IPCR: In Month 11 the Trust had a surplus of £108,000 compared to a planned surplus of over £500,000. The reduction is directly impacted by Commissioner fines which were withdrawn and re-invested. Month 11 showed signs of positive variance in service lines so it had been reinvested to give flexibility and spend on frontline resources to give staff some respite. JK noted that £100,000 is a respectable position based on the quality of our service and performance levels. The Trust had been asked to consider its financial outturn; this has been considered by FIC but was agreed to be too difficult to achieve a greater surplus at this point.


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PL noted that it was good to show investment can demonstrate performance gain. KW stated that the intention of the short-term investment in frontline staff was not to deliver a gain in performance but to give staff respite, encouraging them to take their breaks, to not overrun and have a better day. This would have been achieved alongside high levels of patient safety. HS noted that it was a small surplus but considering the number of NHS providers in deficit it was an important statement by the Trust. JK gave an update on the contract position and the Commissioner convergence principles that the Trust worked to. She explained the current investment schedule that had been put together which totaled £10.5m. JK explained the recurrent difference that existed between the two parties was £9.9m. JK explained the Commissioners’ position was that they could not afford the Commissioner convergence principles that had been signed up to and worked to in previous years. This included no recurrent funding for Right Care, which would have meant more time on scene for paramedics and the Trust absorbing all risks regarding growth in 16/17. KW explained that as a transparent organisation he was not looking to create tension with the Commissioners but needed staff to understand that it was not the Trust dedicating money to the frontline resources and that the Trust was committed to working with the Commissioners to secure the best deal possible for SWASFT, while continuing to support the whole health economy. The Union representatives both thanked KW for the honesty he had shown in the situation and reported that staff would be grateful for the Trust’s ongoing negotiations with CCG. HS confirmed that appropriate conversations would continue with the Commissioners but it was good to note the staffside support. VJ added that despite the lack of funding available it was difficult to see why those principles had been withheld as they were key levers for demand management. HS added public information films were required nationally to invest in public services and to signpost how to access them. HH added it appeared a systemic issue where urgent and emergency care was being used to absorb patients who had no alternate routes. HS asked about call stacking and delayed responses. KW explained that there had been up to 100 to 120 calls waiting with no resource available.


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9.7

This is happening on a regular basis and far too often. KW reiterated the safety policy in place where patients were called back and triaged as appropriate. KW explained that he was also being more proactive in complaint management, explaining to the public that resource had been outstripped by demand. KW said it was appropriate for the Board to monitor it. PT asked about hand-over delay and the lack of national decision. HS added that Monitor have also asked about hand-over delays. The Board discussed hand-over delays and capping of payments. NHS 111 – JW confirmed that 111 nationally have struggled for the last 6 weeks; a couple of providers have achieved the 90% call rate. Lack of primary care access is a contributing factor. The abandonment rate in February 2016 was low and we are doing what we can to manage; the service remains calm but the tender process in Devon and Cornwall adds uncertainty. Dorset works better as it is part of an integrated service. Recruitment and induction courses continue. JW added she was proud of the 111 team. CN added the engagement of staff in 111 is better than ever and all parties are doing whatever they can to make it work. HS thanked and praised the team for all their efforts.

10.0 Corporate Risk Register and Board Assurance Framework

10.1 10.2

The Risk Register has been re-formatted with nine risks with multiple casual risks and what contributes to them, and has been seen by Audit and Assurance Committee. JK advised us there was a new risk around corporate financials and reputation as well as major risks to performance and quality. All risks have been mapped to the strategic roles of the Trust. Internal Audit Report was completed on the BAF with rotation through the lower scoring risks on the BAF to ensure their Board visibility. HS commended the new approach. Action: JW to make the font bigger for the Risk Register VJ really liked the new format, noting it is easier to focus on issues. Recommended reviewing the graph for the risk profile. The Board of Directors took assurance from the Risk Register and Board Assurance Framework noting the controls, assurance and actions in place to manage the organisation’s risks.

JW


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11.0 2015 Staff Survey Update

11.1 11.2 11.3

EW presented the summary of the 2015 Staff Survey which was completed by 40.6% of staff (2% lower than 2014). Notable areas of improvement were seen in the following areas:

“immediate manager does not take positive interest in my health and wellbeing”,

“do not receive regular updates on patient /service feedback in my Directorate/Department”,

“Communication between senior management and staff is not effective”,

“dissatisfied with the extent the organisation values my work”,

“in the last month saw errors/near misses/incidents that could hurt staff”, and

“care of patients is not the organisation's top priority”. Trust engagement improved by three points with improved engagement in the North. EW talked through the improvement areas required. When comparing with other Trusts we were better on 55 questions, average on 29 and worse on 2. Working on local action plans. EW is looking at alternative ways for the survey to be completed and allowing longer for completion. Tony Fox noted the pressure the Trust is under, noting good engagement in the North. Hugh Hood noted the amazing results against the backdrop that the Trust is working in and asked for examples of the sorts of things that had led to this change. EW cited the OO structure, career pathways and career conversations. CN added the Unison conversations with staff were better including the development for SOPs. JF added from a North perspective that the new OOs and Managers are very supportive and relationships/mentoring are being developed and are being seen as supportive. EW considering incentives for completing linked to health and well-being. The Board of Directors approved the next steps including the introduction of a mixture of completion methods and an extended window of time.

12.0 Patient Safety and Experience Report

12.1 12.2

JW presented the Patient Safety and Experience Report covering November 2015 to February 2016. 16 SIs were reported in the period (0.002% of patient contact), compared to 13 for the same period last year. 12 moderate harm incidents were reported (0.0017% of patient contact)


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12.3 12.4 12.5 12.6

which is the same number as in the previous reporting period, and 504 complaints were received (0.075% of patient contact), an increase on the same period of last year when 457 were received. JW explained 3 themes were emerging: clinical care, access and waiting and communication. Confirmation bias is a new emerging theme which JW explained to the Board and will be raised with Clinicians on the next Clinician-on-reflect. As a result the Trust had been reviewing its guidance and feeding it out to staff. JW explained human factors and how people make errors, and how we use this information to identify system failures. HS added this is a Quality Account priority this year. JW advised a national expert on Human Factors would like to work with the Trust and she is in discussion with the AHSM. JW added that at the last Quality Development meeting there was a deep dive into communication and the impact that staff can have. EW is establishing a peer support network. Trust receives more compliments than complaints (669 in period). The Board noted the Friends and Family test data. JW reported that a clinical negligence claim was withdrawn during the period. Board of Directors took assurance from the Report and the Trust actions around delivering a safe service and positive service for our patients with a positive experience.

13.0 Information Governance Year to Date Report

13.1 13.2 13.3

FG presented the report which had already been presented to the Audit and Assurance Committee. FG confirmed he had filed the IG return reporting Level 2 compliance.

FOIs are up by 40 requests, achieving a 95.4% response rate. The Trust has received a number of media FOIs. The Trust has seen an increase in Data Protection requests (16% increase from 1173 to 2049).

The Board welcomed the detailed breakdown of adverse incidents labeled ‘Other’.

The Board of Directors took assurance from the information provided.


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14.0 Communication and Engagement

14.1

LB was welcomed to her first meeting. LB explained there had been lots of media coverage interest in the Trust and FOY requests. There is a lack of effective monitoring and evaluation of our reputation in the media, so LB brought a proposal to the Board for media monitoring. LB noted the short assurance report provided this time and explained she was developing a pro-active media plan which would ensure better representation and information to the Board. The Board of Directors took assurance from the communication.

15.0 Draft Regulatory Framework 2016/17

15.1 15.2 15.3

The Board of Directors reviewed the regulatory framework. Health and Safety was noted as an omission. KW requested that this be put back in. Action: JW. KW explained the Board would continue to receive more information regarding Health and Safety and that he and JW would be meeting an HSE Executive. AF confirmed that he was the Board lead for H&S and would be happy to support further.

JW

16.0 Board Annual Declarations

16.1 MM shared the Board Annual Declarations with the Board prior to their inclusion in the Annual Report. Action: MM to add PL’s declaration to the report. The Board of Directors took assurance from the disclosures.

MM

17.0 Membership Engagement Strategy

17.1 MM presented the draft Membership Engagement Strategy. The previous strategy had focused on ‘recruitment’ and this strategy focuses on ‘engagement’. HS requested one of the aims be amended to show that COG links with patient groups. Action: MM to amend as requested Ian Reynolds, as the Board lead for this area, welcomed the strategy and looked forward to seeing details of plans of how this would happen.

MM


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The Board of Directors approved the Membership Engagement Strategy.

18.0 Code of Conduct for Trust Governors

18.1 MM presented the Code of Conduct for Trust Governors which is a requirement of Monitor’s Code of Governance. The Board discussed the confidentiality section of the Code of Conduct, noting that there was no accountability to Governors as there is for Board members. Action: FG to pick up as part of his presentation to the next Council of Governors meeting. The Board of Directors approved the Code of Conduct for Trust Governors.

FG

19.0 Speak Up, Speak Out Policy

19.1 MM presented an update on the Speak Up, Speak Out Policy which has been renamed the “Whistleblowing Policy” with immediate effect. Due to the absence of national guidance on the role of Speak Up guardians, the Policy Review Alignment Group (PRAG) met and agreed to extend the Policy review date by a further 6 months, meaning that its review of this Policy will now be due in September 2016. MM confirmed this was being reported to the Board for their oversight. Ian Reynolds noted that the internal audit had a scheduled review of whistleblowing planned and suggested that review would help inform the policy review. EW welcomed this suggestion and the update was noted for assurance.

20.0 Committee Terms of Reference

20.1 MM presented the Terms of Reference for the Quality Committee and Audit and Assurance Committee. The Board requested one amendment to the Quality Terms of Reference: under 6.1 it states that the Committee will appoint a Deputy Chair. Action: MM to add that the Deputy Chair should also be a NED.

MM

21.0 Audit Committee Assurance Report – March 2016

21.1

PL gave a verbal update on the business of the March 2016 meeting. PL noted of particular interest to the Board was the internal audit report on the Board assurance framework which achieved significant assurance and the one recommendation had already been actioned.


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22.0 Any Other Business Identification of New Risks (incl. Health & Safety) Identification of New Legislation

No other business was discussed.

Signed: (Chair)

Dated:

A final, signed copy of the minutes are available from the meeting administrator on request

Date of MeetingMinutes

Reference

Agenda Item

(Topic)Action Allocated To Deadline Progress Date Completed

30-Jul-15 9.3.3

Corporate Risk

Register, Board

Assurance

Framework (BAF)

and Assurance Log

HS requested that when the scoring is reviewed it is important to

have clear definitions of 5 by 5. ACTION: JW and MM noted this

request.

JW 24/09/2015UPDATE: Action yet to be completed. To be

incorporated into the new risk platform

24-Sep-15 15.2. Data QualityHS requested a presentation on how the Trust uses data

collected for the Council of Governors MM to liaise with FGMM/FG 28.01.2016

UPDATE: FG delivered a presentation to the April 2016

Council of Governors

UPDATE: ACTION COMPLETE

24-Sep-15 18.2. Audit Committee

HS advised that at the next Trust Board Seminar Meeting a

discussion will be held with regard to how the Committees fit

together and how the Trust will get the best out of each one. MM

to add to the Agenda for the October 2015 Trust Board Seminar

MM 29.10.15

UPDATE: Changes to the Committee Structure have

been agreed and new TOR are being developed by each

Committee. Audit Committee training being linked to this.

New TOR will be presented for approval at the Trust

Board in March 2016.

UPDATE: Terms of reference for Audit and Quality on

Board agenda for March 2016.


26-Nov-15 8.25 ACQIsAGS and JW to provide an update at the Trust Board of Directors

Meeting in March 2016.AGS / JW 31.03.15

Update to be provided in May 2016

UPDATE: ON AGENDA

26-Nov-15 9.8 BAF

The Risk Assurance Group needs to review why strategic goal 2

has risks and strategic goal 3 has none. JW and MM to take

forward.

MM / JW 31.03.2016

UPDATE: Risk Assurance Group to meet on 8 February

and review the mapping of the existing risks and the

developemnt of new ones in line with the strategic goals.

Update to the Trust Board in March 2016. BAF shows

risks mapped against strategic goals


26-Nov-15 10.3Information

Governance

HS noted that in previous years the Trust Board of Directors has

undertaken IG Training. FG agreed that this was of benefit to the

members and to the Trust. Non-Executives to do online training

by end of quarter 4.

MM 28.03.2016 Action not yet completed.

Trust Public Board Meeting Action Point Register - 2015-16

At each Trust Board Meeting action points are recorded throughout the meeting to note items which need further development, additional work or raise other issues which need to be considered or discussed. This document has been created

to keep a record of these action points. This will be a yearly document and incomplete action points will be reported to each meeting along with action points which have been completed since the last meeting.

26-Nov-15 11Patient Safety and

Experience Report

With regard to the Friends and Family Test data KW asked if it

would be possible to get other ambulance services data. JW to

include this for next report.

JW 28.01.16

Benchmarking data that is available is minimal with many

Trusts doing it differently. Working with commissioners to

agree local change. Reported to the March 2016 Board.


28-Jan-16 10.8Integrated Corporate

Performance Report

NLC to provide a report on utilisation of CFRs for review at the

next Trust Board of Directors Meeting in March 2016.NLC 31.03.2016 Deferred to July 2016 Board meeting

28-Jan-16 19.3 Quality Approach

JW will present the full Quality Strategy to the next Trust Board of

Directors in March 2016. The full Quality Strategy would be

presented to the Quality Committee for approval. ACTION: JW

to take this forward.

JW 31.03.2016Quality Committee to receive in April 2016 and Board to

reciev in May 2016.

28-Jan-16 19.3Academic health

Science Network

JK to compile a list of subscriptions to organizations for

presentation to the Trust Board of Directors .JK 31.05.2016

Subscriptions information will be collated post year end

and presented to the Board in May 2016.

UPDATE: ON AGENDA

30-Mar-16 10.2

Corporate Risk

Register and Board

Assurance

Framework

JW to make the font bigger for the Risk Register JW 26.05.2016

This is under review pending the new risk register system.

If the font size is made bigger this will mean we will have

to remove text from the cells due to the maximum number

of characters per cell. This will have an impact on the

information to support the management of the risk.

30-Mar-16 15.2Draft Regulatory

Framework Health and Safety to be added to the Regulatory Framework MM 26.05.2016

Health and Safety added


30-Mar-16 16.1Board Annual

Declarations Paul Love's declaration to be added MM 26.05.2016

Declaration added


30-Mar-16 17.1

Membership

Engagement

Strategy

One of the aims be amended to show COG links with patient

groups MM 26.05.2016

Amendment made


30-Mar-16 18.1Code of Conduct for

Trust Governors

FG to cover as part of his presentation to the Council of

Governors FG 26.05.2016

Francis covered in April 2016 COG meeting


30-Mar-16 20.1Committee Terms of

Reference Add that the Vice Chair of the Committee must be a NED MM 26.05.2016

Amendment made


Integrated Corporate Performance Report

April 2016

Title of originator/author: Paul Quick, Performance Manager

Jessica Hodgman, Director of Planning and Performance

Name of responsible director: Jennie Kingston, Deputy Chief Executive/Executive Director of Finance

Date issued: 20 May 2016

SWASFT Integrated Corporate Performance Report

INTEGRATED CORPORATE PERFORMANCE REPORT PAGE 2 of 63

1. Introduction

1.1. The South Western Ambulance Service NHS Foundation Trust (SWASFT) monthly Integrated Corporate Performance Report (ICPR), reports performance by exception and focuses on action being taken by the Trust to address off plan performance.

1.2. The Integrated Corporate Performance Report is structured as follows:

Reported in the ICPR Monthly Reported in the Confidential

Addendum

• A Performance Dashboard summarising performance across all metrics;

• Ambulance National Quality Measures, covering Patient Safety, Effectiveness and Experience;

• Ambulance National Clinical Quality Indicators;

• Local standards and thresholds agreed with NHS Commissioners;

• Internal Trust Key Performance Indicators (KPIs);

• Resource Performance Measures, covering REAP level, service line activity, financial position and capacity and capability metrics;

• A&E and PTS activity levels are reported within this report;

• Trust performance against the NHS Improvements (NHSI) Compliance Framework (and subsequently Risk Assessment Framework);

• Analysis of the Trust Carbon Footprint (including vehicle carbon emissions);

• Right Care 2.

• The position against the A&E, OOH and NHS 111 commissioning contracts;

• CQUIN performance;

• Performance ‘deep dives’ as appropriate.

Corporate Objectives 2016/17

1.3. The Trust Board has agreed four Corporate Objectives for 2016/17, these provide a framework for delivering the major change programmes and service developments:

Supporting Staff: This objective focuses on embedding a robust culture of supporting staff and changes the shape of training and support;

Delivering Performance: This objective focuses on the Trust’s contractual and national obligations in relation to key performance indicators and how the Trust intends to deliver these in the current year;

Clinical Quality: This objective continues the focus of the Trust on delivering the basics to a high standard and ensuring that a high quality safe and effective service is delivered to patients, It includes the Trust’s approach to quality improvement, proposed CQUIN initiatives for 2016/17 and the Trust’s ‘sign up to safety’ priorities;

No Compromise: This objective addresses the change in financial risk appetite within the Trust in relation to existing contracts, securing new business and approaching new opportunities.

A&E Operational Plan 2016/17

1.4. 2016/17 will be a year of significant change and uncertainty. The Trust is operating in the context of wide scale NHS reforms that are, and will continue to have a material impact on the future operating model.



1.5. A number of significant developments come together during 2016/17, creating a period of flux and uncertainty for the first half of the year, followed by whole system transformation in the latter part of 2016/17 driven by national and local policy and initiatives.

1.6. The most material of these are:

The national Ambulance Response Programme (ARP);

The next stage of the Urgent and Emergency Care Review;

The development of transformation plans across health and care systems.

1.7. This is coupled with an intensive programme of internal modernisation that addresses both legacy issues from the acquisition of the Great Western Ambulance Service and new plans for service change in systems, clinical pathways and structures. All of these elements need to align to inform the development of a realistic and deliverable plan for 2016/17 and beyond.

1.8. In this context the Trust has considered how best to approach the development of an Operational Plan for 2016/17. The Plan needs to deliver “business as usual‟, key contractual requirements and maintain a high quality, safe and effective service for patients, whilst remaining sufficiently flexible in order to incorporate the material changes that lie ahead.

1.9. In response to the uncertainty that exists, the Trust is working up a two year planning framework that will be overlaid with the five year Sustainability and Transformation Plan (STP). This aligns to the planning requirements of NHSI and NHS England and recognises the sequencing of events that sit outside of the Trust’s control which will ultimately dictate the shape of the final Plan for the organisation in 2016/17.

1.10. For 2016/17 the Trust prepared has prepared a six month work programme covering the period 1 April to 30 September 2016 setting out the key activities that will support delivery of the major transformation and modernisation programmes including a triangulation of the key workforce, financial and quality indicators where known. The Trust will then produce an 18 month 999 A&E Operating Plan for the period 1 September 2016 to 31 March 2018



2. Performance Exceptions

2.1. The ICPR focuses on exceptional performance and aims to provide the Trust with an early warning of deteriorating performance.

2.2. The four reporting categories assigned to individual performance metrics contained within the

ICPR are as follows:

Performance In Line With Plan: Performance in the reporting period is on or above target and there are currently no predicted risks to the Trusts quarterly or forecast year end performance. However where performance is below a national or contractual target this is taken into account when assigning this performance exception category;

Early Warning: Performance in the reporting period could be on or above target but there is evidence that performance is deteriorating or moving off trajectory AND/OR a metric has been escalated by a Directorate as part of the Trusts Performance Management arrangements. This indicates to the Trust that there is a perceived risk to performance regardless of whether this is evident in the reporting period;

Improvement Expected: Performance in the reporting period is below target but there is evidence that performance is improving AND/OR there is confidence in the action(s) being taken by the Trust. The forecast outturn position is therefore expected to be on or above plan if a performance metric is reported in this category;

Escalated Performance Issue: Performance in the reporting period is significantly off plan and there is currently no action plan in place OR there is insufficient evidence of improvement as a result of actions already agreed and being taken by the Trust in order to improve performance.

2.3. There is a direct link between the exception category assigned to individual performance metrics and the level of detail and assurance provided in the ICPR. Appendix A sets out the Trust approach to reporting performance exceptions and specifies the level of information and assurance required by the Board of Directors.

Table 1: Performance Exception Overview in the Reporting Period

Early Warning

The staff turnover rate remains high at 15.07% at the end of April 2016 (reducing to 14.08% excluding redundancies);

Staff Appraisal rates were below the internal KPI target of 85%.

Performance In Line With Plan

A&E (999) Activity levels (demand) in April 2016 was 3.02% below contracted volumes and 0.73% lower than the activity levels seen in April 2015.

Re-contact rates following treatment at scene were lower (better than) the local performance threshold;

Re-contact rates following telephone advice were lower (better than) the local performance threshold;

Ambulance calls closed with telephone advice are above (better than) local thresholds;

ROSC following cardiac arrest was above (better than) local thresholds;

Stroke patients receiving the appropriate care bundle is above local thresholds;

Information Governance Toolkit is RAG rated as Green at the end of April 2016.

Urgent Care Service QR12: In the county of Dorset performance for Less Urgent Base Consultations was above (better than) the 95% performance target;

Urgent Care Service QR12: In the county of Gloucestershire performance for Less Urgent Base Consultations was above (better than) the 95% performance target;



NHS 111 call abandonment rates were below (better than) the national KPI level of 5% in all three counties in April 2016;

Tiverton UCC performance against the 4 hour

treatment time was above the 95% target;

Vehicle deep clean compliance was above (better than) local target levels in April 2016.

Compliance with Infection Prevention and Control.

Escalated Performance Issue

1,962 of operational resource hours were lost to

chargeable handover delays at acute hospitals in April 2016. This equates to an average of 65 hours lost per day across the Trust.

NHS 111 call answering performance is below (worse than) the 95% national KPI level in April 2016, although improved compared to March 2016.

Improvement Expected

Red Performance (ARP) for the period 19 to 30 April 2016 was below (worse than) the performance target of 75%;

Red 1 performance for the period 1 to 18 April 2016 was below (worse than) the national performance target of 75%;

Red 2 and Red 19 performance were below (worse than) national targets for the period 1 to 18 April 2016 2016 however this is in part related to the Ambulance Response Programme (ARP) changes implemented during 2015/16.

Percentage of A&E calls abandoned and Time to

Answer Calls in April 2016 were marginally above (worse than) the local thresholds;

Ambulance incidents managed without transport

to A&E department are below (worse than) local thresholds;

Outcome from STEMI PPCI, patients receiving primary angioplasty commencing within 150 minutes;

Outcome from Stroke, patients receiving thrombolysis at an hyper-acute centre within 60 minutes is below (worse than) local thresholds;

Acute STEMI patients receiving the appropriate care bundle was below the local threshold;

Outcome from cardiac arrest, survival to discharge rates, were marginally below the local thresholds;

NHS 111 Call Audit volumes are below (lower than) the target level at present, the Trust has internal improvement trajectories for both Hubs.

Urgent Care Service QR12: An improvement is expected for both the Gloucestershire and Dorset OOH performance for those measures where performance is below the national target levels;

Two PTS KPIs in the BNSSG contact are below agreed levels for April 2016;

Sickness levels across the trust are improving but was 5.19% in April 2016 compared to a Trust target of 4.00%.



3. National Ambulance Response Programme (ARP)

3.1. The current time-based ambulance response standards, in the face of rising demand for ambulance resources, have led to a range of operational behaviours that appear increasingly inefficient.

3.2. The issues with the current standards include:

Dispatching resources to a 999 call, on blue lights and sirens, before it has been determined what the problem is and whether an ambulance is actually required;

Dispatching multiple ambulance vehicles to the same patient, on blue lights and sirens and then standing down vehicles least likely to arrive first;

Diverting ambulance vehicles from one call to another repeatedly, so that ambulance clinicians are constantly chasing time standards;

Using a ‘fast response unit’ to ‘stop the clock’, when this provides limited clinical value to a patient, who then waits for a conveying ambulance;

Very long waits for lower priority calls that nevertheless need assessment and conveyance to hospital.

3.3. There is a requirement to develop a better model of response to enhance patient outcomes, significantly improve patient experience and reduce mortality by accurately prioritising those patients with the greatest need.

3.4. The national Ambulance Response Programe (ARP) aims to improve response times to critically ill patients, making sure the best response is sent to each incident first time with the appropriate degree of urgency. ARP is not about the fastest possible response, but the best response for each patient.

3.5. As part of the ARP, during 2015/16, the Trust worked closely with NHS Commissioner, NHS England and the Association of Ambulance Chief Executives (AACE) to develop more effective and appropriate methods of dispatching ambulance resources. This included the prioritising the dispatch of ambulance resources to the more acute patients (i.e. Red 1 incidents).

3.6. For the next phase of the ARP, SWASFT and the Yorkshire Ambulance Service have been selected to undertake a 12 week trial which commenced on 19 April 2016.

3.7. The objectives of the trial are to:

Use a new pre-triage (nature of call) set of questions for 999 incidents;

Achieve a more clinically focused and patient based set of outcome standards delivering an improved experience for all patients;

Deliver more available resources, as a result of fewer multiple allocations, to respond to life-threatening incidents;

Allocate the most clinically appropriate resource to patients by taking time to triage the call and increase the use of the Hear & Treat and See & Treat patient pathways where clinically appropriate;

Create a new evidence-based set of clinical codes that better describe the patient’s problem and response/resource required.

3.8. The development and delivery of the ARP is underpinned by a comprehensive governance structure, led by NHS England and includes NHS Improvement and AACE. The findings from the trial will also be subject to independent review by the Sheffield University.

3.9. At a local level the Trust is ensuring additional quality controls are in place to provide further assurance and oversight as the trial progresses, this includes a dedicated Programme Board led by the Chief Executive which will report progress to the Trust Board.



3.10. The trial will include the introduction of new call categories and definitions, moving away from the existing Red 1, Red 2, Red 19, Green 1, etc classifications:

RED

Time critical life threatening event needing immediate intervention and/or resuscitation. e.g. cardiac/respiratory arrest, airway obstruction, ineffective breathing, unconscious with abnormal or noisy breathing, hanging. Mortality rates are high, where a difference of one minute in response time is likely to affect the outcome and there is evidence to support the fastest response.

AMBER (R) e.g. Probable MI, serious injury Blue light response needing face to face assessment by a suitably qualified clinician. Potentially serious conditions that may require rapid assessment, urgent on-scene intervention, analgesia and/or urgent transport. A difference of 15 minutes response time is likely to affect outcome and there is evidence to support early dispatch of resources.

AMBER (T) e.g. Stroke

AMBER (F) e.g. Fits, diabetic, overdose, hyper/hypoglycaemia

GREEN (F) Face to face assessment and management that may include transport.

Urgent problem that needs transport within a clinically appropriate timeframe or a further face to face or telephone assessment and management. Mortality rates are very low or zero. A difference of one hour or more might affect outcome and there is evidence to support alternative pathways of care.

GREEN (T) Transport only required, including calls from Healthcare Professionals.

GREEN (H)

Calls which do not require an ambulance response, but do require onward referral or attendance of non-ambulance provider in line with locally agreed plans or dispositions, or can be closed with clinical advice (Hear and Treat incidents).

3.11. The trial aims to collect sufficient evidence to inform the optimum response model for ambulance trusts and to inform future performance and outcome targets applicable to the ambulance sector. Initial targets for the trial are therefore limited, but the trusts involved will be subject to the close governance and monitoring identified above.

3.12. A single target to deliver 75% of responses to Red incidents within 8 minutes has been introduced during the trial period. Performance against the 75% target will be reported on a monthly basis within the Integrated Corporate Performance Report. Response times will also be reported at the 50th, 75th and 95th percentiles during the trial period.



3.13. In addition to the Red response time information the Trust will report against the times taken for conveying resources to arrive at scene, this will be reported as Red (T). For this report times will be reported at the 50th, 75th and 95th percentiles for reference. There are currently no specific targets for this metric.

3.14. For Amber and Green incidents the trial will collect an evidence base to inform future performance and outcome metrics against which ambulance trusts will be monitored. During the initial stage of the trial response time information will be reported for Amber R, Amber T, Amber F, Green F and Green T metrics giving the 50th, 75th and 95th percentiles for reference.

3.15. NHS England will also collect accelerated clinical outcome data during the trial period. This will provide ambulance-dependent clinical indicator data for cardiac arrest, stroke and heart attack incidents every two weeks.

3.16. From Quarter 2 onwards NHS England aims to refine the code sets and associated performance standards and develop a set of new, patient focused, outcome measures. As these refined and new measures emerge the Trust will be in a position to undertake further modeling and analysis to identify the optimal operational model and investment plan. The outputs from this work will be built into the Trust Transition Plan effective from 1 October 2016.



4. Summary of Benchmarked Position - March 2016

4.1. The following benchmarking data compares the performance of the Trust with other ambulance services in England. National benchmarking data is only available for March 2016 and not for April 2016.

4.2. Performance for all ambulance trusts in 2015/16 was reported against the Red 1, Red 2 and A19 performance metrics. Due to the ARP comparable figures will not be available with effect from April 2016 with only SWASFT and Yorkshire Ambulance Service partaking in the trial during April 2016.

National Benchmarking Against Other Ambulance Trusts 4.3. National average performance (all ambulance services) against all three Red performance for

the year ending 31 March 2016 was below the national targets.

Table 2: National Average Performance –12 Months Performance

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

2015/16

Red 1 75.63% 76.72% 74.79% 74.53% 73.65% 72.90% 73.35% 71.92% 72.56% 69.90% 68.02% 66.50% 72.47%

Red 2 72.37% 73.22% 71.37% 70.58% 69.73% 68.93% 68.81% 67.38% 67.15% 63.30% 60.28% 58.00% 67.25%

A19 95.03% 95.31% 94.36% 93.78% 93.55% 93.17% 93.02% 92.58% 92.55% 91.10% 89.75% 88.00% 92.63%

Impact of the Ambulance Response Review Programme (ARP) on SWASFT 2015/16

4.4. As part of the Ambulance Response Review (including the introduction of Dispatch on

Disposition) SWASFT reported Red 1 performance above the national average performance for the period April 2015 to January 2016, but was marginally below the national average in both February 2016 (66.03% compared to the national average of 68.02%) and March 2016 (66.50% compared to the national average of 67.91%).

4.5. For the year ending 31 March 2016 SWASFT was above the national average for Red 1 performance but below the national average for Red 2 and A19 performance metrics.

Note: Performance against both of these targets has been impacted by the introduction of Dispatch on Disposition in SWASFT. SWASFT was the first ambulance service in the UK to move to this way of dispatching resources and therefore this needs to be taken into account in comparing the performance of SWASFT with other UK ambulance services.

4.6. As part of the second phase of the ARP, dispatching resources on disposition was introduced into four more ambulance trusts in the UK with effect from October 2015. Also as part of this next stage of the ARP, SWASFT made further changes to the dispatch processes in November and December 2015 in line with national guidance and agreement.

4.7. The impact on patient care and Trust performance as a result of these changes is reviewed internally on a daily basis and reviewed nationally within the ARP Working Group on a weekly basis. The data provided by SWASFT will be used to help inform further national developments.

4.8. It has been agreed that the impact on Red 2 performance for SWASFT is a reduction in performance of 5%. If this is added to the reported performance of 63.60% for the year ending 31 March 2016 then SWASFTs adjusted performance that should be used to compare SWASFT nationally is 68.60%, 1.35% above the national average for Red 2 in the same period.



4.9. The graphs below compare UK performance and include SWASFTs Red 2 adjusted performance. Based on this SWASFT is above average Red 1 and 2 UK performance.

March 2016 (12 Months) Benchmarking Against Other Ambulance Trusts

4.10. For the period April 2015 to March 2016 SWASFT was above the national average for Red 1 and for Red 2 (adjusted position).



5. NHS Improvement’s Risk Assessment Framework 5.1. On 1 April 2016, NHS Improvement (NHSI) launched, bringing together Monitor, NHS TDA,

Patient Safety team, the National Reporting and Learning System, the Advancing Change Team and the Intensive Support Teams.

5.2. NHSI provide a single oversight framework during 2016/17 that is based on the principle of

earned autonomy and that segments providers according to the extent to which they meet the single definition of success that incorporates:

Finance and use of resources;

Quality;

Operational performance;

Strategic change;

Leadership and improvement capability.

5.3. NHSI intend to launch a consultation on proposals for this framework during Quarter 1 of

2016/17. In the meantime, the current frameworks, including Monitor’s Risk Assessment Framework (RAF) and the TDA’s Accountability Framework will remain in place.

Risk Assessment Framework 5.4. Since 1 April 2013 all NHS Foundation Trusts have needed a license from NHSI (previously

from Monitor), the independent regulator, stipulating conditions they must meet to operate. This includes financial sustainability and governance requirements. NHSI’s Risk Assessment Framework (RAF) sets out the approach to assessing compliance with these conditions, including information on the two risk ratings that are allocated to a Trust on a quarterly basis to indicate any concerns:

The Governance Risk Rating – is explained further in the following paragraphs;

The Financial Sustainability Risk Rating – this is set out in more detail in section 12.

5.5. NHSI uses the Governance Risk Rating to describe their views of the governance of the Trust. NHSI generates this rating by considering a range of information and forms a view as to whether this is indicative of a potential breach of the Governance Condition. Further details on how the Rating is derived can be found within Appendix C.

ARP and the Risk Assessment Framework 5.6. Following the introduction of the ARP Trial on 19 April 2016 three of the Access and

Outcomes metrics included within the Governance Risk rating assessment for ambulance services are no longer collected (Red 1, Red 2 and A19 performance metrics).

5.7. SWASFT are the only ambulance service with a Foundation Trust licence that is participating

in the ARP trial at present, therefore the Quality and Outcome metrics remain applicable to other ambulance services for 2016/17. NHSI has yet to confirm to the Trust what quality measures they intend to assess in place of the Red 1, Red 2 and A19 metrics.

5.8. The Trust is working on the assumption that all other elements of the Risk Assessment

Framework remain the same for 2016/17.

Regulatory Ratings 2015/16 5.9. During 2015/16 the Trust achieved its planned governance risk rating of Green for the first

two quarters. Following assessment of the Quarter 3 return Monitor (now NHSI) communicated that they had decided to change the Trust’s governance rating from Green to ‘under review – requesting further information’.



5.10. This assessment followed a period where the Trust failed to meet the Red 2 and A19 response time targets, the NHS England investigation report findings into a serious incident and whistleblower allegations regarding the NHS 111 service.

5.11. The Trust commissioned an independent investigation, by PricewaterhouseCoopers, into

these allegations and the Trust, NHSI and linked CCGs are awaiting the outcome. The Trust is currently reviewing a draft report on the first phase of this investigation.

5.12. During 2015 the Trust also achieved its planned continuity of services risk rating of 4 for three

quarters. These scores were determined through an assessment of key submissions to Monitor (now NHSI) supported by assurance reports to the Board of Directors against the requirements of the Risk Assessment Framework.

5.13. The outcome of the Trust’s monitoring return for quarter 4 of 2015/16 has not been confirmed

by NHSI at the time of this report.



6. Accident and Emergency (999) Performance

This section reviews the 999 activity and the factors contributing to performance.

Accident and Emergency (999) Activity Levels 6.1. The Trust has a single A&E contract for 2016/17, based on a contract currency of ‘incidents’,

covering all operational areas of the Trust. The baseline contract for 2016/17 incorporates an

uplift of 3.90% compared to the actual incident numbers reported in 2015/16.

Month of April 2016

6.2. Incident volumes during the month of April 2016 in isolation were 3.02% below contract. Further information can be found in Section 10 of this report.

6.3. Trust activity and performance is monitored across 3 Divisions as follows:

West: Kernow CCG, NEW Devon CCG and South Devon & Torbay CCG;

East: Somerset CCG and Dorset CCG;

North: Bath & North East Somerset CCG, Bristol CCG, South Gloucestershire CCG, Wiltshire CCG, North Somerset CCG, Swindon CCG and Gloucestershire CCG.

Table 3: Comparison of Activity against the Contract in the Month of April 2016

Actual Activity

April 2016

Contract Activity

April 2016 % Variance

West Division A&E Incidents

24,598 25,154 -2.21%

East Division A&E Incidents

18,241 19,237 -5.18%

North Division A&E Incidents

28,936 29,725 -2.65%

Total

A&E Incidents 71,881 74,116 -3.02%

6.4. The table above compares actual activity levels to the contract and table 4 below compares actual activity levels to the same month last year. It should be noted that Easter in 2015 fell in the month of April, while Easter in 2016 fell in the month of March.

Table 4: Activity in the Month of April 2016 compared to April 2015

Actual Activity

April 2016

Actual Activity

April 2015 % Variance

West Division A&E Incidents

24,598 23,863 +3.08%

East Division A&E Incidents

18,241 18,447 -1.12%

North Division A&E Incidents

28,936 28,909 +0.09%

Total

A&E Incidents 71,881 72,409 -0.73%

6.5. Ambulance activity originates from three main sources:

Incidents received from the public calling 999;

Incidents received from Healthcare Professionals (including GPs and Hospitals);

Incidents received from the NHS 111 service providers.

6.6. For April 2016 the activity volumes from these three sources show variances compared to the

April 2015. The volume of incidents from the Public (down 2.71%) and Healthcare



Professionals (down 2.21%) have reduced while the volume of incidents originating from NHS 111 has increased by 8.59%.

Table 5: Source of the Activity Variances comparing 2016/17 to 2015/16

Source of Incident April 2015 April 2016 Variance

Public Incidents 49,418 48,077 -2.71%

NHS 111 Incidents 12,230 13,281 +8.59%

HCP Incidents 10,761 10,523 -2.21%

Total Incidents 72,409 71,881 -0.73%

Weekly Incident Volumes 6.7. Weekly incident numbers reduced below 17,000 incidents per week during April 2016, having

peaked above 18,000 incidents per week during March 2016 leading up to the Easter period.

6.8. Activity increase to 17,801 incidents for the week commencing 2 May 2016 following the Bank

Holiday Weekend, this equated to an average of 2,543 incidents per day across the week. The largest proportion of activity remains over the weekend period, when incident numbers regularly exceed 2,750 incidents per day on both Saturdays and Sundays.

Handover Delays 6.9. There has been a small improvement in the operational time lost to handover delays in April

2016. The total time lost to chargeable handover delays in April 2016 was 1,962 hours or an average of 65 hours lost per day.

6.10. Note that chargeable delays are only applicable for identified delays recorded over 30

minutes although the time lost on these delays is calculated from 15 minutes. 15 minutes is recognised as the ‘zero tolerance’ national standard for the NHS.

Table 7: Average Hours Lost per Day to Chargeable Handover Delays

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

Average Hours Lost per Day

37 34 32 35 37 43 49 50 46 62 71 84 65



6.11. Despite the recent reduction, the total time lost to chargeable handover delays in excess of

15 minutes in April 2016 was 859 hours greater than the time lost in April 2015 representing a 78% increase. This equates to an average increase in the time lost of 29 hours per day across the month.

6.12. The year on year increase in handover delays and particularly the further stepped increase

from January 2016 onwards, has undoubtedly impacted on performance and has reduced the time ambulance resources have been available to respond to incidents across the South West. The Trust continues to work extremely closely with its commissioner colleagues and colleagues in the acute hospitals to help manage the flow of patients into hospital. Capacity challenges in a significant number of acute hospitals remain however and therefore the ability to manage increased activity levels is becoming increasingly difficult in some areas.

6.13. The Trust has local action plans with hospitals to reduce delays but the impact of these plans

is variable and the time lost to all handover delays over 15 minutes in length (chargeable and non-chargeable) is increasing and peaked at an average of 120 hours of lost operational resource per day in March 2016, reducing to 98 hours per day in April 2016.

Table 8: Average Hours Lost per Day to All Handover Delays (Chargeable and Non

Chargeable)

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

Average Hours Lost per Day

56 50 49 52 55 62 68 71 72 87 100 120 98

Operational Resource Changes 6.14. 2016/17 will be a year of significant change within the ambulance sector and for SWASFT.

The Trust is operating in the context of wide scale NHS reforms that are, and will continue to have a material impact on the future operating model.

6.15. The most material of these are the national Ambulance Response Programme (ARP), the next stage of the Urgent and Emergency Care Review and the development of transformation plans across health and care systems.

6.16. This is coupled with an intensive programme of internal modernisation that addresses both legacy issues from the acquisition of Great Western Ambulance Service and new plans for service change in systems, clinical pathways and structures.

6.17. As a result of the above the Trust is undertaking significant resource modeling and analysis with the assistance of ORH during Quarter 1 of 2016/17. This work continues on the back of the work already completed at the end of 2015/16 in preparation for the ARP trial.

6.18. This objective of this review is to assess the resource consequences of the new performance regime and the new operational delivery model ARP will require.

6.19. The findings of this workstream are likely to include:

changes to the resource mix within the service - making sure the right types of resources are available;

frontline recruitment required to provide the optimum mix of frontline staff for the new resource mix;

changes to rotas for operational resources - making the right resources available at the right time to match demand;

introduction of revised dispatch points for operational resources;



investment in the A&E Clinical Hub to deliver optimum resources to manage incoming incidents – call advisors and clinicians working within the Hub;

introduction of revised technology to realise the benefits offered by the new ways of working under ARP.

Management of Green Incidents

6.20. The Trust has been running a ‘Green Call Pilot’ in the NEW Devon CCG area from 18 January 2016 on behalf of all commissioners. The objective of the pilot is to assess whether there is a different dispatch, operating and resourcing model for handling green calls that are received by the ambulance service.

6.21. The Trust is extending the pilot exercise into South Devon and Torbay CCG and Kernow

CCG areas during 2016/17 as part of a CQUIN scheme.

6.22. The data provided by the trial to date is being reviewed to identify any immediate actions that

can be taken within the NEW Devon area, but the Trust will look to use the increased data set available from the enlarged operational area to inform any trust-wide developments.



7. Ambulance National Quality Measures

7.1. This section provides a summary of performance against each of the Ambulance National Quality Measures. The definition and national target for each measure is provided in Appendix C.

7.2. Performance for Red1, Red 2 and Red 19 performance metrics are included in this

report for completeness but only apply for the period 1 to 18 April 2016. From the 19

April 2016 the Trust will be reporting against the ARP trial metrics as outlined earlier in

this report and included at Appendix B of this report for future reference.

Accident and Emergency Service Line: Category A Performance: Red 1 (75%) Performance Exception Status: Red 1 Performance for the period 1 to 18 April 2016 was 2.27% below the national performance target of 75%.

Reason(s) for the performance exception category assigned in the reporting period: • The Trust is contracted by NHS Commissioners to deliver performance of 75% at a whole Trust level.

• The Red 1 target is a challenging target due to the small number of Red 1 incidents across the South West.

• Red 1 performance for the month of March 2016 was 67.91%, 7.09% below the national target of 75%, this improved to 72.73% in April 2016 but was still 2.27% below the national target.

• The Trust recorded 924 Red 1 incidents in the period 1 to 18 April 2016 (an average of 52 Red 1 incidents per day across the South West). Of these incidents 672 received a response within the 8 minute performance target.

Actual Performance National Target

Variance to National

Target

Month: April 2016 (1

st to 18

th April 2016 only)

Actual Performance 72.73% 75.00% (2.27%)

Accident and Emergency Service Line: Category A Performance: Red 2 Performance Exception Status: Performance in April 2016 was below the national performance target.


• The Trust has agreed a contract variation with Commissioners confirming that the Trust should deliver 70% performance for Red 2 accounting for the impact of ARP (calculated at 5%).

• Red 2 performance for the period 1 to 18 April 2016 was 56.87% (49.85% in March 2016).

Actual Performance


Target (75.00%)

Variance to Adjusted

Target (70.00%)


st to 18

th April 2016 only)

Actual Performance 56.87% (18.13%) (13.13%)



Accident and Emergency Service Line: Category A Performance: Red 19 (95%) Performance Exception Status: Performance in April 2016 was below the national performance target.


• The Trust delivered Red 19 performance of 86.07% for the period 1 to 18 April 2016 (80.90% in March 2016).



Target

Month: April 2016 (1st to 18

th April 2016)




ARP Trial Performance (19 to 30 April 2016)

Accident and Emergency Service Line: Red Response Performance (ARP Trial) Performance Exception Status: Performance for the period 19 to 30 April 2016 was below the national performance target.

Reason(s) for the performance exception category assigned in the reporting period: • The Red Response performance target during the trial period is 75% of incidents receiving a response within

8 minutes at a whole Trust level.

• Red Response performance for the period 19 to 30 April 2016 was 66.79%, 8.21% below the target of 75%.

• During the first two days of the ARP trial the Trust experienced some technical difficulties which required the Clinical Hub to move to manual card entry for a period of time which effected Red performance in particular during this period. These issues have now been resolved.

• Excluding performance on the first two days of the trial the Trust delivered Red performance of 68.58% for the period 21 to 30 April 2016.



Target


th to 30

th April 2016 only)


7.3. 50% of Red incidents received a response within 6.6 minutes, 75% received a response within 9.2 minutes and 95% of Red incidents received a response within 18 minutes.



7.4. Approximately 6% of all incidents received by SWASFT during the trial period to date have been identified as Red incidents. This equates to an average of 149 Red incidents per day across the South West.

7.5. This compares to an average of 50 Red 1 incidents per day and 860 Red 2 incidents per day across SWASFT in 2015/16.

7.6. Throughout the trial period the Trust is reviewing the activity volumes and profile of Red

activity by hour of day/day of week to identify any recurrent trends of patterns which may be used to inform future operational resource modeling.

Red Response Performance by CCG

19 April 2016 to 30 April 2016

CCG Red Incidents

Red Incidents

Receiving a

Response within

8 Mins

Red Performance %

Red Response

Time 50th

Percentile (Mins)

Red Response

Time 75th

Percentile (Mins)

BANES 45 30 66.67% 7.0 8.5

Bristol 163 119 73.01% 6.8 8.2

Dorset 270 190 70.37% 5.9 8.5

Gloucestershire 160 94 58.75% 7.0 10.4

Kernow 188 122 64.89% 6.4 9.5

NEW Devon 286 197 68.88% 6.2 9.4

North Somerset 52 33 63.46% 6.7 10.9

Somerset 137 99 72.26% 6.0 8.7

South Devon & Torbay 98 72 73.47% 6.1 8.1

South Gloucestershire 62 43 69.35% 6.7 10.0

Swindon 69 44 63.77% 6.7 8.8

Wiltshire 103 49 47.57% 8.3 11.8

Total 1,635 1,092 66.79% 6.6 9.2



7.7. Red Transport response time metrics measure the time taken for conveying resources to arrive at the scene of the incident.

7.8. For the period 19 to 30 April 2016, 50% of incidents received a conveying resource within 9.2 minutes, 75% within 16.1 minutes and 95% within 32.0 minutes.

7.9. Amber incidents require a blue light emergency response by a suitably qualified clinician. These incidents are potentially serious conditions that may require rapid assessment, urgent on-scene intervention, analgesia and/or urgent transport.

7.10. The type of response required and the clinical qualification of the resource required are

determined by the clinical triage process in the Clinical Hub. The response time metrics are designed to measure the time taken to deliver the appropriate response to the incident as opposed to any response arriving at scene.

7.11. Nearly 74% of the activity during the first 11 days of trial has been coded as Amber, either

Amber F (13%), Amber R (47%) or Amber T (14%).

7.12. For the period 19 to 30 April 2016, 50% of Amber F incidents received a response within 15.2

minutes, 50% of Amber R incidents received a response within 19.7 minutes an 50% of Amber T incidents received a response within 22.2 minutes.



7.13. Green Incidents are urgent problems that need transport within a clinically appropriate timeframe or a further face to face or telephony assessment and management. Green F and Green T (999) incidents were triaged as requiring a response at scene.

7.14. 50% of Green F incidents received an appropriate response at scene within 37.0 minutes and 50% of Green T (999) incidents received an appropriate response at scene within 47.7 minutes.

7.15. The Green T (HCP) incidents relate to requests from Healthcare Professionals (including GPs and Hospitals) to undertake urgent transfers of patients within a 1, 2, 3 or 4 hour time windows dependent on their clinical assessment of the requirements of the patient.

7.16. In the period 19 to 30 April 2016 66.93% of the 1,412 Green T (HCP) incidents received a response within the required time window.

Exception Report: Red Performance in April 2016 7.17. A number of key actions, originally identified and introduced during Quarter 4 of 2015/16,

have been carried forward in April and May 2016 to support operational performance during the early stages of the ARP trial.

7.18. These actions were focused on: Clinical Hub: Improving call handling capacity and call answering performance; Clinical Hub: Improving the Clinical Support available in the Hub; A range of actions focusing on increasing frontline operational resources; A focus on Call Cycle length; Completion of CAD implementation and the staff familiarisation programme.



7.19. In addition, as identified earlier in this report, the Trust is working closely with ORH to review the operational model for delivery following the changes made under the ARP trial.

7.20. The key actions are summarised in the table below.

Planned Mitigating Action being

taken by the Trust Timescales for Action

Performance Improvement / Impact

Expected

Review of the current Operational Model for Delivery

• The review will focus on the location and profile of current resources to deliver the best match to current demand.

• In particular the review will identify any required changes to resource types and profiles required as a result of the changes made under the ARP trial introduction in April 2016.

• To complete this review the Trust has commissioned Occupational Research in Health (ORH):

• An independent review of the current position;

• Support in reviewing potential options for operational models of delivery for 2016/17 and beyond.

• Scope and specification for this completed in August 2015.

• Interim meetings to discuss outputs and further areas for review October and November

• A staged approach to the review has been agreed - report outlining the key findings of initial review January 2016.

• Following stage one of this review the Trust, working with the consultants, has identified a number of key areas for focus and modelling in stage two of the review during Q4 of 2015/16.

• Revised operational models to be considered following ARP trial going live during April and May 2016.

• The review is designed to identify short and long term changes that can be made to deliver improvements in performance.

• Stage two focuses on operational rotas, profile of resources by hour/day and mix of resource types by area to ensure they remain fit for purpose.

• Identify any further potential benefits to be obtained from the ARP Trial process by changes to the current operational model across the Trust.

Abstraction Management: Increased Operational focus on all Abstractions including Sickness

• A renewed focus on Sickness Management (short term).

• Implementation of Trust agreed Time Off in Lieu (TOIL) policy

• Identify all ‘other’ abstractions that can be reduced / removed.

• Increased managerial rigour for unauthorised absences.

• Review of current annualised hours contracts.

• Focus on improving staff retention.

• Daily resourcing information provided through the Trust Resourcing team.

• Weekly Resource Management Meetings held across the Trust.

• Bi-monthly ‘deep dives’ on operational sickness absences by Heads of Operations and the HR Department representatives.

• Increase available resource hours on the road to respond to incidents.

• Improved retention levels. Reduces abstractions for new starters.

• Most significant reductions in the past 12 months have been seen in relation to long term sickness, with the focus moving to short term sickness during Q3 and Q4 of 20115/16.

Clinical Hub: Introduction of a New, Single, Common CAD

• Introduction of a single common Computer Aided Dispatch (CAD) system across the Trust.

• Delivery of a new, enhanced, Trust-wide CAD system to improve resource visibility and deployment across the South West area.

• Upgrade to the South Clinical Hub November 2015.

• Period of checks and resilience tests completed December.

• Implementation in the North 24 February 2016.

• Post implementation period of familiarisation and additional staff support to improve the efficiency of call handling and resource dispatching.

• Uniform and enhanced CAD functionality within the Clinical Hubs will enable to Trust to support the delivery of operational resources across the Divisional boundaries within the SWASFT geographical area.

• It is expected that the benefits of a Trust-wide uniform system will start to impact in Q1 of 2016/17 as Hub and Operational staff become more familiar with the new dispatch system.






Expected

Clinical Hub: Increase the Call Handling Resource

• Introduce additional call advisors.

• Release NHS Pathways trained staff from other roles.

• Overtime shifts to be reviewed to deliver increased support at key operational times across the week.

• Improving call answering performance delivers reduced call cycles for the most serious incidents.

Clinical Hub: Increase the Clinical Support

• Target both Clinical Hubs.

• Introduce additional clinical resources.

• Identify GPs who could support.

• Consider additional administrative support for GPs

• Increase the number of Clinical floorwalkers in NHS 111 SWASFT services.

• Overtime shifts to be reviewed to deliver increased support at key operational times.

• Additional GP shifts to be offered within the Clinical Hub.

• Medical Directorate to provide Clinicians within the Hub on a rota basis through March and April 2016.

• Improve the clinical management of all incidents.

• Increase number of incidents that can be resolved through clinical advice or referral.

• Reduce the level of inappropriate 999 responses from NHS 111.

Increasing Operational Resources

• Introduce additional resources through overtime payments and continuation of current third party resources / privates.

• Review of current operational secondments.

• Utilise available Operational Managers and other clinicians to respond to incidents where appropriate.

• Introduction of additional overtime shifts and third party resources in March 2016 continuing into April 2016.

• Provide additional red response capacity in key areas of high demand across the Trust.

Demand Mitigation: Joint action with 12 CCGs to manage demand to contracted levels

• Review local Care, Residential and nursing homes with high levels of ambulance activity.

• Improve engagement to support Community Responders.

• Identification of locations that would benefit from the location of a Public Access Defibrillator.

• Identification of any activity undertaken by SWASFT which would more appropriately be directed elsewhere (e.g. local falls support services, Community Nurses).

• Demand Management Plans were developed for delivered during 2015/16.

• ORH has given the Trust a list of key locations to target additional Defibrillators.

• Overall aim of the demand management schemes is to offset growth.

Demand Mitigation: Working with NHS 111

• SWASFT 999 clinicians in the NHS 111 control rooms.

• For North Division this relates to shifts in Care UK control room assisting the operation of the Ambulance Validation Line.

• Identification of activity undertaken by SWASFT which would more appropriately be

• On-going regular liaison between the ambulance service and NHS 111 service.

• Working with NHS 111 Providers to review the volume of calls and particularly the appropriateness of red calls being transferred to the ambulance service.

• The aim is to reduce the volume of inappropriate 999 transfers from 111






Expected

directed elsewhere (e.g. local falls support services, Community Nurses).

Demand Mitigation: Handover Delay Action Plans

• Finalise the hospital handover action plan template

• Implementation of action plans at acute hospitals to reduce the amount of operational resource time lost to extended handover delays of patients.

• Participation in a number of national and local events to review management / best practice

• Action plans should be being implemented during Quarter 4 of 2015/16.

• Expected that the national and local events will take place in Q1 of 2016/17.

• Reduction in operational time lost.

• Clarity of the local barriers and actions being taken

• Clear escalation plans

• The improvement expected is delivery of the trajectories agreed with commissioners in July 2015.

Other Identified Actions: Introduction of Additional Red Response Resources – North Division

• Introduction of additional operational resources to respond exclusively to Red 1 and Red 2 incidents in the North Division.

• 5 additional 24/7 response resources introduced during January 2016 continuing Q4.

• Continuation of additional third party resources confirmed through to end of April 2016.

• Target is additional Red response capacity in key areas of high demand across the North Division.

Other Identified Actions: Increase in Trust REAP Level

• Increase in REAP level to RED with effect from 16 March 2016.

• Increase in REAP level has a number of implications including:

• Cancelation of all non-performance related meetings

• Cancelation of all LDR training.

• Introduction of daily conference calls to discuss operational pressures.

• Increase in Operational Officer deployment where possible.

• Increase in REAP level confirmed and communicated across the Trust on 16 March 2016.

• Increased Trust wide focus as per the REAP plan, reducing the level of abstractions for non-operational duties.

Other Identified Actions: Increase Fleet Availability

• Increase Fleet availability through increase in logistical support.

• Introduction of additional Make Ready Operatives to move and clean vehicles, reducing operational staff time lost to unscheduled unavailability.

• Additional logistics resources to assist in monitoring of ‘vehicles off the road’ within the Clinical Hub to insure vehicles are returned to operational status at the earliest opportunity.

• Additional Make Ready Operative shifts to be provided through overtime during March and April 2016.

• Reduction in time lost to unscheduled unavailability will increase the time clinically trained staff are available to respond to emergency incidents.



NHS 111 Service: 60 Second Call Answering and Call Abandonment Rates Performance Exception Status: Call answering performance was below national target levels in April 2016, but call abandonment rates were below (better than) national target levels in all three counties.

Reason(s) for the performance exception category assigned in the reporting period: • The Trust did not deliver the national call answering target in April 2016, performance was partially compliant in

the county of Dorset (94.00%) and non-compliant in the counties of Devon (74.19%) and Cornwall (73.35%).

• Call answering performance in April 2016 showed some improvement on the performance in March 2016 and call abandonment rates for all three counties were below (better than) the national target of 5% - Dorset (0.88%), Cornwall (4.02%) and Devon (4.17%).

• Local call answering performance improvement trajectories were agreed with NHS Commissioners from 31/8/2016 to 31/3/2016. Until mid-February 2016 the Trust was delivering the improvement expected.

• A number of recent external events have led to deterioration in performance during March 2016, with some recovery seen in April 2016, particularly in the county of Dorset.

• The Trust has highlighted on-going risks to the delivery of call answering performance in the counties of Devon and Cornwall due to the high level of vacancies (particularly clinical) and other abstractions (eg sickness) within the service at present and the continued high level of attrition in call advisor and clinician numbers seen in recent months. This is particularly impacting on the West Hub.

Risk Assessment: • There are signs of improvement in Dorset during April 2016.

• The Trust has however highlighted an on-going risk in relation to call answering performance in Devon and Cornwall. The Trust expects to see a further deterioration in the Devon service as a result of the re-procurement of the service and a new provider commencing October 2016.

April 2016 Performance

Actual

Performance


Target

Percentage of Calls Answered Within 60 Seconds - KPI Target 95% In Month: Performance

Dorset 94.00% (1.00%)

Devon 74.19% (20.81%)

Cornwall 73.35% (21.65%)

Percentage of Telephone Calls Abandoned 30 seconds after the recorded message - KPI Target 5% In Month: Performance

Dorset 0.88% (4.12%)

Devon 4.17% (0.83%)

Cornwall 4.02% (0.98%)

Percentage of Calls Answered Within 60 Seconds - KPI Target 95% Year to Date Performance

Dorset 94.00% (1.00%)

Devon 74.19% (20.81%)

Cornwall 73.35% (21.65%)

Percentage of Telephone Calls Abandoned 30 seconds after the recorded message - KPI Target 5% Year to Date Performance

Dorset 0.88% (4.12%)

Devon 4.17% (0.83%)

Cornwall 4.02% (0.98%)






Expected

Staff Engagement and Support

Provide support for all staff across the NHS 111 service during a period of change.

Support to be delivered will include:

Regular briefings for all staff;

Focus on delivery of staff appraisals;

Regular staff feedback;

Monthly Urgent Care Service Line meetings.

Monthly Urgent Care Service Line meeting re-established with effect from January 2016.

Staff engagement to improve staff retention levels across the NHS 111 service.

Clinical Staff

Clinical Development Plan developed and agreed with NHS 111 Clinicians.

Headline actions from the plan:

Recruitment to fill current NHS 111 Clinician vacancies;

Review of the role of the NHS 111 Clinician and development of a retention plan;

Operational issues including abstraction management and performance management;

NHS 111 Clinician shift/rota review;

Clinical process including queue management, management of frequent callers, call backs and complex call handling;

Information technology developments required to support clinical practice;

Explore opportunities for NHS 111 and A&E 999 Clinicians to work together to provide support.

Clinical Development Plan agreed in February 2016.

Specific targeted action to improve clinical cover in the West Hub to fill current vacancies.

Improved engagement, recruitment and retention of NHS 111 Clinicians will improve Clinical coverage across the NHS 111 service.






Expected

Call Audits

Increase the number of call audits undertaken and deliver these audits in conjunction with staff coaching plans.

Additional analysis reports to assist in reviewing themes will go live with effect from May 2016.

Internal improvement trajectories have been agreed for each Hub.

Resilience framework and a rota for auditor absence has been agreed.

Improved feedback and support for NHS 111 call advisors and clinicians through the call audit process.

Operational Management

Increased call auditing and coaching – a plan with identified actions has been drawn up to increase the number and quality of audits undertaken.

An enhanced focus on managing individual performance including the use of the Intelligent Data Tool to create new performance reports.

Options appraisal being undertaken to establish potential future delivery base for Cornwall 111 post September 2016.

Weekly productivity and call answering performance reports available for individual call takers and teams.

Options appraisal due by the end of April 2016.

Identify coaching opportunities to support staff and improve morale.

Deliver performance improvements including improved call answering performance.

Non Pathways Agents (NPAs)

Review of the call flow process and call queue management for Non Pathways Agents (NPAs) particularly during peak periods of demand for the NHS 111 service.

Introduction of increased clinical and managerial oversight of the NPA call queue.

Changes to the call flow for NPAs were implemented in February 2016 to deliver a more appropriate and proportionate call queue during peak periods.

More appropriate management of call queues and targeted use of NPAs to appropriate calls, particularly at peak periods of demand.

Recruitment: Recruitment of additional Call Advisors/Clinical Supervisors and Revise Shift Patterns

Recruitment Plan developed for NHS 111 Call Advisors and Clinicians

Renewed focus on clinical KPIs once Clinician numbers improve.

Recognition of impact of increased turnover during Quarter 4 of 2015/16 as a result of contract status.

On-going recruitment to fill vacancies. The majority of current vacancies relate to part-time evening and weekend positions.

Additional recruitment plans have been developed through to the end of September 2016.

Consideration being given to additional remuneration for staff to aid retention.

To deliver improved call answering and provide greater resilience to meet shortfalls in resourcing at short notice.

Increase in current establishment of call advisors and clinicians to provide additional resilience to the NHS 111 service, particularly during the weekend peak periods of demand.



Urgent Care Service Line

QR12: Urgent and Less Urgent Base (Treatment Centres) and Home Visits Performance Exception Status: The Trust is expecting both standards to be met and move to full compliance for both Out of Hours contracts in Dorset and Gloucestershire.

Reason(s) for the performance exception category assigned in the reporting period:

Treatment Centres

• Urgent Consultations were partially compliant against the NQR in the county of Gloucestershire (93.70%, 654 of 698 consultations) and non-compliant in the county of Dorset (88.79%, 95 of 107 consultations) for April 2016.

• For Less Urgent Consultations the Trust was fully compliant in both counties in April 2016 - in Dorset (97.21%) and Gloucestershire (97.30%).

Home Visits

• Trust performance for Urgent Consultations started within 2 hours was partially compliant in Dorset (91.27%, 303 of 332 consultations) and non-compliant in Gloucestershire (88.60%, 202 of 228 consultations).

• Trust performance for Less Urgent Consultations started within 6 hours was partially compliant in both counties in April 2016 – in Dorset (93.77%) and Gloucestershire (92.68%).

Risk Assessment: • The expectation is that these standards will be delivered. The Trust continues to report exceptions on an

individual basis to commissioners at the contract meetings.

April 2016 Performance Actual Performance Variance to National Quality

Requirement

Dorset Gloucestershire Dorset Gloucestershire

Urgent Base Consultations started within 2 Hours Month Performance (95%)

88.79% 93.70% (6.21%) (1.30%)

Less Urgent Base Consultations started within 6 Hours Month Performance (95%)

97.21% 97.30% 2.21% 2.30%

Urgent Home Visit Consultations started within 2 Hours Month: Performance (95%)

91.27% 88.60% (3.73%) (6.40%)

Less Urgent Home Visit Consultations started within 6 Hours Month: Performance (95%)

93.77% 92.68% (1.23%) (2.32%)

Urgent Base Consultations started within 2 Hours

Year to Date Performance (95%) 88.79% 93.70% (6.21%) (1.30%)

Less Urgent Base Consultations started within 6 Hours

Year to Date Performance (95%) 97.21% 97.30% 2.21% 2.30%

Urgent Home Visit Consultations started within 2 Hours


Less Urgent Home Visit Consultations started within 6 Hours




Urgent Consultations at Base Sites (Treatment Centres)

Urgent Home Visits




taken by the Trust

Timescales for

Action

Performance Improvement /

Impact Expected

Gloucestershire Out of Hours Service

The Trust has reviewed the level of activity

being classified as Urgent

Additional triage capacity is now provided at peak times via GPs working remotely

Continued discussions with both NHS Commissioners and the NHS 111 Provider in the North Division to ensure NHS 111 referrals to the Out of Hours service are appropriate

On-going engagement regarding patient flow to the Treatment Centres from the Emergency Department at Gloucestershire Royal Hospital (GRH)

Continue engagement with Commissioners in relation to impact of other services commissioned which impact on the OOH service – those delivered by Gloucester Care Services (GCS) and enhanced GP cover via the Prime Minister’s Challenge Fund.

Additional triage shifts implemented April 2016, remote triage initially implemented September 2015

Review of 111 disposition mapping into the OOH service to commence April 2016

SOP for patient flow between ED & OOH in GRH reviewed & updated April 2016

The addition of extra hub GP shifts and remote triage will add capacity at peak times and improve overall responses to patients

Improved mapping of 111 calls will improve the balance between urgent and less urgent calls, improving performance in particular for those patients with urgent needs

Improved flow of patients from the Emergency Department will ensure that appropriate patients are directed appropriately

There has been a recognition of a need for

localised audit and quality support

Training of clinicians to undertake audit in the Hub has been completed.

Recruitment to a lead nurse role is to be undertaken to support the audit of nursing staff.

Continued development of the GP audit tool.

Lead nurse recruited and commenced work in January 2016.

GP audit tool development continues – due for piloting in May 2016

Increased audit, feedback and support capacity in Gloucester will drive improvements in the quality of call management

Progress has been made on the development of an IT based tool for audit to support GPs – work being led by the Associate Medical Director.

Review of activity profiles and associated

resource profiles in Gloucestershire

A full review of activity and resourcing will be completed which will ensure that staffing in all areas is mapped to meet the activity requirements whilst also being deliverable within the financial envelope of the contract

From this work restructure rotas and resourcing plans accordingly – this work is to be planned across early 2016 to deal with different staff groups and appreciating contractual notice periods for rota changes.

Continued review of skill mix (ANP & SP) within delivery model.

Implementation of new hub rotas/plans commenced in November 2015 – initial focus on hub staff

Updated mobile & PCC shift patterns implemented April 2016

Deliver the optimum resource profiles with associated clinical skill mix to match the demand for both Home Visits and Treatment Centre appointments in Gloucestershire

Urgent Care Service Integration Activities in Dorset

Improved integration between Urgent Care

Service Line services

Full project plan to implement the required changes to facilitate the integration within Urgent Care Services in the Dorset Hub is under development.

The plan is to meet the specification (and aspirations in line with the integrated Hub

Project plan for activities in 2016/17.

Additional planning underway to further develop the Hub across 2017/18.

Progress towards integration – delivering improved performance, quality and financial efficiency.

Longer term plan to take the Hub to a position as described in the future planning for urgent care from NHS England.




taken by the Trust

Timescales for

Action

Performance Improvement /

Impact Expected

guidance) to the end of 2016/17.

The plan will cover all dependencies including IM&T, establishment across all roles, reporting, finance, training, etc.

Improved reporting across the integrated hub –

linking service lines, KPIs and reporting

requirements

Performance from both a governance/quality and KPI aspect is reported on for each service-line.

Discussions have already commenced with commissioners to develop combined reports which have a greater usefulness and which may be able to influence the wider discussions regarding the changes in urgent care commissioning.

Discussions commenced in October 2015.

Draft reports to be scoped during Q3 & Q4 of 2015/16 for possible shadow implementation from April 2016 with the support of Dorset CCG.

Improved reporting may result in stronger links between service-lines and from this clarification about the impact of change

Urgent Care Service Line

Tiverton Urgent Care Centre 4 Hour Waiting Time Target Performance Exception Status: The Trust achieved 99.63% in April 2016. Performance is consistently high and above target levels.

Reason(s) for the performance exception category assigned in the reporting period: • The primary performance measure within the contract is the 4 hour waiting time standard (this is the same

target for acute trust Emergency Departments).

• In April 2016, 1,332 of the 1,337 patients attending the Unit were seen within the 4 hour target giving performance of 99.63% against the 95% performance target.

• This has been delivered consistently along with a local standard to triage patients within 15 minutes.

• In April 2016, 99.48% of patients were triaged within 15 minutes.

Risk Assessment: • Performance against the 4 hour target continues to be monitored on a daily basis and is expected to be

maintained above the 95% target levels.



8. Ambulance National Quality Indicators (AQI)

8.1. This section provides a summary of performance against each of the National Ambulance Clinical Quality Indicators. The definition for each is provided in Appendix C.

8.2. There are no national targets for 2016/17 however all ambulance Trusts are required to use a consistent set of national indicators to evidence

improvements in the quality of service. The indicators reported in the ICPR fall into two groups as follows:

Nationally defined system and clinical indicators;

Locally determined service experience indicators to meet the national requirement to report on how the experience of users of the ambulance service is captured, to publicise the results and to show what has been done to improve the design and delivery of services in light of the results.

8.3. The Trust has agreed performance thresholds for each of the indicators within the Accident and Emergency contract. These performance

thresholds are designed to monitor performance and highlight at an early stage any deterioration in performance and are reviewed annually with NHS Commissioners.

8.4. The Trust continues to participate in national working groups to help develop revised guidance for both the Clinical and System Indicators to

try and deliver improvements in data quality and reporting consistency for all ambulance trusts in England. Revised national guidance documentation for all Ambulance Quality Indicators was released by NHS England in December 2015 and was introduced with effect from 5 January 2016. The Trust implemented the revised guidance and this is reflected in the performance metrics from January 2016.

8.5. As a result of the implementation of the ARP trial the AQI metrics required for submission for SWASFT will be amended to reflect the

information now being collected. At the time of this report the Trust is awaiting final details of the template for data to be collected and as such the information reported below reflects the current known position:

8.6. There are not expected to be any changes to some metrics and therefore figures for April 2016 are included in the tables below in relation to:

o Call abandonment rate;

o Re-contact rates following telephone advice;

o Re-contact rates following treatment at scene;

o Time to answer calls (50th, 75th and 95th percentiles);

o Patients Managed Appropriately– Calls Closed with Telephone Advice;

o Patients Managed Appropriately– Calls Closed without the need for Transport to Emergency Departments;

8.7. The time from call categorisation to arrival at scene metric is no longer relevant under the ARP programme and the information below only covers the period 1 to 18 April 2016;



8.8. New metrics for those Trusts participating in the ARP trial are currently being defined in relation to: o New Red Response Times;

o New Amber Response Times;

o Green F Response Times.

8.9. For these new metrics the Trust is waiting the final template and agreed guidance before including the figures within this report.

Table 10: AQI System Indicators

AQI Trust Performance Performance vs Local Thresholds

(where appropriate) Benchmark Exception Reporting

Calls abandoned

Call Abandonment Rate April 2016

1.59% Local Threshold

1.50%

National Average March 2016

1.28%

In the reporting period the percentage of calls abandoned was marginally higher (worse) than local threshold.

The Trust is currently undertaking recruitment to fill vacancies within the Clinical Hubs to improve call handling capacity.

An internal review of resource profiling and rotas within both Clinical Hubs to insure they match the latest demand profiles is being undertaken during Quarter 1 of 2016/17.

Time Taken to Answer calls

April 2016 50

th 3 secs

95th

31 secs 99

th 85 secs

Local Thresholds 50

th 3 secs

95th

19 secs 99

th 60 secs

No national average figures

available for this metric

In the reporting period the call answering times at all percentile measures were higher (worse) than the local thresholds for the 95

th and 99

th percentile metrics.

The actions to improve this performance are linked to the recruitment and rota reviews within the Clinical Hubs outlined under the Call Abandonment metric.





Time from call categorisation to arrival at scene

April 2016 50

th 8.4 mins

95th

30.6 mins 99

th 58.6 mins

No Local Thresholds

Information for the period 1 to 19 April 2016 Only

No national average figures

available for this metric

In the more rural areas of the Trust, the 95th

and 99th

percentile measures are in the lower quartile compared to other ambulance trusts due to greater distances to travel.

The Time to Treatment metric will be replaced by new performance monitoring metrics with effect from 19 April 2016, these include the reporting of percentile response times for all categories of incident as outlined earlier in this report.

The data included in this graph only relates to the period 1 to 18 April 2016.

Re contact with the Ambulance Service following telephone advice

April 2016 10.25%

Local Threshold 11.00%


6.48%

In April 2016 re-contact rates following telephone advice were lower (better than) than the local threshold.

Nationally reported figures for ambulance trusts show considerable variance, between 1.80% and 14.33% in March 2016.

The large variance in national performance raises concerns over the comparability of data being reported against these metrics by ambulance services. The National Ambulance Informatics Group is leading on a review of the data and calculation processes for all ambulance trusts.

Re contact with the Ambulance Service following treatment at scene

April 2016 4.64%



5.51%

In April 2016 re-contact rates following treatment at scene were lower (better than) than the local threshold.

There are considerable variances in the figures reported nationally by ambulance trusts against this metric. In March 2016 re-contact rates varied between 3.15% and 8.77%.

A similar review of the data quality and consistency is being undertaken through the National Ambulance Informatics Group.





Patients Managed Appropriately– Calls Closed with Telephone Advice

April 2016 13.63%



10.24%

In the reporting period with percentage of managed calls resolved by telephone advice were higher (better) than the local threshold.

Patients Managed Appropriately– Calls Closed without the need for Transport to A&E (Emergency Departments)

April 2016 48.84%



38.65%

In April 2016 the percentage of incidents resolved without transport to an Emergency Department was lower (worse than) than the local threshold.

For 2016/17 the Trust is committed to the delivery of Right Care across all incidents and therefore performance against Trust trajectories for Right Care is provided within the Right Care section of this report.

Progress against the identified actions within the Right Care action plans is also included within the Right Care section of this report.

The Trust is investigating data changes following the implementation of the new CAD in the North Division in February 2016. These changes appear to have seen a movement between the number of incidents conveyed to ED and non ED locations. Further updates will be included in the May 2016 report.



Table 11: AQI Clinical Indicators

AQI Trust Performance in

reporting period

Performance vs Local Thresholds

(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Return of spontaneous circulation following cardiac arrest

January 2015 to December 2015


24.00%

National Average

April 2015 to December

2015 27.73%

In the reporting period the Trust was above the local threshold.

The Trust has appointed a Quality Improvement Paramedic to focus on cardiac arrest ROSC and survival.

Cardiac arrest has been chosen as one of the indicators for the 2016/17 Quality Account.

Return of spontaneous circulation following cardiac arrest (Utstein)



45.00%

National Average


2015 50.87%

In the reporting period the Trust was above the local threshold.

The Trust has appointed a Quality Improvement Paramedic to focus on cardiac arrest ROSC and survival.

Cardiac arrest has been chosen as one of the indicators for the 2016/17 Quality Account.

Outcome from acute STEMI - (PPCI)



84.00%

National Average


2015 87.15%

A review of the factors that increase breaches against the 150 minute time target has been undertaken and is being used as the basis for Quality Improvement work.

The ability to convey a patient to a PPCI centre within 150 mins of the call is largely dependent on operational performance with regard to the initial response time and time awaiting DCA back-up, where required.

The Clinical Quality Improvement team have launched a new initiative ‘RAPID’ to work collaboratively with key stakeholders to improve this metric.




reporting period


(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Outcome from Acute STEMI – Care Bundle



90.00%

National Average


2015 78.34%

The local performance threshold for 2015/16 was increased from 85.00% to 90.00%.

The Trust continues to report performance significantly higher than the national average, but for the period January 2015 to December 2015 the Trust was below the Local Threshold of 90.00% at 84.65%.

Feedback from Quality Improvement collaborative indicates that the decrease in pain scoring may be due in part to lack of familiarity with how to record this on electronic patient record and therefor the Trust is working to address this familiarity issue.

Outcomes from Stroke for Ambulance Patients – FAST (Face, Arms, Speech, Time to Call 999)



57.00%

National Average


2015 58.03%

Performance against this metric is challenging due to the very rural nature of the geographical area covered by SWASFT with longer distances to Hyperacute Centres.

At present performance for the rolling 12-month period the Trust is 10.63% below the local performance threshold of 57.00%.

The ability convey a patient to a stroke centre within 60 minutes of the call is largely dependent on operational performance with regard to the initial response time and time awaiting DCA back-up, where required.

The Clinical Quality Improvement team have launched a new initiative ‘RAPID’ to work collaboratively with key stakeholders to improve this metric.

Outcome from Stroke for Ambulance Patients – Care Bundle



97.00%

National Average


2015 97.56%

In the reporting period: performance is higher (better) than local threshold




reporting period


(where appropriate)

Benchmark

vs other

Trusts

Exception Reporting

Outcome from Cardiac Arrest – Survival to Discharge



9.00%

National Average


2015 8.74%

In the reporting period: performance is lower (worse) than local threshold

The Clinical Quality Improvement team have initiated a programme of Quality Improvement work aiming to improve this metric.

Outcome from Cardiac Arrest – Survival to Discharge (Utstein)



27.00%

National Average


2015 28.11%

In the reporting period: performance is lower (worse) than local threshold.

The Clinical Quality Improvement team have initiated a programme of Quality Improvement work aiming to improve this metric.



9. NHS Commissioner Local Standards and Thresholds

9.1. This section includes those local standards and thresholds agreed with local NHS Commissioners as part of the 2016/17 contract negotiations. The definitions are set out in Appendix C.

Table 12: NHS Commissioner Standards and Targets for 2016/17

Measure Local

Target

April

2016

Green 1 Calls (1 to 18 April 2016 only) 90% 72.08%



Green 4 (999) Calls (1 to 18 April 2016 only) 90% 78.67%

Green 4 (HPC) Calls (1 to 18 April 2016 only) 70% 68.16%

Compliance with Infection Prevention and Control Standards at Ambulance Stations

75% 78.00%

Compliance with Infection Prevention and Control Standards for Double Crew Ambulances

75% 76.00%

Vehicle Deep Cleaning Compliance with Schedule

90% 90.38%

Handover Delays at Acute Hospitals Performance Exception Status: The number of handover delays at acute hospitals and time lost has been deteriorating significantly and is significantly worse than last year.

Reason(s) for the performance exception category assigned in the reporting period: • Individual incidents and extended delays at acute hospitals are managed on a day to day basis and are subject

to locally agreed handover escalation procedures.

• There were a total of 1,845 handover delays in excess of 30 minutes in April 2016, of which 193 were

over 60 minutes in length (2,736 delays in excess of 30 minutes in March 2016).

• Whilst the April 2016 time lost to delays represents an improvement on the March 2016 position, the average time lost to chargeable handover delays at acute hospitals remains in excess of 65 hours per day.

• The 1,962 operational hours lost in April 2016 represents an increase of 859 hours when compared to April 2015 (1,102 hours lost to delays), the equivalent of an additional 28.6 hours lost per day across the month.

• In terms of the impact on operational resources, there were twelve hospitals where the Trust lost in excess of 100 operational resource hours to chargeable handover delays in April 2016 – Southmead Hospital (213 hours), Royal Cornwall Hospital (195 hours), Bristol Royal Infirmary (168 hours), Torbay Hospital (154 hours), Musgrove Park Hospital (143 hours), Gloucester Royal Hospital (140 hours), Poole Hospital (133 hours), Great Western Hospital (129 hours), Derriford Hospital (126 hours) and Royal Bournemouth Hospital (104 hours).

• The Trust continues to work closely with NHS Commissioners in targeting hospitals with consistently long delays particularly during periods of high activity levels. Four hospitals have been prioritised based upon consistently high delays; these are Royal Bournemouth Hospital, Poole Hospital, Derriford Hospital and Royal Cornwall Hospital. The Demand Management Plan targets a 25% improvement in delays at these four hospitals and a 10% improvement in all other hospitals. This is not being achieved.

• Local action plans to deliver improvements in handover plans for each of the acute hospitals have been established and are monitored through regular local meetings between SWASFT and each of the hospitals.

April 2016 Year to Date

Operational Time Lost to Chargeable Handover Delays in Excess of 15 Minutes

1,962 hours 1,962 hours

Number of Chargeable Handover Delays between 30 and 60 Minutes

1,652 incidents 1,652 incidents

Number of Chargeable Handover Delays in Excess of 60 Minutes

193 incidents 193 incidents





10. Patient Transport Contract 2016/17 Key Performance Indicators

Table 13: PTS Service Line: Bristol, North Somerset and South Gloucestershire KPIs 2016/17

Measure YTD

Performance Measure

YTD

Performance 1a Patients living up to 10 miles away from the treatment centre (Band A) should not spend more than 60 minutes on the vehicle on either an outward or return journey

(Green >90%, Amber 80-90%, Red <80%)

91.78%

9a Patient satisfaction with the level of service received from the provider = assessed through the annual patient satisfaction survey

(Green >85%, Amber 75-85%, Red <75%)

97.80%

1b Patients living over 10 miles and up to 35 miles away from the treatment centre (Band B) should not spend more than 90 minutes on the vehicle on either an outward or return journey (Green >90%, Amber 80-90%, Red <80%)

93.46%

9b NHS Commissioners to be satisfied with the level of service

(Green = no issues or minor concerns resolved within 1 month) (Amber = minor issues and not resolved within 1 month or major issues resolved within 1 month) (Red = major issues not resolved within 1 month)

100.00%

1c Patients living over 35 miles away from the treatment centre (Band C) should not spend more than 120 minutes on the vehicle on either an outward or return journey (Green >90%, Amber 80-90%, Red <80%)

100.00% 9f Telephone answering (Green >95%, Amber 85-95%, Red <85%)

95.57%

2a Patients should not arrive more than 45 minutes before their booked arrival time (Green >90%, Amber 80-90%, Red <80%)

87.30%

(2.70%)

(87.30% in April 2016)

10a Agreed activity performance report received in correct format and on time within 10 working days of the start of the following month

100.00%

2b Patients should not arrive after their booked arrival time (Green >97%, Amber 87-97%, Red <87%)

92.39%

(4.61%)

(92.39% in April 2016)

10b Activity and finance queries are acknowledged within 3 days of receipt and resolved within 28 days from the date of the query

100.00%

3a SWASFT is to arrive to collect patients from the agreed location within 45 minutes of the outwards journey time (Green >90%, Amber 80-90%, Red <80%)

91.01%

12h Nil Serious Untoward Incidents (SUIs). Any SUIs are to be reported and action plans put in place – in line with NHS Bristol standard and timeframes (reported immediately; investigated within 24 hours and lessons learnt shared, then closed within 60 working days of the incident)

(Green - No SUIs, Amber – SUIs reported but resolved within timeframe, Red SUIs reported but not resolved within timeframe)

100.00%

3a SWASFT is to arrive to collect patients from the agreed location within 75 minutes of the outward journey time (Green >90%, Amber 80-90%, Red <80%)

96.55%

12d Compliance with the agreed SWASFT complaints procedure – full response made in a timely manner agreed with the complainant (assessed quarterly)

100.00%

8c Pick-up time to be confirmed by text, email or personal phone call to the patient within a week of the appointment (phone call being the preferred method (assessed quarterly)

100.00%

3b A summary of reasons and actions to be provided, for each month, for all cases where collection was outside (i.e. later) of the KPI limits. This may include case by case analysis as deemed necessary.

100.00%

10.1. Further analysis of those metrics that are currently below KPI levels for the year to date (metrics 2a and 2b) is being undertaken with a view to identifying internal actions that are required to deliver sustained improvements against both of the performance metrics.



11. Right Care, Right Place, Right Time 2

11.1. The Right Care2 proposal ‘A Healthy System Productivity Offering in the Form of Right Care2’ was produced by South Western Ambulance Service NHS Foundation Trust (SWASFT) ahead of the 2014/15 contracting round.

11.2. SWASFT is the only English ambulance service offering commissioners a bespoke

programme which actively focuses on supporting patients to be treated at home, or to receive assessment and / or treatment at a location other than an Emergency Department (ED).

11.3. Right Care2 has been progressing to plan and new activities for 2016/17 are in the process of

being scheduled following conclusion of the contract negotiations.

11.4. All CCGs continue to be fully engaged with this SWASFT led initiative which has been

supported by the regular SWASFT assurance reporting regime.

11.5. The trust wide Right Care2 proposal for 2016/17 has been aligned to the High Impact Actions

as described in the Monitor, TDA and NHS England Winter Readiness 2015/16 letter. This was shared at the last Integrated Quality and Performance Meeting (IQPMG) with commissioners on 23 March 2016.

11.6. Locally agreed initiatives for 2016/17 have been developed and agreed with 10 of the 12

CCGs. Meetings with each CCG took place during February and early March 2016 with all 12 local commissioners, to review local Right Care actions and agree priorities for local 2016/17 schemes.

11.7. Development of the trust wide Right Care Champions’ events have included the attendance

of local commissioners, commissioning GP leads to represent Primary Care and specific groups of Health Care Professionals to start and continue discussions to improve relationship between SWASFT and other local health care organisations. The next event, scheduled for 7 July 2016, will facilitate discussions around the management of mental health and care homes patients.

11.8. The current priority work, identified as a result of external healthcare professional (HCP) and

SWASFT staff feedback, is around changing the way the clinical hub processes of managing HCP originated incidents. Communications are being developed and work has commenced with the clinical hubs and IM&T teams. However IM&T capacity to support any system changes, to include a screen driven call advisor script, is currently limited due to resourcing for the ARP project.

Right Care - Non Conveyance Rates 2016/17

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17Year to

Date

Hear & Treat Incidents 8,021 8,021

See & Treat Incidents 25,599 25,599

See & Convey Non ED Incidents 4,054 4,054

See & Convey ED Incidents 34,207 34,207

Total Incidents 71,881 71,881

Hear & Treat Incidents 11.16% 11.16%

See & Treat Incidents 35.61% 35.61%

See & Convey Non ED Incidents 5.64% 5.64%

See & Convey ED Incidents 47.59% 47.59%

% of All Incidents Resolved

Without Conveyance to an

Emergency Department

52.41% 52.41%



12. Internal Trust Headline Performance Indicators for 2016/17

12.1. The performance metrics set out in the table below are included in the ICPR as the internal Trust headline measures for 2016/17.

Table 14: Performance Indicators:

Metric Internal

Target

April

2016

Quarter 1

Forecast

Staff Appraisal Completion 85% 59.18%

On-going Compliance with Care Quality Commission Regulations and Quality Risk Profile

Compliant Green Green

Information Governance Toolkit Level 2 Green Green

Implementation of the Equality Delivery System (EDS)

On Plan Green Green

Environmental Strategy & Work Programme On Plan Green Green

Delivery and Assessment of Environmental Impact Pilots

On Plan Green Green

NHS Constitution and Staff Pledges On Plan Green Green

12.2. Trust performance against the internal 85% staff appraisals target was 51.36% at the end of

March 2016, this position has improved to 59.18% at the end of April 2016.

12.3. The under performance against the 85% KPI level is predominantly due to operational

pressures seen as a result of the Trust operating at REAP level 4 and now operating at REAP Level Red for extended periods throughout 2015/16 and into Quarter 1 of 2016/17.



13. Trust Resource Performance Measures

13.1. This section includes resource measures specified by the Trust as having a significant impact on performance and delivery:

The Resource Escalation Action Plan (REAP) level;

Service line activity;

The Trusts financial position;

Capacity and Capability.

Resourcing Escalation Action Plan (REAP) Level

13.2. The Trust REAP assessment takes into account the following measures:

A&E actual activity levels compared to contracted activity levels;

Performance against national performance targets and local performance trajectories;

Clinical Hub call answering performance;

Frontline staff sickness levels;

Average turnaround times at acute hospitals (Handover and Wrap Up times);

Local weather forecasts;

Other issues impacting on operational delivery:

o Winter pressures;

o Local events;

o ICT/System upgrades;

o Other national/local risks to operational delivery.

13.3. In November 2015 the new UK Ambulance Service REAP was approved nationally and revised national guidance documentation was released by the National Ambulance Resilience Unit (NARU). This guidance included new definitions for 4 REAP levels across ambulance services (replacing the previous REAP levels 1 to 6) to align ambulance REAP levels more consistently to those used in other areas of the health community:

o REAP Level 1 – Green – Steady State;

o REAP Level 2 – Amber - Moderate Pressure;

o REAP Level 3 – Red – Severe Pressure;

o REAP Level 4 – Black – Extreme Pressure.

13.4. The SWASFT REAP Plan has been reviewed and updated as an annex to the National plan

and was approved by Trust Directors and has been produced on a partnership basis internally and externally and builds on national plans that are in place to manage variations in demand through a process of escalation throughout the year. In December 2015 the Trust confirmed the revised REAP Level of Amber (level 2).

13.5. On 5 February 2016, following local challenges in performance, the Trust moved to REAP Level of Red in the North Division. The Trust moved to Trust wide REAP level of Red with effect from 16 March 2016 and remains at REAP level Red at the time of this report.

Accident and Emergency Service Line Activity 13.6. Accident and Emergency activity is measured for contracting and performance management

purposes and for 2016/17 the currency is ‘incidents’.

13.7. Incidents are defined as any unique call resulting in the ambulance service providing a

service which could include telephone advice only or referral to another service where appropriate.



13.8. Incidents are split into three categories:

o Hear & Treat/Refer – those incidents that were resolved by providing clinical advice over the telephone (without an ambulance resource attending the scene) or where the caller was referred to a more appropriate service (e.g. to contact the NHS 111 service);

o See & Treat/Refer – where an ambulance resource arrives at the scene of an incident and the patient is treated without the need to convey the patient. This may include referring the patient to an alternative care pathway (e.g. to visit their GP) where appropriate to best meet the needs of the patient.

o See & Convey – where an ambulance resource arrives at the scene of an incident and following treatment by the ambulance service, at least one patient requires conveyance. This measure includes all conveyances, therefore the See & Convey figure is often split between Emergency Department (type 1 and type 2) and non-Emergency Department destinations.

Table 15: Accident and Emergency Service Line Incidents by Month compared to Contract:

Actual Contracted Variance %

April 2015 71,881 74,116 -3.02%

Year to Date 71,881 74,116 -3.02%

Table 16: Accident and Emergency Service Line Incidents by CCG:

Actual Contracted Variance % Actual Contracted Variance %

Kernow CCG 8,001 8,141 -1.72% 8,001 8,141 -1.72%

NEW Devon CCG 12,066 12,329 -2.13% 12,066 12,329 -2.13%

South Devon & Torbay CCG 4,531 4,684 -3.27% 4,531 4,684 -3.27%

Somerset CCG 6,921 7,276 -4.88% 6,921 7,276 -4.88%

Dorset CCG 11,320 11,961 -5.36% 11,320 11,961 -5.36%

Bath & North East Somerset CCG 1,953 2,096 -6.82% 1,953 2,096 -6.82%

Bristol CCG 6,201 6,406 -3.20% 6,201 6,406 -3.20%

North Somerset CCG 2,664 2,812 -5.26% 2,664 2,812 -5.26%

South Gloucestershire CCG 3,018 2,888 4.50% 3,018 2,888 4.50%

Gloucestershire CCG 7,328 7,579 -3.31% 7,328 7,579 -3.31%

Swindon CCG 2,489 2,524 -1.39% 2,489 2,524 -1.39%

Wiltshire CCG 5,283 5,420 -2.53% 5,283 5,420 -2.53%

Total 71,881 74,116 -3.02% 71,881 74,116 -3.02%

In Month Year to Date

RAG ratings: Green Less than 4% above contract, Amber 4% to 6% above contract, Red greater than 6% above contract.



The Trusts Financial Position

13.9. As a consequence of delays in agreeing the A&E 999 contract for 2016/17 there has been a

delay in the final approval of the Trust Financial Plan and confirmed of budgets to budget holders for 2016/17.

13.10. Heads of Terms were confirmed in writing by the Lead CCG on 25 April 2016.

13.11. Budgets have now been loaded onto the Trust financial ledger, however this has

unfortunately led to an unrecoverable delay in closing Month One of the accounts for the current year.

13.12. A verbal update will be provided at the public Board meeting on 26 May 2016.

Table 17: Capacity and Capability:

Key Performance Indicator April

2016

YTD

2016/17

Staff Sickness % YTD (Target 4%) 5.19% 5.19%

Staff Turnover Rate 15.07%

Staff Turnover Rate (excluding redundancies) 14.08%

Trust Total Staffing (WTE) 3,968.34

Trust Total Funded Establishment (WTE) 4,079.51

Total Staffing vs Funded Establishment (WTE) (111.17)

Trust Total Vacancy Rate (%) -2.73%

Operational Qualified Establishment (WTE) 1,646.99

Operational Qualified Vacancy Rate (%) -4.35%

Operational Non-Qualified Establishment (WTE) 881.63

Operational Non-Qualified Vacancy Rate (%) -0.33%

Staff Numbers and Turnover

13.13. As at 30 April 2016 the Trust reported an establishment of 3,968.34 Whole Time Equivalents (WTE) against a funded establishment of 4,079.51 WTE. The Trust therefore has 111.17 WTE vacancies (2.73%) compared to the funded establishment.

13.14. On-going recruitment continues for additional frontline resources to address residual vacancies across the Trust. A further 4% of additional frontline resource was deployed by way of bank, agency and overtime.

Recruitment Update 13.15. During February 2016, the Trust launched its 2016/17 graduate Paramedic campaign and

early signs show a successful amount of applications received. Assessments for these candidates took place in March and April 2016.

13.16. Early indication of successful applicants has been positive and the Trust is working with all

candidates to ensure that they receive an offer of a position with SWASFT within their preferred location.



13.17. The Trust vacancy model for 2016/17 has a recruitment forecast of 140 Graduate and Qualified Paramedics and the Recruitment team are working to convert all applicants into successful candidates.

13.18. The Qualified Paramedic candidate attraction campaign is still on going and assessments of shortlisted candidates have been planned throughout 2016/17.

Sickness

13.19. In April 2016 the Trust reported sickness of 5.19%, 1.19% above the internal target of 4.00%. Actions being undertaken by the Trust to address the current sickness abstractions across the Trust are detailed in the exception report below.

Table 18: Planned Actions to Reduce Sickness Levels:

Planned Mitigating Action being taken by the Trust to reduce Sickness Levels

Following a comprehensive review further changes have been made to the Trusts Sickness Absence

Policy.

A Sickness Management Action Plan has been developed to monitor the delivery of associated initiatives, including training of managers, changes to systems and reporting methods and improved staff communication about the impact of absence. All Operational Officers and Managers have been briefed in a series of Operational Leadership Days held in May and June 2015.

Deep Dives into the management of sickness are taking place each quarter with areas for improvement being identified and action plans being put in place. This scrutiny ensures the policy is being adhered to and that we continue to drive sickness down.

Active reconsideration of all staff on long term sickness against temporary secondments and alternative duties is being undertaken regularly with a database maintained to ensure staff are matched to suitable assignments where these exist throughout the Trust.

This process ensures that all options are considered to assist rehabilitation of staff back to the workplace. A new process to facilitate this has been developed.

Stress management procedures have been reviewed, resulting in better signposting for staff and managers to available support services as well as the re-launch of an improved stress risk assessment tool.

Occupational Health services are now being provided by Optima due to Capita withdrawing from the contract. Existing KPIs are being met and further KPIs will be agreed at the contact review at 6 months.

The Health and Wellbeing consultation has concluded and the business case was presented to Directors in July 2015. Health and Wellbeing forums are now established across the Trust to discuss the response to this consultation. This feedback will inform the design and implementation of the Trust’s Health and Wellbeing Strategy.

The Trust introduced a new Staying Well service in November 2015, to provide staff with immediate access to sources of personal support and guidance.



Appendix A: Trust Approach to the Management of Performance Exceptions in 2015/16

Early Warning Performance in the reporting period could be on or above target but there is evidence that performance is deteriorating or moving off trajectory AND/OR a metric has been escalated by a Directorate as part of the Trusts Performance Management arrangements. This indicates to the Trust that there is a perceived risk to performance regardless of whether this is evident in the reporting period. The focus of the ICPR is on providing the Board of Directors with information on trends, forecasting and mitigating actions being taken by the Trust.

Performance In Line With Plan Performance in the reporting period is on or above target and there are currently no predicted risks to the Trusts quarterly or forecast year end performance.

However where performance is below a national or contractual target this is taken into account when assigning this performance exception category. The focus of the ICPR is on providing the Board of Directors with ongoing assurance that performance can be maintained.

Escalated Performance Issue Performance in the reporting period is significantly off plan and there is currently no action plan in place OR there is insufficient evidence of improvement as a result of actions already agreed and being taken by the Trust in order to improve performance. The focus of the ICPR is on agreeing remedial action which may be escalated to Board level. Remedial actions are therefore likely to have Trust wide consequences.

Improvement Expected Performance in the reporting period is below target but there is evidence that performance is improving AND/OR there is confidence in the action(s) being taken by the Trust. The forecast outturn position is therefore expected to be on or above plan if a performance metric is reported in this category. The focus of the ICPR is on providing the Board of Directors with sufficient detail in order to provide an appropriate level of assurance. This will include detail contained within individual action plans as necessary.



Appendix B: ARP Trial Metrics (from 19 April 2016)

The national Ambulance Response Programe (ARP) aims to improve response times to critically ill patients, making sure the best response is sent to each incident first time with the appropriate degree of urgency. ARP is not about the fastest possible response, but the best response for each patient.

RED

Time critical life threatening event needing immediate intervention and/or resuscitation. e.g. cardiac/respiratory arrest, airway obstruction, ineffective breathing, unconscious with abnormal or noisy breathing, hanging. Mortality rates are high, where a difference of one minute in response time is likely to affect the outcome and there is evidence to support the fastest response.

AMBER (R) e.g. Probable MI, serious injury Blue light response needing face to face assessment by a suitably qualified clinician. Potentially serious conditions that may require rapid assessment, urgent on-scene intervention, analgesia and/or urgent transport. A difference of 15 minutes response time is likely to affect outcome and there is evidence to support early dispatch of resources.

AMBER (T) e.g. Stroke

AMBER (F) e.g. Fits, diabetic, overdose, hyper/hypoglycaemia

GREEN (F) Face to face assessment and management that may include transport.

Urgent problem that needs transport within a clinically appropriate timeframe or a further face to face or telephone assessment and management. Mortality rates are very low or zero. A difference of one hour or more might affect outcome and there is evidence to support alternative pathways of care.

GREEN (T) Transport only required, including calls from Healthcare Professionals.

GREEN (H)

Calls which do not require an ambulance response, but do require onward referral or attendance of non-ambulance provider in line with locally agreed plans or dispositions, or can be closed with clinical advice (Hear and Treat incidents).



The trial aims to collect sufficient evidence to inform the optimum response model for ambulance trusts and to inform future performance and outcome targets applicable to the ambulance sector. Initial targets for the trial are therefore limited, but the trusts involved will be subject to the close governance and monitoring identified above. A single target to deliver 75% of responses to Red incidents within 8 minutes has been introduced during the trial period. Performance against the 75% target will be reported on a monthly basis within the Integrated Corporate Performance Report. Response times will also be reported at the 50th, 75th and 95th percentiles during the trial period. In addition to the Red response time information the Trust will report against the times taken for conveying resources to arrive at scene, this will be reported as Red (T). For this report times will be reported at the 50th, 75th and 95th percentiles for reference. There are currently no specific targets for this metric. For Amber and Green incidents the trial will collect an evidence base to inform future performance and outcome metrics against which ambulance trusts will be monitored. During the initial stage of the trial response time information will be reported for Amber R, Amber T, Amber F, Green F and Green T metrics giving the 50th, 75th and 95th percentiles for reference. NHS England will also collect accelerated clinical outcome data during the trial period. This will provide ambulance-dependent clinical indicator data for cardiac arrest, stroke and heart attack incidents every two weeks. From Quarter 2 onwards NHS England aims to refine the code sets and associated performance standards and develop a set of new, patient focused, outcome measures. As these refined and new measures emerge the Trust will be in a position to undertake further modeling and analysis to identify the optimal operational model and investment plan. The outputs from this work will be built into the Trust Transition Plan effective from 1 October 2016.



Appendix C: National Measures Definitions and Glossary

National Ambulance Quality Measures (Introduction of ARP on 19 April 2016 – National metrics only applicable 1 to 18 April 2016)

Performance

Measure

2016/17

Target Definition Aim of the Target

How the Target is

measured

Red 1 75% Quarterly

Calls that are identified as the most time critical response and cover cardiac arrest patients who are not breathing and do not have a pulse and other severe conditions such as airway obstruction

To deliver better outcomes for patients by achieving a faster response for those patients with immediately life-threatening conditions

The percentage of Red 1 calls receiving an emergency response at scene within 8 minutes

Red 2 75% Quarterly

Calls that may be life-threatening but less time critical then Red 1 calls.

To deliver better outcomes for patients by achieving a faster response for those patients with life- threatening conditions

The percentage of Red 2 calls receiving an emergency response at scene within 8 minutes

Red 19 95% Quarterly

Calls that may be life-threatening (Red 1 and Red 2 calls) receive a response at scene which is able to transport the patient in a clinically safe manner.

To deliver better outcomes for patients with life-threatening conditions by ensuring they receive a response at the scene which is able to transport the patient if required.

The percentage of life-threatening calls receiving an ambulance able to transport the patient within 19 minutes

Monitor Risk Assessment Framework – The Financial Sustainability Risk Rating Monitor will regularly consider a Trust’s planned and actual financial performance and assign a Financial Sustainability Risk Rating to assess financial risk. This Risk Rating incorporates the previous Continuity of Services Risk Rating with two additional measures. Focused on financial elements only it comprises of four financial criteria:

Capital servicing capacity: the degree to which the organisation’s generated income covers its financing obligations;

Liquidity: days of operating costs held in cash or cash-equivalent forms, including wholly committed lines of credit available for drawdown;

Income and expenditure (I&E) margin: the degree to which the organisation is operating at a surplus/deficit;

Variance from plan in relation to I&E margin: variance between a foundation trust’s planned I&E margin in its annual forward plan and its actual I&E margin within the year.

Calculating the Financial Sustainability Risk Rating for NHS Foundation Trusts



* Scoring a 1 on any criteria will cap the weighted rating to 2, potentially leading to investigation. ** Scores are rounded to the nearest number, i.e. if the Trust scores 3.6 overall, this will be

rounded to 4, if the Trust scores 3.4, this will be rounded to 3. *** A 2* rating may be awarded to a Trust where there is little likelihood of deterioration in its

financial position. Monitor will use the thresholds set out within the diagram to assign a rating of 1, 2, 3 or 4 to each of the criteria once they have been calculated. The Risk Rating is the average of the four figures, rounded up.

Monitor Risk Assessment Framework – The Governance Risk Rating The Risk Rating is generated by considering the metrics set out within the table below. In relation to the Access and Outcome metrics, each ambulance trust is monitored on a quarterly basis against the national ambulance performance standards. In addition to these, as the Trust operates the contract for Tiverton Minor Injuries Unit, the 4 hour waiting time target for Emergency Departments is also included within the Trust’s quarterly reports to Monitor.

Category Metrics Governance concern triggered by

CQC Information

CQC judgments CQC warning notice issued

Civil and/or criminal action initiated

Access and Outcomes Metrics (see table below)

For ambulance trusts, Category A response times (Red 1, Red 2 and A19 performance)

For minor injury units (e.g. Tiverton) compliance to the Emergency Department 4 hour wait target

Three consecutive quarters’ breaches of a single metric or a service performance score of 4 or greater*

Third Party Reports

Ad hoc reports from GMC, the Ombudsman, commissioners, Healthwatch England, auditors reports, Health & Safety Executive, patient groups, complaints, whistle-blowers, medical Royal Colleges etc.

Judgment based on the severity and frequency of the reports.

Financial Risk

Financial Sustainability Risk Rating.

Breaching any continuity of service license condition as a result of governance

Inadequate planning processes.

Quality Governance Indicators

Patient Metrics

o Patient satisfaction

Staff metrics

o High executive team turnover

o Satisfaction

o Sickness/absence rate

o Proportion temporary staff

o Staff turnover

Aggressive cost reduction plans

Material reductions in satisfaction, or increase in sickness or turnover rates

Material increases in proportion of temporary staff

Cost reductions in excess of 5% in any given year.

* Where this score is 4.0 or greater, this represents a governance concern for Monitor. In addition if a Trust breaches a target systematically (i.e. for three consecutive quarters) this could reflect a governance concern and consequently trigger Monitor to review further information or undertake possible regulatory action.

Access and Outcome Metrics Threshold Weighting

Category A call – emergency response within 8 minutes, comprising Red 1 calls Red 2 calls

75% 75%

1.0 1.0

Category A call – ambulance vehicle arrives within 19 minutes (Red 19) 95% 1.0

Minor Injury Units – patient waiting time less than 4 hours 95% 1.0

Certification against compliance with requirements regarding access to health care for people with a learning disability

1

N/A 1.0

1 Meeting the six criteria for meeting the needs of people with a learning disability, based on recommendations set out in Healthcare for All



The Governance Risk Rating could represent one of three broad views:

Monitor will assign a Green rating if no governance concern is evident;

Where Monitor identifies potential material causes for concern with the Trust’s governance in one or more of the categories (requiring further information or formal investigation), Monitor will replace the Trust’s Green rating with an Under Review rating and a description of the issues and the steeps (formal or informal) Monitor is taking to address;

Monitor will assign a Red rating if they take regulatory action.

In assigning an appropriate governance risk rating, Monitor will be informed by the seriousness of the issue, information they already have concerning the situation, the effectiveness of the Trust’s initial response to the situation and the time-critical nature of the situation:

More detail on the monitoring and assessment regime can be found in Monitor’s Risk Assessment Framework at www.gov.uk

(DH, 2008)

http://www.gov.uk/



Ambulance Clinical Quality Indicators

Ambulance Quality

Indicator

What is the Indicator Measuring & Why

is it Measured? Measure

Local

Performance

Threshold

2016/17

Call Abandonment Rate

The call abandoned rate is a marker of patient experience. A high call abandoned rate is not safe and may reflect a high level of clinical risk for patients

% of calls received that abandoned before being answered. 1.50%

Time to Answer Calls

The time until a call is answered represents a period of clinical risk to the patients prior to assessment from trained ambulance service personnel. Many adverse events are related to initial delays in care and many emergency conditions are time-sensitive therefore the time before a patient begins treatment represents a clinical risk.

Average time (in seconds) to answer 999 calls presented to the Trust switchboard. Measured at the 50

th,

95th and 99

th

percentiles

50th 3 secs

95th 19 secs

99th 60 secs

Time from Call Categorisation to Arrival at Scene

The period before being seen by a health professional represents a period of clinical risk and anxiety for the patient. By encouraging earlier definitive care and reducing delays in treatment this indicator seeks to improve health outcomes and patient experience for all patients with life threatening conditions.

Time for the first emergency response vehicle to arrive at scene for A category Incidents measured to 50

th, 95

th and 99

th

percentiles

To be confirmed

Re-Contact with the Ambulance Service following Telephone Advice

Patients may re-contact the ambulance service because their condition has worsened. However in some cases there may be further contact due to an incorrect initial telephone diagnosis or poor explanation by clinical staff. Unplanned re-contact is a marker of the accuracy of initial telephone assessment in identifying those patients requiring an escalation of care or likely to experience deterioration.

% of unplanned re-contact within 24 hours following initial telephone advice.

11.00%

Re-Contact with the Ambulance Service following Treatment at Scene

Ambulance staff will always use the most appropriate treatment pathways based on their clinical assessment of the patient on scene. However patients may re-contact the ambulance service because their condition has worsened or they have received a poor explanation. Unplanned re-contact is a marker of the accuracy of initial treatment at scene in identifying those patients requiring an escalation of care or likely to experience deterioration.

% of unplanned re-contact within 24 hours following treatment at scene

5.50%

Patients Managed Appropriately (Right Care, Right Place, Right Time) – Calls Closed with Telephone Advice

Providing clinically appropriate pre-hospital care through clinical telephone advice may result in better outcomes for patients and a more efficient use of ambulance resources. This can include advice from Nurses within our Clinical Hubs and advice about other NHS facilities the patient could attend themselves (Minot Injury Units, etc.)

% of calls that are managed through telephone advice without the need for an ambulance resource arriving on scene

7.50%



Ambulance Quality

Indicator



Local

Performance

Threshold

2016/17

Patients Managed Appropriately (Right Care, Right Place, Right Time) – Calls Closed without the need for Transport to A&E (Emergency Departments)

Providing effective pre-hospital care allows for better care for the patient; such as care being delivered closet to home. A reduction in avoidable emergency patient journeys and admissions to hospitals whilst responding to and conveying those patients who would not be suitable for treatment at the scene or through clinical telephone advice.

% of calls that are managed through without the need for an ambulance resource arriving on scene, or onward transport to major Emergency Department

52.00%

Return of spontaneous circulation following cardiac arrest

The aim of this indicator is to reduce the proportion of patients who die from out of hospital cardiac arrest. It reviews patients who were in cardiac arrest but, following resuscitation, have a pulse on arrival at hospital. Improvement in ROSC rates informs the effectiveness of pre-hospital response and intervention. The ROSC is calculated for two patient groups:

The overall rate measures the overall effectiveness of the pre-hospital response and intervention for all out of hospital cardiac arrest patients;

The rate for the Utstein comparator group applies to a sub-set of all cardiac arrest patients and provides a more comparable measure of management of cardiac arrest for patients where timely and effective clinical care can particularly improve survival.

% of resuscitated cardiac arrest patients that had a Return of Spontaneous Circulation (ROSC) at the point of handover of clinical care of the patient to the hospital

24.00%

Return of spontaneous circulation following cardiac arrest (Utstein)

% of resuscitated cardiac arrest patients that had a Return of Spontaneous Circulation (ROSC) at the point of handover of clinical care of the patient to the hospital – where the arrest was witnessed and the initial rhythm was VF or VT.

45.00%

Outcome from acute STEMI - (PPCI)

Early access to reperfusion and other assessment for care interventions are associated with reductions in mortality and morbidity for inpatients suffering an ST elevation myocardial infarction (STEMI) mortality and morbidity. This is evidenced in both NSF and CHD and National Infarct Angioplasty Project Gateway 9116 (2008) and Mending Hearts and Brains (2006).

% of patients suffering a STEMI receiving Primary Percutaneous Coronary Intervention (PPCI), also known as primary angioplasty, within 150 mins of call.

84.00%

Outcome from Acute STEMI – Care Bundle

% of patients suffering a STEMI who receive an appropriate care bundle.

90.00%

Outcomes from Stroke for Ambulance Patients - FAST

Patients should be arriving at the hyper-acute stroke centre as soon as possible so that they can be rapidly assessed for thrombolysis, with this being delivered following a CT scan in a short but safe time frame. This has been demonstrated to reduce mortality and improve recovery. Eligibility criteria, particularly in relation to the therapeutic time window, will vary between local services, depending on the availability of local expertise e.g. intra-arterial clot lysis. This indicator supports the NICE national

% of patients assessed face to face and provided a FAST (Face, Arms, Speech, Time to Call 999) positive response and were potentially eligible for thrombolysis that arrive at hospitals with a Hyper Acute Stroke Centre within 60 mins of the call.

57.00%



Ambulance Quality

Indicator



Local

Performance

Threshold

2016/17

Outcome from Stroke for Ambulance Patients – Care Bundle

quality standard that indicates this is an effective measure of the ambulance service’s contribution to the stroke pathway.

% of suspected stroke patients assessed face to face who receive an appropriate care bundle

97.00%


Survival to discharge is where a patient is able to be discharged from hospital and continue recovery after a cardiac arrest. The indicator measures the effectiveness of the whole urgent and emergency care system in managing out of hospital cardiac arrest. Survival to discharge is calculated for two patient groups:

The overall survival rate measures the overall effectiveness of the urgent and emergency care system in managing care for all out of hospital cardiac arrest patients;

The Utstein survival rate applies to a sub-let of all cardiac arrest patients and provides a more comparable measure of management of cardiac arrest for patients where timely and effective clinical care can particularly improve survival.

% of patients who had resuscitation (Advanced or Basic Life Support) commenced/continued by the ambulance service following an out-of-hospital cardiac arrest.

9.00%

Outcome from Cardiac Arrest – Survival to Discharge (Utstein)

% of patients who had resuscitation (Advanced or Basic Life Support) commenced or continued by the ambulance service following an out-of-hospital cardiac arrest of presumed cardiac origin, where the arrest was bystander or emergency medical service witnessed and the initial rhythm was VF or VT.

27.00%



NHS 111 Service Quality Requirements

Quality

Requirement What is the Indicator Measuring? Measure

National Quality

Requirement

Standard

QR1 National Quality Requirement performance reporting

Providers must report regularly to NHS Commissioners on their compliance with the national Quality Requirements

Trust compliance with reporting requirements against the national Quality Requirements

Compliance

QR2 NHS 111 Consultations to GP surgeries by 08:00 next working day

Providers must send details of all out of hours consultations to the practice where the patient is registered by 08:00 the next working day

Percentage of NHS 111 consultations where details are provided to GPs by 08:00 next working day

Greater than 95%

QR3 Systems for exchange of information on patients with predefined needs

Providers must have systems in place to support and encourage the regular exchange of information between all those who may be providing care to patients with predefined needs (including e.g. patients with terminal illness)

Trust compliance with system requirements and exchange of information

Compliance

QR4 Audit of patient contacts to review clinical performance of individuals working in the service

Providers must regularly audit a random sample of patient contacts. This sample must be defined in such a way that it will provide sufficient data to review the clinical performance of each individual working within the service

Trust compliance with audit requirements for to review clinical performance

Compliance

QR5 Regular Audit of Patient Experience

Providers must regularly audit a random sample of patients’ experiences of the service

Compliance with patient experience audits on a regular basis

Compliance

QR6 Compliance with NHS Complaints procedure principles

Providers must operate a complaints procedure that is consistent with the principles of the NHS complaints procedure

Compliance with NHS complaints procedure principles

Compliance

QR7 Ability to match capacity to demand

Providers must demonstrate their ability to match their capacity to meet predictable fluctuations in demand for their contracted service, especially at periods of peak demand, such as Saturday and Sunday mornings, and the third day of a Bank Holiday weekend. They must also have robust contingency policies for those circumstances in which they may be unable to meet unexpected demand.

Compliance

QR8 call answering performance

Initial Telephone Call into the NHS 111 service should be handled promptly.

Percentage of abandoned telephone calls. Time taken for the call to be answered by a person within 60 seconds of the end of the introductory message.

Less than 5% of calls abandoned.

More than 95% of calls answered

within 60 seconds



Quality


National Quality

Requirement

Standard

QR9 telephone triage performance

Providers must have a robust system for identifying all immediate life threatening conditions and, once identified, those calls must be passed to the ambulance service within 3 minutes.

Providers that can demonstrate that they have a clinically safe and effective system for prioritising calls must meet the required standards for clinical assessment.

Compliance with system requirements for passing calls to the ambulance service. Where required patient call backs are commenced within 10 minutes

Compliance

Greater than 95%

QR13 provision of interpretation services when required

Patients unable to communicate effectively in English will be provided with an interpretation service within 15 minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or impaired sight.

Compliance with service provision within 15 minutes of initial contact.

Compliance

QR14 compliance with Information Governance Toolkit

Providers must demonstrate the online completion of the annual assessment of the Information Governance Toolkit at level 2 (satisfactory) or above and that this is audited on an annual basis by Internal Auditors using the national framework.

Compliance with IG Toolkit Requirements at level 2.

Compliance

QR15 compliance with Department of Health Information Governance SUI Guidance

Providers must demonstrate that they are complying with the Department of Health Information Governance SUI Guidance on reporting Information Governance incidents appropriately.

Compliance with Department of Health guidance on the reporting of Information Governance incidents appropriately.

Compliance



Urgent Care Services Quality Requirements

Quality


National Quality

Requirement

Standard

QR1 National Quality Requirement performance reporting

Providers must report regularly to NHS Commissioners on their compliance with the national Quality Requirements

Trust compliance with reporting requirements against the national Quality Requirements

Compliance

QR2 Out of Hours Consultations to GP surgeries by 08:00 next working day

Providers must send details of all out of hours consultations to the practice where the patient is registered by 08:00 the next working day

Percentage of out of hours consultations where details are provided to GPs by 08:00 next working day

Greater than 95%

QR3 Systems for exchange of information on patients with predefined needs

Providers must have systems in place to support and encourage the regular exchange of information between all those who may be providing care to patients with predefined needs (including e.g. patients with terminal illness)

Trust compliance with system requirements and exchange of information

Compliance

QR4 Audit of patient contacts to review clinical performance of individuals working in the service

Providers must regularly audit a random sample of patient contacts. This sample must be defined in such a way that it will provide sufficient data to review the clinical performance of each individual working within the service

Trust compliance with audit requirements for to review clinical performance

Compliance

QR5 Regular Audit of Patient Experience

Providers must regularly audit a random sample of patients’ experiences of the service

Compliance with patient experience audits on a regular basis

Compliance

QR6 Compliance with NHS Complaints procedure principles

Providers must operate a complaints procedure that is consistent with the principles of the NHS complaints procedure

Compliance with NHS complaints procedure principles

Compliance

QR7 Ability to match capacity to demand

Providers must demonstrate their ability to match their capacity to meet predictable fluctuations in demand for their contracted service, especially at periods of peak demand, such as Saturday and Sunday mornings, and the third day of a Bank Holiday weekend. They must also have robust contingency policies for those circumstances in which they may be unable to meet unexpected demand.

Compliance

QR10 face to face triage performance

Face to Face Clinical Assessment: Providers must have a robust system for identifying all immediate life threatening conditions and, once identified, those calls must be passed to the ambulance service within 3 minutes.

Compliance with system requirements for passing calls to the ambulance service. Start definitive clinical

Compliance



Quality


National Quality

Requirement

Standard

Providers that can demonstrate that they have a clinically safe and effective system for prioritising calls must meet the required standards for clinical assessment.

At the end of the assessment, the patient must be clear of the outcome, including (where appropriate) the timescale within which further action will be taken and the location of any face-to-face consultation.

assessment for urgent calls within 20 minutes of the patient arriving at the centre Start definitive clinical assessment for all other calls within 60 minutes of the patient arriving at the centre Compliance with assessment requirements.

Greater than 95%

Greater than 95%

Compliance

QR11 patient treatment requirements

Providers must ensure that patients are treated by the clinician best equipped to meet their needs in the most appropriate location. Where it is clinically appropriate, patients must be able to have a face-to-face consultation with a GP, including where necessary, at the patient's place of residence.

Compliance with patient treatment requirements.

Compliance

QR12 face to face consultation within agreed timescales

Face-to-Face Consultations (assessed for both patient home visits and patients visiting a treatment centre) must be started within the appropriate timescales, after the definitive clinical assessment has been completed.

Emergency calls within 1 hour Urgent calls within 2 hours Less Urgent calls within 6 hours

Greater than 95%

Greater than 95%

Greater than 95%

QR13 provision of interpretation services when required

Patients unable to communicate effectively in English will be provided with an interpretation service within 15 minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or impaired sight.

Compliance with service provision within 15 minutes of initial contact.

Compliance

Note: Following the introduction of the NHS 111 service with effect from February 2013, the Out of Hours service are no longer required to report on QR 8 (call answering performance) and QR9 (definitive clinical assessment by telephone) as these areas are now under the remit of the NHS 111 service provider contracts.



Appendix D: Local Measures Definitions and Glossary

A&E Local Key Performance Indicators

Measure 2016/17

Local Target Definition

How the Target is

measured

Green 1* 90%

These are calls where presenting conditions are serious but not life threatening, and there is a less serious clinical need. These calls should receive an emergency response within 20 minutes.

Monthly performance vs KPI monitoring

Green 2* 90%

These are calls where presenting conditions are serious but not life threatening, and there is a less serious clinical need. These calls should receive an emergency response within 30 minutes


Green 3* 90%

These are calls which are assessed as lower acuity calls requiring a response at normal road speeds within 60 minutes or a phone assessment within 30 minutes (a clinician calling back for a secondary telephone triage to establish the most appropriate care pathway for the patient).


Green 4 (999)* 90%

These are calls where presenting conditions are not serious and therefore not life threatening and do not require an emergency response. These calls should receive a clinical response within 60 minutes


Green 4 (HCP)* 70%

The Green 4 category includes all responses made by the Trust to requests from Healthcare Professionals to undertake urgent transfers of patients within a 1, 2 or 4 hour time window


Non Conveyance Rate

n/a Incidents that are completed without the need to convey a patient to an Emergency Department at an acute hospital.

Monthly performance vs local trajectory and KPI

targets

*Note that the Green 1, 2, 3 and 4 incidents are only applicable for the period 1 to 18 April 2016 as they no longer exist under the ARP Trial.



Appendix E: Board Assurance

Board Assurance

Framework (BAF)

Integrated

Performance

Report

Annual Cycles and

Records

Committee

Assurance

Medicines

ManagementEnd of Life

Research

and AuditSepsis CQUIN

Clinical audit plan CE CE All

PS PE PS

CQC registration

compliance

PS PS All

CE PE All

CE PS All

Safeguarding PS PE

PS

PECritical Assurance

RolesCritical assurance roles appointed to include: Caldicott Guardian, Senior Information Risk Owner, Accountable

Officer for Controlled Drugs, and Board Champions

Where and how the Board has received assurance at key forums against key performance indicators and objectives

plus documenting external assurance and an assurance evaluation tool

NHSLA compliance

Codes of conduct

Risk RegistersCorporate Risk Register reviewed at each Board meeting; all risk registers, including directorate, reviewed annually

(cross referenced on BAF)

Code of governance

Quality

Governance

Reviews

Quality reviews of Trust arrangements against negative assurance about other trusts: eg Mid Staffs. Action plans

developed and monitored

Board DevelopmentBoard development and training register is maintained for all Board members. Regular annual training includes: risk

management; health and safety; and information governance

Clinical and governance policy and strategy

Governance checklist initiative designed to provide a quick assessment of the governance requirements for any new

function or initiative

Quality Board Assurance

Governance Reporting

Each Board commitee is chaired by a Non Executive Director (NED); an action point register and minutes from each

committee are reviewed by the Board of Directors at each meeting

Governance

Checklists

The new Integrated Corporate Performance Report, from February 2013, provides the Board with assurance

against a set of contractual and statutory metrics on a monthly basis. The report focuses on peformance exceptions

and provides the Board with an early warning of metrics that are of concern across the Trust.

Regulatory

Framework

The Regulatory Framework contains details of all statutory and regulatory targets with details of which forum they

should be presented to.

Board, and each of its committees, has an annual cycle of business, reviewed and revised at the start of each

year;and a record of all business conducted detailing review, approval or referral of key documents

The following working groups provide assurance to the Quality and Governance Committee:

Health and Safety

Accident statistics, risk assessments, health,

safety and security indicators

Aggregated review of serious and other incidents,

safeguarding, MECs, claims; and identification of trends

and lessons learned; as well as review of compliance

with key targets such as CQC outcomes

Clinical

Effectiveness

The Board of Directors uses a variety of mechanisms to seek assurance that the Trust is meeting its corporate objectives;

identifies and manages any risks; and remains compliant with its statutory and regulatory targets

Assurance Mechanisms

Quality and Governance

Committee

Develop and implement effective

quality and governance assurance

systems and processes

Audit Committee

Review and seek assurance on the effectiveness of

processes in place for the management of

arrangements for Governance, Risk Management,

Clinical Assurance, Internal Control, and Financial

Reporting; and to ensure the Trust and its auditor

remain compliant with Monitor's Audit Code for NHS

Foundation Trusts (terms of authorisation)

Finance and Investment

Committee

Review financial planning,

cost improvements,

investments and financial

performance

Information governance

Learning from

Experience

Patient experience

Infection

Prevention and

Control

Resuscitation

PS

Clinical guidelines

HR key indicators

Infection prevention and

control

Infection Prevention and Control policies, procedures and guidelines; clinical efficiency and best practice. The work of the

Group is supported by a set of sub groups:

Air

Ambulance

Clinical

Vehicle

Equipment &

Uniform Working

Corporate and Directors' risk registers

Identification of risk

The Quality Strategy and Quality Account are each structured around five priorities: patient safety (PS); patient experience

(PE); clinical effectiveness (CE); access; and value for money

Ambulance Clinical Quality indicators Assurance framework

Quality account

Identification of legislation

Health and safety KPIsMedicines management plan

The following quality reports and action plans are received at each Quality and Governance committee meeting and used as mechanisms of

quality assurance. Highlighted boxes show which quality priority they meet:

Appendix Fi - Clinical Dashboard 2016/17 Month: Apr-16 Year: 2016/17

National

TargetTrend YTD Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Q1 Q2 Q3 Q4

Red 1 Category A - Red 1 Performance 75.00% 72.73% 72.73%

Red 1Category A - Red 1 Time to Treatment - 95th percentile of time from call connect to an emergency response

arriving at the scene of the incident (mins)n/a 15.4 15.4

Red 2 Category A - Red 2 Performance 75.00% 56.87% 56.87%

A19 A19 Performance 95.00% 86.07% 86.07%

National

TargetTrend YTD Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Q1 Q2 Q3 Q4

Red R Red Response Performance 75.00% 66.79% 66.79%

Red R Red Performance Response Time - 50th Percentile (minutes) n/a 6.6 6.6



Red T Red Transport Performance n/a 81.25% 81.3

Red T Red Performance Transport Response Time - 50th Percentile (minutes) n/a 9.2 9.2



Amber T Amber T Response Time - 50th Percentile (minutes) n/a 22.2 22.2

Amber F Amber F Response Time - 50th Percentile (minutes) n/a 19.7 19.7

Amber R Amber R Response Time - 50th Percentile (minutes) n/a 15.2 15.2

Green F Green F Response Time - 50th Percentile (minutes) n/a 37.0 37.0

Green T 999 Green Transport Response Time - 50th Percentile (minutes) n/a 47.7 47.7

Green T HCPHealthcare Professionals that receive a response within a agreed time window (1, 2 or 4 hours in

length depending on acuity)n/a 66.93% 66.93%

Performance

Threshold 2016/17Trend YTD Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

CO1.1 Call Abandonment Rate (% of calls abandoned before answering) 1.50% 1.59% 1.59%

CO1.2Re-Contact Rate Following Discharge of Care (unplanned re-contact with the ambulance service

within 24 hours of discharge of care by clinical telephone advice)11.00% 10.25% 10.25%

CO1.2Re-Contact Rate Following Discharge of Care (unplanned re-contact with the ambulance service

within 24 hours of discharge of care following treatment at scene)5.50% 4.64% 4.64%

CO1.8Time to Answer Emergency Calls - Median time spent between call connect and call answer

(seconds)3 3 3

CO1.8Time to Answer Emergency Calls - 95th percentile of times from call connect and call answer

(seconds)19 31 31

CO1.8Time to Answer Emergency Calls - 99th percentile of times from call connect and call answer

(seconds)60 85 85

CO1.9Time to Treatment (time to arrival of ambulance dispatched health professional for immediate life

threatening (cat A) calls - Median time spent to arrival of a qualified health professional (mins)n/a 8.4 8.4

CO1.9Time to Treatment (time to arrival of ambulance dispatched health professional for cat A calls - 95th

percentile of times to arrival of a qualified health professional (mins)n/a 30.6 30.6

CO1.9Time to Treatment (time to arrival of ambulance dispatched health professional for cat A calls - 99th

percentile of times to arrival of a qualified health professional (mins)n/a 58.6 58.6

CO1.10Ambulance calls closed with telephone advice or managed without transport to A&E departments

(where clinically appropriate) - calls closed with telephone advice7.50% 13.63% 13.63%

CO1.10Ambulance calls closed with telephone advice or managed without transport to A&E departments

(where clinically appropriate) - incidents managed without the need for transport to A&E52.00% 48.84% 48.84%

CO1.11 Number of Emergency Patient Journeys n/a - 33,882 33,882

Ambulance Performance Targets (1st to 18th April 2016 only)

Ambulance Clinical Quality Indicators - System Indicators

Following the implementation of the ARP trial on 19 April 2016 additional AQI metrics will be collected from May 2016, SWASFT are currently awaiting the final template for the data collection, data will be included regarding the new metrics from the May 2016 report.

Performance Thresholds detailed above have been agreed locally with Commissioners and performance against these thresholds will be monitored within this report throughout 2015/16.

ARP - Performance Metrics (ARP trial metrics from 19th April 2016)

CO1.9 Time to treatment metrics refer to Red incidents pre ARP, therefore the data included within the April 2016 report only relates to performance during the period 1 to 18 April 2016, all other metrics in April 2016 cover the whole period 1 to 30 April 2016.

Performance

Threshold 2015/16Trend

Rolling 12

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

CO1.3Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital

(overall)24.00% 25.54% 27.38% 23.44% 26.05% 27.00% 23.60% 25.17% 22.19% 22.73% 29.79% 25.09% 27.83% 26.10%

CO1.3Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital

(Utstein Comparator Group)45.00% 48.23% 53.19% 42.86% 41.46% 47.50% 48.48% 53.85% 43.59% 44.23% 60.47% 53.33% 50.00% 41.30%

CO1.5

Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - % of patients suffering a STEMI

and who, following a direct transfer to a PPCI centre, primary angioplasty commences within 150

minutes of call

84.00% 75.19% 70.75% 74.29% 74.56% 75.83% 70.99% 76.79% 74.82% 73.64% 80.58% 78.45% 75.50% 77.86%

CO1.5Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - % of patients suffering a STEMI

and who receive an appropriate care bundle90.00% 85.08% 88.57% 88.44% 88.77% 85.45% 89.15% 82.68% 84.58% 76.24% 83.15% 79.80% 87.37% 82.00%

CO1.6

Outcome from Stroke for Ambulance Patients - % of Face Arm Speech Test (FAST) positive stroke

patients (assessed face to face) potentially eligible for stroke thrombolysis, who arrive at a

hyperacute stroke centre within 60 minutes of call

57.00% 46.37% 48.72% 49.22% 56.35% 50.86% 51.30% 50.00% 43.58% 41.25% 40.23% 42.86% 46.50% 39.31%

CO1.6Outcome from Stroke for Ambulance Patients - % of suspected stroke patients (assessed face to

face) who receive an appropriate care bundle97.00% 97.05% 97.88% 97.99% 96.96% 98.02% 97.36% 97.07% 98.32% 96.45% 95.82% 95.60% 96.82% 96.51%

CO1.7 Outcome from Cardiac Arrest - Survival to Discharge - overall survival rate 9.00% 8.81% 8.33% 9.12% 7.79% 9.00% 8.71% 13.33% 7.36% 7.58% 10.99% 7.12% 8.46% 8.01%

CO1.7 Outcome from Cardiac Arrest - Survival to Discharge - Utstein Comparator Group survival rate 27.00% 25.60% 25.53% 27.08% 23.08% 27.50% 18.18% 43.59% 23.08% 21.15% 37.21% 23.81% 16.13% 18.60%

Improving Trend

No Change

Reducing Trend

Performance for the Clinical Indiciators is monitored against a rolling 12 month performance for the Trust

Ambulance Clinical Quality Indicators - Clinical Indicators

Appendix Fii - A&E Local Performance Targets Month: Apr-16 Year: 2016/17

KPI Trend YTD Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Q1 Q2 Q3 Q4

Green 1Percentage of calls that are serious, but not life threatening, receiving an emergency response within 20

minutes90.00% 72.08% 72.08%

Green 2Percentage of calls where presenting conditions are serious, but there is a less clinical need, receiving

and emergency response within 30 minutes90.00% 68.02% 68.02%

Green 3Percentage of lower acuity calls which receiving a response within 60 minutes or a telephone assessment

within 30 minutes90.00% 94.15% 94.15%

Green 4 (999) Low acuity calls received from the public receiving a response at normal road speed within 1 hour 90.00% 78.67% 78.67%

Green 4 (HPC)Low acuity calls received from Healthcare Professionals that receive a response at normal road speeds

within a agreed time window (1, 2 or 4 hours in length depending on acuity)70.00% 68.16% 68.16%


Activity Percentage of Incidents through Hear & Treat Pathway - 11.16% 11.16%

Activity Percentage of Incidents through See & Treat Pathway - 35.61% 35.61%

Activity Percentage of Incidents through See & Convey to Non Emergency Department Locations - 5.64% 5.64%

Activity Percentage of Incidents through See & Convey to Emergency Departments - 47.59% 47.59%

Non

ConveyancePercentage of Incidents Closed without Conveyance to Emergency Departments - 52.41% 52.41%


Handover

DelaysTime lost to Chargeable Handover Delays in excess of 15 minutes (hrs) 0 1,962 1,962

Handover

DelaysNumber of Chargeable Handover Delays between 30 minutes and 60 minutes 0 1,652 1,652

Handover

DelaysNumber of Chargeable Handover Delays in excess of 60 minutes 0 193 193


A&E Contract A&E Actual Incidents vs Contracted Incidents 100.00% 96.98% 96.98%

Ambulance Performance Targets (1st to 18th April 2016 only)

Right Care, Right Place, Right Time 2

A&E Service Line Key Performance Indicators

Contract Activity

Appendix Fiii - PTS KPIs and Local Performance Targets Month: Apr-16 Year: 2016/17

KPI Trend YTD Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

1aPatients living up to 10 miles away from the treatment centre (Band A) should not spend more than

60 minutes on the vehicle on either an outward or return journey90.00% 91.78% 91.78%

1bPatients living over 10 miles and up to 35 miles away from the treatment centre (Band B) should not

spend more than 90 minutes on the vehicle on either an outward or return journey90.00% 93.46% 93.46%

1cPatients living over 35 miles away from the treatment centre (Band C) should not spend more than

120 minutes on the vehicle on either an outward or return journey90.00% 100.00% 100.00%

2a Patients should not arrive more than 45 minutes before their booked arrival time 90.00% 87.30% 87.30%

2b Patients should not arrive after their booked arrival time 97.00% 92.39% 92.39%

3aSWASFT is to arrive to collect patients from the agreed location within 45 minutes of the outward

journey time90.00% 91.01% 91.01%

3aSWASFT is to arrive to collect patients from the agreed location within 75 minutes of the outward

journey time90.00% 96.55% 96.55%

8cPick up time to be confirmed by text, email or phone call to the patient within a week of the

appointment (phone call being the preferred method (assessed quarterly)100.00% 100.00%

9aPatient satisfaction with the level of service received from the provider - assessed through the

annual patient satisfaction survey85.00% 97.80% 97.80%

9b NHS Commissioners to be satisfied with the level of service 100.00% 100.00%

9f Call answering performance 95.00% 95.57% 95.57%

10aAgreed activity performance report received in correct format and on time within 10 working days of

the start of the following month100.00% 100.00%

10bActivity and finance queries are acknowledged within 3 days of receipt and resolved within 28 days

from the date of the query100.00% 100.00%

12h

Nil Serious Untoward Incidents (SUIs) - Any SUIs to be reported and action plans put in place - in

line with NHS Bristol standard and timeframes (reported immediately, investigated within 24 hours

and lessons learnt shared, then closed within 60 working days of the incident)

100.00% 100.00%

12dCompliance with the agreed SWASFT complaints procedure - full response made in a timely

manner agreed with the complainant (assessed quarterly)100.00% 100.00%

3b

A summary of reasons and actions to be provided, for each month, for all cases where collection

was outside of the KPI limits (i.e. later than agreed timeframes). This may include case by case

analysis as deemed necessary

100.00% 100.00%

Patient Transport Services - Bristol, North Somerset and South Gloucestershire - 2016/17

Contract KPIs

Appendix Fiv - Urgent Care Services Quality Requirements Month: Apr-16 2016/17

QR YTD Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

QR1 Providers must report regularly to NHS Commissioners on their compliance with the Quality Requirements Compliance Compliant Compliant

QR2Providers must send details of all consultations (including appropriate clinical information) to the practice where

the patient is registered by 8.00 a.m. the next working day. 95.00% 82.85% 82.85%

QR3Providers must have systems in place to support and encourage the regular exchange of information between

all those who may be providing care to patients with predefined needsCompliance Compliant Compliant

QR4Providers must regularly audit a random sample of patient contacts (audit should provide sufficient data to

review the clinical performance of each individual working within the service)Compliance 1.02% 1.02%

QR5 Providers must regularly audit a random sample of patients' experiences of the service 1.00%Not Yet

Available

Not Yet

Available

QR6Providers must operate a complaints procedure that is consistent with the principles of the NHS complaints

procedureCompliance Compliant Compliant

QR7Providers must demonstrate their ability to match their capacity to meet predictable fluctuations in demand for

their contracted serviceCompliance

Non

Compliant

Non

Compliant

QR8a No more than 5% of calls abandoned before being answered 5.00% 0.88% 0.88%

QR8b Calls to be answered within 60 seconds of the end of the introductory message 95.00% 94.00% 94.00%

QR9a All immediately life threatening conditions to be passed to the ambulance service within 3 minutes 100.00% 88.89% 88.89%

QR9b Patient callbacks must be achieved within 10 minutes 100.00% 20.34% 20.34%

QR13Patients unable to communicate effectively in English will be provided with an interpretation service within 15

minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or

impaired sight

100.00% 100.00% 100.00%

QR14Providers must demonstrate the online completion of the annual assessment of the Information Governance

Toolkit at level 2 or above and that this is audited on an annual basis by Internal Auditors using the national

framework

Compliance Compliant Compliant

QR15Providers must demonstrate that they are complying with the Department of Health Information Governance

SUI Guidance on reporting of Information Governance incidents appropriately.Compliance Compliant Compliant










Available

Not Yet

Available





Non

Compliant

Non

Compliant







impaired sight

100.00% 100.00% 100.00%



framework




Urgent Care Services - NHS 111 Devon

Data in relation to QR5 is not available at the time of writing this report, this information will be updated and included in the May 2016 report.

Urgent Care Services - NHS 111 Dorset











Available

Not Yet

Available





Non

Compliant

Non

Compliant







impaired sight

100.00% 100.00% 100.00%



framework





Urgent Care Services - NHS 111 Cornwall



QR2Percentage of Out of Hours consultation details sent to the practice where the patient is registered by 08:00 the

next working day95.00% 97.47% 97.47%




review the clinical performance of each individual working within the service)Compliance Compliant Compliant

QR5 Providers must regularly audit a random sample of patients' experiences of the service Compliance Compliant Compliant




their contracted serviceCompliance Compliant Compliant

QR10aAll immediately life threatening conditions (walk in patients) to be passed to the ambulance service within 3

minutes of face to face presentation95.00% N/A N/A

QR10bDefinitive Clinical Assessment for Urgent cases presenting at treatment location to start within 20 minutes - not

applicable to this service as a separate clinical assessment is not carried out between presentation and clinical

consultation at walk-in-centres

95.00% N/A N/A

QR10bDefinitive Clinical Assessment for Less Urgent cases presenting at treatment location to start within 60 minutes -

not applicable to this service as a separate clinical assessment is not carried out between presentation and

clinical consultation at walk-in-centres

95.00% N/A N/A

QR10d At the end of an assessment, the patient must be clear of the outcome Compliance Compliant Compliant

QR11Providers must ensure that patients are treated by the clinician best equipped to meet their needs in the most

appropriate locationCompliance Compliant Compliant

QR12 Emergency Consultations (presenting at base) started within 1 hour 95.00% n/an/a

(0 cases)

QR12 Urgent Consultations (presenting at base) started within 2 hours 95.00% 88.79% 88.79%

QR12 Less Urgent Consultations (presenting at base) started within 6 hours 95.00% 97.21% 97.21%

QR12 Emergency Consultations (home visits) started within 1 hour 95.00% n/an/a

(0 cases)

QR12 Urgent Consultations (home visits) started within 2 hours 95.00% 91.27% 91.27%

QR12 Less Urgent Consultations (home visits) started within 6 hours 95.00% 93.77% 93.77%



impaired sight


Urgent Care Services - Dorset Out of Hours

Following the introduction of the NHS 111 Service in Dorset on 19 February 2013 all calls for urgent services (including out of hours services) are now processed through NHS 111 telephony systems.

Any appropriate incidents are then transferred to the Urgent Care Services in Dorset and Somerset for action. As a result QR8 and QR9 are no longer applicable to the Urgent Care Services in Dorset and Somerset with effect from March 2013.



QR2Percentage of Out of Hours consultation details sent to the practice where the patient is registered by 08:00 the

next working day95.00% 100.00% 100.00%




review the clinical performance of each individual working within the service)Compliance Compliant Compliant

QR5 Providers must regularly audit a random sample of patients' experiences of the service Compliance Compliant Compliant




their contracted serviceCompliance Compliant Compliant

QR10All immediately life threatening conditions (walk in patients) to be passed to the ambulance service within 3

minutes of face to face presentation95.00% n/a n/a

QR10aDefinitive Clinical Assessment for Urgent adult cases presenting at treatment location to start within 20 minutes

of arrival in the treatment centre95.00% 86.67%

86.67%

(15 cases)

QR10aDefinitive Clinical Assessmnet for children who are ill and have an urgent Out of Hours to start within 15

minutes of arrival in the treatment centre95.00% 33.33%

33.33%

(3 cases)

QR10bDefinitive Clinical Assessment for Less Urgent cases presenting at treatment location to start within 60 minutes

of arrival in the treatment centre95.00% 96.26% 96.26%

QR10d At the end of an assessment, the patient must be clear of the outcome Compliance Compliant Compliant

QR11Providers must ensure that patients are treated by the clinician best equipped to meet their needs in the most

appropriate locationCompliance Compliant Compliant

QR12 Emergency Consultations (presenting at base) started within 1 hour 95.00% 100.00%100.00%

(1 case)

QR12 Urgent Consultations (presenting at base) started within 2 hours 95.00% 93.70% 93.70%

QR12 Less Urgent Consultations (presenting at base) started within 6 hours 95.00% 97.30% 97.30%

QR12 Emergency Consultations (home visits) started within 1 hour 95.00% 0.00%0.00%

(2 cases)

QR12 Urgent Consultations (home visits) started within 2 hours 95.00% 88.60% 88.60%

QR12 Less Urgent Consultations (home visits) started within 6 hours 95.00% 90.56% 90.56%



impaired sight



Percentages of Cases completed within 4 Hours 95.00% 99.63% 99.63%

Urgent Care Services - Tiverton Urgent Care Centre

Any appropriate incidents are then transferred to the Urgent Care Services in Dorset and Somerset for action. As a result QR8 and QR9 are no longer applicable to the Urgent Care Services in Dorset and Somerset with effect from March 2013.

Urgent Care Services - Gloucestershire Out of Hours

Following the introduction of the NHS 111 Service in the counties of Gloucestershire on 19 February 2013 all calls for urgent services (including out of hours services) in these areas are now processed through NHS 111 telephony systems.

Appendix Fv - A&E Local Performance Targets Month: Apr-16 2016/17

National

TargetYTD Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Sickness Staff Sickness Level 4.00% 5.19% 5.19%

Appraisals Staff Appraisals Completed within 12 month period 85.00% 59.18% 59.18%

Infection

ControlCompliance with Infection Prevention and Control Standards at Ambulance Stations 75.00% 83.00% 83.00%

Infection

ControlCompliance with Infection Prevention and Control Standards for Double Crew Ambulances 75.00% 82.00% 82.00%

Vehicle Deep

CleanVehicle deep cleaning compliance with schedule 90.00% 90.38% 90.38%

YTD Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

Patient Safety Adverse Incidents reported relating to medication administration, prescription and supply errors 71 71

Patient Safety Central Alert System (CAS) received 2 2

Patient Safety Central Alert System warnings (outside deadline) 3 3

Safety

MeasuresNumber of Moderate Incidents Reported 2

Safety

MeasuresNumber of Moderate Incidents Currently Under Investigation 7

Safety

MeasuresNumber of Adverse Incidents Reported 928 928

Safety

MeasuresNumber of Adverse Incidents Closed 748 748

Safety

MeasuresNumber of Adverse Incidents Currently Under Investigation 2,997

Safety

MeasuresNumber of Security Incident Reported (SIRS) 99

Safety

MeasuresNumber of Security Incidents Closed 77

Safety

MeasuresNumber of Security Incidents Currently Under Investigation 129

Safety

MeasuresSerious Incidents Identified in Month 8 8

Safety

MeasuresSerious Incidents Investigated and Presented to Panel 3 3

Safety

MeasuresSerious Incidents Currently Under Investigation 21

Safety

MeasuresNever Events' Identified in Month (included in Serious Incidents figure above) 0 0

Patient

ExperienceNumber of MECS Reported 161 161

Patient

ExperienceNumber of MECS Closed (resolved with the Complainant and all investigations completed) 160 160

Patient

ExperienceNumber of MECS Resolved (with the Complainant but internal investigation ongoing) 10

Patient

ExperienceNumber of MECS Open (not resolved with the complainant and currently under investigation) 214

Patient

Experience

Number of MECS where an investigation has been returned but the complainant is still awaiting

feedback.24

Patient

ExperienceTotal PALS Reported 79 79

Patient

ExperienceTotal PALS Closed 76 76

Patient

ExperienceTotal PALS Currently ongoing 24

Patient

ExperienceCompliments Received 136 136

Local Indicators

Patient Experience

Trust Public Board of Directors Meeting – 26 May 2016

Page 1 of 1

Trust Public Board of Directors Meeting 26 May 2016

Title: Corporate Risk Register and Board Assurance Framework

Prepared by: Marty McAuley, Trust Secretary

Vanessa Williams, Head of Risk and Patient Safety

Presented by: Jenny Winslade, Executive Director of Nursing and Governance

Main aim: To provide the Board of Directors with the updated Risk Register and Board Assurance Framework

Recommendations: The Board of Directors is asked to take assurance from the information provided.

Previous Forum: None

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Underlying Causal Risks:

Accountable Director

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on

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Co

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(po

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Pro

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isk

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Date

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Ris

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)

Pe

rfo

rma

nc

e T

arg

ets

Re

d (A

RP

)

X X X

The potential for not achieving and sustaining the

Red target which could impact on patient safety,

staff experience, financials, Monitor's Risk

Assessment Framework and the Quality Premium

Payment.

Chie

f E

xecutive

SG

1

V.SERIOUS

(5)

POSS (3) 15 •Robust business plan and corporate objectives monitored by Directors Group;

•Effective and fully staffed Clinical Hub with rolling recruitment programme;

●Implementation of Early Exit procedure within Clinical Hubs;

●Implementation of Enhanced Pre Hospital Care within Clinical Hubs;

●Roll out of Public Automatic Defibrillators;

●Roll out of Airwave Responder Pagers;

•Appointment of Joint Liaison post with St John Ambulance regarding the

positioning and development of responder groups;

•Development of divisional Operational Implementation Plans;

●Developments identified within MAVIS being implemented;

● Trust wide hospital handover SOP agreed with Commissioners;

●Use of agency paramedics and private ambulance services to address

establishment levels;

•Twice-weekly Trust Performance Briefings focusing on barriers to performance

and mitigating actions, these become daily when Trust is at REAP level Red;

●Implementation of revised REAP;

•Fortnightly performance focus group meetings with Chief Executive to deep dive

into areas of concern;

•Daily and weekly conference calls;

•Daily review of all missed Reds;

•Improved initial triage of Red calls through early questionning/nature of call;

Increased focus on allocation of Red calls due to reduced numbers as part of ARP

trial;

•ARP Programme Board in place.

V. SERIOUS

(5)

LIKELY (4) 20 •Fortnightly Performance meetings;

•Monthly reports to IQPMG;

•ICPR report for Trust Board;

•Reports to Monitor;

•Daily reporting of ARP activity to NHS England;

•Fortnightly meetings with NHS England regarding

ARP.

• Ongoing internal monitoring and improvement;

●Implementation of Trust Operating Plan;

•Ambulance Response Programme trial which aims to improve

response times to critically ill patients, and making sure the best

response is sent to each patient first time with the appropriate degree of

urgency;

•Maintain a minimum of 65% Trust wide performance in any given

week during ARP trail period;

•Trust to report any SIs directly related to ARP trial;

•Implementation of revised AQI guidance in relation to ARP;

●Sheffield University overseeing data associated with ARP;

•Trust rota review.

Jul-16 V. SERIOUS

(5)

UNLIKELY

(2) 10 M

Directo

rs G

roup

27/1

1/2

012

D788

↔

Performance Targets Red (ARP)

The potential for not achieving and sustaining the Red target which could impact on

patient safety, staff experience, financials, Monitor's Risk Assessment Framework and

the Quality Premium Payment.

Confidential

Corporate and Directors Risk Register 8 May 2016

Risk

Page 1 of 17

http://hqweb/metatraffic2/track.asp?mtr=../../images/swastftlogo_new.jpg

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(Cu

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V.

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(5)

Likely

(4) 20


Performance Targets Amber

Performance Targets R19

Data Quality



Ris

k T

itle

Qu

ality

Ris

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Perf

orm

an

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isk

Fin

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ls R

isk

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Controls in Place

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(po

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Lik

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(po

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isk

Ris

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Date

ad

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Ris

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pd

ate

)

Op

era

tio

na

l R

es

ou

rce

s (

A&

E)

X X X

Potential reduced resource levels below core

within A&E service line at times of peak demand.

Directo

r of

Opera

tions

SG

1

SERIOUS

(4)

LIKELY

(4)

16 ●Centralisation of the Resource Operations Centre (ROC) and GRS implemented

across Trust;

●Workforce plan sets out resource forecast and planning;

●Provision of staff by third parties, agencies, bank and overtime;

•Absence Management Training being delivered as part of Leadership and

Management development programme;

●University Liaison Officer appointed to actively recruit students;

●National recruitment marketing campaign;

●Additional conversion from ECA to Paramedic to increase number of Paramedics;

• Restricted leave over busy periods;

•Ambulance Response Programme in place which improves deployment of

resources;

●Common CAD implemented which will enable resources to be moved around to

meet demand;

●Implementation of Staying Well Service to provide support for staff;

•Implementation of revised REAP levels which informs escalation;

•Revised Demand Management Plan in place to manage activity.

V.SERIOUS

(5)

POSS (3) 15 •Monthly establishment reports to IQPMG

(Commissioner meetings);

•ICPR reports to Board;

•Positive progress against recruitment trajectory;

•Daily conference calls to Gold Commander on

coverage for the day;

•Weekly Resource Management Groups to look at

forecasting.

●Payment of relocation incentives/'Golden Hellos';

●Additional bank staff being appointed;

•Appointment of full time bank resource manager within the ROC;

•Implement actions contained within Staff Survey Action Plan (EW) to

address wellbeing issues;

●Ongoing dialogue with Commissioners regarding handover delays

being led by CSU;

●Payment of incentivised shifts where necessary;

●Consideration of increased payments for bank staff;

●Implementation of robust recruitment plan ;

●PR firm appointed to market the Trust as an employer;

•Funding for additional ECA to Paramedic course

•30 new specialist paramedics due to be qualified in July 2016;

Early sign up of graduate paramedics;

Recruitment of additional ECAs;

Additional funding for 16 x 12 hour DCAs;

•Increased use of private ambulance services for 999 calls;

Additional funding for provision of private resources to bring

establishment above core;

•Monitor impact of change in clock start position associated with

Ambulance Performance Review (Dispatch on Disposition).

External consultants undertaking review of frontline workforce to

maximise resources to meet demand;

Trust wide rota review commencing in July2016 to review all

operational station rotas;

Erlang C remodelling to rebase call taker ratios within Clinical Hub;

Additional funding to place additional Clinical Supervisors in the Clinical

Mar-17 V. SERIOUS

(5)

POSS (3) 15 S

Qualit

y R

isk W

atc

h

20/0

9/2

013

HR

815A

↔

Pe

rfo

rma

nc

e T

arg

ets

Am

be

r

X X X

The potential for not achieving and sustaining the

Amber target which could impact on patient

safety, staff experience, financials and Monitor's

Risk Assessment Framework.

Chie

f E

xecutive

SG

1

SERIOUS (4) LIKELY (4) 16 •Robust business plan and corporate objectives monitored by Directors Group;


●Implementation of Early Exit procedure within Clinical Hubs;


●Roll out of Public Automatic Defibrillators;

●Roll out of Airwave Responder Pagers;

●Developments identified within MAVIS being implemented;

●Use of agency paramedics and private ambulance services to address

establishment levels;

•Ambulance Response Programme plan in place;

•Appointment of Joint Liaison post with St John Ambulance regarding the

positioning and development of responder groups;

•Twice-weekly Trust Performance Briefing to identify any barriers to performance

and mitigating actions, these become daily when the Trust is at REAP Red;

•Implementation of demand management plan;


SERIOUS

(4)

LIKELY (4) 16 •Monthly reports to IQPMG;

•ICPR report to Board of Directors;

•Daily reports to NHS England;

•Fortnightly meetings with NHS England


•Implementation of Trust Operating Plan;


•Review of demand management with CCGs ;

•ORH conducting modelling exercise of resources against demand;

•Ongoing review and escalation of inappropriate 111 dispositions

including categories of calls transferred;

•Ongoing monitoring of performance;


•Focus on managing Amber stack with additional clinicians being

employed (Sept 2016).

Jul-16 SERIOUS

(4)

LIKELY (4) 16 M

Qualit

y R

isk W

atc

h

11.0

5.2

015

D788B

↔

Major IT Service Failure

Operational Resources (A&E) Delay in the arrival of back up resource

Clinical Hub Rationalisation

The potential for not achieving and sustaining A&E Performance targets which could

impact on patient safety, staff experience, financials, Monitor's Risk Assessment

Framework and the Quality Premium Payment.

Confidential


Risk


Pe

rfo

rma

nc

e T

arg

ets

A1

9

X X X

The potential for not achieving and sustaining Red

Transport (R19) target which could impact on

patient safety, staff experience, financials and

Monitor's Risk Assessment Framework.

Chie

f E

xecutive

SG

1

SERIOUS (4) LIKELY (4) 16 • A&E service line operating plan approved and monitored at A&E service line

• Effective capital programme in place for vehicles and equipment

• Trust workforce strategy focused on frontline staff



● Trust wide hospital handover SOP agreed with Commissioners;

•Daily monitoring of R19 performance;

•Bi-weekly Trust Performance Briefings to identify barriers to delivery and

mitigating actions, these become daily during REAP level Red;

●Implementation of revised REAP levels;


SERIOUS

(4)

LIKELY (4) 16 •Monthly reports to IQPMG;

•ICPR report to Board of Directors;

•Daily reports to NHS England;

•Fortnightly meetings with NHS England


●Implementation of Trust Operating Plan;


•Monitoring of ARP trial.


•Review of demand management with CCGs ;


•Ongoing monitoring of performance;

•Increase the number of conveying resources in line with ARP trial;


Jul-16 SERIOUS

(4)

POSS (3) 12 M

Qualit

y R

isk W

atc

h

11.0

5.2

015

D788C

↔

Ma

jor

IT S

erv

ice

Fa

ilu

re

X X

Major ICT service failure of clinical hub and/or

radio and mobile data may lead to potential

business continuity risk in A&E, UCS or PTS.

Executive D

irecto

r of

IM&

T

SG

4

SERIOUS

(4)

POSS (3) 12 ●ICT Strategy action plans in place to deliver agreed business continuity

arrangements;

●Card System and manual practices defined and in place to support loss of

computer systems;

●Uninterrupted Power Systems and Generators in situ covering critical ICT

Services within clinical hubs;

• Fallback plans cover Minor, Major and Critical faults;

● BCM Strategy and outline plan agreed;

• Virtual CAD implemented and tested (East, West and North Hubs);

●Production and implementation of timely ICT business continuity plans;

•Clinical Hub business continuity lead;

•IT on call rota;

●Generator testing has taken place in East and West Hubs;

●North Clinical Hub Duty Managers trained in new Fall Back arrangements;

●New C3 contract signed and delivered;

●Ongoing support in relation to Estates development and employee IT

infrastructure;

•Quality meetings with 'gold' suppliers from June 2015;

•South and North CAD implementation;

●Clinical Hub fallback Business Continuity Plan reflects use of common CAD;

•Whole Trust fallback workshop took place Feb 2016;

•Business continuity exercise took place in North Hub as part of CAD migration;

•New CAD is stable. Executive Director of IM&T reported no recent issues have

taken place.

V.SERIOUS

(5)

POSS (3) 15 •Internal Audit Report on Business Continuity;

•Monthly Project Board meetings for IM&T

projects.

● Staff to be trained and plans tested (Sept 2016, FG);

• Deliver IG Toolkit plan for 2016/17 (March 2017, FG);

• Deliver IT work programme for 2016/17 (June 2017, FG);

•Review of core network underway in HQ (Sept 2016) including links to

Acuma House (Dec 2016, FG) and Ringwood (Sept 2016);

●Implementation of actions arising from serious incident investigation

relating to IT failures;

●East and West Hub Duty Managers to receive training on fallback

arrangements in relation to new BC plan;

●Generator testing programme to be developed for North Division (first

quarter 2016 by Estates dept);

•Relocation of North Hub to new premises which will improve IT

capability (Dec 2016).

Dec 2016 SERIOUS

(4)

POSS (3) 12 L

Executive D

irecto

r of

IM&

T

12/0

2/2

007

ICT

199

↓

De

lay

in

Arr

iva

l o

f B

ac

k U

p R

es

ou

rce

X X

Delays in the arrival of conveying resources to

back up RRVs and Community Responders could

affect-

Patient care - delayed treatment by other

providers;

Patient experience;

Reputation;

Financial implications;

Availability of resources;

Staff morale.

Directo

r of

Opera

tions

SG

1

SERIOUS (4) LIKELY (4) 16 •Effective performance monitoring arrangements in place through A&E Service Line

meetings;

•C3 Pathways Front End Screen developed and implemented within Hubs (East

and West);

●New back up SOP D045 section 6 issued, amended regarding priority 1 back up

requests and general broadcasts;

●Dual response SOP in place;

•Implementation of ELAN3 which will allow better utilisation of resources;

●REAP Escalation Plan;

•Trust Operating Plan;

•Use of third party resources to increase resource availability;

•SOP OP005 describes the allocation of back up by the Clinical Hub;

•Issue regarding impact of handover delays in hospitals escalated to

Commissioners. In addition a meeting was held with the Accountable Officer at

Glos CCG to discuss performance issues;

•Ambulance Response Programme trial which aims to improve response times to

critically ill patients, and making sure the best response is sent to each patient first

time with the appropriate degree of urgency.

SERIOUS

(4)

LIKELY (4) 16 •Live web reporting;

•Fortnightly performance review meeting.

•A&E Service line and Information Cell to review status plan and

utilisation reports;

●Implementation of A&E Operating Plan;

●Contract negotiations;

•Increase the number of conveying resources in line with ARP trial;

•Review impact of ARP trial in association with Sheffield University.

July 2016 SERIOUS

(4)

UNLIKELY

(2) 8 M

Executive D

irecto

r of

Deliv

ery

02/0

2/2

012

D176

↔

Da

ta Q

ua

lity

Iss

ue

s (

Hu

bs

)

X

The use of the Data Warehouse within the North

Division Clinical Hub impacting on the ability to

view live performance data.

Risk to be transferred to IM&T RR following

feedback from Exec Director of IM&T - to be

reviewed by RAG Executive D

irecto

r

of

IM&

T

SG

3

SERIOUS (4) POSS (3) 12 ●Process in place for producing performance data;

●Development of Performance Cube;

•Controls within Clinical Hub Rationalisation project;

•Implementation of new CAD across Trust.

SERIOUS

(4)

RARE (1) 4 Reports to IASG ●Structured review of Data Warehouse system as part of CAD project;

●Develop resilience within team to be able to cleanse data;

•Clinical Hub Restructure as part of Rationalisation.

Sep-16 MOD (3) RARE (1) 3 S

Clin

ical H

ub R

isk

Regis

ter

02/1

2/2

013

IT827

↓

Clin

ica

l H

ub

Ra

tio

na

lis

ati

on

X X

Implementation of new CAD and triage system

and estates project with changes to each element

could impact on short term quality and

performance.

Executive D

irecto

r of

IM&

T

SG

4

SERIOUS (4) POSS (3) 12 ●Project Group

●Programme Board includes attendance from Estates Programme Manager;

●Weekly meetings with Clinical Hub managers;

●Programme workbook monitored by Programme Board;

●Dedicated project team in place;

●Trust has previous experienced of transferring to new triage systems;

●Communications Strategy developed;

●Head of Terms agreed for new North hub premises;

●Clinical Hub layout agreed;

●Implementation of MIS training;

●Information on handover and arrival screens disseminated internally and

externally;


V.SERIOUS

(5)

UNLIKELY

(2) 10 •FIC approval;

•Project report presented quarterly to Board.

●Ongoing monitoring by Project team;

●Ongoing positive liaison with CAD supplier

●Escalate issues through the Programe Board;

●Testing to take place locally to enable quick installation and reduce

testing at new estate (July 2016);

●Implementation of Telephony Platform (July 2016);

●Roll out of NHS Pathways training in North division (from March

2016);

•Roll out of NHS Pathways in North hub (Sept 2016).

Nov-16 SERIOUS

(4)

UNLIKELY

(2) 8 S

Deputy

Directo

r of

Fin

ance

5 D

ecem

ber

2014

D875

↓

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(Cu

rre

nt)

Ris

k

Ra

tin

g

V. SERIOUS

(5)

POSS (3) 15


Increase in Activity

Handover Delays

24/7 Working



Ris

k T

itle

Qu

ality

Ris

k

Pe

rfo

rma

nc

e R

isk

Fin

an

cia

ls R

isk

Underlying Causal

Risk

Ac

co

un

tab

le D

ire

cto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

se

qu

en

ce

Sc

ore

Ori

gin

al L

ike

lih

oo

d

Sc

ore

Un

mit

iga

ted

(Ori

gin

al/In

he

ren

t) R

isk

Ra

tin

g

Controls in Place

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(C

urr

en

t)

Ris

k R

ati

ng


Ac

tio

n D

ea

dlin

e

Fo

rec

as

t C

on

se

qu

en

ce

(po

st

ac

tio

ns

)

Fo

rec

as

t L

ike

lih

oo

d

(po

st

ac

tio

ns

)

Fo

rec

as

t ri

sk

ra

tin

g

(po

st

ac

tio

ns

)

Pro

xim

ity

Ris

k

Ris

k S

ou

rce

Da

te a

dd

ed

to

re

gis

ter

Re

f

Ris

k R

ati

ng

Mo

ve

me

nt

(sin

ce last

up

date

)

Inc

rea

se

in

Ac

tiv

ity

X X X

Changes in daily and hourly spread of demand

within all service lines impacting on ability to

respond, funding, patient care and experience,

performance and staff experience.

Ch

ief

Exe

cu

tive

SG

3

SERIOUS (4) POSS (3) 12 •Activity reports sent to Commissioners on a daily and monthly basis;

•Daily monitoring of activity growth and impact of NHS 111 on A&E;

•Signed contracts which have activity growth embedded within the terms;

●Implementation of handover SOP.

•Revised Demand Management Plan for Clinical Hub implemented;


●Ongoing work with stakeholders and other providers of services;

●Revised Interhospital Transfer Procedure implemented;

●Right Care 2;

●'Choose well' campaign;

●Introduction of additional Clinical Supervisors within Hubs;

●111/999 Liaison Group in place;

•System level demand management plans being agreed with Commissioners and

monitored through the Integrated Quality and Performance Management Group;

●Implementation of revised REAP levels;

•Fortnightly performance focus group meetings to deep dive into areas of

concern;

•Internal daily conference calls to review demand management;

•Review of Demand Management Plan;

●Introduction of common CAD to assist in managing demand.

SERIOUS

(4)

LIKELY (4) 16 •Commissioners Demand Management Plan with

agreed actions to manage demand which is

recognised as an issue shared across the health

community (to be revised in Q2);

•Minutes of Performance Management Briefings

where pressures are identified and addressed;

•Daily and monthly activity reports to

Commissioners;

•Daily Operations call to review demand;

•Daily reporting to NHS England regarding effect

of ARP.

●Review of performance activity against demand monitored through

contract meetings;

●Daily review of activity profiles;

●Daily review of source of activity, specifically inappropriate callbacks

and abandonments;

●Additional resources to meet anticipated uplifts in demand including

agency and private providers reviewed weekly at the Resource

Management Group;

●Continue to work with 111 providers;

•Review of demand management with CCGs;

•Use of private and agency resources utilised at peak times;

•Review of status plan management;

•Use of clinical floor walkers within 111 to review appropriateness of

dispositions;

•Rota review to be undertaken by external organisation;

•Ongoing review and escalation of inappropriate 111 dispositions

including categories of calls transferred;

•Independent organisation undertaking modelling exercise;.

•ORH demand management modelling taking place;

•Monitor impact of Ambulance Review Programme trial.

Mar-17 SERIOUS

(4)

LIKELY (4) 16 M

Str

ate

gic

Fo

rwa

rd P

lan

nin

g R

isk R

eg

iste

r

24

Se

pt

20

12

F7

86

↔

Ha

nd

ov

er

De

lay

s a

t H

os

pit

al

- Im

pa

ct

on

Pa

tie

nt

Sa

fety

an

d R

es

ou

rce

s

X X

Increasing number of handover delays in acute

hospital trusts potentially resulting in delays in

attending patients who require emergency and

urgent assessment, treatment and/or conveyance

affecting clinical care and patient safety. In

addition the handover delays impact on the ability

to provide a timely conveying resource to patients

assessed by a clinician as requiring conveyance

to hospital affecting patient safety and experience

and staff morale.

Ch

ief

Exe

cu

tive

SG

3

V.SERIOUS

(5)

ALMOST

CERTAIN

(5)

25 •Provision of Bronze Commander to ED;

•Joint working between Trust and acute trusts to resolve issue through local action

plans between OMs and Commissioners;

• Clinical Notice issued to ensure that observations and continuity of clinical care

continues whilst patients are waiting in handover area;

•Clinical Supervisor call-back to manage risk of delayed responses;

•Implementation of delayed handover SOP (OP008) to introduce 30 minute

handover (incorporated within Contracts) when there is a risk to patient safety

which can be reduced to 15 minutes at periods of high risk;

•24/7 Logistics Cell in place to escalate handover delays as appropriate;

●Strategically deployed trolleys placed in acute hospitals to improve turnaround

times;

●Issue highlighted to CSU by Director of Operations;

●Trust wide hospital handover SOP agreed with Commissioners;

●Automatic implementation of handover SOP when Trust is at REAP Red;

•Reviewing handover delays with individual CCGs;

•Monthly contract Boards discuss handover delays and take appropriate action;

•Handover delays monitored at Trust Daily Performance Briefing;

•Implementation of revised REAP;

•Operational Officers placed in Emergency Departments to manage flow of

patients, this includes a dynamic risk assessment of patient condition and

symptoms to manage clinical risk.

V. SERIOUS

(5)

POSS (3) 15 •Fortnightly Performance meetings;

•Monthly reports to IQPMG;

•ICPR report for Trust Board;

•Live monitoring by Logistics Cell;

•Daily conference call to review all handover

delays.

●Continue to monitor situation and submit adverse incident reports for

each handover delay of more than 90 minutes;

•Review of handover procedure with Commissioners;

•OMs liaising with acute hospital trusts;

●Contract discussions;

●Trust monitoring impact of implementation of ECS on handover times;

•Introduction of NEWS scoring system;

•Demand Management Plan agreed with Commissioners in reduction

of handover delays;

•Development of ECS as an electronic means of capturing handover

timings.

Mar-17 V. SERIOUS

(5)

POSS (3) 15 M

Ris

k A

sse

ssm

en

t

11

Ap

ril 2

01

3

D8

05

↔

24

/7

Wo

rkin

g

X X

Impact of 24/7 working on Trust income,

resources and demand.

Ch

ief

Exe

cu

tive

SG

3

V.SERIOUS

(5)

LIKELY (4) 20 Appropriate commissioning;

Workforce planning.

V.SERIOUS

(5)

POSS (3) 15 •Undertake operational modelling exercise;

•Ongoing monitoring of risk;

Sep-16 V. SERIOUS

(5)

POSS (3) 15 M

Qu

alit

y

Ris

k

Wa

tch

20

Au

gu

st

20

15

F8

89

↔

Commissioner Affordability

Devolution

People with Unmet Needs

External Influences on the Trust Resources Impacting on the Trust's ability to

respond, funding, patient care and experience, performance and staff experience

Confidential


Risk


Co

mm

iss

ion

er

Aff

ord

ab

ilit

y

X X X

The ability of the Trust to mitigate the gap in

funding within the contracts as part of contract

negotiations

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4

V.SERIOUS

(5)

LIKELY (4) 20 •Contracts in place with Commissioners;

•Operational Modelling;

•Trust Financial plan;

•MAVIS 2016/17;

•Ambulance Response Programme plan in place.

V.SERIOUS

(5)

LIKELY (4) 20 •A&E modelling of resource and demand

•Monitor situation.

Mar-17 V.SERIOUS

(5)

POSS (3) 15 M

Ris

k A

ssu

ran

ce

Gro

up

26

/04

/16

F9

56

NEW

De

vo

luti

on

X

Potential impact of any devolution within the Trust

area on commissioning arrangements,

performance, variances in response, resource

availability, non contract activities and resilience

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

ti

ve

Dir

ecto

r o

f

Fin

an

ce

SG

3

SERIOUS

(4)

POSS (3) 12 •Contracts in place with Commissioners; SERIOUS

(4)

POSS (3) 12 •A&E modelling of resource and demand

•Monitor situation.

Mar-17 SERIOUS

(4)

POSS (3) 12 M

Qu

alit

y R

isk

Wa

tch

20

/08

/20

15

F8

88

↔

Ca

lle

rs w

ith

Un

me

t N

ee

ds

X X

People with unmet needs, who may be vulnerable

frequently contacting Trust services (A&E, 111

and UCS) impacting on:-

• Trust performance through increased activations

and decrease in Trust performance levels;

• Call taking ability through increased numbers of

calls;

• Recontact data;

• Other 999 callers local to frequent caller;

• Residents local to frequent callers due to

ambulance activity locally leading to complaints.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d G

ove

rna

nce

SG

1

SERIOUS (4) POSS (3) 12 •Clinical Supervisors and Clinical Supervisor Administrator review frequent callers

monthly;

•Frequent caller data shared with other agencies;

•Warnings on addresses of frequent callers;

•Clinical Supervisors to take calls of identified frequent callers when available;

•Frequent caller process followed to manage frequent callers;

•Operational staff attend local multiagency meetings as arranged by clinical

Supervisors/Safeguarding/other agencies;

•Acceptable behaviour contracts issued as part of the process;

●Frequent Caller process reviewed;

●Permanent Frequent Caller Leads appointed in North and West Hubs;

●Frequent Caller CQUIN halved the number of calls received from the top 10 care

homes by 50%;

●Management of Frequent Caller Process now in place;

●Monthly Frequent Caller meetings in place;

●Frequent Caller Policy.

SERIOUS

(4)

POSS (3) 12 •111 and OOH Frequent Caller reports provided to

Commissioners as part of quality indicator reports;

•Reports provided to Commissioners as part of

CQUiN.

•Hub to obtain national guidance on "what is a frequent caller to 999"

as currently no proposed national definition;

●Clinical Hub Clinical Lead to develop Frequent Caller report;

●Commissioners discussing managing frequent caller demand;

•111 review of Frequent Caller process.

Sept

2016

SERIOUS

(4)

POSS (3) 12 M

De

live

ry D

ire

cto

rate

Ris

k R

eg

iste

r

08

/02

./2

01

3

D7

99

↔

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(Cu

rre

nt)

Ris

k

Ra

tin

g

V.

Serious

(5)

Poss

(3) 15


Audit Compliance

Impact of REAP

Training - Clinical Skills

Regional Care Plan Strategy Health and Safety Strategic Oversight

Serious Incident Process

Complaints Performance

OOH Triage Delays

Impact of ARP


Ris

k T

itle

Qu

ality

Ris

k

Pe

rfo

rma

nc

e R

isk

Fin

an

cia

ls R

isk

Underlying Causal

Risk

Ac

co

un

tab

le D

ire

cto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

se

qu

en

ce

Sc

ore

Ori

gin

al L

ike

lih

oo

d

Sc

ore

Un

mit

iga

ted

(Ori

gin

al/In

he

ren

t) R

isk

Ra

tin

g

Controls in Place

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(C

urr

en

t)

Ris

k R

ati

ng


Ac

tio

n D

ea

dlin

e

Fo

rec

as

t C

on

se

qu

en

ce

(po

st

ac

tio

ns

)

Fo

rec

as

t L

ike

lih

oo

d

(po

st

ac

tio

ns

)

Fo

rec

as

t ri

sk

ra

tin

g

(po

st

ac

tio

ns

)

Pro

xim

ity

Ris

k

Ris

k S

ou

rce

Da

te a

dd

ed

to

re

gis

ter

Re

f

Ris

k R

ati

ng

Mo

ve

me

nt

(sin

ce

la

st

up

da

te)

Call

Sta

ckin

g (

A&

E)

X X

Stacking of Amber and Green calls due to

availability of resources and high demand could

affect patient safety, patient experience, staff

morale and performance.

Dire

cto

r o

f O

pe

ratio

ns

SG

1

V. SERIOUS

(5)

LIKELY (4) 20 •Increased number of clinicians within the Clinical Hub;

•Rewording of Exit advice to ensure call backs are appropriate;

•SOP CH058 - Passing calls to OOH Services During Periods of Extreme Demand, in place;

•SOP CH046 - Ensuring Patient Safety at Times of High Demand, reviewed and updated which sets

out process for Welfare Calls;

•SOP CH063 - 999 Clinical Hub Doctor Support, outlines the scope of practice for GPs undertaking

telephone triage within the Clinical Hub.

V. SERIOUS

(5)

LIKELY (4) 20 •ICPR and performance reporting to Board of

Directors;

•SI reports to Quality Committee;

•Reports to IQPMG at Commissioner meetings;

•Duty Performance Manager monitors stack and

escalates as appropriate to Gold Commander.

•Introduction of ARP should result in a more appropriate response to patients;

•Review of role and function of clinician in 999 hub;

•Risk assessment being conducted;

•Restructure of Clinical Hubs as part of Clinical Hub Programme of Change;

•Additional funding for clinicians within Clinical Hub;

•Green 4 trial taking place in Devon and Cornwall to improve utilisation of resources;

•Daily review of Adverse Incident reports associated with ARP;

•Introduction of new Orange code for high risk patients identified by Clinical Supervisor.

Nov-16 V. SERIOUS

(5)

UNLIKELY

(2) 10 M

Executive D

irecto

r of N

urs

ing

and G

overn

ance

18 A

pril 2016

N9

49

↔

Au

dit

Co

mp

lian

ce

X

Failure to meet call taking audit compliance could

have the potential to compromise patient safety

and the requirements of software licences.

Executive D

irecto

r of N

urs

ing a

nd G

overn

ance

SG

2

SERIOUS (4) LIKELY (4) 16 ●Executive leadership and management strengthened;

●Interim additional CQI team in place (on temporary basis in A&E Hub);

●Model of CQI revised utilising Senior Call Advisors to undertaken 500 audits per month within 111;

•Clinical Development Plan for UCS Service line;

•Quality Development Group Action Plan;

•Paper to Board of Directors proposing new approach to Call Audits approved;

•Procurement of new electronic audit support tool to support data collection;

•Capacity for audit improved through extending peer audit for clinicians and increasing clinical time for

audit;

•Minimum standards agreed for 111 call audits.

SERIOUS

(4)

LIKELY (4) 16 •Reports to Commissioners (monthly for 111and bi-

monthly for OOHs);

•Proposals for new approach to Call Audit process

approved by Board of Directors.

●Review of Audit process underway including structure, frequency and performance

management;

●Review of UCS structure underway;

●Review of Clinical Hub structure in light of change to triage system in North Hub;

● NHS Pathways review implementation;

●A&E Business Plan;

•Feedback to staff in place;

•Overtime offered to auditors and members of audit pool in A&E hub to increase

number of A&E audits undertaken;

•Installation of new audit tool for A&E Hub to assist quality and speed of returns;

•Undertake review of new A&E audit tool software for UCS use;

•Executive Director of Nursing & Governance meeting with service line to discuss

priorities and agree actions;

•Implement actions contained within Clinical Development Plan;

•Meeting arranged to progress agreed process for call auditing across both service

lines;

•Capacity review to be undertaken;

•Quality framework for call auditing to be co-designed with staff oversight from the

Board for assurance;

•Single quality assurance group to be established across both service lines;

•Overtime for call audit capacity agreed.

Sept

2016

SERIOUS

(4)

POSS (3) 12 S

Ris

k W

atc

h

04/0

6/2

014

N8

51

↔

Safe

gu

ard

ing

Co

mp

lian

ce

X

Risk of potential for non-compliance with

Safeguarding requirements:

•an increase in the number of referrals and quality

of referrals received affecting capacity and

potentially patient safety, this may be a

consequence of reporting via the EPCR and the

addtional training;

•insufficient capacity within the Safeguarding team

to maintain the current high standard of reporting

and management for all referrals;

•some Safeguarding referrals may not reach the

intended destination in a timely way from frontline

staff due to the user interface issues with the

EPCR.

New Composite risk incorporating the 3

Safeguarding risks previously on the risk register.

Executive D

irecto

r of N

urs

ing a

nd G

overn

ance

SG

1

SERIOUS (4) LIKELY (4) 16 •Extension until 1 September 2016 to secondment of additional triage post within the Safeguarding

team;

•Safeguarding referrals processed in accordance with RAG rating with review of all outstanding

referrals taking place at the end of each week with the Executive Director of Nursing and Governance;

•IT system in place involving an email being sent to staff advising that the referral has been submitted;

•Staff advised to notify Safeguarding service if confirmation email not received;

●Management of Allegations Policy in line with Trust and Local Authority Policy;

●Safeguarding Lead in post;

●Training provided to HR and Delivery Directorates;

●Code of Conduct;

●Review of Saville, Stoke Mandeville and Morecombe Bay reports completed;

•New Visitor Access Policy in place;

•Meeting with EPCR lead and Executive Director of IM&T to review quality of referrals and any issues

of non-transmission;

•Review completed internally with the Safeguarding team of a sample of referrals with validation by

the local authority.

SERIOUS (4) LIKELY (4) 16 •Reports quarterly to Quality Committee

•Safeguarding Operational Group in place and

meeting regularly;

•Risks escalated to Directors Group and Internal

Audit commissioned to review the risks.

•Head of Safeguarding to provide additional guidance to staff regarding how to submit

quality referrals;

•Head of Safeguarding to continue to meet with EPCR project lead;

•Weekly monitoring of referral process and weekly call with Executive Director of

Nursing and Governance to review weekly position and any potential risks;

•Issue reminders to advise staff to notify Safeguarding service if confirmation email not

received;

●Safeguarding Lead to undertake thematical analysis of all referrals;

•Risk assessment to be reviewed through Risk Assurance Process by 31/05/2016;

•Directors Group to receive risk assessment and internal audit review when complete

to agree actions to maintain quality of service.

Sept

2016

SERIOUS

(4)

LIKELY (4) 16 M

Ris

k A

ssu

ran

ce

Gro

up

2 M

arc

h 2

016

NG

88

1

↔

Module 2 Training

Executive Director of Nursing and Governance

Safeguarding Compliance

Ambulance Clinical Quality Indicators

Electronic Care System Progress

Medicines Management Systems and Processes

Gazzetteer

Clinical Hub Triage System

Appraisals

Impact of ARP

Call Stacking (A&E)

Asbestos Management

Potential for Not Providing a Quality Service, affecting Patient Safety and Experience, Staff

Morale, Reputation and Compliance

Confidential


Risk

UCS Clinician Capacity


UC

S C

lin

ical

Cap

acit

y

x

Potential for insufficient clinical capacity within the

UCS service line affecting patient safety and staff

morale due to an inability to recruit to current

vacancies.

Executive D

irecto

r of N

urs

ing a

nd G

overn

ance

SG

1

SERIOUS (4) LIKELY (4) 16 •2 meetings held with UCS clinicians and Clinical Development Plan circulated to all UCS clinicians for

comment and challenge on a bi-weely basis;

•Risk assessment of the NPA model completed and review completed of all incidents reported within

the last 6 months relating to NPAs. No cases requiring further follow up were identified;

•Change in threshold for NPAs taking general calls implemented;

•Monthly meetings with Royal College of Nursing to review clinical capacity being held;

•Chief Executive and Executive Director of Nursing & Governance attending clinicans meetings;

•Weekly calls to oversee implementation of Clinical Development Plan chaired by Chief Executive;

•Integrated clinician meetings held bi-monthly;

•Working groups established for clinical staff in relation to IT, recruitment and retention and clinical and

operational issues;

•SOPs reviewed with clinical staff and updated SOPs circulated and in place within 111 for

management of call backs, health information calls and management of the clinical queue at times of

extremis;

•Review of all incidents relating to clinical capacity reported within last 6 months - no cases which

required further review identified.

SERIOUS (4) LIKELY (4) 16 •Clinical development plan progression;

•Staff and staff side oversight;

•Reporting to commissioner meetings;

•Chief Executive and Executive oversight;

•RCN review of clinical development plan.

•Further work to dynamically assess the risk due to continued issues with recruitment;

•Delivery of the clinical development plan;

•Further engagement with clinical staff to review rotas and capacity;

• Report to Directors group;

• Continued engagement with staff to understand the risks and concerns;

• Recruitment continues for all clinical groups, recruitment group to consider alternative

approaches;

• Retention premia to be considered;

• Streaming to OOH services in place for vulnerable patients;

• Review of floor-walker model;

•Bespoke performance management framework being developed to support Call

Advisors;

•Root and branch analysis of clinical staffing being produced;

•Risk assessment of clinical staffing being undertaken;

•Assessment of risk for delayed clinical cll backs;

•Further discussion with OOH service regarding streaming.

Oct 2016 SERIOUS (4) POSS (3) 12 S

Executive D

irecto

r of N

urs

ing a

nd G

overn

ance

2 M

arc

h 2

016

N8

90

↔

Imp

act

of

RE

AP

Levels

, an

d

Su

mm

er,

Win

ter

an

d P

eak p

ressu

res

X X X

Increased REAP levels as a result of a threat to

national performance indicators leading to:-

•over activity against contract ;

•slippage to training programme deliveries and

other workstreams, including cancellation of priority

meetings dependent on REAP levels, winter

pressures and weather;

•increased demand on three core services;

•impact on delivery of business plans;

•impact on resilience within the Trust.

Trust currently at REAP RED

Directors Group agreed to update risk score as a

result of REAP level movement

Ch

ief

Exe

cu

tive

SG

4

SERIOUS

(4)

LIKELY (4) 16 • Effective escalatory process with clear command and control process in place;

• Performance management arrangements in place to monitor achievement of objectives;

• Business Continuity arrangements and processes in place;

• Weekly review of performance including assessment of REAP level by DIrector of Operations;

•Demand Management Plan for Clinical Hub;

•Updated escalatory management plan;

•New REAP monitoring introduced for NHS 111 service provided by the Trust;

•Revised REAP escalation plan implemented with divisional REAP levels;

•Bi-weekly Trust Performance Briefing focusing on barriers to performance and mitigating actions,

these become daily when REAP becomes Red;

•Ambulance Response Review;

●Implementation of new REAP levels (January 2016);

•Daily conference calls.

SERIOUS (4) LIKELY (4) 16 •ICPR to Board;

•Weekly review of REAP by Director of Operations.

• Ongoing discussions with Commissioners at C&P meetings to review activity and

demand profile in each CCG area and agree actions to mitigate increase in demand

including the review of alternative pathways;

• Executive Gold meetings convened as required;

•Meeting with all Strategic Resilience Groups to establish working arrangements and

escalation plans;

•Review of REAP triggers in light of ARP;

•Implement actions within REAP document as required.

Mar-17 SERIOUS

(4)

UNLIKELY

(2) 8 L

Ris

k R

eg

iste

r R

evie

w D

ay 2

00

7

22/0

2/2

007

EP

218

↔

Med

icin

es M

an

ag

em

en

t S

yste

ms a

nd

Pro

cesses

Imp

lem

en

tati

on

X

Inconsistent application of medicines management

systems and processes may result in inadequate

medicines management and controlled drugs

processes affecting patient and staff experience.

Executive M

edic

al D

irecto

r

SG

2

SERIOUS

(4)

POSS (3) 12 ● Medicines Management Policy implemented throughout the Trust (2016);

•Implementation of single system of medicines management across whole Trust;

•All stations/treatment centres required to reconcile actual stock against CD register running balance

and L11/Adastra record;

• Distribution and supply of medicines reviewed so that all medicines are supplied in accordance with

Policy for Safer Procurement and no intermediary organisation involved in supply chain;

•Medicines Management leads nominated on each ambulance station;

• Full time dedicated Pharmaceutical Advisor;

•Storage of controlled drugs standardised to restrict access to staff without authority to possess;

•Standardised audit of medicines records required in all locations;

•Appointment of clinicians to manage the stores at St Leonards, Staverton and Exeter;

●Medicines Management Group monitors implementation of policy by reviewing Adverse Incident

reports, progress resports and audit reports;

•Implementation of new morphine pouches and SOP for management of personal morphine;

•Standard Trust Controlled Drugs registers in place;

● Revised Medicines Management SOPs disseminated across Trust to harmonise procedures;

●Implementation of Medicines Management module for Adastra to provide electronic support in UCS;

•Trust worked with external provider of pharmaceutical service training to develop an accredited

course for non clinicians working in roles supporting front line staff. Ongoing education and training

planned for the members of this team which is known as the 'Pharmacy Team;

•New drug bags issued to all staff;

●Standardisation of morphine management across Trust.

SERIOUS

(4)

LIKELY (4) 16 •Medicines audits completed at all stations during

Dec 2015 and Jan 2016;

•Station quality development audits;

•Monthly station medicines audits reported to

Medicines Management Group.

;●Visits to stations and treatment centres to audit medicines management;

●Production of flow charts to simplify SOPs;

●Clinicians and Logistics Manager appointed to visit stations and support the

implementation process;

• All stations/treatment centres required to have an approved maximum and minimum

stock level for station/treatment centre ;

•Unannounced visits to stations by Pharmaceutical Advisor;

●Implement restriction of access to LSCDs by amendments to drug storage on

stations.

Sep-16 SERIOUS (4) UNLIKELY

(2) 8 M

Me

dic

ines M

an

ag

em

ent

Gro

up

CL

44

↔

Healt

h a

nd

Safe

ty -

Str

ate

gic

Overs

igh

t

X X X

Lack of strategic oversight for health and safety

could impact on patient and staff safety,

compliance with legislation, Trust reputation,

Executive D

irecto

r of N

urs

ing

and G

overn

ance

SG

1

V. SERIOUS

(5)

POSS (3) 15 •Executive Director in place with responsibility for health and safety;

•Non-Executive Director identified as health and safety lead;

•Health and safety structure in place with associated policies;

•Health and safety reports to Quality Committee.

●Chief Executive and Executive Director of Nursing and Governance met with HSE inspector to

discuss findings of inspection and plans moving forward;

• Facilities time for Union Health and Safety representatives reviewed and agreed;

•Board oversight of actions.

V. SERIOUS

(5)

POSS (3) 15 •Health and Safety reports to Quality Committee

and Board of Directors.

•Development of health and safety action plan for presentation at May 2016 Board of

Directors;

•Health and Safety Strategy to be produced;

•Health and Safety risks to be added to all committee agendas;

•Quality Committee to monitor implementation of action plan as delegated by the Trust

Board of Directors;

•Trust Board to undertake Directing Safely course;

•Identified managers to undertake Managing Safely course;

•Introduction of site responsible officers.

Sep-16 V. SERIOUS

(5)

UNLIKELY

(2) 10 M

HS

E I

nspe

ctio

n

13 A

pril 2016

N9

47

ne

w

Asb

esto

s M

an

ag

em

en

t

X X

Potential breach of Asbestos Management

systems impacting on safety and compliance with

legislation.

Dire

cto

r o

f O

pe

ratio

ns

SG

1

V. SERIOUS

(5)

POSS (3) 15 • Estates staff and external specialists carry out periodic inspections of retained asbestos;

• Asbestos Policy in place;

•All Trust Sites have an asbestos register and access to online surveys;

•All Estates Staff trained in Asbestos Awareness plus two Estates staff trained in Asbestos

Management;

•New compliance and contracts Manager in post since Jan 2016 to review compliance status;

•Asbestos Briefing produced and sent to all OOs and OMs for guidance.

V. SERIOUS

(5)

POSS (3) 15 •Reports to Quality Committee •Implement recommendations arising from HSE inspection;

•Development of health and safety action plan for approval by May 2016 Board;

•Ensure all sites containing asbestos have the appropriate labelling and on site records;

•Ongoing control and annual inspection, at some Trust sites where there is a

requirement to check the condition and labelling of retained asbestos containing

materials;

•Risks and actions to be reported to the Trust Board of Directors;

•Ongoing work with Somerset County Council Asbestos Team to ensure joined up

working and industry best practice and independent advice;

•Improved contract management.

Sep-16 V. SERIOUS

(5)

UNLIKELY

(2) 10 M

HS

E I

nspe

ctio

n

13 A

pril 2016

N9

48

ne

w

Seri

ou

s I

ncid

en

t P

rocess

X X

Potential for non-compliance with the National

Serious Incident Framework due to:

•insufficient capacity within the the Patient Safety

team;

•limited capacity/resilience for Quality Leads to

investigate serious incidents;

•Investigating Officers capacity;

•an increase in the number of potential SIs being

reviewed.

Executive D

irecto

r of N

urs

ing a

nd G

overn

ance

SG

4

MOD (3) LIKELY (4) 12 •Serious and Moderate Harm Incident Policy updated and presented to the Quality Committee April

2016 which is informed by the updated National Framework;

•Additional support for team to review potential Serious Incidents being provided by Clinical

Development Manager;

•Recruitment process underway to provide support for Patient Safety Manager;

• Reports to Board of Directors regarding Serious Incident performance;

• Quality Leads in place and trained;

• Serious Incident Review meetings chaired by a clinically qualified Director for each SI;

● Root Cause Analysis training for Investigating Officers. Further updates have been provided, most

recently March 2016;

●Regular communication regarding serious incidents and actions with CSU Patient Safety lead;

●Investigation training for Operational Officers delivered;

•Patient Safety team closely monitor investigation timescales;

•Actions from serious incidents followed up until completion confirmed and evidenced.

MOD (3) LIKELY (4) 12 •All SIs are reported on STEIS monitored by the

CSU and CCGs;

•Reports regarding Serious Incidents are presented

to Board of Directors;

•Quality reports presented to CCGs (for 111 and

OOH) and CSU for (A&E) which includes serious

incident data;

•Regular reports on serious incidents and

outstanding actions to Directors Group.

•Review and implement actions arising from Internal Audit Review;

•Appoint temporary Patient Safety Manager;

•Utilise clinical staff on light duties to provide assistance within Patient Safety team;

•Undertake review of Quality Lead role;

•Review Patient Safety team structure;

•Identify additional Investigating Officer capacity.

Nov-16 MOD (3) UNLIKELY

(2) 6 S

Executive D

irecto

r of N

urs

ing a

nd G

overn

ance

26/0

4/2

016

N9

52

ne

w

Co

mp

lain

ts P

erf

orm

an

ce

X X

Delays in acknowledging and responding to

complaints from patients and relatives; and

potential for limited learning opportunites as a

result of:

•An increase in the number of complaints being

received impacting on the capacity of the Patient

Experience team;

•The time taken by Investigating Officers to

investigate complaints;

•Level 2 actions being managed locally.

Executive D

irecto

r of N

urs

ing a

nd G

overn

ance

SG

4

MOD (3) LIKELY (4) 12 •Complaints Policy in place;

•A number of staff within the Patient Experience team are trained to undertake all aspects of the

administration process;

•Investigation training provided to Investigating Officers;

•History sheet provides an audit trail of each complaint;

•Complainants are kept updated of any expected delays;

•Level 3 complaint actions monitored by Complaints team.

MOD (3) LIKELY (4) 12 •Patient Safety and Experience report to Board of

Directors provides performance data;

•Compliments, PALS and Complaints report to

Quality Committee provides performance data;

•Quality reports presented to CCGs (for 111 and

OOH) and CSU for (A&E) which includes complaints

data;

•Number of complaints re-opened is low.

•Review team structure when appropriate, i.e. during recruitment for any vacancies;

•Introduce hub audit sustem to allow for quicker sourcing of documents resulting in

additional capacity within team;

•Heads of Operations to review time available to Investigating Officers to investigate

complaints;

•Review of all level 2 actions;

•Learning disseminated via Reflect;

•Implementation of Learning from Incidents and Complaints process;

•Quality Development Forum will address wider Trust learning.

Oct-16 MOD (3) POSS (3) 9 S

Ris

k A

sse

ssm

en

t

26/0

4/2

016

N9

53

ne

w

Mo

du

le 2

Tra

inin

g

(111)

X

Delays in the completion of Module 2 training for

111 NHS Pathways Call Advisors and Clinicians

which could impact on staff morale and Pathways

licence which would impact on safety and quality.

Executive D

irecto

r of

Nu

rsin

g a

nd

Govern

ance

SG

2

MOD (3) LIKELY (4) 12 •Clinical Development Plan in place;

•Plan in place to address staff requiring outstanding training in the East division;

•Head of Operations (UCS) implemented plan in July 2015 to address outstanding training within the

West Hub.

MOD (3) LIKELY (4) 12 Reports to Quality Committee All remaining East Clinical Hub staff to receive training by end of June 2016;

Confirm training dates for outstanding staff within West Clinical Hub;

Risk Assessment being completed.

Jul-16 MOD (3) UNLIKELY

(2) 6 S

Executive D

irecto

r of

Nu

rsin

g a

nd

Govern

ance

26/0

4/2

016

N9

54

ne

w

OO

H T

riag

e D

ela

ys

X

Delays within OOH triage queues and call backs

to patients which could affect patient safety.E

xecutive D

irecto

r of

Nu

rsin

g a

nd

Go

ve

rna

nce

SG

2

SERIOUS (4) POSS (3) 12 •Additional GP triage shifts in place in Gloucestershire;

•SOP agreed with ED for transfers of patients in Gloucestershire;

•Current integration of clinical management within the Dorset hub;

•ICPR reporting to Board on NQR performance.

SERIOUS (4) POSS (3) 12 Reports to Commissioners

ICPR reporting to Board of Directors

•Additional GP triage shifts within the hubs;

•Risk assessment to be completed of patient experience and patient safety where

delays occur;

•Additional call advisor capacity to be sourced;

•Comfort calling SOP for patients waiting longer than advised;

•Review of 111 mapping and triage of 111 calls;

•Review of walk in SOPs;

•Additional nurse triage capacity;

•Integration of clinical queues within the Dorset hub.


(2) 8 S

Executive D

irecto

r of

Nu

rsin

g a

nd

Go

ve

rna

nce

4 M

ay 2

016

N9

55

ne

w

Reg

ion

al

Care

Pla

n

Str

ate

gy

X

Lack of Regional Care Plan Strategy resulting in

different approaches by individual CCGs to care

records impacting on the ability to use different

systems.

Executive

Dire

cto

r o

f IM

&T

SG

3

MOD (3) LIKELY (4) 12 ●Care Record Working Group established;

●Promotion of Summary Care Record;

●Ongoing monitoring of Enhanced Summary Care Record;

•National Information Board (NIB) assessment complete.

MOD (3) LIKELY (4) 12 ●Implement actions arising from Care Record Working Group;

●Agree strategy;

●Communications underway with Local Area Team and CCGs;

●Monitor initiatives taking place across region, e.g. Connecting Care;

•Joining Up Your Information (JUYI) Dorset Care Record.

Sep-16 MOD (3) UNLIKELY

(2) 6 S

Executive

Dire

cto

r o

f IM

&T

28/1

1/2

014

IMT

878

↔

Tra

inin

g -

Cli

nic

al

Skil

ls

X

Lack of awareness, skills and accountability by

staff of personal responsibility for clinical practice

and maintaining competence could result in

inappropriate clinical practice and compromise

patient care.

Poor Attendance at SME could result in poor

clinical practice

Executive D

irecto

r of H

R a

nd O

rganis

ational D

evelo

pm

ent

SG

2

SERIOUS

(4)

LIKELY

(4)

16 ●Extended training day;

●Trajectory in place with monthly reporting to the Directors Group and Quality Committee;

●Included within Annual Accountability Agreement and monthly progress reported through

Performance Management Framework;

●Overtime provided to assist in completion of training;

●New Learning Development Officer structure implemented and new offers approved for

strengthening team and capability in 2016/17;

•Placement educators in place.

•Staff educated during refresher training - personal responsibility for clinical practice stressed;

•All staff who are members of a regulatory body are required to maintain a CPD portfolio to maintain

registration;

• Additional training request forms available to all staff;

• Performance review system in place;

•Clinical supervision and OO structure established;

•Right Care Award launched Jan '15;

•LearnwithSwasft website;

•Specialist Paramedic education pathway;

•An educational platform has been made available to clinical and non-clinical staff across the Trust;

•Developed Clinical Career Pathways as part of the Talent Management Strategy;

• Roll out of CPD and access on the Trust intranet;

•SME rebranded for 2016/17 as Development Day;

•SME performance as at 14/03/16 for Trust 81.9% (Permanent and bank), and 85.2% (Permanent

only);

•Launch of Aspire microsite.

SERIOUS

(4)

POSS (3) 12 ●TNA presented to Directors Group.

●Reports to Quality Committee;

●New reporting in place and shared at Committee.

●Clinical Effectiveness Group Jan 2016 signed off

SME needs.

●Corporate meetings on future L&D provision

providing clarity on budget needs, training

schedules.

●Corporate visability of SME elements provided and

CPD activities, demonstrating skill set underway for

publication March 2016;

•Review of ECS training for 2015/16 conducted and

completion anticipated in 2016/17 in line with roll out;

•Agreement in place for every member of frontline

staff to have an 'on the road' assessment' during

2016/17.

●Director of Operations and Head of Education developed plan to address outstanding

training and future training moving forward;

•All staff to be provided with 2 hours overtime to complete workbooks and 2 hours

overtime to complete e-learning;

•Trust paying for Bank staff to attend SME training as part of new Bank Policy;

•Agreement in place for every member of frontline staff to have an 'on the road'

assessment;

•Work closely with training dept to support practitioners in developing individual learning

programme;

•Head of Education has been working with a national group to develop on line -

nationally accredited courses- in paediatrics and obstetrics;

• Development of Capita E-Learning Programme;

•'Learn with SWAST' training opportunity being developed with accompanying webpage

to support the centralisation of CPPD programmes as part of Aspire microsite;

•Annual TNA linked to abstraction plan and more development days planned 2016/17

amending abstraction from 12 to 6 to improve attendance. Monitoring of per momth

activity will take place;

•Continued CPPD offer as part of Talent and Career Strategy to upskill clinical practice;

•UCS clinical training will be provided separately and with A&E where possible, this has

been approved by Directors as part of the TNA process and resources allocated;

•All UCS, clinical hub trainers and others working to directorates other than L&D will be

transferred to L&D by end of Juen 2016 to ensure consistency of provision, quality and

improved record keeping.

Oct-16 SERIOUS

(4)

UNLIKELY

(2) 8 S

Executive D

irecto

r of H

R a

nd G

overn

ance

20/0

9/2

013

HR

81

6

↔

Am

bu

lan

ce C

lin

ical

Qu

ali

ty

Ind

icato

rs

X

Trust performance and/or publication of

benchmarking ACQI targets may impact on:-

Clinical care;

Future Compliance;

Staff morale; and

Trust reputation.

Executive M

edic

al D

irecto

r

SG

4

SERIOUS (4) POSS (3) 12 •Effective and fully staffed Clinical Hub with rolling recruitment programme;

•ACQIs monitored, managed and reviewed as part of Corporate Objectives through the Performance

Management Framework and reported bi-monthly to Lead Commissioners;

•PCR reviewed to enable improved data capture and feedback provided to clinicians;

•Monthly review of re-contacts with Trust within a 24 hour period;

•ACQIs reported within ICPR on monthly basis to the Board of Directors;

•System Indicator sub group to increase focus, monitor data and improvement;

●ELAN live in East and West Hubs;

●ACQIs reviewed by Information Assurance Steering Group (IASG);

•Implementation of new CAD within South and North Hubs;

•Quality Improvement Paramedics appointed;

•Clinical Quality Improvement team under leadership of CQI work streams, i.e. RAPID for

cardiovasculor ACQIs and programme of work looking at quality of CPR.

SERIOUS

(4)

POSS (3) 12 •IQPMG report and minutes (external assurance);

•ICPR report;

•Minutes of Clinical Effectiveness Group.

• Ongoing internal monitoring and improvement (ongoing, AGS);

●Introduction of Electronic PCR to improve data capture and data quality on clinical

indicator performance (ongoing until July 2016);

●Implement plan for commencement of new ACQI definitions;

●Commissioners reviewing ACQIs;

●Medical Directorate undertaking review to identify ways of improving performance

against clinical indicators;

•Cardiac arrest chosen as one of the indicators for the 2016/17 Quality Priorities.

Jul-16 SERIOUS (4) UNLIKELY

(2) 8 L

Dire

cto

rs G

rou

p

03/0

8/2

010

D6

10

↔

Ele

ctr

on

ic C

are

Syste

m (

EC

S)

Pro

gre

ss

X X

Potential delay to the implementation of the

Electronic Care System (ECS) (including patient

record) project as a result of conflicting priorities

could result in financial benefits not being realised

and impact on the ability to provide timely and

accurate data against ACQIs and other

assessments.

Executive D

irecto

r of IM

&T

SG

3

SERIOUS (4) POSS (3) 12 • Monitoring situation;

• Bi-weekly updates to Directors Group;

• Project manager in place;

• Regular project meetings

• Executive Director of IM&T in regular liaison with HSCIC as SRO;

• Project workbook;

●ECS Programme Board;

•Regular meetings with suppliers;

●Internal resources identified to deliver implementation;

●Approved Implementation Plan agreed with suppliers.;

●All posts recruited to for roll out of implementation;

●Training in progress;

●ECS rolled out in East and West Divisions;

●Trust worked with Emergency Departments to agree referral form;

•System upgrades undertaken.

SERIOUS

(4)

POSS (3) 12 ●Operations testing of system;

●Document set for Operations being developed;

●Monitoring of pilot testing;

●Meeting to take place to review pilot;

●Roll out of ECS programme

●System upgrades being made during roll out;

●ECS being rolled out within North Division.

Jun-16 SERIOUS (4) UNLIKELY

(2) 8 S

Executive D

irecto

r of IM

&T

19.0

4.2

010

IT561

↔

Ap

pra

isals

X X

Failure to achieve the internal KPI for completion of

appraisals and the production of poor quality

structured appraisals could impact on quality,

individual morale, and performance.

Ch

ief

Exe

cu

tive

SG

2

SERIOUS (4) LIKELY (4) 16 •Monthly reporting to ICPR and Board;

•Trust policies and procedures;

•Updated appraisal system launched;

•Regular reminders issued;

•Appraisal management included within Leadership Development Programme;

●Dedicated manager identified with responsibility for implementation of appraisal system;

●Reports to Quality Committee;

●Exception reporting for areas where appraisal performance does not meet targets;

●Trajectories in place and addressed at local staff survey action plan meetings;

●Quality Audit completed and presented to Deputy Director of HR for review;

●New Performance Appraisal process in place - all Ops Managers have received training;

●Launched 'My Career Conversation' Bands 1-7 and 8 plus.

●Development of leadership development centres to link with 'My Career Conversation';

●Annual Accountability Agreement links with objectives (including appraisals);

●Appraisals linked to incremental points;

●LDOs discuss 'My Career Conversation' at LDR's.

●Link to 'Talent Strategy' and Aspire and the use of 'My Career Conversation' to create talent pools

launched.

SERIOUS

(4)

POSS (3) 12 ●Quality Committee 14/01/2016 revisited targets.

●Improved staff survey view of appraisals;

•Reporting to Board via IPCR;

•Reports to Quality Committee.

•Implement quality audits;

●Internal audit review;

•Quality Development Group set target for completion of all support staff appraisals.

Jun-16 POSS (3) POSS (3) 9 M

Executive D

irecto

r of H

R a

nd G

overn

ance

21/1

2/2

012

HR

97

0

↔

Safe

ty n

ett

ing

X

Risk of lack of adequate safety netting for patients

who access the service.

Risk to be moved to directorate RR by Executive

Medical Director - RAG to review.

Executive M

edic

al

Dire

cto

r

SG

1

SERIOUS

(4)

POSS (3) 12 ●Training and Education provided to staff;

•Dorset and Somerset Falls Referral process launched July 2012;

•SPoA operating within Dorset;

•Monthly 24 hour review of non-conveyed patients and re-contact review;

●Right Care 2 team in place;

•Review of arrangements presented to Directors Group;

•Right Care 2 Programme;

•EPCR being rolled out across Trust.

SERIOUS

(4)

UNLIKLEY

(2) 8 •Risk should be mitigated with roll out of Electronic Patient Record as supports onward

transmission to patient's GP;

●Complete full audit of non-conveyance;

•Complete roll out of EPCR.


(2) 8 M

Co

ron

er

CL

31

5

↓

Gazett

eer

X X

Gazetteer updates not taking place in a timely

manner could result in resources being dispatched

to an incorrect location

Executive D

irecto

r of IM

&T

SG

4

SERIOUS

(4)

POSS (3) 12 •GPS and satellite navigation on vehicles updated bi-annually;

•Map books available on vehicles;

•Manual gazetteer update process in place for local updates;

•Monthly meetings with Heads of Operations to agree priority of system changes in Clinical Hubs;

•Upgrade of C3 application (which included gazetteer improvements);

●Paper recommending quarterly updates agreed by Quality and Governance Committee (Sept 2013);

●Implementation of Gazetteer updates within North division, East and West Division underway;

•Programme of Gazetteer updates implemented;

•Introduction of address base premium;

•New CAD provides improved Gazetteer.

SERIOUS

(4)

POSS (3) 12 •Ongoing work on Trust's reporting infrastructure to ensure that migration to Polygon

reporting standard will be effective;

•Audit electronic sat nav maps on all vehicles (FG);

●Work ongoing within CAD Project to provide regional gazetteer;

•Introduction of new address seeking capability within new CAD;

•Address actions identified as part of CAS alert.

Sep-16 SERIOUS

(4)

UNLIKELY

(2) 8 M

Dire

cto

rs G

rou

p

08/0

7/2

013

IT810

↔

Cli

nic

al

Hu

b

Tri

ag

e S

yste

m

X X

The use of two separate triage systems within the

Clinical Hubs could result in patients being triaged

differently. This impacts on patient experience and

performance.

Risk transferred to IM&T risk register by Exec

Director of IM&T - to be reviewed by RAG Executive D

irecto

r

of IM

&T

SG

4

SERIOUS (4) POSS (3) 12 ●All 3 divisions are using accredited triage systems;

●Fallback plans in place;

●Clinical Hub Replacement Programme;

●Decision made regarding preferred triage system;


SERIOUS

(4)

UNLIKLEY

(2) 8 ●Implementation of one triage system across the Trust (Sept 2016). Sep-16 LOW (2) RARE (1) 2 S

Clin

ica

l H

ub R

isk

Re

gis

ter

02/1

2/2

013

IT826

↓

Imp

act

of

AR

P

X X X

Potential impact of ARP clinical or system failure

on patient safety, reputation and performance.

Dire

cto

r o

f O

pe

ratio

ns

SG

1

SERIOUS (4) POSS (3) 12 ●ARP Expert Reference Group in place;

●Dedicated project lead;

●ARP issues log in place;

• Reporting arrangements in place to monitor ARP pilot;

•ARP Programme Board chaired by Chief Executive;

•National Operations ARP Group in place;

•Fortnightly NHS England meetings regarding ARP;

•Daily monitoring of Adverse Incidents related to ARP;

•Robust fall back arrangements between North and West Hubs;

•On call IT arrangements in place;

•ARP Programme Plan monitored twice weekly;

•ARP issus log in place;

•Business continuity arrangements in place with fall back plans;

•Review of ARP trial should a related SI occur.

SERIOUS (4) POSS (3) 12 •ARP is reported to each Board meeting;

•Reporting to Commissioners through contractual

arrangements;

•Chief Executive oversight and chairs National ARP

Operations Group;

•Director of Operations is national performance lead

for NDOG;

•Fortnightly meetings with NHS England;

•Daily reports to NHS England.

• Daily monitoring of adverse incidents and complaints received;

•Implementation of communications plan;

•Confirm processes for data capture for clinical outcome measurement and

interpretation;

•Demand Management Plan to set out clinical guidance to meet performance and

patient needs;

•Monitoring of hear and treat and vehicle allocations;

•Implementation of stack escalation feature.

Oct-16 SERIOUS (4) RARE (1) 4 S

Board

of D

irecto

rs

13/0

4/3

016

D9

46

new

Cu

rren

t

Co

nseq

uen

ce

Sco

re

Cu

rren

t

Lik

elih

oo

d

Sco

re

Mit

igate

d

(Cu

rren

t) R

isk

Rati

ng

V.

SeriousPoss 15


Care Quality Commission Off Payment Arrangements

Infection Control Compliance IG and Security Arrangements


Ris

k T

itle

Qu

ality

Ris

k

Perf

orm

an

ce R

isk

Fin

an

cia

ls R

isk

Underlying Causal

Risk

Acco

un

tab

le D

irecto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

seq

uen

ce

Sco

re

Ori

gin

al L

ikelih

oo

d

Sco

re

Un

mit

igate

d

(Ori

gin

al/In

here

nt)

Ris

k

Rati

ng

Controls in Place

Cu

rren

t C

on

seq

uen

ce

Sco

re

Cu

rren

t L

ikelih

oo

d

Sco

re

Mit

igate

d (

Cu

rren

t)

Ris

k R

ati

ng


Acti

on

Dead

lin

e

Fo

recast

Co

nseq

uen

ce

(po

st

acti

on

s)

Fo

recast

Lik

elih

oo

d

(po

st

acti

on

s)

Fo

recast

risk r

ati

ng

(po

st

acti

on

s)

Pro

xim

ity R

isk

Ris

k S

ou

rce

Date

ad

ded

to

reg

iste

r

Ref

Ris

k R

ati

ng

Mo

vem

en

t (s

inc

e l

as

t u

pd

ate

)

Ca

re Q

ua

lity

Co

mm

iss

ion

X

Failure to achieve compliance with the

requirements of the Care Quality Commission

registration and new inspection regime (from

2015/16) could result in non-compliance, leading

to loss of reputation, and impact upon foundation

trust risk ratings.

Executive D

irecto

r of

Nurs

ing a

nd

Govern

ance

SG

4

V.SERIOUS

(5)

UNLIKELY

(2)

10 ● CQC Relationship meetings take place regularly;

● Internal Audit Report of Compliance with 4 CQC regulations each year, CQC

Compliance is also considered when specific workstreams are audited;

● Monitoring of Serious Incidents;

● Ongoing collection of evidence and gap analysis undertaken against

requirements of new regime;

● Quality Development Group established;

● Action plan developed post 111 inspection based on verbal feedback;

•Quality Development Plan revised;

•Direct staff engagement through Chief Executive drop in at A&Es;

•Staff meetings arranged.

V.SERIOUS

(5)

POSS (3) 15 •QDG plans shared with all Executive Directors,

plan presented to each Directors Group;

•Directors attend QDG;

•Board reports.

•Revised Quality Development Group;

•Weekly review at exec directors and reporting to Directors Group

regularly;

•1:1 review of actions with leads and Head of Governance;

•111 CQC action plan to be reviewed by executive directors weekly -

head of operations for urgent care taking accountability, plan to be

shared with staff;

•Enhanced staff engagement by Chief Executive, Directors Group and

Non-Executive Directors to gain staff feedback;

•Patient Engagement Strategy;

•Quality Strategy drafted for engagement with staff and the public.;

•Procurement of compliance software solution.

Jun-16 V.SERIOUS

(5)

UNLIKELY

(2) 10 M

Head o

f G

overn

ance

12/0

5/2

010

SP

562

↔

Infe

cti

on

Co

ntr

ol

Co

mp

lia

nc

e

X

Risk of not being compliant with Hygiene Code.

Executive M

edic

al D

irecto

r

SG

1

SERIOUS

(4)

POSS (3) 12 ● Infection Control nurse in post;

●Executive Director of Nursing and Governance is the Trust DIPC;

•Established Infection Prevention and Control Group in place;

•Annual Infection Prevention and Control Action Plan;

•Annual review of Trust premises;

•Monthly Infection Prevention and Control station audit monitored at Infection

Prevention and Control Group;

•Comprehensive Infection Prevention and Control Policy in place;

•Mandatory workbook provided to all Trust staff includes Infection Prevention and

Control;

•Infection Prevention and Control included within the Learning and Development

Review (LDR shift).

SERIOUS

(4)

POSS (3) 12 Quarterly reports to Quality Committee ●Implementation of A&E Operating Plan;

•Ongoing monitoring of compliance by Infection Control Group.

Mar-17 SERIOUS

(4)

POSS (3) 12 M

Executive D

irecto

r of

Nurs

ing a

nd

Govern

ance

16/0

3/2

015

M880

↔

Info

rma

tio

n G

ov

ern

an

ce

an

d S

ec

uri

ty

Re

qu

ire

me

nts

X X

Potential non-compliance with Information

Governance and Information Security

Requirements as a result of:

the potential loss or theft of paperwork containing

personal information;

failure to follow appropriate technical solutions to

protect personal/confidential information;

information being out of date, incomplete,

inaccurate or deleted;

non-compliance with the process for completion

and delivery of records.

Composite Risk of IG risks

Executive D

irecto

r of

IM&

T

SG

4

MOD (3) LIKELY (4) 12 ●Maintain Information Governance training and education programme;

●Clinical Records Management Policy sets out process for PCRs;

●Corporate Records Management Policy;

●Data flows mapped and risk assessed;

●Regular monitoring of adverse incidents;

•SOP on Secure Transfers of Information available on IG Directorate page of the

Intranet and promoted in the Bulletin;

●Monitoring the use of emails by IT and auto alert on any key words in emails sent

insecurely;

●Use of IM&T Services Policy;

●Information Security Plan;

●Data Quality Policy;

●Information Assurance Steering Group;

●Monthly data quality checks completed and submitted to the Information

Management team;

●Data Quality Lead appointed;

•Outcome of internal audit review was 'green' with no recommendations.

SERIOUS

(4)

POSS (3) 12 •Bi-monthly assurance reports to Quality

Committee and Quarterly reports to the Board;

●Include issue within IG communications plan and consider the use of

posters, aide memoires, etc.;

●Changes to be made to Corporate marking scheme;

●Roll out of ECS.

●Include issue within IG communications plan and consider the use of

posters, aide memoires, etc.;

•Review of IG training;

●Proposal to extend ESR to include IG e-learning module for ease of

use and tracking.

●Information Security Manager reviewing more intelligent email

monitoring software with a view to quarantining emails before they are

sent;

●Ongoing completion and submission of data quality checks;

●Monitor implementation of revised Data Quality checking process and

provide report to IASG;

•Internal Audit review of Data Integrity.


(2) 6 M

IM&

T R

isk R

egis

ter

11/0

8/2

014

IMT

852

↔

Off

Pa

ym

en

t

Arr

an

ge

me

nts

X

Procurement issues associated with legislation

regarding Off Payment arrangements

Deputy

Chie

f

Executive/E

xecutive

Directo

r of

Fin

ance

SG

4

LOW (2) ALMOST

CERTAIN

(5)

10 Ongoing monitoring of agency and consultant spend on monthly basis. LOW (2) ALMOST

CERTAIN

(5)

10 Robust governance register to be developed. Jun-16 LOW (2) LIKELY (4) 8 M

Deputy

Directo

r of

Fin

ance

04.0

3.2

015

F879

↔


The potential for not meeting Regulatory Requirements.

Confidential


Risk


Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(Cu

rre

nt)

Ris

k

Ra

tin

g

V.SERIOUS

(5)

POSS (3) 15


Corporate Financials (A&E)

Agency and Locum Ceiling

Use of Agency Staff Rates of Pay


Ris

k T

itle

Qu

ality

Ris

k

Pe

rfo

rma

nc

e R

isk

Fin

an

cia

ls R

isk

Underlying Causal

Risk

Ac

co

un

tab

le D

ire

cto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

se

qu

en

ce

Sc

ore

Ori

gin

al L

ike

lih

oo

d

Sc

ore

Un

mit

iga

ted

(Ori

gin

al/In

he

ren

t) R

isk

Ra

tin

g

Controls in Place

Cu

rre

nt

Co

ns

eq

ue

nc

e

Sc

ore

Cu

rre

nt

Lik

elih

oo

d

Sc

ore

Mit

iga

ted

(C

urr

en

t)

Ris

k R

ati

ng


Ac

tio

n D

ea

dlin

e

Fo

rec

as

t C

on

se

qu

en

ce

(po

st

ac

tio

ns

)

Fo

rec

as

t L

ike

lih

oo

d

(po

st

ac

tio

ns

)

Fo

rec

as

t ri

sk

ra

tin

g

(po

st

ac

tio

ns

)

Pro

xim

ity

Ris

k

Ris

k S

ou

rce

Da

te a

dd

ed

to

re

gis

ter

Re

f

Ris

k R

ati

ng

Mo

ve

me

nt

(sin

ce last

up

date

)

Na

tio

na

l P

os

itio

n O

n

Pa

ram

ed

ic B

an

din

gs

X

The potential national increase in bandings for

Paramedics from 5 to 6 could create a significant

financial cost to the Trust.

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

tive

Dir

ecto

r

of

Fin

an

ce

SG

4

V.SERIOUS

(5)

LIKELY (4) 20 The Trust's Chief Executive is working on this nationally with the Association of

Ambulance Chief Executives.

V.SERIOUS

(5)

LIKELY (4) 20 ●Awaiting outcome of national discussions. Residual risk scoring

remains the same until further clarification is received;

●Element of national pay review negotiations;

•Sub group of National Staff Council due to make recommendations in

November 2015;

•PEEP recommendations on BSc suggests implementation from

2021/22.

●Funding requirement raised with the Commissioners

Mar-17 V. SERIOUS

(5)

POSS (3) 15 S

De

pu

ty D

ire

cto

r o

f F

ina

nce

05

/12

/20

14

HR

87

3

↔

Co

rpo

rate

F

ina

nc

ials

(UC

S)

X

Adverse financial variances within Urgent Care

Service line impacting on the overall financial

position of the Trust. Variance due to a mixture of

non-recurrent issues relating to the re-profiling of

resources to activity and the slippage in the

delivery of cost improvement schemes.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d

Go

ve

rna

nce

SG

4

SERIOUS (4) LIKELY (4) 16 ●Stabilisation of 111 performance;

●Robust management of abstractions;

●Ongoing budget monitoring;

•Staff engagement plan in place;

●Financial controls in place;

•Recovery plans in place for 111;

● 2015/16 budget setting finalised;

•Business case approved and implementation commenced;

•Gloucestershire OOH weekly performance review;

•Signed contracts in place.

SERIOUS

(4)

LIKELY (4) 16 ●Implementation of rota changes;

●Review of services provided by SPoA;

●Further work to be conducted on OOH rotas;

●Review of penalty arrangements;

●Deliver revised Performance Recovery action plan;

●Review of UCS structure including management structure;

•Reconciliation of GRS, ESR and local rotas;

•Review of GP rota and payment systems;

●Monthly Director ledescalation plans in place;

•Budget setting process to identify recovery plan for 2016/17.

Mar-17 SERIOUS

(4)

POSS (3) 12 S

Dir

ecto

rs G

rou

p

18

Ju

ly 2

01

4

N8

50

↔

Co

rpo

rate

F

ina

nc

ials

(A&

E)

X

Potential adverse financial variances the A&E

Service line impacting on the overall financial

position of the Trust. Possible variance due to

commissioner affordability, increased cost

pressures, ability to identify recurrent cost

improvements and increases in demand

De

pu

ty C

hie

f E

xe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4

V.SERIOUS

(5)

LIKELY (4) 20 ●Robust management of abstractions;

●Ongoing budget monitoring;

●Financial controls in place;

● Lead Commissioner arrangements

● Strong stakeholder engagement

● Cost improvement governance framework in place

● Mitigation Escalation Action Plan (MEAP) process in place

V.SERIOUS

(5)

LIKELY (4) 20 ●Contract negotiations

●Budget setting 2016/17

●Review of penalty arrangements;

●Identification of MEAP schemes

●Identification of CIP schemes

●Review of cost pressures;

●Monitoring of the position in relation to the 2015/16 pension

agreement as part of the 2015/16 pay award.

Mar-17 V.SERIOUS

(5)

UNLIKELY

(2) 10

De

pu

ty D

ire

cto

r o

f F

ina

nce

2 M

arc

h 2

01

6

F8

92

↔

Wo

rkfo

rce

Inte

gra

tio

n

Iss

ue

s

X

Outstanding A4C Appeals

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

ti

ve

Dir

ecto

r o

f

Fin

an

ce

SG

4

V.SERIOUS

(5)

LIKELY (4) 20 •Appropriate legal representation in place. V. SERIOUS

(5)

POSS (3) 15 •On-going liability review by solicitors and Trust. Mar-17 V. SERIOUS

(5)

RARE (1) 5 M

Sta

ff G

rie

va

nce

s

24

.12

.10

HR

47

↔

Potential inability for the Trust to manage its financial position within the resources

available leading to a deterioration in the Trust financial standing

Service Line Controls

Potential Loss of Contracts

Procurement Compliance

Use of Agency Staff (UCS)

Estates Strategy

Resourcing

Clinical Hub Rationalisation (delays)

Changing Commissioning Arrangements

Deputy Chief Executive/Executive Director of Finance

National Position on Paramedic Bandings

Corporate Financials (UCS)

Workforce Integration Issues

Cost Improvement Strategy

Confidential


Risk


Co

st

Imp

rov

em

en

t S

tra

teg

y

X X

Non achievement of the 5 year cost improvement

strategy targets could result in:-

• lack of investment in service infrastructure;

• a trigger of downside scenarios;

• compromised delivery of national targets;

● non delivery of Financial Plan.

De

pu

ty C

hie

f E

xe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4

V.SERIOUS

(5)

POSS (3) 15 •Strict controls on costs and monitoring of budgets;

• Downside scenario planning identified in IBP;

• 5 year strategy robustly detailed;

• Established Governance framework in place;

• Finance and Investment Committee monitor CIS at each meeting;

• Implementation plans developed with clear accountability identified and

implemented;

• Recognition Agreement in place and ongoing dialogue with staffside;

•Workforce Planning aligned to CIS programmes;

●IBP updated and disseminated;

•2 year and 5 year Monitor Plans in place (2014/15);

●Quality Impact Assessments to be signed off for each CIP;

•Cost Improvement Strategy workshop held on 11 August 2015;

•2016/17 Cost Improvement Strategy agreed by Board of Directors as part of

Financial Plan.

V. SERIOUS

(5)

POSS (3) 15 ●Internal Audit Report Jan 2016 • In the event of downside instigate MEAP or CEAP;

•Monitoring of implementation plans;

•Undertake review of operational remodelling;

• Review local OM budget savings (ongoing, NLC);

●Delivery of enabling strategies;

●Implementation of updated IBP;

• Implementation of A&E Operating Plan being led by Director of

Operations;

•Quarterly monitoring against 1 year Monitor Operational Plan;

•Deputy Clinical Director to 'sign off' Cost Improvement Strategy.

Mar-17 SERIOUS

(4)

POSS (3) 12 M

Ch

ief

Exe

cu

tive

9 D

ece

mb

er

20

10

F6

77

↔

Po

ten

tia

l L

os

s o

f

Co

ntr

ac

ts

X

Potential loss of contracts for UCS may result in:

• Loss of synergy between service lines and

patient pathways;

• Strengthened position of competitors;

• Opens the Trust to competition for other service

lines;

• Poor staff morale;

●Additional financial pressure.

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f

Fin

an

ce

an

d E

xe

cu

tive

Dir

ecto

r

of

Nu

rsin

g a

nd

Go

ve

rna

nce

SG

4

SERIOUS

(4)

LIKELY

(4)

16 • Effective performance management system in place;

• Regular performance meetings with Commissioners;

●Commercial principles in place;

• TUPE applicable for directly employed staff;

• Local performance targets have been negotiated with Commissioners;

•Urgent Care MEAP developed;

•FIC review tender financials for any service line;

●Trust attends Urgent Care Review Boards;

●Business Development Manager appointed and tender lead identified;

●Senior leadership team fully engaged;

•Signed contracts until 2018 for Dorset and Glos OOH services and Dorset 111.

SERIOUS

(4)

LIKELY (4) 16 ●Contracts

●Commissioning arrangements

●Development pipeline

•Action Plan in place to deliver performance targets;

• Contract discussions ongoing between UCS Service Line, Finance

and Commissioners;

•Implementation of revised performance management system;

●Review of non medical clinical workforce;

●Review of UCS structure;

●Consideration of integration opportunities.

Sep-16 SERIOUS

(4)

POSS (3) 12 M

Fin

an

ce

Te

am

16

/10

/20

09

F5

44

↔

Pro

cu

rem

en

t

Co

mp

lia

nc

e

X

Failing to comply with procurement processes

could result in legal challenges. This would

impact on the Trust's reputation and finances, and

timescales for project completion.

De

pu

ty C

hie

f

Exe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4MOD (3) LIKELY (4) 12 ●Standing Financial Instructions in place;

●EU Procurement regulation;

●Public sector contract 2006:

●Specification writing course took place for managers (Dec 2013);

●Standardised tender documents;

●Department of Health Tender terms and conditions implemented;

●Procurement workplan;

●Waivers published in FIC report;

●Procurement Policy approved and disseminated;

•Dedicated Procurement page on intranet.

MOD (3) LIKELY (4) 12 ●Report provided to Directors and Audit and

Assurance to highlight improved position.

●Monitor compliance with SFIs;

●Undertake review of waivers.

●Work ongoing in relation to UCS agency.

Mar-17 MOD (3) LIKELY (4) 12 M

Fin

an

ce

Ris

k R

eg

iste

r

05

/03

/20

14

F8

40

↔

Us

e o

f N

on

Co

mp

lia

nt

Ag

en

cy

Sta

ff

X X

Use of staff from agencies and third parties by

not going through the national procurement

framework resulting in patient safety and

governance implications.

Exe

cu

tive

Dir

ecto

r o

f N

urs

ing

an

d

Go

ve

rna

nce

SG

2

SERIOUS (4) POSS (3) 12 ●Crown Commercial Services (CCS) presented details of available frameworks to

UCS managers, Procurement and HR;

●Extension to contract with current provider for drivers agreed with Procurement;

●Trust using GPs and nurses from agencies which are part of the Procurement

Framework and applying appropriate checks;

●New checking procedure implemented within UCS for those staff who are

recruited outside the Framework.

SERIOUS

(4)

POSS (3) 12 •Internal Audit Report and Action Plan ●HR and Procurement to continue to work with UCS managers to

ensure use of agency staff is through the national framework.

●Procurement workstream in place.

Jul-16 SERIOUS

(4)

UNLIKELY

(2) 8 S

Fin

an

ce

Ris

k R

eg

iste

r

05

/03

/20

14

F8

43

↔

Cli

nic

al

Hu

b R

ati

on

ali

sa

tio

n

X

Potential delays to the implementation of the new

virtualised hub including NHS Pathways and

telephony could have financial implications and

would delay the benefits realisation of single

virtualised hub.

Risk to be transferred to Directorate RR by Exec

Director of IM&T - review by RAG

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

4

MOD (3) LIKELY (4) 12 ●Project Group

●Weekly meetings with Clinical Hub managers;

●Programme workbook monitored by Programme Board;

●Dedicated project team;

●Weekly meetings between key leads to ensure effective communication of issues

and risks;

●Project Administrator appointed to monitor Controls;

●Project Manual developed detailing work packages and deliverables from key

stakeholders;

•Implementation of new CAD across Trust;

•Decoupling of telephony and triage from Clinical Hub Rationalisation project -

now standalone projects.

MOD (3) POSS (3) 9 ●Ongoing monitoring by Project team;

●Ongoing positive liaison with CAD supplier;

●Escalate issues through the Programme Board;

●Development of new Clinical Hub structure;

●NHS Pathways training to be completed;

●NHS Pathways business to be refreshed and operationalised;

●Single telephony to be implemented;

•A&E Project across Phase 1 to be implemented by Sept 2016.


(2) 6 S

CA

D P

rog

ram

me

Te

am

21

/10

/20

14

IMT

87

7

↓

Ag

en

cy

an

d L

oc

um

Ce

ilin

g

X

Requirement to ensure all agency and locum

expenditure is within the defined ceiling.s

De

pu

ty C

hie

f E

xe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4

SERIOUS (4) POSS (3) 12 ●Forecast analysis undertaken

●Request to Monitor for increase ceiling

●Review of Monitor escalation process

SERIOUS (4) POSS (3) 12 Report provided to Directors Group, Audit and

Assurance Committee and Board - March 2016

●A&E service line / Procurement workplan;

●UCS service line / Procurement workplan;

Jun-16 SERIOUS

(4)

POSS (3) 12 S

De

pu

ty D

ire

cto

r o

f F

ina

nce

31

/03

/20

16

F9

50

↔

Us

e o

f A

ge

nc

y S

taff

Ra

tes

of

Pa

y

X

Requirement to ensure compliance for all agency

shifts with an approved NHS Improvement

framework and within the price cap values

De

pu

ty C

hie

f E

xe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4

SERIOUS (4) POSS (3) 12 ●Identified frameworks available;

●Contracts in place for certain agencies;

●Reporting requirement to report on non compliant shifts on a weekly basis;

•Regular reporting to Board of Directors and Directors Group on agency use;

•Procurement work programme in place to ensure compliance.

SERIOUS (4) POSS (3) 12 Report provided to Directors Group, Audit and

Assurance Committee and Board - March 2016

●A&E service line / Procurement workplan;

●UCS service line / Procurement workplan;

•Request to Monitor to revise threshold for the Trust given the number

of sessional GPs used.

Jun-16 SERIOUS

(4)

POSS (3) 12 S

De

pu

ty D

ire

cto

r o

f F

ina

nce

31

/03

/20

16

F9

51

↔

Se

rvic

e L

ine

Co

ntr

ols

X X X

The potential for services to expand the scope

and responsibilities which compromises the Trust

Financial position. This may include the risk of

change in banding within Agenda for change or

undertaking additional work outside the original

scope of contracts

De

pu

ty C

hie

f E

xe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4

MOD (3) LIKELY (4) 12 •All roles sent for Job matching are reviewed by Directors first

•Commissioning Managers in place;

•Use of tenders;

MOD (3) LIKELY (4) 12 •Ongoing review of roles;

•Service line management roles.

Mar-17 MOD (3) LIKELY (4) 12 S

Ris

k a

ssir

an

ce

Gro

up

26

/04

/16

F9

57

NEW

Re

so

urc

ing

X

Governance of Resourcing

resulting in financial issues as a result of GRS

and ESR not matching

Dir

ecto

r o

f

Op

era

tio

ns

SG

4

LOW (2) ALMOST

CERTAIN

(5)

10 •GRS system audit and data analyst roles in post.

•Manual review of GRS and ESR for whole Trust has been completed which

identified some errors all of which have been resolved within ESR or local

management.

LOW (2) ALMOST

CERTAIN

(5)

10 •Workplan presented to A&E Service Line •Internal Audit Review regarding link between GRS and ESR;

•Trust rolling out electronic timesheet linked with GRS which will

provide accurate information on contracted hours;

•Quarterly manual reviews of GRS and ESR take place;

•Automated report to be developed which will provide live

reconciliation data.

Sep-16 LOW (2) ALMOST

CERTAIN

(5)

10 S

Qu

alit

y R

isk W

atc

h

11

/06

/20

15

D8

84

↔

Ch

an

gin

g C

om

mis

sio

nin

g

Arr

an

ge

me

nts

X

Changes to funding priorities and commissioning

intentions may lead to:-

• Loss of commissioning knowledge and

understanding / changes in personnel could

impact on future contract negotiations;

• There is a risk that Clinical Commissioning

Groups may wish to move away from the

previously agreed ‘principles of commissioner

convergence’;

• CCGs may wish to move away from lead

commissioning arrangements.

De

pu

ty C

hie

f E

xe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

SG

4

V.SERIOUS

(5)

POSS (3) 15 • Quarterly meeting of Commissioning DDMG and SWAST Directors (CSU, all

CCGs);

• Bi-monthly contract meeting (North Commissioners and East & West);

• CQUIN work programme established and potential schemes generated for

2015/16 for agreement by Commissioners;

•Ongoing engagement with new Clinical Commissioning Groups;

●SWASFT representation at all A&E contract meetings at Director and Deputy

Director level;

●Single A&E Contract;

●2 year Financial Framework agreed;

●Trust has good working relationship with CSU;

●Programme of contract meetings established;

●Confirmation of Lead Commissioner and deputy;

●Commissioners published timeline for contract discussions and signing.

V.SERIOUS

(5)

UNLIKELY

(2) 10 ●CCGs to agree terms of contracts for signature;

●Performance reports to be produced at CCG level;

●Focussed discussions to take place at FIG (Commissioners).

Mar-17 V.SERIOUS

(5)

UNLIKELY

(2) 10 M

De

pu

ty C

hie

f E

xe

cu

tive

/Exe

cu

tive

Dir

ecto

r o

f F

ina

nce

13

/08

/20

10

CE

60

2

↔

Esta

tes S

trate

gy

X

Estates Strategy - potential failure or delay in

implementation of individual projects and the

possibility of additional costs incurred due to

external influences.

Risk to be transferred to Directorate RR by Exec

Director of IM&T - RAG to review

Exe

cu

tive

Dir

ecto

r o

f IM

&T

SG

4

V.SERIOUS

(5)

UNLIKELY

(2)

10 •Strategic estates team now integrated within larger Estates dpartment for one

single joined department which will enhance joint working;

•Close collaboration between existing teams - some sites already marked for

disposal - planning assumptions around disposal in Strategy;

•Agreed list of major estates projects which will be the subject of business cases;

•Executive Director of IMT member of Estates Project Board to project manage

larger capital projects;

•Estates Strategy signed off by Board of Directors;

•Monthly estates project boards held and attended by Chief Executive, Director of

Operations and Executive Director of IM&T;

●Capital, revenue and strategic project plans under continuous monitoring

arrangements via Directors Group, Project Board and FIC;

•Acting Estates Manager in post;

•Plan for 2016/17 in place.

SERIOUS (4) UNLIKELY

(2) 8 •Reports to Board and FIC;

•Estates Strategic Project Board chaired by Chief

Executive.

•Consider impact of potential delays on financials, review flexibility of

financial model, early discussion with local planning authority and

potential developers;

•Consider ability to sell and obtain market value for estate, alongside

willingness of staff to relocate;

•Underpinning business cases to be reviewed by FIC prior to Board

receiving Estates Strategy;

●Estates staff capacity under continuous review;

●Communications Strategy to be developed for each project;

•Internal Audit review;

•Recruitment of new Estates Manager and Estates Officer

Mar-17 SERIOUS

(4)

UNLIKELY

(2) 8 M

Inte

gra

tio

n P

lan

nin

g R

isk R

eg

iste

r

14

/09

/20

12

IP7

63

↓

Cu

rren

t

Co

nseq

uen

ce

Sco

re

Cu

rren

t

Lik

elih

oo

d

Sco

re

Mit

igate

d

(Cu

rren

t) R

isk

Rati

ng

SERIOUS

(4)

ALMOST

CERTAIN

(5)

20


NHS 111 Devon Contract

111 Demand Profile


Ris

k T

itle

Qu

ality

Ris

k

Perf

orm

an

ce R

isk

Fin

an

cia

ls R

isk

Risk Description

Acco

un

tab

le D

irecto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

seq

uen

ce

Sco

re

Ori

gin

al L

ikelih

oo

d

Sco

re

Un

mit

igate

d

(Ori

gin

al/In

here

nt)

Ris

k

Rati

ng

Controls in Place

Cu

rren

t C

on

seq

uen

ce

Sco

re

Cu

rren

t L

ikelih

oo

d

Sco

re

Mit

igate

d (

Cu

rren

t)

Ris

k R

ati

ng


Acti

on

Dead

lin

e

Fo

recast

Co

nseq

uen

ce

(po

st

acti

on

s)

Fo

recast

Lik

elih

oo

d

(po

st

acti

on

s)

Fo

recast

risk r

ati

ng

(po

st

acti

on

s)

Pro

xim

ity R

isk

Ris

k S

ou

rce

Date

ad

ded

to

reg

iste

r

Ref

Ris

k R

ati

ng

Mo

vem

en

t (s

inc

e l

as

t u

pd

ate

)

Ca

ll A

ns

we

rin

g P

erf

orm

an

ce

(1

11

)

X X X

Potential failure to meet performance against

national benchmarking for call answering (95%

within 60 seconds) could result in call

abandonment, affecting service quality, patient

safety and experience, reputation, contractual non-

compliance and have financial implications. This

is exacerbated by the difficulty in recruiting Call

Advisors.

Executive D

irecto

r of

Nurs

ing a

nd G

overn

ance

SG

1

SERIOUS (4) POSS (3) 12 •Daily telephony performance reports;

•Ongoing recruitment and training of Call Taking staff and Clinical Supervisors;

•Weekly Call Taker performance reports;

●Automated Caller Dispatch Queues (ACDQ) implemented in both 111 hubs;

●Development of Performance Management Framework for call answering;

●Executive and management leadership strengthened including appointment of

permanent managers within the 111 teams;

●Review of staff profiling complete;

●Recruitment campaign targetted at specific demographics;

●Review and analysis of data to inform modelling and activity profiles;

●Integrated Voice Response (IVR);

●Performance Recovery Plan in place;

●Review of source of activity, specifically inappropriate callbacks and

abandonments;

●Provision of management information;

●Increased audit capacity;

•Bi-weekly Trust Performance Briefing meetings where actions are identified to

address anticipated performance issues;

•Revised performance recovery plan and metrics agreed with CCGs;

•Separation of Dorset from Devon and Cornwall services;

•Resilience between hubs maintained through business continuity arrangements.

SERIOUS

(4)

ALMOST

CERTAIN

(5)

20 •Business case for Dorset approved by Directors

Group;

•Work with Devon and Cornwall Commissioners to

improve the service resulting in an approved

performance trajectory;

•Amber/Medium Internal Audit Report;

•Minutes of UCS Service Line meetings;

•111 Performance reports to Directors Group;

•ICPR to Board of Directors.

•Weekly monitoring of performance;

●Review of core cover and staff absence;

●Review of actions within Performance Recovery Plan with

Commissioners;

●Ongoing work with key stakeholders, specifically looking at patient

pathways;

●Additional resources to meet anticipated uplifts in demand being

recruited to;

●Ongoing recruitment to funded establishment;

●Performance management of all staff through productivity metrics to

be achieved once the IT and telephony actions are complete, these

actions cover a review of telephony pins and review of Adastra

permissions;

●Implementation of the intelligence data tool;

●Review framework for providing feedback to staff on call taking;

•Staff engagement meetings being held;

•Dorset 111 Service Business Plan;

•Devon and Cornwall trajectory and milestones to be agreed for 16/17;

•Further work on early exit from Pathways to be undertaken with clinical

staff;

•Retention premia to be considered.

Sep-16 SERIOUS

(4)

LIKELY (4) 16 S

Executive D

irecto

r of

IM&

T

30/0

4/2

013

D806

↔

NH

S 1

11

De

vo

n

Co

ntr

ac

t

X X X

The loss of the NHS 111 Devon contract has the

potential to adversley affect performance, staff

retention, business continuity arrangements,

patient safety and staff morale.

Risk escalated at UCS Service Line Meeting

05.05.2016

Executive D

irecto

r of

Nurs

ing a

nd

Govern

ance

SG

4

SERIOUS (4) LIKELY

(4)

16 •Ongoing dialogue with commissioners regarding maintenance of the service and

performance;

• Regular reporting to Directors Group Continued recruitment and retention

actions;

• Regular monthly staff meetings

•1:1 meetings with all staff regarding future opportunities within the Trust or

support for TUPE discussions;

•Ongoing communications with staff as information becomes available .

V.SERIOUS

(5)

LIKELY (4) 20 •Regular reporting to Board and Directors Group;

•Business continuity arrangements in place.

•Maintain close dialogue with staff;

•Business case regarding the extension of the Cornwall contract

•Continued recruitment;

•Consideration of retention premia;

• Close working relationship with Devon commissioners regarding the

procurement;

•1:1 meetings with all staff;

•Incentives offered to staff.

Sep-16 SERIOUS

(4)

LIKELY

(4)

16 S

Executive D

irecto

r of

Nurs

ing a

nd

Govern

ance

2 M

arc

h 2

016

N893

↑

11

1 D

em

an

d P

rofi

le

X X X

Changes in demand profile and variances in

peaks in demand above expected call volume

Executive D

irecto

r of

Nurs

ing a

nd

Govern

ance

SG

3

SERIOUS (4) LIKELY

(4)

16 •Weekly performance meetings;

•Monthly Commissioner meetings;

•Ongoing monitoring and reporting of activity;

•Bi- weekly performance briefings where performance issues are identified;

•Use of bank staff;

•Introduction of SOP regarding comfort calling to ensure robust safety measures

are adhered to.

SERIOUS

(4)

LIKELY (4) 16 •111 Dashboard to Directors Group;

•ICPR containing metrics presented to Board of

Directors;


•Minutes of Commissioner meetings.

•Weekly monitoring of performance;

●Ongoing review of core cover and staff absence;

●Ongoing work with key stakeholders, specifically looking at patient

pathways;

●Additional resources to meet anticipated uplifts in demand;

●Ongoing recruitment to funded establishment;

•Review staffing profile;

•Review of demand and service response to demand at peak times;

•Consider staff profiling Cornwall 111 service;

•Review Dorset business case and improvement plan;

•Incentives offered to 111 staff.

Sep-16 SERIOUS

(4)

LIKELY

(4)

16 M

Executive D

irecto

r of

Nurs

ing a

nd

Govern

ance

2 M

arc

h 2

016

N894

↔


The potential for not achieving and sustaining UCS Service Line Performance targets

which could impact on patient safety, staff experience and financials.

Confidential


Risk

UCS Base and Home Consultation Targets

OOHs GP Cover

UCS Agency

Call Answering Performance (111)

Operational Resources (UCS)



Op

era

tio

na

l R

es

ou

rce

s (

UC

S)

X X X

Potential reduced resource levels (clinicians and

non-clinicians) within UCS service line at times of

peak demand.

Executive D

irecto

r of

Nurs

ing a

nd G

overn

ance

SG

1

SERIOUS

(4)

LIKELY

(4)

16 ●Centralisation of the Resource Operations Centre (ROC) and GRS implemented

across Trust;

●Workforce plan;


•Management reports provided to iCPR, Directors Group and Quality Committee;

●Recruitment Plan in place;

•New assessment tool for 111 Call Advisors to improve quality of selection which

should have a positive impact on retention (June 2015);

• Trust Performance Briefing where resource issues and mitigating actions are

identified;

•111 Call Advisor Recruitment Open Evenings held;

•Rota review completed with 111 staff;

●Implementation of Staying Well Service to support staff;

•Resilience from OOH Service and SPoA;

•Virtual Hub;

•UCS Integrated Clinician meetings;

•UCS Clinical Development Plan;

•Recruitment and Retention Working Group.

SERIOUS

(4)

LIKELY (4) 16 •Reports to Commissioners;

•ICPR to Board of Directors identifying

performance issues and actions;

•OOH and 111 performance dashboards reported

to each Directors Group.

•Implement actions contained within Staff Survey Action Plan (EW);

●Advanced Nurse Practitioner development programme;

●Implementation of incentivised shifts where appropriate;

•Business case for Dorset;

•Improvement actions to be reviewed with Devon and Cornwall

Commissioners;

•Cornwall to agree plan for 111 to November 2017;

•Ongoing recruitment campaign and recruitment and retention working

group;

•Clinical Development Plan;

•Clinical Working Groups in place;

•Review of OOH models;

•Further GP engagement ;

•Managerial capacity enhanced;

•Review of demand profile.

Sep-16 SERIOUS

(4)

UNLIKELY

(2) 8 S

Executive D

irecto

r of

HR

and G

overn

ance

20/0

9/2

013

HR

815 (

B)

↔

UC

S A

ge

nc

y

X X X

The introduction of the NHS Improvement rules

for the use of agency staffing from 01 April 2016

will impact on the availability of operational

resources for UCS. These rules include the use of

compliant agency and fixed maximum prices from

suppliers.

Executive D

irecto

r of

Nurs

ing a

nd G

overn

ance

SG

4

SERIOUS

(4)

LIKELY

(4)

16 ●Monitoring and awareness of agency usage in place

●National Procurement Frameworks in place

●Use of employed staff , bank, overtime and sessional GPs

SERIOUS

(4)

LIKELY (4) 16 ●GP engagement programme;

●Advanced Nurse Practitioner development;

●Implementation of incentivised shifts where appropriate;

•Ongoing recruitment campaign.

• Procurement work programme in place to meet compliance

• Only companies on the agreed frameworks are used

•Specification documents required for each company and service

provided

•Current framework prices above the agency caps

•Weekly return required to NHS Improvement from 01/04/16

Sep-16 SERIOUS

(4)

UNLIKELY

(2) 8 S

Executive D

irecto

r of

HR

and G

overn

ance

20/0

9/2

013

HR

815 (

C)

↔

OO

Hs

GP

Co

ve

r

X X

The potential challenge in providing Out of Hours

GP cover due to a national shortage of GPs, high

in hours workloads, re-tendering and annual leave

could impact on GP shifts not being filled within

the OOH services resulting in financial penalties

Executive M

edic

al D

irecto

r

SG

1SERIOUS

(4)

POSS (3) 12 •QMM meetings with Commissioners;

•GP Lead appointed;

•Performance and Medicines Management audits fed back to GPs;

•Part B of Commissioning meeting includes performance issues;

•UCS GP Lead currently undertaking reviews of GPs causing concern;

•GP tool kit audits;

•Enhanced Medical Directorate structure with increased Medical Director capacity

at a leadership level across Trust;

•Medical Director (Primary Care) in place providing support for OOH;

•Performance reporting to Board of Directors via IPCR and Directors Group via the

performance dashboard;

•Regular reports to Commissioners.

SERIOUS

(4)

POSS (3) 12 •Performance reporting as part of IPCR to Board of

Director;

•Reports to Directors Group via the performance

dashboard;

•Regular reports to Commissioners.

•Review current GP performance documentation;

• Undertake risk assessment of GP performance arrangements;

• Ongoing monitoring of adverse and serious incidents and patient

feedback to identify any causes of concern;

●Develop assurance framework for contracted GPs;

●Undertake review of GP audit process;

•Medical Director Primary Care setting up meeting to develop method of

performance management for GPs;

•Review of opportunities to recruit salaried GPs;

• Review provision of MPS cover;

•Ongoing dialogue with commissioners re the impact of primary care

commissioning intentions.

Sep-16 SERIOUS

(4)

POSS (3) 12 M

Learn

ing F

rom

Experience G

roup

25/0

1/2

011

D679

↔

UC

S B

as

e a

nd

Ho

me

Co

ns

ult

ati

on

Ta

rge

ts

X X

Failure to achieve home and base consultation

targets as set out within contracts could affect

contract performance

Executive D

irecto

r of

Nurs

ing a

nd G

overn

ance

SG

3

SERIOUS

(4)

POSS (3) 12 ▪ UCS business plan;

▪ Statistical reports available on triage and home visits;

▪ GP Lead and 111 Nurse Lead in place;

▪ Clinician audit and 'league tables' underway;

•Nurse/ECP Triage Service being developed to provide a consistent approach to

assessment;

●UCS Service Line meeting with Terms of Reference to include monitoring of

targets;

●Focus on performance within Directors Group meetings;

●ECP Strategy;

•Trust reviews every case which is missed;

•Deep dive undertaken by Performance and Planning team;

•Current integration of clinical management within the Dorset hub;

•ICPR reporting to Board on NQR performance.

MOD (3) LIKELY (4) 12 •ICPR board reports;

•Performance reports to Directors Group;

•Performance reports to Commissioning meetings.

• Continue extra focus on shift cover & rota planning;

• Continue exclusive use of UCS ECPs;

• Improve joint working with District Nurses;

• Improve dispatch process e.g. clinical supervisor, single allocation

visits, merge ECP/GP visits;

●Implementation of Home Visits Performance Improvement Plan;

●Review of home visits underway which includes recommendations for

improvement in terms of clinical care and resource deployment;

•Review with commissioners the impact of local primary care

commissioning on availability of GPs;

•Work with 111 services to review appropriateness of cases transferred;

•Review of procedures related to walk in patients;

•Risk assessment to be completed of patient experience and patient

safety where delays occur;

•Additional call advisor capacity to be sourced;

•Comfort calling SOP for patients waiting longer than advised.


(2) 6 M

Assura

nce F

ram

ew

ork

30/0

6/2

010

D581

↔

Cu

rren

t

Co

nseq

uen

ce

Sco

re

Cu

rren

t

Lik

elih

oo

d

Sco

re

Mit

igate

d

(Cu

rren

t) R

isk

Rati

ng

V.SERIOUS

(5)

LIKELY (4) 20


Reputation


Ris

k T

itle

Qu

ality

Ris

k

Perf

orm

an

ce R

isk

Fin

an

cia

ls R

isk

Risk Description

Acco

un

tab

le D

irecto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

seq

uen

ce

Sco

re

Ori

gin

al L

ikelih

oo

d

Sco

re

Un

mit

igate

d

(Ori

gin

al/In

here

nt)

Ris

k

Rati

ng

Controls in Place

Cu

rren

t C

on

seq

uen

ce

Sco

re

Cu

rren

t L

ikelih

oo

d

Sco

re

Mit

igate

d (

Cu

rren

t)

Ris

k R

ati

ng


Acti

on

Dead

lin

e

Fo

recast

Co

nseq

uen

ce

(po

st

acti

on

s)

Fo

recast

Lik

elih

oo

d

(po

st

acti

on

s)

Fo

recast

risk r

ati

ng

(po

st

acti

on

s)

Pro

xim

ity R

isk

Ris

k S

ou

rce

Date

ad

ded

to

reg

iste

r

Ref

Ris

k R

ati

ng

Mo

vem

en

t (s

inc

e l

as

t u

pd

ate

)

Re

pu

tati

on

X X

Potential for adverse reputation as a result of

adverse national media, including social media,

poor experience, non-compliant performance and

non compliance with regulatory requirements.

Chie

f E

xecutive

SG

4

SERIOUS

(4)

ALMOST

CERTAIN

(5)

20 ●Proactive Communications team in place;

•Ongoing reviews of Freedom of Information Requests.

V.SERIOUS

(5)

LIKELY (4) 20 Patient survey responses ●Ongoing public relations activity;

•Proactive Communications Plan being prepared;

•Media monitoring and evaluation being set up to understand reputation

scoring;

•Board and Directors reports being developed to include reputation

scoring .

Sep-16 SERIOUS

(4)

POSS (3) 12 M

Ris

k A

ssura

nce

Gro

up

04/0

4/2

016

C958

↔

Chief Executive

Potential for adverse Reputation as a result of adverse media, poor experience, non-

compliant performance and non compliance with regulatory requirements.

Confidential


Risk


Cu

rren

t

Co

nseq

uen

ce

Sco

re

Cu

rren

t

Lik

elih

oo

d

Sco

re

Mit

igate

d

(Cu

rren

t) R

isk

Rati

ng

SERIOUS

(4)

POSS (3) 12


Terrorist Activity

Business Continuity


Ris

k T

itle

Qu

ality

Ris

k

Perf

orm

an

ce R

isk

Fin

an

cia

ls R

isk

Risk Description

Acco

un

tab

le D

irecto

r

Str

ate

gic

Go

al

Ori

gin

al C

on

seq

uen

ce

Sco

re

Ori

gin

al L

ikelih

oo

d

Sco

re

Un

mit

igate

d

(Ori

gin

al/In

here

nt)

Ris

k

Rati

ng

Controls in Place

Cu

rren

t C

on

seq

uen

ce

Sco

re

Cu

rren

t L

ikelih

oo

d

Sco

re

Mit

igate

d (

Cu

rren

t)

Ris

k R

ati

ng


Acti

on

Dead

lin

e

Fo

recast

Co

nseq

uen

ce

(po

st

acti

on

s)

Fo

recast

Lik

elih

oo

d

(po

st

acti

on

s)

Fo

recast

risk r

ati

ng

(po

st

acti

on

s)

Pro

xim

ity R

isk

Ris

k S

ou

rce

Date

ad

ded

to

reg

iste

r

Ref

Ris

k R

ati

ng

Mo

vem

en

t (s

inc

e l

as

t u

pd

ate

)

Te

rro

ris

t A

cti

vit

y

X X X

Terrorist activity (including cyber threats) could

affect delivery of Trust services and impact on its

business continuity.

Potential for Trust resources to be utilised for

terrorist activities

Current National Terrorist Threat Level is at

SEVERE (an attack is highly likely)

Chie

f E

xecutive

SG

4

V.SERIOUS

(5)

POSS (3) 15 ●Major Incident Plan in place and reviewed annually;

●Staff training in CBRNE;

●Special Operations Response Teams (SORT) teams formed and trained;

• Trust has a strong track record and experience of dealing with major incidents and

events;

• AACE national agreement on mutual aid;

• Annual training exercise in programme;

• Trust HART teams have received extensive training;

• Trust Commander training for Bronze, Silver and Gold officers;

•Members of Enhanced Ambulance Intervention Team Cadre have received training;

• Implementation of National Ambulance Service Command and Control guidance;

•REAP escalation process;

•Dedicated on call tactical advisors within Resilience team;

•Implementation of Trust wide National Interagency Liaison Officers (Technical

Advisors);

●PREVENT training delivered to trainers for roll out;

●Introduction of Joint Emergency Services Interoperability Programme (JESIP);

●Revision of Maraudering Terrorist Firearms (MTFA) Incidents training completed;

●New Commander package developed following review of Commander Policy;

•Exercise and planning for a potential IT related incident;

●Delivery of JESIP training programme;

•New Dispatchers and EMAs receive training on EPRR;

•NILO daily report on any intelligence;

•One common Special Operations desk (specialising in Terrorist incidents) in place in

North to cover whole Trust.

V. SERIOUS

(5)

POSS (3) 15 •Daily reports submitted centrally on capacity in

relation to HART, MTFA and SORT;

•Major Incident Exercise reports;

•Reports to A&E Service line on recommendations

from exercises.

• Implement recommendations arising from exercises and incidents

(lessons learned);

●Trust to review compliance with PREVENT requirements;

●Commander training to take place for newly appointed Operational

Officers;

●Recruitment of additional SORT and Ambulance Intervention Team;

●PREVENT workplan and training strategy to be developed by

Safeguarding Lead;

●Initial Operations Response (IOR) - training of all operational staff in

dry decontamination underway;

•Extension of MTFA training - doubling capacity;

•Report to be produced for Quality Committee on preparedness;

Sep-16 V. SERIOUS

(5)

POSS (3) 15 O

Assura

nce F

ram

ew

ork

29/0

5/2

009

EP

004

↔

Re

silie

nc

e -

Bu

sin

es

s C

on

tin

uit

y

X X

The potential inability to respond to major service

disruption because BCPs have not been tested to

ensure effectiveness which could impact on

continuity of service, patient safety and

experience, and staff morale.

Executive D

irecto

r of

IM&

T

SG

4

•Business Continuity Policies implemented across full Trust area;

•ICT BCP reviewed and integrated with departmental BCP's;

•Business Continuity lead appointed and working with leads to develop plans;

•Bronze Commander structure replicated across North division;

●Business Continuity Strategy approved;

●National Peer Review of Business Continuity;

●Executive Director of IM&T confirmed as lead director for business continuity;

●Business Continuity monthly progress dashboard reviewed by Directors Group;

●North Clinical Hub Duty Managers trained in new Fall Back arrangements;

●Annual Accountability Agreements include responsibility for business continuity;

●Implementation of SWASFT5 (business continuity awareness campaign);

●Regular generator testing now takes place;

•Twice weekly Performance Briefings take place with attendees from all Trust functions;

●All actions arising from internal audit report have been implemented.

SERIOUS

(4)

POSS (3) 12 •Reports on compliance with Business Continuity

programme to Directors Group;

•Minutes of Business Continuity Steering Group.

•Develop programme of business continuity plan testing;

•All Business Continuity Plans within North division to be tested;

●East and West Hub Duty Managers to receive training on fallback

arrangements;

•Ensure representatives from all key functions attend Business

Continuity Steering Groups;

•Updated pocket action cards to be disseminated to Hub staff regarding

fall back procedures..

Sep-16 MOD (3) POSS (3) 9 O

GW

AS

T R

isk R

egis

ter

25/0

4/2

012

RU

22

↔

Executive Director of IM&T

Potential inability to respond to business continuity event affecting continuity of service,

patient and staff safety and experience, reputation and regulatory requirements

Confidential


Risk


Joint Board Assurance and Risk

Report

May 2016

Title of originator/author: Marty McAuley, Trust Secretary

Vanessa Williams, Head of Patient Safety and Risk

Date issued: May 2016

1. Introduction

1.1 The purpose of the joint Risk and Board Assurance report is to enable the Board to have meaningful discussions about the management of key strategic risks that could impact upon the achievement of long term, strategic priorities. The report will continually evolve and will require regular review and update in order for its content, and the framing of strategic risks, to remain live.

1.2 This report is composed of two parts which taken together should enable the Board

to take assurance from the range of activities undertaken and the evidence provided. The two key parts are the:

1.3 Corporate & Executive Risk Register - The Trust’s Risk Management Strategy sets

out the process for the management of the risk registers. The Risk Assurance Group is responsible for reviewing the content of the risk registers, quality assuring and proposing changes to risks. The combined risk register is presented for information.

1.4 Board Assurance Framework - The BAF will provide a simple but comprehensive

method for the effective and focused management of the principle risks to meeting the strategic objectives of the Trust and provide a structure for the evidence to support the Annual Governance Statement. The highest rated risks from the Corporate Risk Register have been explored in more detail for the Board of Directors to be able to gain the assurance that they require that the risks are being effectively managed.

1.5 The scoring matrix for risk and assurance is in appendix A of this report.

2. Summary 2.1 There are 64 current risks on the Corporate and Executive Risk Register, an increase

from March 2016 when there were 55.

Date Total Scored at

15 - 20 Scored at

8 - 14 Scored at

Less than 8

May 2016 64 32 31 1

March 2016 55 28 27 0

2.2 There are eight risks that have a current score of 20. These are:

Risk Current Forecast

Performance Targets Red (ARP) 20 10

National Position on Paramedic Banding 20 15

Corporate Financials (A&E) 20 10

Call Answering Performance (111) 20 16

Reputation 20 12

NHS 111 Devon Contract 20 16

Commissioner Affordability (new risk) 20 15

Call Stacking (A&E) (new risk) 20 10

2.3 The two new risks will be presented to the Risk Assurance Group for development and will be included in the next BAF. The remaining six will be deep dived in this board assurance framework.

2.4 There are a number of new risks on the risk register in May 2016. They are:

Name of Risk Score Name of Risk Score

Commissioner Affordability

20 Potential Loss of Contracts 16

Call Stacking (A&E) 20 Asbestos Management 15

Serious Incident Process 12 Health & Safety Strategic Oversight

15

Module 2 Training (111) 12 Use of Non-Compliant Agency Staff

12

Impact of ARP 12 Complaints Performance 12

Service Line Controls 12 OoH Triage Delays 12

Use of Agency Staff Rates of Pay

12

2.5 Risks based on current and forecast scores

Current Score Number of

Risks Forecast score

Number of Risks

20 8 20 0

16 14 16 6

15 10 15 6

12 23 12 16

10 4 10 8

9 1 9 3

8 3 8 15

4 1 6 6

5 1

4 1

3 1

2 1

No Forecast Score 0

3. Corporate Risk register mapping against the strategic goals

3.1 The Risk Register has been reviewed and risks are now grouped together in themes. 9 themes have been identified each with multiple causal risks. For each risk there is an overall score as well as the individual risk scores. These are outlined in the table below:

3.2 Theme: Red 1 Performance

Theme Risk Description Theme Risk Score

Red Performance (ARP)

The potential for not achieving and sustaining the Red 1 target which could

impact on patient safety, staff experience, financials, Monitor's Risk Assessment Framework and the Quality Premium

Payment.

20

Number of Causal Risks

Causal Risks Causal Scores

1 Performance Targets Red (ARP) 20

3.3 Theme: A&E Performance


A&E Performance

The potential for not achieving and sustaining A&E Performance targets which

could impact on patient safety, staff experience, financials, Monitor's Risk

Assessment Framework and the Quality Premium Payment.

20



7

Operational Resources (A&E) 15

Performance Targets (Amber) 16

Performance Targets R19 16

Delay in the arrival of back up resource 16

Clinical Hub Rationalisation 10

Major IT Service Failure 15

Data Quality Issues (Hubs) 4

3.4 Theme: Reputation


Reputation

Potential for adverse Reputation as a result of adverse media, poor experience, non-

compliant performance and non-compliance with regulatory requirements.

20



1 Reputation 20

3.5 Theme: External Influences


External Influences

External Influences on the Trust Resources Impacting on the Trust's ability to respond,

funding, patient care and experience, performance and staff experience

15



6

Increase in Activity 16

Handover Delays at Hospital - Impact on Patient Safety and Resources

15

24/7 Working 15

Devolution 12

Callers with Unmet Needs 12

NEW: Commissioner Affordability 20

3.6 Theme: UCS


UCS Performance

The potential for not achieving and sustaining UCS Service Line Performance

targets which could impact on patient safety, staff experience and financials.

20



7

Call Answering Performance (111) 20

NHS 111 Devon Contract 20

111 Demand Profile 16

Operational Resources (UCS) 16

UCS Agency 16

OOHs GP Cover 12

UCS Base and Home Consultation Targets 12

3.7 Theme: Quality


Quality Potential for Not Providing a Quality Service,

affecting Patient Safety and Experience, Staff Morale, Reputation and Compliance

15



21

Audit Compliance 16

Safeguarding Compliance 16

UCS Clinical Capacity 16

Regional Care Plan Strategy 12

Impact of REAP Levels, and Summer, Winter and Peak pressures

16

Training - Clinical Skills 12

Ambulance Clinical Quality Indicators 12

Electronic Care System (ECS) Progress 12

Appraisals 12

Safety netting 8

Medicines Management Systems and Processes Implementation

16

Gazetteer 12

Clinical Hub Triage System 8

Serious Incident Process 12

Complaints Performance 12

OoH Triage Delays 12

Impact of ARP 12

UCS Clinician Capacity 16

Health & Safety Strategic Oversight 15

Asbestos Management 15

Module 2 Training 12

Call Stacking (A&E) 20

3.8 Theme: Business Continuity


Business Continuity

Potential inability to respond to business continuity event affecting continuity of service, patient and staff safety and

experience, reputation and regulatory requirements

12



2 Terrorist Activity 15

Resilience - Business Continuity 12

3.9 Theme: Regulatory


Regulatory The potential for not meeting Regulatory

Requirements. 15



4

Care Quality Commission 15

Infection Control Compliance 12

Information Governance and Security Requirements

12

Off Payment Arrangements 10

3.10 Theme: Financials


Financials

Potential inability for the Trust to manage its financial position within the resources

available leading to a deterioration in the Trust financial standing

15



15

National Position On Paramedic Bandings 20

Estates Strategy 8

Corporate Financials (UCS) 16

Corporate Financials (A&E) 20

Workforce Integration Issues 15

Cost Improvement Strategy 15

"Potential Loss of Contracts 16

Changing Commissioning Arrangements 10

Procurement Compliance 12

Use of Non Compliant Agency Staff 12

Clinical Hub Rationalisation 9

Agency and Locum Ceiling 12

Use of Agency Staff Rates of Pay 12

Service Line Controls 12

Resourcing 10

4. Corporate Risk register mapping against the strategic goals

Strategic Goal 1: Safe, Clinically Appropriate Responses

Risk description Current Forecast

Performance Targets Red (ARP) 20 10

Operational Resources A&E 15 15

Performance Targets Amber 16 16

Performance Targets A19 16 12

Delay in Arrival of Back Up Resource 16 8

Callers with Unmet Needs (frequent callers) 12 12

Safeguarding Compliance 16 16

UCS Clinical Capacity 16 12

Safety Netting 8 8

Call Answering Performance (111) 20 16

Operational Resources (UCS) 16 8

OOHs GP Cover 12 12

Infection Control Compliance 12 12

Call Stacking (A&E) 20 10

Health and Safety – Strategic Oversight 15 10

Asbestos Management 15 10

Impact of ARP 12 4

Strategic Goal 2: Right People, Right Skills, Right Values


Audit Compliance 16 12

Training - Clinical Skills 12 8

Appraisals 12 9

Medicines Management 16 8

Module 2 Training (111) 12 6

OOH Triage Delays 12 8

Use of Non-Compliant Agency Staff 12 8

Strategic Goal 3: 24/7 Emergency and Urgent Care


Increase in Activity 16 16

Data Quality Issues (Hubs) 4 3

Handover Delays at Hospital 15 15

24/7 Working 15 15

Devolution 12 12

ECS Progress 12 8

111 Demand Profile 16 16

UCS Base and Home Consultation Targets 12 6

Regional Care Plan Strategy 12 6

Strategic Goal 4: Creating Organisational Strength


Major IT Service Failure 15 12

Clinical Hub Rationalisation (impact) 10 8

Impact of REAP 16 8

Ambulance Clinical Quality Indicators 12 8

Gazzatter 12 8

Clinical hub Triage System 8 2

National Position on Paramedic Bandings 20 15

Corporate Financials UCS 16 12

Corporate Financials A&E 20 10

Workforce Integration Issues 15 5

Cost Improvement Strategy 15 12

Procurement Compliance 12 12

Clinical Hub Rationalisation (Delays) 9 6

Resourcing 10 10

Changing Commissioning Arrangements 10 10

Estates Strategy 8 8

NHS 111 Devon Contract 20 16

UCS Agency 16 8

Reputation 20 12

Information Governance and Security Requirements 12 6

Care Quality Commission 15 10

Terrorist Activity 15 15

Business Continuity 12 9

Commissioner Affordability 20 15

SI Process 12 6

Complaints Performance 12 9

Off Payment Arrangements 10 8

Potential Loss of Contracts 16 12

Agency and Locum Ceiling 12 12

Service Line Controls 12 12

Use of Agency Staff Rates 12 12

5. Heat Map overview of May 2016 Risk Register

5.1 The heat map has been populated using all 64 risks contained within the Corporate and Executive Directors Risk Register.

May 2016 – CURRENT SCORE

May 2016 – FORECAST SCORE

Rare Unlikely Possible Likely

Almost Certain

Negligible

Low

2

Moderate

1 7

Serious 1 3 16 14 1

Very Serious

2 10 7


Almost Certain

Negligible

Low 1 1 1

Moderate 1 6 3 2

Serious 1 14 14 6

Very Serious

1 7 6

6. Board Assurance - Deep Dive: Performance Targets Red

Date added: May 2015 (Renamed from Red 1)

Risk Owner: Chief Executive

Risk Description

The potential for not achieving and sustaining the Red target which could impact on patient safety, staff experience, financials, Monitor's Risk Assessment Framework and the Quality Premium Payment.

Risk Score – CURRENT Risk Score – FORECAST

Consequence Likelihood Risk Score Consequence Likelihood Risk Score

V Serious 5

Likely 4

20 V. Serious

5 Unlikely

2 10

Rationale for current score

Reputational

Regulatory

Rationale for forecast score

Reputational

Regulatory

Overall Assurance Score

How much assurance

Basis for assurance

Timeliness Rigour Assurance Score

2

2 3

2 9

History of the risk

Score Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Feb 2016

Mar 2016

Apr 2016

May 2016

Current - - 15 15 15 15 15 15 20 20 20 20

Forecast - - 15 10 10 10 10 10 10 10 10 10

History of the assurance

Score Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Feb 2016

Mar 2016

Apri 2016l

May 2016

Current 9 9 9 9

Controls in place

Robust business plan and corporate objectives monitored by Directors Group;

Effective and fully staffed Clinical Hub with rolling recruitment programme;

Implementation of Early Exit procedure within Clinical Hubs;

Implementation of Enhanced Pre Hospital Care within Clinical Hubs;

Roll out of Public Automatic Defibrillators;

Roll out of Airwave Responder Pagers;

Appointment of Joint Liaison post with St John Ambulance regarding the positioning and development of responder groups;

Development of divisional Operational Implementation Plans;

Developments identified within MAVIS being implemented;

Trust wide hospital handover SOP agreed with Commissioners;

Use of agency paramedics and private ambulance services to address establishment levels;

Twice-weekly Trust Performance Briefings focusing on barriers to performance and mitigating actions, these become daily when Trust is at REAP level Red;

Implementation of revised REAP;

Fortnightly performance focus group meetings with Chief Executive to deep dive into areas of concern;

Daily and weekly conference calls;

Daily review of all missed Reds;

Improved initial triage of Red calls through early questioning/nature of call;

Increased focus on allocation of Red calls due to reduced numbers as part of ARP trial;

ARP Programme Board in place. Assurance Source Evidence of Assurance

Fortnightly Performance meetings Meeting records

Monthly reports to IQPMG Minutes

ICPR report for Trust Board Board minutes

Reports to Monitor Record of reports

Daily reporting of ARP activity to NHS England;

Fortnightly meetings with NHS England regarding ARP

Actions due by July 2016

Ongoing internal monitoring and improvement;

Implementation of Trust Operating Plan;

Ambulance Response Programme trial which aims to improve response times to critically ill patients, and making sure the best response is sent to each patient first time with the appropriate degree of urgency;

Maintain a minimum of 65% Trust wide performance in any given week during ARP trail period;

Trust to report any SIs directly related to ARP trial;

Implementation of revised AQI guidance in relation to ARP;

Sheffield University overseeing data associated with ARP;

Trust rota review.

7. Board Assurance- Deep Dive: Call Answering Performance (111)

Date added: April 2013

Risk Owner: Executive Director of Nursing and Governance

Risk Description

Potential failure to meet performance against national benchmarking for call answering (95% within 60 seconds) could result in call abandonment, affecting service quality, patient safety and experience, reputation, contractual non-compliance and have financial implications. This is exacerbated by the difficulty in recruiting Call Advisors.



Serious 4

Almost Certain

5

20 Serious

4 Likely

4 16


Reputational

Regulatory


Reputational

Regulatory


How much assurance

Basis for assurance


Partial

assurance (2)

External verification (3)

Within last 3 months (3)

Moderate

(2) 10 - STRONG

History of the risk

Score Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Feb 2016

Mar 2016

Apr 2016

May 2016

Current 20 20 20 20 20 20 20 20 20 20 20 20

Forecast 16 16 20 20 16 16 16 16 16 16 16 16


Score Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Current 10 10 10 10

Controls in place monitored quarterly

Daily telephony performance reports;

Ongoing recruitment and training of Call Taking staff and Clinical Supervisors;

Weekly Call Taker performance reports;

Automated Caller Dispatch Queues (ACDQ) implemented in both 111 hubs;

Development of Performance Management Framework for call answering;

Executive and management leadership strengthened including appointment of permanent managers within the 111 teams;

Review of staff profiling complete;

Recruitment campaign targetted at specific demographics;

Review and analysis of data to inform modelling and activity profiles;

Integrated Voice Response (IVR);

Performance Recovery Plan in place;

Review of source of activity, specifically inappropriate callbacks and abandonments;

Provision of management information;

Increased audit capacity;

Bi-weekly Trust Performance Briefing meetings where actions are identified to address anticipated performance issues;

Revised performance recovery plan and metrics agreed with CCGs;

Separation of Dorset from Devon and Cornwall services;

Resilience between hubs maintained through business continuity arrangements.

Assurance Source Evidence of Assurance

Business case for Dorset approved by Directors Group Meeting minutes

Work with Devon and Cornwall Commissioners to improve the service resulting in an approved performance trajectory

Meeting minutes

Minutes of NHS 111 updates to Directors Group Minutes


•111 Performance reports to Directors Group;

•ICPR to Board of Directors.

Actions due by September 2016

Weekly monitoring of performance;

Review of core cover and staff absence;

Review of actions within Performance Recovery Plan with Commissioners;

Ongoing work with key stakeholders, specifically looking at patient pathways;

Additional resources to meet anticipated uplifts in demand being recruited to;

Ongoing recruitment to funded establishment; Retention premia to be considered.

Performance management of all staff through productivity metrics to be achieved once the IT and telephony actions are complete, these actions cover a review of telephony pins and review of Adastra permissions;

Implementation of the intelligence data tool;

Review framework for providing feedback to staff on call taking;

Staff engagement meetings being held;

Dorset 111 Service Business Plan;

Devon and Cornwall trajectory and milestones to be agreed for 16/17;

Further work on early exit from Pathways to be undertaken with clinical staff;

8. Board Assurance - Deep Dive: Corporate Financials (A&E)

Date added: March 2016

Risk Owner: Deputy Chief Executive/Executive Director of Finance

Risk Description

Potential adverse financial variances the A&E Service line impacting on the overall financial position of the Trust. Possible variance due to commissioner affordability, increased cost pressures, ability to identify recurrent cost improvements and increases in demand



Very Serious (5)

Likely (4)

20 Very Serious

(5) Unlikely

(2) 10


Finance


Finance


How much assurance

Basis for assurance


TBC TBC TBC TBC TBC

** Assurance will be reviewed at the next Risk Assurance Group and scored then

History of the risk

Score Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Feb 2016

Mar 2016

April 2016

May 2016

Current - - - - - - - - - - 20 20

Forecast - - - - - - - - - - 10 10


Score Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Feb 2016

Mar 2016

April 2016

May 2016

Current - - - - - - - - - - - TBC

Controls in place

Robust management of abstractions;

Ongoing budget monitoring;

Financial controls in place;

Lead Commissioner arrangements

Strong stakeholder engagement

Cost improvement governance framework in place

Mitigation Escalation Action Plan (MEAP) process in place


Actions due by March 2017

Contract negotiations

Budget setting 2016/17

Review of penalty arrangements;

Identification of MEAP schemes

Identification of CIP schemes

Review of cost pressures;

Monitoring of the position in relation to the 2015/16 pension agreement as part of the 2015/16 pay award.

10. Board Assurance - Deep Dive: National Position on Paramedic Banding

Date added: December 2014

Risk Owner: Deputy Chief Executive / Executive Director of Finance

Risk Description

The potential national increase in bandings for Paramedics from 5 to 6 could create a significant financial cost to the Trust.



V. Serious 5

Likely 4

20 V. Serious

5 Possible

3 15


Financial


Financial


How much assurance

Basis for assurance


2

3 3

2 10

History of the risk

Score Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Feb 2016

Mar 2016

Apr 2016

May 2016

Current 20 20 20 20 20 20 20 20 20 20 20

Forecast 16 16 20 20 16 16 16 16 16 16 16


Score Nov 2014

Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Feb 2016

Mar 2016

April 2016

Current - - - - - - - - - - 10 10

Controls in place

The Trust's Chief Executive is working on this nationally with the Association of Ambulance Chief Executives

Chief Executive and Executive Director of HR and OD are working with NHS Employers on matters

Executive Director of HR and OD is the ambulance representative on the NHS Staff Council

Chief Executive and Executive Director of HR and OD lead on National Ambulance Strategic Partnership Forum where discussions are being held

Head of Training and Education is a lead on National PEEP programme


External Attendance at meetings Minutes of meetings and feedback

Actions due by March 2017

Awaiting outcome of national discussions on job banding. Expected May 2016 but Pay Review Body has asked NHS England to take ownership.

Residual risk scoring remains the same until further clarification is received;

Element of national pay review negotiations;

PEEP recommendations on BSc suggests implementation from 2021/22 but business case has not yet been approved by Department of Health. Anticipated May 2016.

Funding requirement raised with the Commissioners locally and nationally

The Pay Review Body recommendations made in March 2016 suggest NHS England should take ownership of this matter and build a business case on financial implications

Executive Director of HR and OD liasing with the Department of Health on how much and when they will commission NHS England to progress the matter. Letter sent 24 March 2016

11. Board Assurance - Deep Dive: Reputation

Date added: April 2016

Risk Owner: Chief Executive

Risk Description

Potential for adverse reputation as a result of adverse national media, including social media, poor experience, non-compliant performance and non compliance with regulatory requirements.



V. Serious 5

Likely 4

20 Serious

4 Possible

3 12


Reputation


Reputation


How much assurance

Basis for assurance


TBC TBC TBC

TBC

TBC


History of the risk

Score Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Feb 2016

Mar 2016

Apr 2016

May 2016

Current - - - - - - - - - - 20 20

Forecast - - - - - - - - - - 12 12


Score Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

Mar 2016

May 2016

Current - - - - - - - - - - - TBC

Controls in place

Proactive Communications team in place;

Ongoing reviews of Freedom of Information Requests.


Patient survey responses


Ongoing public relations activity;

Proactive Communications Plan being prepared;

Media monitoring and evaluation being set up to understand reputation scoring;

Board and Directors reports being developed to include reputation scoring .

12. Board Assurance - Deep Dive: NHS 111 Devon Contract

Date added: March 2016

Risk Owner: Executive Director of Nursing and Governance

Risk Description

The loss of the NHS 111 Devon contract has the potential to adversley affect performance, staff retention, business continuity arrangements, patient safety and staff morale.



V. Serious 5

Likely 4

20 Serious

4 Possible

4 16




How much assurance

Basis for assurance



History of the risk

Score Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Feb 2016

Mar 2016

Apr 2016

May 2016

Current - - - - - - - - - 16 16 16

Forecast - - - - - - - - - 16 16 16


Score Jan 2015

Feb 2015

May 2015

June 2015

Aug 2015

Sep 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

Mar 2016

Apr 2016

Current - - - - - - - - - -- - -

Controls in place

•Ongoing dialogue with commissioners regarding maintenance of the service and performance;

Regular reporting to Directors Group Continued recruitment and retention actions;

Regular monthly staff meetings

1:1 meetings with all staff regarding future opportunities within the Trust or support for TUPE discussions;

Ongoing communications with staff as information becomes available .


Regular reporting to Board and Directors Group;

Business continuity arrangements in place.


Maintain close dialogue with staff;

Business case regarding the extension of the Cornwall contract

Continued recruitment;

Consideration of retention premia; • Close working relationship with Devon commissioners regarding the procurement;

1:1 meetings with all staff;

Incentives offered to staff.

Recommendation The Board of Directors is asked to take assurance from the information provided.

Marty McAuley Trust Secretary

Appendix A - Risk Scoring

Consequence score

Severity Descriptors

1 2 3 4 5

Negligible Low Moderate Serious Very Serious

Likelihood score

1 2 3 4 5

Descriptor Rare Unlikely Possible Likely Almost Certain


Almost Certain

Negligible 1 2 3 4 5

Low 2 4 6 8 10

Moderate 3 6 9 12 15

Serious 4 8 12 16 20

Very Serious 5 10 15 20 25

Assurance scoring

How much Full 3 Partial 2 Minimal 1

Basis External verification 3 Internal verification 2 Self-assessment 1

Timeliness Within last 3 months 3 3 and 9 months 2 9 months + 1

Rigour Strong 3 Moderate 2 Weak 1

Score Level of assurance

0 – 5 Weak – very limited reliance

6 - 8 Moderate – limited reliance

9 - 12 Strong – strongly relied upon

Trust Public Board of Directors Meeting, 26 May 2016

Page 1 of 33


Title: Patient Safety and Experience Annual Report – 2015/2016

Prepared by: Governance Team

Presented by: Jenny Winslade, Executive Director of Nursing and Governance

Main aim: The purpose of this paper is to provide the Board of Directors with a copy of the Patient Safety and Experience Annual Report for assurance.

Recommendations: The Board of Directors is asked to take assurance from the Patient Safety and Experience Annual Report.



Page 2 of 33

Patient Safety and Experience Annual Report 2015/16

1. Executive Summary 1.1 The Trust is committed to the delivery of high quality services designed around the

needs of patients, carers and the public, staff, local communities and all relevant stakeholders. We continually seek to improve what we do, but must also consider action where services fall short of what patients and service users expect and deserve.

1.2 This involves investigating and learning from patient safety incidents and from comments, concerns and complaints. It also involves being open about incidents where harm has been caused to a patient.

1.3 The purpose of this annual report is to provide a summary of the high level data, as well as information about themes, trends and learning identified from complaints, adverse, moderate and serious incidents and claims received during 2015/16.

1.4 This report is supported by a number of appendices which provide the data to support the narrative within the document: Annex A of the report includes a breakdown of data by service line; Annex B sets out incidents by reporting category; Annex C includes a list of definitions; and Annex D provides the patient survey data.

Learning 1.5 The report reviews the learning from serious and moderate harm incidents and

complaints focusing on four core categories of root cause of which the three key areas identified during the year were Clinical Care, Access and Waiting and Communication.

1.6 Learning that has taken place during the year as a result of reviewing adverse

incidents, serious and moderate incidents, and complaints has been reported within the Patient Safety and Experience report provided to the Trust Board of Directors and reports provided to the Quality Committee. The areas of learning covered both the UCS and A&E service lines and included:

The impact of human factors on patient safety, including telephone triage which has been identified as one of the Trust’s Quality Priorities for 2016/17 and will be the subject of a review overseen by the Trust’s Quality Development Forum.

Confirmation bias by clinicians;

Levels of demand and the associated impact on the availability of resources (for A&E) and clinicians (UCS);

Levels of clinical cover within the UCS service line;

Completion of patient records;

Fracture management which is included within the programme for dissemination of learning referred to at paragraph 1.7 below;


Page 3 of 33

The moving and handling of patients which led to frontline staff being advised to complete the new online Patient Moving and Handling course;

Issues identified with probing and referral to clinicians during telephone triage;

Recognition of less common ECG abnormalities resulting in the development of an ECG package;

Issues associated with the identification of sepsis resulting in a significant programme of work including development and implementation of a training package for 111 staff, the production and dissemination of leaflets for operational staff, the roll out of the Paediatric ‘Big6’ guidelines and modification to the EPCR;

Implementation of the Repeat Caller process within the UCS service line resulting in the issue of further guidance.

1.7 The Trust has launched a new Learning from Incidents process which is currently

being led by a Clinical Development Manager. This brings together learning from complaints, adverse, serious and moderate incidents, claims and inquests, HR cases and learning development reviews. Identified learning is being shared weekly via the Trust’s weekly Bulletin and a monthly meeting of representatives from each of the functions takes place to agree a programme and method of dissemination.

2. Patient Safety and Experience Activity

Serious Incidents 2.1 41 serious incidents were confirmed during 2015/16 (0.002% of patient contacts) as

compared to 51 in 2014/15 during the same period representing a decrease of 19.6%. They represent 0.5% of the adverse incidents reported during the year. The following table indicates how serious incidents were split by service line.

Serious Incidents by service line (2015/16 and 2014/15 comparison) Total Serious Incidents 2014/15

A&E

PTS

OOH

NHS 111

Other

40 0 2 6 3

Total Serious Incidents 2015/16

A&E

PTS

OOH

NHS 111

Other

27 0 3 8 3

Serious Incidents currently Under Investigation

A&E PTS OOH NHS 111 Other

8 0 2 4 0


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2.2 The National Serious Incident Framework states that serious incidents should be

closed within 60 working days. During 2015/16 27 serious incidents have been investigated and closed within the timescales set out in the national framework, or within an extended period justified and agreed with the Lead Commissioner. The Trust has not received any penalties as a result of these extensions in 2015/16.

Moderate Harm Incidents 2.3 In 2015/16 40 moderate harm incidents (0.02% of patient contacts) were confirmed

compared to 48 in 2014/15 which represents a decrease of 16.6%. The following table indicates how moderate incidents were split by service line.

Moderate Incidents by service line (2015/16 and 2014/15 comparison) Total Moderate Incidents 2014/15

A&E

PTS

OOH

NHS 111

Other

35 0 1 11 1

Total Moderate Incidents 2015/16

A&E

PTS

OOH

NHS 111

Other

30 0 2 8 0

Serious Incidents currently Under Investigation


3 0 0 2 0

Complaints 2.4 1,519 comments, concerns and complaints were received during 2015/16 (0.075%

of patient contacts). This compares to 1,268 complaints received during 2014/15, an 20% increase for the year.

Of the 1,519 number of comments, concerns and complaints received and, where

the investigations have been concluded, 750 were considered to be well-founded. The definition of well-founded is if any, or all, of the complainants concerns have been upheld.

In addition to the comments, concerns and complaints received, the Trust has also

dealt with 1,128 PALS enquiries.


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Complaint handling satisfaction

The Trust is keen to understand how patients and their families feel about the way we have managed their complaint and so the Patient Experience team send a short survey to patients and their representatives when their complaint has been closed.

During the year 2015/16, the Patient Experience team received completed questionnaires from 178 patients or their representatives – equivalent to around 12% of complaints. Patients and their representatives are generally extremely positive about the way in which the Patient Experience team has managed their complaint, even where they do not necessarily agree with the outcome of their concerns. When asked whether we took their complaint seriously 90% (160 out of 178 respondents) felt that the Trust took their complaint seriously. One complainant told us “The Investigating Officer was a really excellent representative for the Trust - listened as well as spoke, responded in a heartfelt way and made me feel confident that we had been heard..” 93% of respondents (165 out of 178 respondents) said they felt that, if the Trust made a mistake, it did apologize. Overall, 85% of respondents (152 out of 178) said that, overall, they were satisfied with the way in which their complaint was handled. Other comments made by complainants included: “I am very impressed with the depth of investigation carried out” “I was very happy and satisfied especially with how fast my complaint was handled by the Trust” “Handled well, taken seriously and mistakes admitted”

2.5 The following table and charts demonstrate how the complaints were split by

service line: Complaints by service line (2015/16 and 2014/15 comparison) Total Complaints 2014/15

A&E

PTS

OOH

NHS 111

Other

864 59 91 247 7

Total Complaints 2015/16

A&E

PTS

OOH

NHS 111

Other

1101 63 143 208 4

Complaints A&E PTS OOH NHS 111 Other


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Currently Under Investigation relating to those received in 2015/16

70 7 12 5 0

2.6 A Level 3 complaint is a comment, concern or complaint which requires a more

complex investigation or has resulted in a detrimental outcome (of a moderate level) for the patient, or a complaint that was considered as a Serious Incident but deemed not to meet the criteria. Of the 1,401 complaints closed during 2015/16, some of those of which will have been received in 2014/15, only 100 were deemed to have caused a moderate level of harm to the patient, resulting in a Level 3 PE investigation. Of the 100 moderate harm level 3 complaints, 91 related to the A&E service line and 9 related to the UCS service line.

2.7 During 2015/16, 35.5% of level 2 complaints were closed within the internal 25

working day deadline and 35.2% of level 3 complaints were closed within the internal 35 working day deadline. Whilst this percentage is low only 40 files (less than 3%) were re-opened, thus demonstrating that the vast majority of complainants were satisfied with the handling of their complaint and its subsequent outcome.

Adverse Incidents 2.8 The Trust received 7,997 adverse incidents and Health Care Professional Feedbacks

(HCPFs) during 2015/16 (0.39% of patient contacts). This compares with 8,775 adverse incidents and HCPFs received in 2014/15, a decrease of 778 (9%).

2.9 There has been an increase in incidents reported by Trust staff during the last

financial year with 6,684 Adverse Incidents reported in 2015/16 compared with 6,596 the previous year, an increase of 1%. Conversely, the number of Adverse Incidents received from external Healthcare Professionals and other sources has decreased by 40% with 1,313 being reported during 2015/16 compared with 2,179 during the previous year.

68% 5%

7%

19%

1%

Complaints by Service Line 2014/15

A&E

PTS

OOH

NHS 111

Other

73%

4%

9%

14% 0%

Complaints by Service Line 2015/16

A&E

PTS

OOH

NHS 111

Other


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2.10 The largest decrease in Healthcare Professional feedback was seen within the NHS

111 Service, where external reporting was 60% down in 2015/16 from the previous year. This decrease canbe attributed to the cessation of service provision by an external Out of Hours Care provider who were frequent reporters.

2.11 The Non Injury Faller process, implemented during this year has prompted 365 reports of inappropriate ambulance requests from care homes or domiciliary Care Agencies for the purpose of lifting uninjured service users. Analysis of the incident reports indicates that that the most common issue relates to the enforcement of ‘no lifting policies’ by care providers. A process is in place to review all reports of these incidents, where appropriate, a letter is sent to the care provider outlining their responsibilities and legal obligations.

2.12 During 2015/16 the Trust has experienced a significant increase in demand and has

seen an associated increase in reporting figures for incidents relating to delays to treatment. The increased pressure on Trust resources has been highlighted to our Commissioners.

2.13 2015/16 saw the Trust implement the use of an Electronic Patient Care Record to

replace the use of paper records. This may have contributed to a 67% reduction in the number of Adverse Incidents submitted during 2015/16 relating to missing records, believed lost or stolen and inadequate or illegible records.

2.14 An increase in adverse incidents reported relating to medication errors prompted

concerns that medicines may not be being routinely double checked. A new mandatory ‘MedCheck’ process was implemented along with a number of practical solutions such as new drug bags and different presentations for similar looking medicines. The ‘MedCheck’ process formalises the check and double check processes required within the Trust’s Medicines Management Policy.

2.15 Incidents relating to Medical Devices and equipment reported by Trust staff

increased from 540 incidents reported during 2014/15, to 771 reported during 2015/16. Bulletin articles throughout the year have encouraged staff to report issues of this nature. A Central Alerting System alert received in February, relating to the reporting of defects and failures further prompted a reminder to be circulated to staff and managers. A widespread issue with the electric suction units used by the Trust was identified through incident reporting and is now under investigation by the manufacturer who are working closely with the Trust to resolve the issue. A Clinical Notice was circulated to ensure that all vehicles carry a back-up hand operated device and that operational staff carry out a test on the electronic units during every vehicle defect inspection.

2.16 The following table and charts demonstrate how the adverse incidents and HCPFs

were split by service line:

2.17 The Trust has an internal target of 25 working days to investigate and close adverse


Page 8 of 33

incidents. During 2015/16, 57% of incidents investigated were closed within this target timeframe. As Investigating Officers are Operational managers the increase on demand has impacted their ability to investigate and close incidents within the target timeframe. Prior to the implementation of the new ambulance Resource Escalation Action Plan (REAP) levels, the Trust was on REAP level 4 for the majority of the financial year which has directly impacted the capacity for Operational managers to undertake any additional responsibilities.

Adverse Incidents by service line (2015/16 and 2014/15 comparison) Total Incidents 2014/15


5973 23 357 2117 305

Total Incidents 2015/16


6176 26 411 1138 246

Adverse Incidents Currently Under Investigation1


1127 5 299 1136 183

Number of investigations overdue2

A&E PTS OOH

NHS 111 Other

625 3 258 1004 151

2.18 To assist managers to monitor outstanding adverse incident investigations, the

monthly KPI report has been reinstated and amended to provide clarity on the number that are assigned to that individual function and those that have been referred elsewhere.

1 As of 31

st March 2016

2 This figure includes those referred out to other organisations or functions for investigation and the data reported is as of 31

st March

2016


Page 9 of 33

3. Learning

3.1 The following table sets out the root causes identified following investigation into serious and moderate harm incidents and moderate complaints (i.e. investigations undertaken and complete) during 2015/16 These have been grouped under subject codes, taken from complaint coding to allow comparison across complaints and incidents.

3.2 The number of level 3 complaints, deemed to have caused moderate harm to the

patient through the investigation appears to be high this is due to the fact that there are normally multiple root causes identified during a complaint investigation due to the multifaceted nature of the complaint and the service lines involved.

Root Causes Serious Incidents

Moderate Incidents

Moderate Complaints (actions identified)

Total

Clinical Care – missed sepsis,

moving and handling including lack of immobilisation,

incorrect use of equipment,

incomplete assessment, remote caller

incorrect pathway

poor PCR completion,

misinterpretation of clinical signs

clinical triage (111 and 999)

Inadequate safety netting when discharged at home

Poor pain management

10

16

91 117

68% 0%

4%

24%

4%

Adverse Incidents by Service Line YTD 2014 - 15

A&E

PTS

OOH

NHS 111

Other

77%

1%

5%

14%

3%

Adverse Incidents by Service Line YTD 2015 - 16

A&E

PTS

OOH

NHS 111

Other


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Root Causes Serious Incidents

Moderate Incidents

Moderate Complaints (actions identified)

Total

Missing neurological symptoms associated with headache or CVE

No capacity assessment

Knowledge gaps – Ottawa ankle rules, kidney injury, dyspnoea associated with rib injury, plastering skills, ECG interpretation, Kernig/Brudzinski tests for meningitis

Access and Waiting – demand/limited resources,

below core resourcing,

delayed call backs,

management of resources,

welfare calls not made

resource not dispatched at first opportunity,

incorrect hospital,

confirmation bias

Duplicate Call policy or Rest Break policy not followed

2 11

44 57

Communication – failure to probe on questioning,

poor communication with control and patients at RTC,

poor location information taken by control,

delayed response to remote location, information disregarded,

handover from OOH to 999,

lack of clarity around remote callers

Not reporting accidental injury to patients on Datix

‘Silent call’ passed to police not ambulance

Poor communication with relatives

1 3 26 30

Infrastructure – Hub system error

IT process error

3

2 0 5

No Root Cause Identified 3 1 4 4

3.3 The table above illustrates that the area of Clinical Care is the most commonly

identified root cause with the highest number of remedial actions. It is important to recognise that this category also includes the care afforded by telephone triage. These incidents are often difficult to categorise and may also appear in the communication category under a failure to probe or similar.


Page 11 of 33

3.4 A theme of Human Factors has been identified through out the year and an in depth analysis of the issues associated with human factors will be taken forward within the relevant service lines supported by the Patient Safety Manager. Further work on the theme of staff behaviour will be undertaken and this has been discussed at depth in the Trust’s Quality Development Forum.

3.5 Examples of learning from each of the identified root cause themes are set out

below:

Clinical Care

3.6 Within this period there have been 10 Patient Safety incident investigations relating to clinical care and 91 clinical care actions highlighted as a result of complaints. There have been no overriding themes identified by the Patient Experience and Patient Safety teams. Clinical Care has been identified as a topic to be reviewed by the Quality Development Forum in 2016/17.

3.7 In terms of concerns relating to clinical care issues during face to face

assessments, the learning points were:

Confirmation bias – this is an emerging theme. Confirmation bias occurs when a clinician allows other factors to cloud their assessment and diagnosis of a patient – for instance if a patient is nervous of travelling to hospital they may tailor their answers to convince you they are feeling better than they are. Clinicians should continue with a full assessment and questioning in order to understand the full picture. Confirmation bias can lead to clinicians making inadequate treatment plans for their patients as they have negated to consider all of the differential diagnoses. It has been agreed at the Learning From Incidents Group that an article regarding confirmation bias will form part of the Trust’s Chief Executive’s Bulletin, disseminated to all Trust personnel, in 2016/17.

Incomplete Patient Clinical Records (PCR). Examples of incomplete PCRs include the recording of less than two complete sets of observations and the lack of a systematic assessment using the ‘Medical model’. This can led to poor decision making with regards to non-conveyance and safety netting. As these issues arise, the Individuals immediately receive further training from the Trust’s Learning and Development Team or relevant GP Lead.

The Trust has also noted an ongoing theme in relation to spinal care. This was highlighted previously as a trend and the Medical Directorate have revisited the guideline producing a supplement. Initially the reporting figures reduced however it has become evident that cases have still been occurring and have been coming to light via delayed reporting routes. In order to address this, the Trust immediately issued an article reinforcing the guidelines prior to any recommendations from the small number of serious incident investigations ongoing. In addition, the investigations for each of the serious incidents relating


Page 12 of 33

to spinal care are being led by the same Quality Lead to improve the identification of themes across each of the incidents. It should be stated that these cases are outside the reporting period of this paper but are still worthy of noting to the Board of Directors.

Concerns regarding the moving and handling of patients led to frontline staff being advised to complete the Trust’s new online course via the WebPortal Training System entitled ‘Patient Moving and Handling’.

An ECG package is being developed by one of the Trust’s Clinical Development Officers to assist with recognition of the less common ECG abnormalities.

Sepsis cases remain a high profile nationally and learning continues to be embedded across all service lines within the Trust. ‘Sepsis Assessment and Management (SAM)’ leaflets have been produced and put onto vehicles – these leaflets are written for the lay person to understand, so members of public know what to look out for. The e-PCR has been modified to alert the crews if they are about to leave a patient at home who has signs of symptoms of sepsis and Paediatric ‘Big6’ guidelines were issued in August 2015, covering the six main causes of paediatric illness and symptoms to look out for.

The Trust’s Out of Hours GP Clinical Leads hold regular development days on topical learning subjects which have included risk factors associated with DVTs following a missed DVT in the out of hours setting, increasing awareness around recognizing sepsis and symptoms of kidney injury.

Human Factors 3.8 Human factors can influence how people behave and perform. In the context of

the Trust, human factors are environmental, organisational and job factors, and individual characteristics which influence behaviour.

3.9 In this reporting period, learning in respect of behaviours has identified learning

resulting in:

Remedial training on clinical guidelines and supervised shifts;

Reflective practice.

The human factors that influence those behaviours will be part of a bigger piece of work which will be undertaken by the Patient Safety team and overseen by the Trust’s Quality Development Forum.

3.10 The Trust has met with an expert in Human Factors investigations methodology and

will be liaising with the Academic Health Science Network regarding moving this area of work forward.


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3.11 Telephone triage inherently is subject to issues of Human Factors and potential error given the nature of the system. One of the Trust’s Quality Priorities for 2016/17 is to undertake a review of patient safety incidents where telephone triage errors were identified as a concern and analyse these using an agreed human factors model with a view to developing proposals for improvement.

Access and Waiting 3.12 Of the remedial actions relating to access and waiting, a small number of actions

relate to dispatching errors. There was no identified relationship between each of

the cases and individual learning actions for the staff involved were put into place. 3.13 Demand and resourcing continued to be an issue for the Trust as it continues to

face two acute challenges; demand for services which is growing by more than 6% per year; and challenges in resourcing to meet that demand. The Trust aims to deliver the very best service it can to its patients within these constraints, despite that a number of complaints and incidents have identified demand and the availability of resources as a root cause. In order to address this issue, the Trust has developed an improvement plan and holds twice weekly performance briefings attended by representatives from all key functions. It has been agreed that the Trust and Commissioners will work collaboratively to understand where they can best concentrate resources in order to provide the greatest improvement and to focus on the external factors which impact demand.

The Trust has been involved in extensive recruitment drives for Paramedics and is

working closely with regional Universities to optimise the number of new Paramedics entering the profession. Continuous professional development for Trust Clinicians is also integral to growth, a Paramedic Conversion Course is currently in progress for a cohort of Emergency Care Assistants (ECAs) wishing to develop in their field of practice.

Demand and resourcing shortfalls with the Trust’s OOH GP services have impacted directly on achieving timely consultations and return telephone calls from OOH GPs. As a result, the UCS Management team introduced a escalation matrix and a Rota Review paper has been approved and will be introduced in 2016/17.

Communication 3.15 The area of communication skills has been identified as a theme by the Trust’s

Quality Development Forum in relation to complaints and adverse incidents, this has subsequently been linked to emotional resilience of staff. It is anticipated that the Trust’s new Peer Support Network will support staff in this area and in addition it was proposed that the Trust develop an Emotional Resilience course for accreditation.

3.16 Individual action has taken place as a result of complaints regarding the attitude of

staff which includes attendance at a Customer Care course.


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3.17 At the end of each NHS 111 Service telephone triage assessment that requires referral to a ‘Primary Care Service’, 111 Call Advisors (CA) are presented with a ‘Directory of Services (DoS) that supplies a list of appropriate health care providers, profiled to match the symptoms described who are available to see patient at that particular time and day. As a result of a small number of cases whereby call advisorswere not reading all available information shown of the DoS, some cases were either not being passed to other healthcare providers (ie some require verbal instruction as the receiving healthcare provider do not use the automatic link system) or patients were being directed to incorrect providers. In an attempt to resolve this issue, an email reminder was issued to all 111 staff by the UCS Management team reminding them of the importance of reading all available information.

3.18 To improve effective communication within the 111 hubs, the UCS Management

team introduced a day known as ‘Change Day’. This falls on every Wednesday. All updates, including new or amended guidelines, Standard Operating Procedures, instructions etc are disseminated ‘Change Day’ via the UCS Management team to all 111 staff.

4. Transparency

Duty of Candour 4.1 As of 27 November 2014 the statutory Duty of Candour, Regulation 20 of the Health

and Social Care Act 2008 (Regulated Activities) Regulations 2014 became a statutory requirement for NHS Trusts.

4.2 The duty requires that the patient (or legally appointed person acting on behalf of

the patient) is notified of a potential or actual patient safety incident that has or may have caused moderate harm, severe harm or death.

4.3 There are stipulated timescales and notification requirements in relation to the

completion of the investigation and communication with patients or their next of kin. One of the requirements is that contact is made with patients or their next of kin within 10 working days of the confirmation date of a serious or moderate incident.

4.4 During 2015/16 this timescale was met for 40 of the 81 moderate and serious incidents

confirmed. 29 incidents received contact past the initial 10 working day deadline due to the nature of the investigation. For the remaining 12 incidents:

four cases did not involve patients directly,

two cases were coordinated by other organisations,

in two cases contact was attempted, however the Trust did not receive a response and were unable to make contact;

in two cases there were issues in identifying and confirming the next of kin;

one case refused contact;


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one case it was deemed due to the sensitive nature of the incident, that contact should be coordinated with the hospital trust..

Pro-Active Apologies 4.5 The Trust introduced the proactive apology process in July 2014 as it was

considered that there were some instances where a patient’s experience of the service received was not of the standard that the Trust would normally expect and that an apology would be appropriate. Proactive apologies are related to incidents where no prior contact has been made or a where a complaint has been received by the patient.

4.6 27 proactive apologies were made during the reporting period. It should be noted

that the Patient Safety team now encourage local management teams to verbally apologise to patients and their families when deemed necessary as an acceptable and more welcomed response.

5. Patient Engagement

Compliments 5.1 A total of 2,225 compliments were received during 2015/16. This compares to

2,055 received in 2014/15 an increase of 170 (7%). The content of compliments often refers to the elements of care that were most important to the author of the feedback. Quite often, compliments highlight the compassion displayed to them or their loved ones and this is regularly cited to be the most important aspect of their experience.

5.2 The Patient Engagement Team now record the presenting condition, where

available, referred to in the details of incidents from which plaudits arise. The conditions referred to during this reporting period included trauma, attendance at events (schools, community events et al), chest pain, assaults, falls, diabetic related illness’ and maternity events including giving birth.

5.3 Formalising a ‘thank you’ to clinical staff is often part of the healing process for

patients, and those around them. Some of the consistent themes relating to plaudits are that staff:

are caring in nature – ‘They were really good and really reassuring, they explained lots of things.’;

reassure patients that it’s ok to call for help – ‘I have had a few experiences with paramedics in the past who have been unsympathetic at best, but I could tell that this man really cared about my condition. I was amazed by his friendliness and compassion and I didn't feel like just another call out, I felt like I really mattered as a patient.; ;


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save lives – ‘I am writing to express my thanks to the paramedics who saved my life. I am certain that without the expert attention of the paramedics I would have died. Words cannot express my thanks.’

Patient Surveys 5.4 The Trust is required to conduct patient experience surveys for NHS111, GP Out of

Hours and PTS in accordance with its contractual requirements. Whilst there is currently no contractual requirement to undertake a 999 service patient survey, the Patient Engagement Team hopes to develop this activity during 2016/17. Full patient survey data is included at Annex D.

5.5 During 2015/16 the Trust carried out NHS111 and GP Out of Hours patient

experience surveys.

NHS111 Survey - highlights

The response rate for the NHS111 survey during the period was 23%.

Concerns regarding triage and disposition results have been presented by survey respondents.

89% of survey respondents would recommend the service to a friend or relative.

GP Out of Hours Service - highlights

The response rate for the GP Out of Hours survey was 25%.

Comments from survey respondents are largely partially or entirely positive.

90% of survey respondents would recommend the service to a friend or relative.

5.6 Comments from patients who responded to the surveys included:

NHS 111 – ‘Questions asked seemed to be totally irrelevant to my problem. Seemed to be more focused on the Ebola Virus.’

GP OOH – ‘Mostly very good service, sometimes tell you too many things you already know the 2nd time.’

GP OOH – ‘I was treated with dignity and respect at all times and received good advice and care.’

NHS 111 – ‘My husband and myself have always been very satisfied when we have had to ring your service.’

5.7 From the quantitative and the qualitative results of the surveys, evidenced in part

within the paragraphs above and the attached appendices, the Trust can take assurance that the services are delivering a good quality patient experience in many cases. There will, however, be occasions when the service delivered does not meet the expectations of patients, and the main themes for comments from patients who expressed that their experience was not entirely positive were:


Page 17 of 33

Waiting times/delays – survey respondents have highlighted their concern in being subject of delays in being seen by or speaking to clinicians.

Triage – survey respondents continue to express dissatisfaction regarding the the triage process, citing it as too long and intrusive.

Local services – the lack of local or specialized services (District Nurses or Mental Health support) have meant that patients have called NHS 111 as they ‘did not know who to call.’

5.8 As the surveys are returned to the Trust anonymously, it is not possible to reconcile

comments whether positive or otherwise to particular staff or events.

Friends and Family Test (FFT) FFT for Patients

5.9 The FFT asks service users ‘How likely are you to recommend our service to friends and family if they needed similar care or treatment?’ Answers are given on a 5-point scale of ‘extremely likely’ to ‘extremely unlikely’, with a further option of ‘don’t know’ and the opportunity to comment further. For our Trust the patients who are eligible to answer the FFT are only those who have received see and treat care (999 and GP OOH) and those travelling with the PTS service. NHS 111 patients are currently ‘out of scope’; the Trust asks the FFT question via the patient experience surveys however this is only for best practice and this information is not reported to NHS England.

5.10 Nationally the picture for the FFT in ambulance services is that response rates are

very low. The subject of the value of the FFT has been taken to the national ambulance groups including the Association of Ambulance Chief Executives. Furthermore, efforts have been made to suggest alternate means for gathering patient feedback to NHS England, however these have been rejected to date.

5.11 The Trust has moved the FFT invitation onto the back of the new ‘Left at Home’

leaflet that clinicians leave with patients who are not conveyed. We hope that this will improve response rates as clinicians will not need to remember to offer a separate document to patients.

5.12 FFT data for the reporting period is set out at Annex A.

Staff FFT 5.13 The Trust is required to carry out the Friends and Family Test with its staff to help in

promoting the cultural shift in the NHS, whereby staff will have further opportunity and confidence to speak up, and where the views of staff are increasingly heard and are acted upon. The outcome of the Trust’s Staff FFT is set out below:

Responses3 % of Total % would recommend the Trust to % would recommend


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Number of Employees

friends and family if they needed care or treatment

the Trust as a place to work

Yes No Yes No

2014/15

Q1

162 3.5% 86% 4% 59% 28%

Q2

72 1.7% 83% 11% 56% 32%

Q34 1700 42% n/a n/a n/a n/a

Q4

1409 34% 83% 5% 43% 35%

2015/16

Q1

1349 31% 85% 4% 46% 33%

Q2 1198 27% 85% 3% 46% 33%

Q35 1721 n/a n/a n/a n/a

Q4 663 15% 76% 8% 40% 44%

5.14 The HR team are developing local action plans to target those outcomes where the

Trust performs less well. These will be generated following the outcome of this year’s staff survey and will include the feedback and results generated from Q1, Q2 and Q4 Staff FFT.

Feedback The Trust uses a number of mechanisms to consider the most common themes and trends within patient feedback (both positive and negative); word clouds provide an opportunity for the most frequently used words within complaints and compliments to be highlighted.

Words Most Frequently Used by Those Praising the Service

4 Test was replaced by Staff Survey in Q3 2014/15.

5 Test was replaced by Staff Survey in Q3 2015/16


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Words Most Frequently Used by Complainants

6. Litigation and Regulation

Prevention of Future Death Reports (Regulation 28). 6.1 Under the Coroners and Justice Act 2009, coroners have a duty to make a report

where (a) anything revealed by their investigation gives rise to a concern that circumstances creating a risk of other deaths will occur in the future; and (b) in the coroner’s opinion, action should be taken to prevent this.

6.2 During 2015/16 the Trust had 3 Regulation 28, however the Trust has formally

received 2 of these Regulation 28 reports, summaries of which are set out in the following table:

Regulation 28 Recommendations Received 2015/16

Incident Corner’s Concerns Trust’s Response

Hacker Training and policy around the Mental Capacity Act

SWAST was not informed that the inquest was taking place and no witnesses from the Trust were asked to attend. During the inquest, concerns were raised regarding frontline staff’s interpretation and application of the Mental Capacity Act. Information was requested


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from the coroner to enable a comprehensive response to be prepared. The response was sent to the coroner addressing each of the concerns raised and no further request for information has been received.

Skinner Training, mentoring and auditing of clinical supervisors

This incident was investigated as a Serious Incident Investigation and Caroline Tonks attended the inquest hearing. A comprehensive letter of response addressing each of the concerns identified was sent to the coroner and no further correspondence has been received.

Nute The Coroner raised a very broad concern regarding the communication and working relationship between SWAST and Devon and Cornwall Police. However, the Prevention for Future Deaths Report identifying her specific concerns has yet to be received from the Coroner.

During a recent Inquest relating to another case involving Devon and Cornwall Police, similar concerns were raised regarding communication. This presented the Trust with an opportunity to pre-empt and address the concerns raised during evidence, which appears to have satisfied the Coroner that her concerns have been addressed.

Clinical Negligence Claims 6.3 The Trust received 13 clinical negligence claims during 2015/16, a reduction of 11

compared to 2014/15. In order to ascertain any identifiable trends and themes, the principal cause of the claims has been considered separately to the injury sustained by the claimant in each case.

6.4 In considering the cause, it is notable that 9 of the 13 claims received relate to a

delay or failure to convey to hospital, 4 relate to a failure to recognize the severity of the patient’s presenting condition i.e. meningitis/sepsis cases and 3 where the patients were not managed appropriately, for eg were directed to walk to an ambulance rather than being escorted via a chair for eg, leading to a further fall and subsequent injury.


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6.5 In terms of the injury claimed, if bringing the claim in their own right, claims for unnecessary pain and psychological trauma have often been cited. For those claimant’s bringing a claim on behalf of a deceased patient’s estate,fatality is cited as the injury incurred and damages applied for the bereavement in addition to funeral expenses and loss of amenities.

Parliamentary and Health Service Ombudsman 6.6 The Parliamentary and Health Service Ombudsman (PHSO) is the final arbiter for

complaints about the NHS in England where an individual believes there has been an injustice or hardship because an organisation has not acted properly or fairly or has given a poor service and not put things right.

6.7 The PHSO has legal powers to advise the Trust to:-

Compensate if appropriate;

Return the complainant to the position in which they would have been if the maladministration or poor service had not occurred (where possible);

Remedy injustice or hardship. 6.8 During 2015/16, the Trust was asked to submit eight complaint files for independent

review by the PHSO. 6.9 As at 31st March 2016 five of the eight cases were still under review by the PHSO

and three had been confirmed as ‘not upheld’. 6.10 Also during 2015/16, the Trust received written confirmation relating to four files that

had been submitted in 2014/15. Two of these files were confirmed as not upheld and the other two had been upheld in part.

6.11 The first file to be considered upheld in part recommended the following:

A written apology for the failings identified within the PHSO’s report;

Financial recompense of £250.00;

An action plan to demonstrate that learning had taken place.

6. 12 The second file to be considered upheld in part recommended the following:

A written apology for the failings identified within the PHSO’s report;

An action plan to demonstrate that learning had taken place. 6.13 A full breakdown of PHSO cases is presented in a separate report to the Board of

Directors on a bi-annual basis.

Learning Disability and Patient Engagement Programme 6.14 The Trust’s compliance with Learning Disability (LD) requirements is regulated by

the Care Quality Commission (CQC) and Monitor. The Trust will be required to respond to a number of questions regarding LD as part of the new CQC inspection


Page 22 of 33

regime. In addition, Monitor’s Access and Outcome indicators require the Trust to certify compliance with access to healthcare for people with a LD, which is given equal weighting alongside the indicators for Red 1, Red 2, A19, and the A&E Wait for Tiverton Urgent Care Centre. The importance of the LD work programme is recognised by The Trust with the programme overseen by the Quality Committee and the Board of Directors.

6.15 The Trust’s patient group, SWAG has continued to grow with new members

attending and improving their confidence around engaging with the Trust. 6.16 In addition to SWAG the Trust has set up a new meeting, Spot and Space; this

group is attended by patients in the South Devon area who are being supported to live in the community. The aim of the group is to have open conversations regarding the service and to give attendees skills to support them living alone; when to call for an ambulance, understand how to make a complaint or basic first aid at home.

6.17 During the year the Trust initiated a new group for patients with MS; this group will

act as an opportunity for patients who are frequent users of the service who also have specific conveyance needs (patients often need to travel in their own wheelchair) to communicate with the service and offer a patient’s view on a journey to hospital.

7. Recommendation 7.1 Board members are requested to take assurance from this report. Governance Team

Annex A Accident and Emergency Service Line

Feedback received from: Q1 Q2 Q3 Q4 Total

2015/16 Total

2014/15

Compliments 488 567 483 466 2004 1783

Friends & Family Test

Number of returns 100 42 43 38 223 n/a

% that would recommend the Trust 88 95 91 79 90 n/a

PALS (General Enquiries) 165 192 190 198 745 625

Comments, Concerns & Complaints6 243 276 252 330 1101 866

Ombudsman Referrals Upheld 1 (in part) 0 0 1(in part)

2 (in part) 1

Never Events 0 0 0 0 0 0

Serious Incidents Confirmed7

(including from Complaints) 5 2 7 13 27 39

Moderate Incidents 12 5 6 7 30 35

Pro-Active Apologies 7 9 6 0 22 51

Adverse Incidents 1,112 1,404 1,429 1,677 5,622 5,463

HCP Feedback 127 126 97 204 554 510

Regulation 28 Recommendations Received 1 1 0 1 – not receiv

ed 3 3

Clinical Negligence Claims Received 5 2 2 0 9 20

During 2015/16, the A&E service line managed 1,049,921 patient contacts. (Source: Information Cell). Based on this, the A&E service line had:

1.9 compliments per 1000 patient contacts

1.04 complaints per 1000 patient contacts

5.9 adverse incidents per 1000 patient contacts

0.02 serious incidents per 1000 patient contacts

6 Serious Incidents from complaints included in Serious Incident numbers.

7 These figures may be different to previous reports due to Serious Incidents being subsequently downgraded. Downgrades will be reported at the end of the year.

Patient Transport Services


2015/16 Total

2014/15

Compliments 1 3 3 8 15 15





Comments, Concerns & Complaints8 17 18 11 17 63 57

Ombudsman Referrals Upheld 0 0 0 0 0 0



(including from Complaints) 0 0 0 0 0

0



Adverse Incidents 6 6 1 1 14 13

HCP Feedback 2 3 3 4 12 10

Regulation 28 Recommendations Received 0 0 0 0 0 0


During 2015/16 the PTS service line managed 105,440 patient contacts. (Source: Information Cell). Based on this, the PTS service line had:




0 serious incidents per 1000 patient contacts

8 Serious Incidents from complaints included in Serious Incident numbers.

9 These figures may be different to previous reports due to Serious Incidents being subsequently downgraded. Downgrades will be reported at the end of the year.

GP Out of Hours Service


2015/16 Total

2014/15

Compliments 5 10 9 8 32 38





Comments, Concerns & Complaints10

46 33 18 46 143 91

Ombudsman Referrals Upheld 0 0 0 0 0 1 in part



(including from Complaints)

1 1 1 0 3 3




HCP Feedback 44 30 24 20 118 87



During 2015/16 the GP Out of Hours Service (including Tiverton Urgent Care Centre) managed 119,319 patient contacts. (Source: Information Cell). Based on this, the GP Out of Hours service line had:




0.02 serious incidents per 1000 patient contacts

10

Serious Incidents from complaints included in Serious Incident numbers. 11

These figures may be different to previous reports due to Serious Incidents being subsequently downgraded. Downgrades will be reported at the end of the year.

NHS111 Service


2015/16 Total

2014/15

Compliments 25 16 22 20 83 143


12




Comments, Concerns & Complaints13

62 43 49 54 208 247





2 1 2 3 8 6




HCP Feedback 128 102 212 183 625 1,572


Clinical Negligence Claims 2 0 0 1 3 1

During 2015/16 the NHS111 Service managed 728,752 patient contacts. (Source: Information Cell). Based on this, the NHS111 service line had:




0.01 serious incidents per 1000 patient contacts.

12

NHS 111 is not within the scope of the Friends and Family Test. This is a national decision. 13

Serious Incidents from complaints included in Serious Incident numbers. 14 These figures may be different to previous reports due to Serious Incidents being subsequently downgraded. Downgrades will be reported at the end of the year.

Other Trust Activity

Some comments, concerns and complaints, adverse incidents and claims do not relate to a specific, or any, service line. For reporting purposes these have been categorised as ‘other’.

Feedback received from: Q1 Q2 Q3 Q4 2015/16

YTD Total 2014/15

Compliments 18 23 19 8 68 131

Friends & Family Test n/a n/a n/a n/a n/a n/a


Comments, Concerns & Complaints 2 0 0 2 4 7





1 2 0 0 3 3




HCP Feedback 0 0 1 2 3 0


Clinical Negligence Claims 0 0 0 0 0 0

15

These figures may be different to previous reports due to Serious Incidents being subsequently downgraded. Downgrades will be reported at the end of the year.

Annex B Incidents by Reporting Category – 2015/16

Q1 Q2 Q3 Q4

Total 2015/16

Total for 2014/15

Access, Appointment, Admission, Transfer, Discharge

SIs 0 0 0 0 0 1

MIs 0 0 0 0 0 0

AIs 73 78 93 162 406 580

HCPF 1 1 11 46 59 19

Abusive, violent, disruptive or self-harming behaviour

SIs 0 1 0 0 1 0

MIs 0 0 0 0 0 0

AIs 0 0 0 0 0 0

HCPF 0 0 0 0 0 0

Clinical assessment (investigations, images and lab tests)

SIs 3 2 0 1 6 18

MIs 5 1 2 1 9 14

AIs 1 69 130 177 377 12

HCPF 0 3 2 1 6 4

Consent, Confidentiality or Communication

SIs 0 0 0 0 0 0

MIs 0 0 1 0 1 1

AIs 117 149 143 228 637 1,009

HCPF 36 36 32 39 143 222

Conveyance

SIs 4 2 8 8 22 17

MIs 4 5 5 8 22 13

AIs 417 415 417 573 1822 1764

HCPF 51 63 48 89 251 276

Diagnosis, failed or delayed

SIs 0 0 1 0 1 0

MIs 0 0 0 0 0 1

AIs 0 2 0 0 2 0

HCPF 0 0 0 0 0 1

Patient Information (records, documents, test results, scans)

SIs 0 1 0 0 1 0

MIs 0 0 0 0 0 0

AIs 35 28 38 35 136 231

HCPF 5 5 0 6 16 18

Infrastructure or resources (staffing, facilities, environment)

SIs 1 0 0 0 1 5

MIs 0 0 0 0 0 11

AIs 179 160 124 292 755 842

HCPF 129 97 196 181 603 1,369

Medical device / equipment

SIs 0 0 0 0 0 1

MIs 2 0 0 0 2 0

AIs 139 249 206 177 771 540

HCPF 1 1 3 1 6 2

Medication

SIs 0 0 0 0 0 1

MIs 2 0 1 0 3 2

AIs 143 136 135 153 567 603

HCPF 9 3 7 8 27 15

Other

SIs 0 0 1 1 2 0

MIs 0 0 0 0 0 0

AIs 1 2 0 1 4 25

HCPF 0 0 1 0 1 0

SIs 0 0 0 0 0 0

MIs 0 0 0 0 0 0

Security AIs 0 1 0 0 1 0

HCPF 0 0 0 0 0 0

Treatment and intervention

SIs 1 0 0 6 7 8

MIs 3 0 0 0 3 6

AIs 246 324 367 271 1208 990

HCPF 69 52 37 41 199 253

Totals

SIs 9 6 10 16 41 51

MIs 16 6 9 9 40 48

AIs 1351 1613 1653 2069 6686 6596

HCPF 301 261 337 412 1311 2179

Annex C Definitions Risk Pyramid Ratio of low, moderate and serious incidents. The Trust is moving towards the correct proportions with the greatest number of incidents in the negligible/low category; and with the smallest number in the serious category.

Serious Incident Those that occur that have the potential to or actually impact patient safety or an organisation’s ability to deliver ongoing health care. Their occurrence demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm to patients or staff, future incidents of abuse to patients or staff, or future significant reputational damage to the organisations involved.

Moderate Harm Incident A patient safety incident that resulted in a moderate increase in treatment and that caused significant, but not permanent, harm to one or more patients. A moderate increase in treatment is defined as a return to surgery, an unplanned readmission, a prolonged episode of care, extra time in hospital or as an outpatient, cancellation of treatment, transfer to another area such as intensive care as a result of the incident or a scenario that causes or is likely to cause psychological harm for a continuous period of at least 28 days.

Adverse Incident Any event or circumstance arising that could have or did lead to unintended or unexpected harm, loss or damage to any individual or the Trust. Adverse incidents may or may not be clinical and may involve actual or potential injury, mis-diagnosis or treatment, equipment failure, damage, loss, fire, theft, violence, abuse, accidents, ill health, near misses and hazards.

Duty of Candour (DoC) A duty to be open with our patients, informing them of any moderate or serious patient safety incident in which they have been involved. When ‘being open’, the Trust should

acknowledge the incident occurred, apologise to the patient or next of kin, and explain why the incident occurred and what actions will be put in place to try and prevent a recurrence.

Complaint A complaint is defined as any expression of dissatisfaction from a patient, or their duly authorised representative, or any person who is affected by, or likely to be affected by, the action, omission or decision of the Trust and/or its’ staff, whether justified or not.

Moderate Level 3 Complaint A comment, concern or complaint which requires a more complex investigation or has resulted in a detrimental outcome for the patient or a complaint that was considered as a Serious Incident but deemed not to meet the criteria.

Annex D

The table below shows the responses to three important aspects of the surveys from across UCS; the responses are totalled from NHS 111 and GP OOH. The questions concern –

Being treated with respect and dignity

Feeling involved in decisions regarding care and treatment

Feeling listened to (this refers to both call takers and clinicians as relevant)

Quarter 1 2015/16 Quarter 2 2015/16 Quarter 3 2015/16 Quarter 4 2015/16

Res

pec

t an

d D

ign

ity

Degree Totals Degree Totals Degree Totals Degree Totals

Yes,

completely 565

Yes,

completely 414

Yes,

completely 323

Yes,

completely 350

Yes, to some

extent 32

Yes, to

some

extent 24

Yes, to

some

extent 21

Yes, to

some

extent 29

No 8 No 5 No 4 No 9

NS/CR 3 NS/CR 5 NS/CR 3 NS/CR 3

Invo

lved

in

trea

tmen

t

dec

isio

ns


Yes,

definitely 450

Yes,

definitely 330

Yes,

definitely 266

Yes,

definitely 278

Yes, to some

extent 92

Yes, to

some

extent 76

Yes, to

some

extent 49

Yes, to

some

extent 72

No 42 No 22 No 24 No 27


Did

yo

u f

eel l

iste

ned

to

(in

clu

des

all

call

take

rs t

o c

linic

ian

s)


Yes,

definitely 567

Yes,

definitely 372

Yes,

definitely 306

Yes,

definitely 320

Yes, to some

extent 71

Yes, to

some

extent 56

Yes, to

some

extent 31

Yes, to

some

extent 53

No 21 No 13 No 15 No 13



Page 1 of 11


Title: Information Governance YTD Report 2016/17

Prepared by: Debbie Bridge, Information Governance Manager

Presented by: Francis Gillen, Executive Director of IM&T

Main aim: The purpose of this paper is to provide the Board with assurance on delivery of the Information Governance programme

Recommendations: The Board of Directors is asked to note the contents of the report.

Previous Forum: Not Applicable


Page 2 of 11

Information Governance Report

1. Introduction 1.1 This paper is presented to report on the 2016/17 YTD position covering the period

April 2016:

The Information Governance (IG) Toolkit Freedom of Information (FoI) Act requests Data Protection (Subject Access Requests) Records Management Adverse Information Governance incidents

2. Information Governance Toolkit

2.1 The IG Toolkit is an annual self-assessment tool which covers a very broad range of IG issues including the general management and governance of the Trust, confidentiality and information security, data quality, training and business continuity. Significant work is required on an annual basis to ensure the Trust meets Level 2 for all 35 requirements which is the minimum expected by our Commissioners.

2.2 The IG Toolkit return for 2015/16 was submitted and published on 29 March 2016. The return achieved a score of 71% showing a 1% drop on last year. This was primarily due to a changed requirement which we could no longer meet at Level 3 as it would have required us to provide all patients with online access to their medical records. Commissioner’s expectations are that we will achieve a minimum of Level 2 in all 35 requirements. The submission delivered 30 requirements at Level 2 with 5 being achieved at the advanced level, Level 3.

2.3 After financial year end a bench marking exercise of IG Toolkit submissions for all

Ambulance Trust’s is carried out as shown in Table 1.


Page 3 of 11

2.4 The Revisions for the 2016/17 IG Toolkit are due to be published in May/June 2016,

once published they will be reviewed to see which requirements have changed although significant amendments are not expected. Any additional work/evidence will be included in the IG Workplan for 2016/17 and the IG Strategy will be reviewed to ensure new or additional requirements are incorporated.

3. Freedom of Information (FoI) Act Requests

3.1 The volume of FoI requests received in April 2016 has shown an increase on comparative figures for the three previous years as shown in Chart 1.

3.2 Of the 10 requests completed since the 1st April 2016, 10 have been replied to

within the 20 day legislative time limit, a performance of 100% compared to the


Page 4 of 11

target of 95% as shown in Chart 2. Increased activity, staffing challenges and the complexity of requests have all played a part in the performance going below target at the end of the 2015/16 financial year.

3.3 Breakdown of FOI requests

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

2013/14 27 13 18 29 29 19 24 31 16 21 25 14

2014/15 19 22 13 24 10 12 19 25 14 23 22 14

2015/16 24 13 25 21 19 25 22 18 17 27 32 32

2016/17 29

0

10

20

30

40

Chart 1: Monthly Totals of FoI Requests received

96.8% 96.6%

92.8%

100.0%

60%

95%

2013/14 2014/15 2015/16 2016/17

Chart 2: Freedom of Information Requests completed in 20 days Target 95%

91%


Page 5 of 11

Table 2: Shows a breakdown of requests by requestor type, the theme of many requests where the requestor type is unknown indicates a significant proportion are likely to be generated by commercial organisations, The majority of requests therefore appear to originate from the business sector and media sources.

Table 2: FOI Requests by requestor type

Requestor 2014/15 2015/16 2016/17

Unknown 39.8% 42.5% 20.7%

Student/University 6.0% 8.9% 20.7%

Commercial 8.8% 7.1% 20.7%

Media 27.3% 22.1% 17.2%

Action Group / Charity 2.8% 1.8% 10.3%

Local Authority / Gov Dept /MP (Researcher) 1.4% 3.9% 6.9%

Ambulance Service/HCP (Current/Ex) 2.8% 2.1% 3.4%

WDTK (What Do They Know Website) 8.3% 9.6% 0.0%

Trade Union 1.0% 0.7% 0.0%

Patient or Representative 1.0% 0.7% 0.0%

Solicitor 1.0% 0.4% 0.0%

Table 3: Shows a breakdown of requests by topic, the contracts classification is likely to come largely from the commercial sector, other topics which dominate relate to SWASFT’s key activities, staffing and resources.

Table 3 FOI Requests by Topic

Topic 2014/15 2015/16 2016/17

Ambulance Activity / Performance / Protocols (Non Clinical) / Resourcing

19.4% 24.3% 31.0%

Contracts / Facilities / Services / Training Provision / Corporate Protocols

17.4% 21.8% 27.6%

Staffing (Policies (Guidance) / Structure / Absence / Pay / Redundancy / Disciplinary / Conduct / Leaving Reasons / Recruitment)

14.8% 18.6% 13.8%

Clinical Activity / Protocols / Outcomes / Drugs 10.2% 8.2% 13.8%

Fleet / Lease Cars / Driving Protocols / Speeding (Parking) Tickets / Medical Equipment

7.4% 7.1% 3.4%

Private Providers / Agency Staff 4.2% 4.6% 3.4%

Finance (Costs / Expenses / Systems) 5.6% 4.6% 3.4%

Handovers 4.2% 1.8% 3.4%

Complaints / Datix / SIs / Claims 4.2% 2.9% 0.0%

First Responders 3.2% 2.5% 0.0%

Mixed Requests 4.6% 2.1% 0.0%

Assaults / Warning Markers / Thefts / Freq Callers / Hoax / Inappropriate Calls

5.1% 1.4% 0.0%


Page 6 of 11

4. Data Protection Act (Subject Access Requests)

4.1 There has been a 32% increase in requests YTD with 228 requests received compared to 156 in the same period last year as shown in Chart 3. The increase in requests aside from a general increase in activity is primarily originating from Drs (GPs and Hospital Consultants) and Solicitors. The Drs requests are believed to have been prompted by the introduction of ePCR now patients and hospitals no longer having ready access to paper copies of ambulance PCRs, medical claims activity reflects the increasing nature of opportunistic litigation.

4.2 Requests from the Police continue to represent the largest source of those

received, accounting for 43.9% of the 228 requests received in April 2016 as shown in Chart 4.

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

Trust 2013/14 109 142 138 175 177 158 186 176 125 176 158 150

Trust 2014/15 145 125 160 179 161 163 171 174 149 183 163 159

Trust 2015/16 156 179 207 198 168 199 179 183 149 200 231 219

Trust 2016/17 228

0

50

100

150

200

250

Chart 3: Monthly Totals of Subject Access Requests received

100 75 53 117 64 57

43.9%

32.9%

23.2%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

0

20

40

60

80

100

120

140

Police Solicitor and Medical Reporting Other (Data Subject / NHS etc.)

Chart 4: Requests by Source April 2016

Requests Received Requests Closed % by Requestor


Page 7 of 11

4.3 Performance is above target with 100% of the requests closed in April being

responded to within 40 days against the target of 95% as shown in Chart 5.

The average number of calendar days taken to complete a subject access request

per requester category is shown in Table 4. Table 4 Average SAR Completion

Requester Type Average number of days to complete

Police 13.9

Other 26.3

Solicitor 3.7

Overall 14.6

Typically the average time taken to complete a request is increased where we are required to collate crew statements, as is often the case with Police requests or where we are required to confirm consent from patients and third parties / representatives. The figure for solicitors’ requests is inclusive of the time taken between an invoice being raised and confirmation of payment from the Finance team.

5. Records Management

99.4% 99.2% 99.6% 100.0%

60%

95%

2013/14 2014/15 2015/16 2016/17 (YTD)

Chart 5:Subject Access Requests completed in 40 days. Target 95% 91%


Page 8 of 11

5.1 The IG department administers the archiving of paper based records on behalf of the Trust. The Trust’s current archive provider is Iron Mountain; historically Crown Records Management and Restore have been used and some archive records are still accommodated within these organisations. These records will eventually either be moved into Iron Mountain or disposed of in accordance with record retention schedules. Keeping archived records beyond their retention period is not only in contravention of the Data Protection Act but also has significant cost implications for the Trust.

5.2 Table 5: Shows a breakdown of archived records and the associated costs. This

report has been set up to illustrate the costs to the Trust of archiving records thereby underlining to records owners the importance of reviewing records promptly at the end of their retention schedule.

Table 5: Archived Records Activity & Costs

6. Information Governance Adverse Incidents

6.1 All adverse incidents should be reported on Datix following the Trust’s Incident reporting policy. These incidents have been reviewed to identify those relating to Information Governance and the incidents have been coded according to national definitions as shown in Table 6.

Table 6: Incidents by Type 2016/17 (YTD)

Category Breach Type 2013/14 2014/15 2015/16 2016/17

A- Corruption or inability to recover electronic data

0 0 0 0

B- Disclosed in Error 27 (16%) 30 (14%) 39(18%) 3(14%)

C- Lost in Transit 0 3 (1%) 22 (10%) 0

D- Lost or Stolen hardware 1 (1%) 0 4 (2%) 0

E* Lost or Stolen Paperwork 96 (59%) 155 (71%) 59 (28%) 2 (9%)

F- Non-Secure Disposal Hardware 0 0 0 0

G- Non-Secure Disposal Paperwork 4 (2%) 2 (1%) 3 (1%) 0

H- Uploaded to website in error 0 0 0 0

I- Technical Security Failing (including hacking)

0 2 (1%) 0 0


Page 9 of 11

J- Unauthorised Access/Disclosure 0 1 (1%) 15 (7%) 2 (9%)

K- Other 36 (22%) 26 (12%) 72 (34%) 15 (68%)

*Please note these are usually PCRs which can’t be sourced but are not confirmed lost/stolen

The most significant issue has traditionally been PCRs that can’t be located although these figures are steadily reducing with e-PCR rollout. Most of the IG Incidents reported relate to accuracy availability and security of information. Although these are IG Incidents they do not fit the national profile which specifically relates to data breaches. In light of this we have provided a breakdown of the category K – Other to indicate the area of concern.

Table 7 shows the type of incident by the information they relate to.

Finally Table 8 and Chart 6 show where these incidents are happening. This shows a wide variation in the number of incidents being reported across the Trust. Table 7


Page 10 of 11

6.2 The Information Commissioner has the power to fine organisations up to £500,000

for breaches of the Data Protection Act. During 2016/17 (YTD) three fines have been issued to public sector organisations, as shown in Table 9 below. There have been 2 other fines totalling £70,000 issued to private sector organisations during the same period.

Table 9: Fines issued in 2016/17 by the Information Commissioner to public sector organisations for breaches of the Data Protection Act

Date How Much

What For No. of Persons/Patients Impacted

21 April 2016

£80,000 To Chief Constable of Kent Police – Sensitive personal details of a woman who accused her partner of domestic abuse were sent to the suspect

1

0 20 40 60 80 100

111

HART

Hub

Ops East

Ops North

Ops West

PTS

Support Services orUnclear

UCS

Chart 6: IG Adverse Incidents by Function 2013/14 2014/15 2015/16 2016/17


Page 11 of 11

Date How Much

What For No. of Persons/Patients Impacted

04 May 2016

£185,000 To Blackpool Teaching Hospitals NHS Foundation Trust - inadvertently published the private details of 6,574 members of staff, including their National Insurance number, date of birth, religious belief and sexual orientation in March 2014

6,574

09 May 2016

£180,000 To Chelsea and Westminster Hospital NHS Foundation Trust - revealing the email addresses of more than 700 users of an HIV service.

700

7. Other Information Governance issues & topics

7.1 The UK House of Commons Culture, Media and Sport Select Committee has confirmed Elizabeth Denham's appointment as Information Commissioner. Denham, currently the Privacy and Information Commissioner for British Columbia, Canada, fielded questions on a range of matters prior to her appointment. Whilst stating her willingness to levy heavy fines for serious breaches of data protection law, she said she would prioritise proactive guidance, advice and education. She will succeed Christopher Graham on 28th June 2016.

7.2 The European Commission has proposed that the European Council sign and

conclude the EU-US data protection Umbrella Agreement regulating law enforcement cooperation including criminal offence investigation. The EU and US have been negotiating the agreement since March 2011 and a deal was finalised in September 2015. The Council will now adopt a decision authorising the signing of the Agreement.

7.3 The General Data Protection Regulation has now been published in the Official

Journal. The publication was on 4th May 2016, meaning the GDPR will enter into force on 24th May 2016, and provisions will be directly applicable from 25th May 2018. Organisations now have two years to prepare for the changes

8. Recommendation

8.1 The Board of Directors is asked to note the contents of the report. Debbie Bridge Information Governance Manager


Page 1 of 4


Title: Communications update

Prepared by: Louise Bowden, Head of Marketing, PR and Communications

Presented by: Louise Bowden, Head of Marketing, PR and Communications

Main aim: The purpose of this paper is to provide the Board with an update on communication activities.

Recommendations: The Board of Directors is asked to note this report.

Previous Forum: Please list forum and date


Page 2 of 4

Communications update

1. General The main headlines over the previous month has been the introduction of a media monitoring service as reported at the last Board meeting; production of the annual report and accounts; two incidents prompting significant out-of-hours media interest and the live Tweetathon from the Exeter Hub.

2.0 Proactive media activity

A news release was issued in conjunction with the NIHR detailing the success of the trust’s research team.

Several news releases were reviewed and authorised in conjunction with the community engagement team including the launch of two defibrillators, a responder profile in a community magazine and a partnership initiative with the fire service.

We contributed to a partner agency news release led by Devon County Council regarding a safe driving initiative, at which we are delivering a presentation.

Press releases together with video sound bites were issued for the expected busy Easter period and the May bank holiday weekend, together with the Tweetathon just ahead of the May break. This resulted in wide spread pick up of the news releases, links to the video of Ken Wenman and requests for interviews.

A multi-agency feature on BBC Breakfast about the Red Thumb campaign encouraging safer driving, with a particular focus on the dangers of using a mobile phone – four slots through the morning with presence from the Patient Engagement team.

Some patient stories are currently being pursued as it is hoped we can reunite the patient with the crew(s) and gain media coverage. A reporter has also been invited to spend time with a crew in the north division showcasing electronic patient clinical records. Local press releases for the Queen’s long service medals, chief commendations and other awards are also in the pipeline.

2.1 Reactive media activity These are some items or themes to note in addition to the general media enquiries about ambulance attendance at incidents. Information about our wellbeing services and support for staff has been issued to several media. Performance – We have had a number of media calls about time of arrivals, and providing clarity on published performance figures. FOIs – There appears to be a growing number media FOIs which lead to media stories.


Page 3 of 4

Out of hours incidents. The incident at Plymouth station and patients found at a lorry park in Chippenham allowed the Communications team to use the external website as a communication tool with partner agencies in line with incident procedures. Both incidents also resulted in across the board national media interest.

2.2 Media monitoring

The media monitoring service was introduced for April, unfortunately part way through the month the data being received became corrupted so I’m not fully confident of the reputation report. A dashboard will be produced for future Board meetings. A simple analysis though shows that during April there were 617 articles mentioning South Western Ambulance Service of which 29 were generated from proactive activity and 588 reactive. Outcome – 27 positive, 576 neutral, 12 balanced and 2 negative. Future monthly analysis will include comparisons with activity level and factors such as geographical location and genre of media outlet.

2.3 PR

We continue to hold discussions with television production companies on potential new national TV series.

2.4 Publications

Extensive work has been carried out for the production of the annual report and accounts, leading up to the submission to Parliament and NHSI.

2.5 Internal communications

Yammer – the introduction of social media within SWASFT is starting to gain momentum. This will continue to be monitored as another internal communications channel and tool for staff engagement. Board members are encouraged to post their own comments and photos when on Trust activity. Ahead of the CQC inspection in June a series of communication activities are underway including a leaflet explaining to all staff what they can expect during the visit.

2.6 Design

The majority of design requests at present are related to the upcoming CQC inspection in June.


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2.7 Digital

Twitter – The live tweetathon from the Exeter Hub at the end of April before the bank holiday weeks saw a rise in followers to above 7,000. The event was well received internally giving support staff an insight into colleagues work, but also provided the opportunity to reach out to stakeholders’ social media teams as well. Appropriate guidelines have now been drawn up and permission to tweet on the corporate twitter account will now be given to operation officers and operations managers so that more relevant and localised information can be tweeted, promoting the work of SWASFT. Intranet – the intranet has recently had a front page face lift to allow more opportunities to share news and information with staff via this channel. In addition content has been reviewed to make sure it is up to date, searchable with named content owners and automatic updating email alerts. Rostering remains one of the top visited intranet pages with the Chief’s Bulletin making up half of the top ten downloaded documents. Website – the corporate external website will also have a front page refresh following a short analysis of visitor requirements.

2.8 Stakeholder

Co-ordination of papers has been completed for Glos HoSC committee meeting on an OOH review. A number of HoSCs though that had deadlines for papers early in May for meetings in June have now decided to move the requirement for SWASFT attendance to September meetings in anticipation of publication of CQC reports. Some meetings with MPs have been arranged for the Chairman.

3. Recommendation The Board of Directors is asked to note this report. Louise Bowden Head of Marketing, PR and Communications


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Trust Public Board of Directors’ Meeting 26 May 2016

Title: Ambulance Clinical Quality Indicators

Prepared by: Sarah Black, Research and Audit Manager

Presented by: Dr. Andy Smith, Executive Medical Director

Main aim: The purpose of this paper is to provide the Board with an update on clinical quality improvement work associated with the Ambulance Clinical Quality Indicators

Recommendations: The Board of Directors is asked to take assurance from the content of this report



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Clinical Improvement and the Ambulance Clinical Quality Indicators

1. Background The Ambulance Clinical Quality Indicators (ACQIs) were introduced in 2011 and are designed to reflect best practice in the delivery of care for specific conditions and to stimulate continuous improvement in care. Since their introduction ambulance trusts have been working nationally through the National Ambulance Clinical Quality Group (NACQG) to agree and improve the comparability of the datasets reported.

Clear guidance is available nationally, which provides detail on the inclusion criteria and explanation of any valid exceptions (for example where a patient refuses treatment or it is clinically contraindicated).

Whilst there are currently no national performance targets for ACQIs, local thresholds have been agreed with the Trust’s commissioners and are monitored and reported internally to the Clinical Effectiveness Group and the Board. Clinical performance results are also publically available, with each ambulance trust reporting the ACQI performance measures on their external websites and through the NHS England site.

Data from the indicators is used to reduce any variation in performance across all English Ambulance Trusts (where clinically appropriate) and drive continuous improvement in patient outcomes over time.

Information is submitted on a monthly basis, but due to the delay in some services receiving paper clinical records, and the fact that some data is obtained from external sources there is an agreed time lag of four months. This means in practice that data for incidents attended in May 2016 will be submitted in September 2016.

Currently the Trust is participating in the Ambulance Response Programme (ARP) coding trial, operating under a pre-triage sieve and Dispatch on Disposition (DoD) arrangements, and will be piloting a new code set and response categories that differ from those in use by other ambulance trusts in England. There are amended ARP AQIs which are reported on an accelerated timeframe. However the ARP ACQIs have retained consistency with other ambulance trusts where this is possible. For some measures the existing AQIs do not fit the ARP deployment and response arrangements, and hence it is not possible to report against those standards.

The ACQIs cover three clinical conditions and each have two indicators, shown in table 1.


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Table 1 – ACQI indicators and descriptors

ACQI Indicators

Management of Acute ST Elevation Myocardial Infarction (STEMI)

Percentage of patients suffering a STEMI and who receive an appropriate care bundle. The care bundle includes two pain scores recorded, and administration of aspirin, GTN and appropriate analgesia.

Percentage of patients with an initial diagnosis of ‘definite myocardial infarction’ for whom primary angioplasty balloon inflation occurred within 150 minutes of emergency call connected to ambulance service(Call to Balloon CTB time), where first diagnostic ECG performed is by ambulance personnel and patient was directly transferred to a designated pPCI centre as locally agreed.

Management of Acute Stroke

Percentage of suspected stroke or unresolved transient ischaemic attack patients (assessed face to face) who receive an appropriate care bundle. The care bundle includes recording of FAST, blood glucose level and systolic and diastolic blood pressure.

Percentage of Face Arm Speech Test (FAST) positive stroke patients (assessed face to face) potentially eligible for stroke thrombolysis, who arrive at a hyperacute stroke unit ( HASU) within 60 minutes of call.

Outcome from Cardiac Arrest – Return of Spontaneous Circulation (ROSC)

Recording of ROSC at hospital arrival indicates the outcome of the pre-hospital response and intervention.

This indicator is measured for all patients who had resuscitation (Advanced or Basic Life Support) commenced / continued by ambulance service following an out-of-hospital cardiac arrest and a comparator group, (known as the Utstein group) which includes a subset of all resuscitated patients, where the arrest was bystander witnessed and the initial rhythm was Ventricular Fibrillation (VF) or Ventricular Tachycardia (VT)


Survival to discharge reflects the effectiveness of the whole urgent and emergency care system in managing out of hospital cardiac arrest.

This indicator is measured for all patients who had resuscitation (Advanced or Basic Life Support) commenced / continued by ambulance service following an out-of-hospital cardiac arrest and a comparator group, (known as the Utstein group) which includes a subset of all patients who had resuscitation commenced / continued by ambulance service, where the arrest was bystander witnessed and the initial rhythm was Ventricular Fibrillation (VF) or Ventricular Tachycardia (VT)


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2. Current Performance Current performance against each ACQI is detailed in table 2 against the local threshold set by Commissioners Table 2 – August to December 2015 ACQI performance (Whole Trust)

ACQI Indicator element

August 2015

September 2015

November 2015

December 2015

2015/16 Local

threshold

Cardiac Arrest

ROSC (all) 29.8% 25.1% 27.8% 26.1% 24%

ROSC (Utstein)

60.5% 53.3% 50% 41.3% 45%

Survival to discharge (all)

11% 7.1% 8.5% 8% 9%

Survival to discharge (Utstein)

37.2% 23.8% 16.1% 18.6% 27%

STEMI

CTB<150 80.6% 78.4% 75.5% 77.9% 84%

Care bundle

83.1% 79.8% 87.4% 82% 90%

Stroke

HASU<60 40.2% 42.9% 46.5% 39.3% 57%

Care Bundle

95.8% 95.6% 96.8% 96.5% 97%

Performance against the Commissioners target is not examined at ‘in month’ but is documented in the Integrated Corporate Performance Report (ICPR) on a ‘year to date’ measure. It should be noted that whilst performance fluctuates each month, the sample size for some indicators, in particular the Utstein elements of the Cardiac Arrest ACQI is very small and this impacts more significantly on reported percentages.

3. Quality Improvement Activity The Trust is committed to seeing continuous quality improvement in our performance. Staff are actively engaged in feeding in ideas. It is anticipated that rises across a range of ACQI indicators will be seen from the change ideas which are planned; however additional improvements may be made to clinical care that are not fully represented by these measures. For example QI input may reduce the overall call to hospital time for thrombolysis eligible strokes; however a small rise in the HASU 60 indicator may not fully represent the improved care a larger number of patients experience.


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For this reason, secondary measures will be recorded which will more closely measure the impact of QI interventions. These are detailed in table 3 and explained in sections 3.1 and 3.2. Further measures of success may be identified as part of a Plan, Do, Study, Act approach. Table 3 – Primary and Secondary Outcome Measures

ACQI Primary Measures Secondary Measures

Cardiac Arrest ROSC (All) ROSC (Utstein) Survival to Discharge (All) Survival to Discharge (Utstein)

Post ROSC Care Bundle

Qualitative feedback on team training

CPR Quality measured by Compression Fraction

STEMI

CTB<150 Average On Scene time

Care bundle Average Call – Hospital time

Stroke

HASU<60 Average On Scene time

Care Bundle Average Call – Hospital time

A full time Lead Quality Improvement Paramedic was successfully seconded into the Research and Audit team on 1 March 2016. Additionally, three Clinical Development Officers within the Medical Directorate have been allocated one day each to assist with clinical quality improvement activities until their secondments end in July 2016. The team also retains a 0.2 WTE Quality Improvement Paramedic. A detailed plan of QI activity and change ideas to support the ACQI programme was shared with Clinical Effectiveness Group at their meeting on 20 April 2016.

3.1 Cardiac Arrest

As the Trust has selected Cardiac Arrest Outcomes as one of its quality indicators for 2016/17, the team will largely focus on this area. Work has already commenced to trial new defibrillator pads at one large station in West Division. These pads collect data on the ‘compression fraction’, which is the percentage of time in which chest compressions are done by rescuers during a cardiac arrest. In a real-world cardiac arrest, CPR often is interrupted or delayed by things such as rescue breaths, pulse checks and heart rhythm analysis. The defibrillator pads record the depth and rate of chest compressions and measure the amount of time ‘off the chest’ in each case. The Clinical Quality Improvement team are providing feedback to individual members of clinical staff and collating a picture of the quality of CPR undertaken.

This work stream has also undertaken a quality improvement collaborative workshop with a group of clinical staff of all grades who were shown the impact of the ‘team approach’ in


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resuscitation along with discussion of human factors which may be involved, including the importance of leadership and followership. The group helped design a cardiac arrest checklist and an equipment ‘shadow sheet’ which will be trialled in a small area very soon. This work has been shared with the Trust’s Resuscitation clinical sub group. There are also plans to trial an educational initiative, providing Operational Officers with ‘team leader’ training and using this to examine any impact on the compression fraction. 3.2 Cardio-vascular emergencies, STEMI and Stroke Using the quality improvement collaborative approach, a multi-disciplinary group of staff met to discuss methods for improving the outcomes for patients suffering suspected stroke or STEMI. Using recognised quality improvement techniques the group recognised that certain barriers may exist which may impact on the time taken to deliver patients to definitive care. The RAPID mnemonic has been developed to remind both clinical hub and operational staff of the key elements which may save both heart and brain in these two conditions. These are:

Early Recognition

Administer Care Bundle

Priority 1 Backup

Inform Hospital

Depart Scene

A programme of work related to the RAPID work stream is now planned and will be shared with the Clinical Effectiveness Group at it’s next meeting on 18th May 2016, ahead of a launch in the Trust’s Clinical News Publication. All results and progress with these initiatives will be reported to, and monitored by the Clinical Effectiveness Group.

4. Recommendation The Board of Directors is asked to take assurance from the contents of this report and the plans for a programme of continuous quality improvement activity in relation to the ACQIs. Sarah Black Research and Audit Manager


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Title: Report from the Quality Committee

Prepared by: Emma Murgatroyd, Executive Assistant to the Executive Director of Nursing and Governance

Presented by: Venessa James, Chairman of Quality Committee

Jenny Winslade, Executive Director of Nursing and Governance

Main aim: To share with the Board a summary of the meeting held on 14 April 2016 and the approved minutes of the Committee held on 14 January 2016.

Recommendations: The Board of Directors is asked to note the report of the Quality Committee for assurance.


This report references:

Board Assurance Framework

BA05-14 Directorate

Business Plans Nursing & Governance

Directorate

Implications

(including Statutory or Legal References)

Good governance practice


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Quality Committee 1. Overview of the meeting

1.1 The Trust Board of Directors has three committees to which it delegates

responsibility for essential business. They are (i) Quality and Governance; (ii) Finance and Investment; and (iii) Audit.

1.2 Each of these committees is chaired by a Non-Executive Director and operates an

annual cycle of business to ensure statutory, regulatory, strategic, and operational objectives are achieved.

1.3 In order to provide assurance that this work is undertaken, and that Board committees operate effectively, a report is prepared following each committee meeting and presented to the Board of Directors.

Executive Summary

Key issues and risks

Key achievements

Analysis and commentary

Actions

Learning and outcomes

2. Key issues

2.1 The Committee felt that there were three key areas that they picked up from the issues or risks section of the reports, and requested that the Directors look into them further. They were assured that there was no harm or risk to patients but areas that they would like the Trust to consider further. They were around Health and Safety, staff retention and staff welfare and wellbeing.

3. Key achievements 3.1 The Committee were pleased to note the progress and achievements made in the

following service areas: staff recruitment, staff learning and development funding, Right Care, station audits, medicines management and the ongoing work relating to staff welfare.

3 Approval of documents

Document Approved or approved subject to amendment

Any challenge or change requested

Bruising Protocol in Children who are Not Independently Mobile

Approved. No further assurance was requested.


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Serious and Moderate Harm Incident Policy

Not approved. Policy to be presented at the next JNCC ahead of formal approval at the Board Seminar on 28 April 2016.

Managing Allegations Policy


PREVENT Policy Approved subject to amendment.

Amendment to section five required – references to ‘the governing body and commissioning staff’ to be amended to the ‘Board’.

Restraint Policy Approved as a six month trial.

Policy to be rolled out as a six month trial – legal advice to be sought during pilot. Policy to be brought back to Quality Committee at the end of the pilot for review.

Minimal Lifting Policy in Nursing, Care Homes and by Domiciliary Care Providers (Care Agencies)


Extension to: IM&T Security Policy


Enhanced Skills Policy Approved. No further assurance was requested.

Clinical Photography Policy Approved subject to amendment.

Paragraph 4.5 regarding patient lack of capacity to be reworded to be clearer about acting in patients’ best interest.

Dementia Strategy Approved subject to amendment.

Addition required regarding the addition of information on how the strategy will be resourced.

Clinical Supervision Policy Not approved. Approval of policy postponed to the next Quality Committee on 14 June 2016.

Amendments to: Responder Policy and Complaints Policy


4 Assurance

Document (includes deep dives)

Further assurance requested by Committee

2015/16 Quality Report and Account

The Committee requested that the Quality Report and Account be circulated to the Board members and presented at the next Board meeting on 19 May 2016 and at the next Council of Governors meeting on 21 April 2016.

Health, Safety and Security Report

The Committee requested further assurance regarding the reporting of physical assaults on staff in the form of a Deep Dive.


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Patient Safety The Committee requested further assurance around 111 clinical staffing levels – Ken Wenman gave assurance that staffing levels were being managed via the 111 Action Plan as well as a number of supporting documents. Assurance was also requested regarding SWASFT incident management performance compared to other Ambulance Services.

HR and Organisational Development Directorate Report

The Committee sought assurance that the 111 service was retaining enough staff to deliver a safe service and that no areas within the Trust were dangerously short of staff – Emma Wood confirmed that staffing levels within 111 were of a level to allow delivery of a safe service and that no Trust areas were dangerously short of staff.

Infection Prevention and Control Quality Report

The Committee requested further assurance that minor Health and Safety issues would be identified and rectified during the Clinical team’s monthly station visits. Dave Partlow confirmed that Health and Safety issues would be added to the Clinical team’s station audit profile. The Committee took assurance from this.

Safeguarding Service Report Committee assured and no further assurance requested.

Staying Well Service Report Committee assured and no further assurance requested.

Retention of Clinicians Committee assured and no further assurance requested.

Clinical Effectiveness The Committee requested assurance regarding the consequences of SWASFT not following any of the JRCALC guidelines. Dave Partlow gave assurance that although it would be a difficult decision to make, the Trust would continue to work to ensure that it had the best clinical guidelines possible.

Medicines Management Update Committee assured and no further assurance requested.

Clinical Performance Measurement: ACQI/Clinical Audit

Committee assured and no further assurance requested.

Quality and Innovation Report Committee assured and no further assurance requested.

Patient Engagement Committee assured and no further assurance requested.

Compliments, PALS and Complaints

Committee assured and no further assurance requested.

5 Documents for Information 5.1 The following document was presented to the Committee for information:

Quality Committee Risk Register.


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6 Committee Reporting

6.1 The Quality Committee received an update from the Executive Director of Nursing and Governance regarding the new Quality Development Forum which had held its first meeting in March 2016 and had focused on staff attitude and emotional resilience and in future meetings would continue to look at how the Trust responded to staff welfare and support in practice and Trust-wide resilience, recruitment processes and a review of Trauma Risk Management (TRiM).

6.2 The Committee also received an update from the Chair who advised of the

upcoming CQC inspection in June 2016 and who requested that the route of papers, reports and policies before presentation at Board and Committee meetings regarding where they had been reviewed, amended or approved prior to presentation was recorded on front sheets. The purpose of each paper also needed to be explicitly stated on front sheets.

7 Issues Referred to the Board of Directors 7.1 Issues referred to the Board by the Committee were: Board and Committee paper

front sheets, the draft Quality Account and Report and the draft Serious Incident Policy (this policy was also to be referred to the Joint Negotiating and Consultative Committee).

8 Recommendation 8.1 The Board of Directors is asked to note the report of the Quality Committee for

assurance. Emma Murgatroyd Executive Assistant to the Executive Director of Nursing and Governance

Quality and Governance Committee Meeting Thursday 14 April 2016

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Minutes Quality Committee Meeting Thursday 14 April 2016 – 14:00 to 16:00 hours Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Exeter, Devon, EX2 7HY Chairman Venessa James, Non- Executive Director Administration & Minutes Emma Murgatroyd, EA to Executive Director of Nursing and Governance Members: Mr T Fox TF Non- Executive Director Mrs V James VJ Non- Executive Director Mr I Reynolds IR Non- Executive Director Dr A Smith AS Executive Medical Director Professor M Watkins MW Non- Executive Director Mr K Wenman KW Chief Executive Mrs J Winslade JW Executive Director of Nursing & Governance Mrs E Wood EW Executive Director of Human Resources & Organisational Development Non Members: Mrs N Casey NC Head of Governance Mr C Chambers CC Head of EPRR Miss J Fowles JF Staff Side Branch Secretary Mr D Partlow DP Clinical Development Manager, East Division Mrs H Strawbridge OBE HS Chairman Mrs S Thompson ST Head of Safeguarding Mrs V Williams VW Head of Patient Safety and Risk Guests: Darryl Fitzgerald DF Commissioning Support Unit Circulation: All of above



1.1

VJ welcomed all to the Quality Committee. DP confirmed that he was attending on behalf of Dr Andy Smith (Executive Medical Director) and


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1.2

Adrian South (Deputy Clinical Director). CC confirmed that he was attending on behalf of Neil Le Chevalier (Director of Delivery). No formal apologies were received.


2.1 There were no declarations of interest made.


3.1 3.2 3.3

VJ advised that SWASFT was looking ahead to the upcoming CQC visit in June 2016 and this had shaped the Committee’s agenda. She explained that the team had worked very hard to update and produce new policies and strategies in readiness of the Quality Committee. She noted that some of the papers had been sent out quite late and that she wondered whether the Committee’s members had had a full opportunity to fully apprise themselves of these policies and reports. She asked that presenters of the policies informed the Committee of whether the policy being presented was a new or amended policy and to which groups or meetings it had been presented to prior to the Committee. HS raised a concern that a rule had been put in place a few years ago to ensure that when amended policies were designated to a Committee, only the updates or amendments would be presented and not the policy in its entirety. VJ noted that it was also not always made clear on the covering sheets which policies were new and which were updates. MW added that policies should be scrutinised internally in other groups and meetings before being presented at Committees – JW advised that this would be appropriate for some policies but it would be appropriate for some to be presented straight to the Committee. MW advised that it was important that the route policies took to prior to being presented at the Committee be recorded on the front sheet and recorded in the minutes. VJ advised that the front pages needed to be consistent across all policies being presented to Committees and that the cover sheet should be standardised.

4.0 Minutes of Previous Meeting

4.1 4.2

The minutes of the previous meeting were approved as a correct record. JW explained that an issue that had been raised following the HSE visit regarding how assurance was minuted in Committees. Reports identifying concerns and risks were taken at the Quality Committee and


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it needed to be minuted that the members took assurance from the actions and response to these concerns and risks and not from the concerns and risks themselves.

5.0 Report from the Executive Director of Nursing and Governance

5.1 5.2 5.3 5.4 5.5 5.6

JW advised that the Quality Development Forum had been revamped (as it was previously the Learning from Experience Forum) which was now a group which would review raised issues and concerns regarding management or staff. The group had met in March 2016 and had focused on looking at staff attitude and emotional resilience. ST added that there were concerns regarding the welfare of staff in the call taking hubs and issues and with new staff in particular. The Forum would be looking at how the Trust responded to welfare and support in practice, for example, if staff felt they had difficulties communicating their concerns. JW advised that in future meetings the group would also be looking at resilience Trust wide, recruitment processes and would be undertaking a review of TRIM. JW advised that the emotional resilience of staff was difficult presently, particularly in the Hubs and on the frontline with performance and demand having a significant impact. Stress was an increasing trend and ways in which this could be addressed would be looked at. An important piece of work to be undertaken was the review of TRIM. EW confirmed that she was working with ST and her team in order to ascertain how they could create a single understanding. There were also concerns raised that staff P-files may say one thing and complaint data another. Cross pollination would therefore be looked at in order to support staff better in this regard. JW confirmed that actions taken at the Quality Development Forum included VW formulating a way to support staff who have trouble communication. Human factors were to be the focus of the next Forum, with lots of work ongoing. ACTION – JW to provide a written report in future. DP advised that the training team would also be picking up working with universities in the Trust area to look at whether any changes could be made to the way that paramedic education was delivered so that student paramedics were more prepared for working on the frontline as students were now joining the Trust younger and less experienced. EW noted that a lecturer at the University of the West of England (UWE)

JW


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had recently published her PHD which looked at the emotional resilience of staff specifically in SWASFT which she was happy to share with the group.


6.1.1 The Action Point Register was reviewed and updated.

7.0 Quality Strategy

7.1

JW confirmed that the Quality Strategy would be presented to the next Quality Committee on 14 June 2016.

8.0 Quality Report and Account

8.1 8.2 8.3 8.4

NC presented the Quality Report and Account to the Committee. NC explained that the account was currently out for thirty days of consultation with the stakeholders, after which verbatim assurance statements for inclusion in the final report would be gathered from the Clinical Commissioning Groups (CCGs), Healthwatch and the Local Health Overview and Scrutiny Committees. The quality priorities for last year (2015/16) would be audited for completion and the report also included a set of priorities for the coming year. VJ queried what the process was for finalising the Quality Account and Report and what the sign off of formal approval process was. NC confirmed that it needed to be sent both to the Audit and Assurance Committee and the Board of Directors on 19 May 2016. Following this, the report would be finalised and the auditors would complete their review of the document and their report. VJ noted that they would usually expect to see the finalised report in July’s Quality Committee but that as this would be after the CQC inspection scheduled for June, the Committee members needed an alternative way of providing feedback. NC confirmed that she would issue a further version of the report before it was presented to the Board on 19 May 2016. HS requested that report also be circulated to all Board members to be discussed at the Board Seminar on Thursday 28 April 2016. ACTION – NC to circulate the Quality Account and Report to the Board members in readiness for the Board Seminar on 28 April 2016 and also to circulate the finalised version to the Quality Committee members prior to presentation at the Board of Directors on 19 May 2016.

NC


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8.5 8.6

HS requested that the Quality Account and Report be added to the agenda for discussion at the next Council of Governors (COG) meeting on Thursday 21 April 2016 as they would need some information in advance in order to decide which priority areas they would like to be audited and it was not yet on the agenda. NC confirmed that draft priorities had been chosen for last year (2015/16) but that COG did still need to choose their priorities for this year (2016/17). The Quality Account and Report was on the Council of Governors Public Meeting agenda for Thursday 21 April 2016 under item fifteen.

9.0 Health, Safety and Security Report

9.1 9.2 9.3 9.4 9.5

NC presented the Health, Safety and Security Report to the Quality Committee. NC advised that there were a few errors within the paper – on page two, it was noted that a meeting with the Health and Safety Executive (HSE) was to be arranged but this meeting had already taken place. The Trust had received a HSE inspection on the same week as the CQC 111 inspection due to reports of potential exposure to asbestos. A plan had since been developed but no improvements made and therefore some recommendations had been made. She advised that TF was the lead Non-Executive Director (NED) for Health and Safety within the Trust. HS added that the HSE was much more active now, with on the spot fines being made, looking at accidents and whether they were caused by unsafe conditions and whether they were unsafe because there was no safe system of work in place or people were not following the safe system of working (i.e. design or human factors) and whether staff had they been trained etc. They were strict on where it had been recognised that there was no safe system of work and organisations were not monitoring this or effectively mitigating any risk. She advised that it would be beneficial for the Health and Safety team to start reviewing and categorising what risks were procedural and which were environmental. ACTION – NC to task Anne Payne and the Health and Safety team to start reviewing whether Health and Safety risks were procedural or environmental and then provide a report back to the Quality Committee. MW noted her concern that the asbestos at Bournemouth Ambulance Station had been reported and that no action had been taken by the Estates Team or by the Committee to ensure that remedial actions were

NC


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9.6 9.7 9.8 9.9

completed. She advised that the Committee needed to monitor the presented reports and ensure that actions were being undertaken. JW advised that it was clear from her and KW’s meeting with the HSE last Friday afternoon that the Trust had moved into a reactive space and that they needed to be more proactive, doing rather than advising. She explained that actions should be taken at an operational level with advice and support from the Health and Safety team. A shift was also needed in the way that the Board, the Estates team and the Health and Safety team operated around Health and Safety issues and that they needed to listen to grassroots concerns. Moving forward there needed to be agreement on how this was focused on at Board level with specific training for the Board of Directors being required and how Health and Safety representatives could be supported in the workplace. There were a range of actions which needed to be taken forward and a plan was required to be presented at the May 2016 Board of Directors. VJ confirmed that there needed to be more focus on what actions needed to be taken and on making reporting more visible as well as strengthening the Board’s role in terms of leading the Health and Safety agenda. JW advised that a meeting had been set up between Staff Side, Estates, Health and Safety and the Governance Directorate to begin scoping work following the HSE visit and to build a Health and Safety plan. VJ queried whether the plan would be reviewed at the Quality Committee - JW confirmed that the Board would have ownership of the plan but that it would be presented to the Quality Committee for information. HS advised that Health and Safety training for Board members needed to be added into the action plan. KW commented that it had been an interesting meeting with the HSE and that if they had not attended the Trust would have been fined. He confirmed that there was a lot of work to do and reiterated the need to be proactive and not reactive. There was a Trust responsibility for Health and Safety as well as a Staff Side responsibility – this was to be raised at next week’s JNCC for consideration of Staff Side Health and Safety representatives to have facilities time to allow them to carry out Health and Safety based work. HS noted that the Estates Team did not hold sole responsibility for not resolving the asbestos issue but that the management and Director teams also had not acted upon the recommendation or ensured that the actions were picked up. She queried whether there was anything else which had been identified for remedial action which had not yet been dealt with. KW advised that there was a list of locations within the Trust


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9.10 9.11 9.12

where asbestos was and that contractors going into stations to do work where supposed to be mindful and were required to ask about potential risks such as asbestos and they had not been and had gone ahead and done work without supervision. He noted that the Estates team had issues with capacity but were doing as much to monitor as possible. He noted that he could not remember the last time the Quality Committee had reviewed the Health and Safety Strategy or Action Plan – MW confirmed that it had not been presented at the Committee. HS advised that she felt that if building work was going to be undertaken, the contractor needed to be notified of any Health and Safety issues prior to work commencing in order to be proactive. JW advised that the Trust needed to be picking issues up early and should respond after the first incident and not allow multiple incidents. She commented that people needed to take responsibility at a site level for identifying and coordinating the rectification of issues but not for resolving the issues themselves. JW raised that there was a discrepancy between the Staff Survey data and the reporting of physical assaults and whether the Committee could be assured that staff were always able to identify when they had been assaulted. A Deep Dive into the data and the reasons why this might be the case was required. VJ noted how close the station Workplace Inspection target was to being hit, being only four stations below the end of year target.

10.0 Patient Safety

10.1 10.2 10.3

VW presented the Patient Safety report and confirmed that it was a regular report for the Quality Committee. Dr Andy Smith (AS) entered the Committee. VW referred to paragraph 2.1.3 regarding the number of Serious Incidents relating to spinal care and guidelines not being followed – currently five, three of which were the subject of inquests. One inquest had been held the day before (13 April 2016) with no recommendations being made. DP advised that the configuration of the EPCR had been changed to try and alter staff thinking and to raise the profile of spinal care. VW added that the incidents were occurring more in the North Division than in the rest of the Trust and advised that all of these Serious Incidents had been assigned to the same investigator.


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10.4 10.5 10.6 10.7 10.8 10.9

VW noted the issues regarding confirmation bias detailed within paragraph 2.1.4 and that they would be publishing an article regarding this in the Trust’s Reflect bulletin to bring attention to this bias. VW advised that other issues identified within the report included 111 clinical staffing levels (the risk of which was included in the 111 Clinical Development Plan) and a dip in compliance in call taking audits in Cornwall. KW stated that he did not feel that there was enough detail included in paragraph 2.1.5 regarding clinical staffing levels in 111 Hubs and that actual numbers were needed along with statements as to whether adverse incidents were investigated and the result of these investigations etc. VJ referred to the risks associated with 111 and queried whether there was concern that new risks would materialise or existing risks would increase during the period before the contracts were handed over. As there was risk of adverse media coverage, any risks could be quite seriously affected and it would therefore be best practice to provide a more detailed and more robust account to support the organisation in view of the magnitude of the risks. KW noted that a point of criticism included in the CQC feedback had been around quality assurance and they therefore needed to be much tighter on this in the future. HS added that the NEDs needed to ask questions for assurance going forward. JW noted that paragraph 2.1.5 was an executive summary and more detail had been included in section 4.5 although she agreed this was still not pointed enough regarding the issues. KW advised that there was enough assurance around 111 clinical staffing levels due to the 111 Action Plan and many accompanying documents. JW confirmed that the Serious Incident team had reviewed every adverse incident raised about 111 clinician cover over the last six months and they had all been found to be low risk and negligible. They had then been re-reviewed and fed into the plan which had been reviewed by herself and KW. MW noted that the Committee could take assurance in the response from KW and JW. VW advised that the Clinical Development team had been assisting the Serious Incident team in reviewing incidents as there were ongoing capacity issues within the team. These were being addressed and she was sourcing additional support. KW advised that the Committee needed to have some to context of performance relating to incidents in comparison of other Ambulance Services. JW confirmed that AACE had just been commissioned by


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10.10 10.11 10.12 10.13 10.14

QGARD to develop the Proclust system which would allow comparisons between ambulance services. She confirmed that she would ascertain the timescales in regard of accessing this data. Action – JW to ascertain the timescales in regard of accessing the Proclust data to allow comparisons of incident performance across Ambulance Trusts. HS advised that the last Board of Directors meeting had received significant assurance in terms of the 111 CQC response which tallied with a lot of the contents of the Patient Safety paper and would have provided assurance. She noted that it would have been useful to reference the Committee members to the papers which went to the Board to provide key parts of assurance. VW advised that Serious Incident activity up to end of February 2016 had decreased compared to the same period last year with 35 Serious Incidents being confirmed. 37 moderate harm incidents were confirmed during the reporting period which was also a decrease with 111 showing the greatest decrease. A 63% decrease had also been seen in reporting of 111 from other health organisations. VW confirmed that actions moving forward included the ongoing internal audit review for which various documents were being requested. The outcome of this would inform further actions. She added that the Quality Account was concentrating on human factors as a priority for the next year. MW sought clarification on section 4.2.3 and the four Duty of Candour cases which did not require contact as they were not patient safety related incidents and why they had therefore been included in the data. VW advised that these cases were related to IT and Estates but were still Serious Incidents so did require inclusion in the data.

11.0 HR and Organisational Development Directorate Report

11.1 11.2

EW presented the HR and Organisational Development Directorate Report to the Quality Committee and confirmed that it was a highlight report. EW referred to the key issues and risks, one of which was staff retention in the west Hub due to the withdrawal of the Devon 111 contract. Her team was already engaging with staff to ask them about their career plans etc. She had also identified vacancies within the A&E


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establishment as forty by the end of the current month (April 2016) due to a number of non-starters and a redesign in reporting in air operations staff into non-frontline reports where they were previously included in the A&E frontline reporting. MW queried the length of the risk of staff retention as the date of the contract end got closer – JW confirmed that it would be until the contract ended on 01 October 2016. MW sought assurance that the 111 service was currently retaining enough staff to deliver a safe service and EW confirmed that this was the case. JW added that although it was a risk, people were still applying. MW sought assurance that no areas in the Trust patch were dangerously short of staff and EW confirmed that this was correct with the vacancy rate still being under 5%. KW advised that a review of all operational staff working practices was taking place including staff flexible working arrangements. EW added that they would also be looking at each of the thirty secondments from off the frontline to ensure that these secondments were still appropriate and necessary. EW highlighted the Student Paramedic Conference which had taken place on 27 February 2016 which had been well attended and which 100% of the delegates who had completed a feedback questionnaire had rated as good or excellent. HS agreed that it had been a fantastic event to be at and the team behind its organisation should be congratulated. EW confirmed she would pass this feedback on. EW referred to the Talent and Clinical Career Strategy and confirmed that the programme was on track and that another two programmes had been launched including the third cohort of the ECA to Paramedic Conversion Programme which would see another sixty staff members convert to paramedic status in the next two years. EW advised that significant funding had been awarded by Health Education England to enhance further learning and development opportunities. The new North Division College located on the University of the West of England’s (UWE) Glenside Campus had been open as of 01 April 2016 and that she wanted to hold a Board meeting up there. £160,000 of funding had also been awarded by Gloucestershire Clinical Commissioning Group (CCG) to develop Gloucestershire based paramedics plus some funding for golden hellos in that region. EW explained that the appraisal completion rate was currently at 49.44% against a Trust target of 85%. Non-operational staff appraisal completion


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was a priority and the Board expected 100% compliance from this staff group. EW referred to Statutory, Mandatory and Essential (SME) training and confirmed that the Trust had achieved a SME completion rate of 87.3% and an 84.5% completion rate for Learning and Development Reviews (LDRs) by year end. LDR and SME together gave a completion rate of 97.1% with only 2% of staff receiving neither LDR nor SME training. She confirmed the mandatory workbook completion rate was at 64% with an expectation that 82.3% of A&E staff would complete the book in the current three year cycle. EW advised that the paramedic campaign was relaunching and that the Trust had made 116 conditional offers for the summer, of which 94 had been accepted. 34 people had come in from outside of the Trust’s university partnership – DP queried whether it was possible to triangulate the data to ascertain whether any of these 34 had attended the Student Paramedic Conference. EW confirmed that they could and added that many of the attendees had been year one or two students. They would therefore need to run the conference for three years before an accurate assessment of return on investment could be completed. The conference had also highlighted universities outside of the Trust’s region who had not been anticipated for example, paramedics moving down from London. TF queried where new paramedic starters went to within the Trust and EW confirmed that they were told where they were going but that the North Division had been incentivised with a £6000 golden hello. She added that the Trust would continue to over-establish in the West and East Division so that no one who applied was turned away. MW offered her congratulations to EW and her Directorate for getting to grips with recruitment and for all of the work that had been undertaken. VJ agreed and noted the large range of initiatives that had been introduced which were hugely beneficial. AS left the meeting.

12.0 Infection Prevention and Control Quality Report

12.1 12.2

DP presented the Infection Prevention and Control Quality Report to the Quality Committee. DP advised that due to a realignment of Infection Prevention and Control meeting reporting from bimonthly to quarterly, the report overlapped with


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the previous Quality Committee report. DP advised that the number of incidents during the reporting period remained very low when viewed against activity. The previous year (2015/16) had seen a number of incidents relating to the use of razors, this was largely due unilateral manufacturers’ decision to make a change to the safety cap of razors and the trust not being made aware of the change. There had been a significant drop in incidents during the current year, as the razor was changed as soon as we became aware of the issue. There had been a slight increase in incidents involving sharps bins which has been resolved with the introduction of new sharps bins. DP referred to the missing of the performance target for Deep Cleaning of vehicles which had been mostly due to Make Ready Operatives being required to move vehicles to maximise operations and therefore could not undertake the Deep Cleans. Registration numbers of missed vehicles were being recorded and prioritised to catch up. VJ advised that Adrian South (Deputy Clinical Director) had raised the issue at the last Quality Committee and DP confirmed that they were now linking with the Delivery Directorate to ensure that the issue was raised but that vehicles were still ready for operational use. He confirmed that vehicles were taken off the road if needed to undertake emergency Deep Cleans. DP advised that the Medical Directorate had carried out additional visits and audits of every station and had been able to identify and rectify issues, these were mostly minor issues for example, missing hand washing posters. The audits had been such a success that they were now planning to repeat them every year. He added that in future they could link in with the Health and Safety team who could carry out Health and Safety inspections at the same time. KW noted that the Trust had received some criticism from the Health and Safety Executive regarding some of the minor issues picked up in Health and Safety audits when there were major issues which needed to be corrected. He suggested a review of the audit profile. ACTION – DP to link in with the Health and Safety team regarding next year’s Clinical team station audits. DP confirmed that the audits also helped the trust to capture some areas of really good practice that had not been aware of and to now start replicating across the trust. DP referred to clinical waste and confirmed that the contract change last year had been very successful and the Trust was now receiving a much

DP


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better, more cost effective service. DP advised that hand hygiene inspections had also been conducted to ensure that the bare below the elbows initiative was being enforced. Some staff struggle to engage and continue to wear wristwatches but the message was fundamentally getting across. DP confirmed that the influenza vaccination overall completion percentage for the year was 42% which was disappointing and they needed to work out why the figures were down on previous years. Staff could have been receiving vaccinations elsewhere which were not being recorded and included in the data. A deep dive on why vaccinations were being refused was planned. DP noted that the station cleaning tender had had to be paused but that after the tender responses were due to be resent next week they were due to be back on track and were to appoint (a) cleaner/s in August or September 2016. VJ commented that the Infection Prevention and Control report was a very good report and thanked DP and the clinical team for it.

13.0 Safeguarding Service Report

13.1 13.2 13.3

ST presented the Safeguarding Service Report to the Quality Committee. ST explained that they continued to receive a lot of referrals, including referrals from external agencies. A full analysis position was presented to the Directors Group which had identified that the team was at capacity when the referral rate was at 650 per month. The referral rate for February 2016 was 1079. The Board was aware of the position but no further capacity could be realised until the audit was completed by South West Audit. ST advised that in order to provide assurance, a standardised audit was devised and 40 anomalised cases (20 adult, 20 children) had been reviewed. Even though they needed to be pragmatic, they had found that every single case had met a threshold for something for example, child protection section 47, section 17 welfare support etc. The review took place in three stages and included outside agencies to ensure there was no bias. It also ensured that each of the team was consistent and also meant that lessons learned could be included in newsletters for training. VJ asked ST to confirm that out of all of the reviewed cases,


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they had not been able to filter out any that could not be addressed. ST confirmed that this was the case. Social Services and the CCG Adult Lead had also provided comments. ST advised that the national picture was interesting and that she was the chair of the national safeguarding group and had been able to review the referral processes in other Ambulance Trusts, how many referrals they were receiving and where they were being sent to. Most had teams of twenty to thirty Hub staff (as opposed to dedicated Safeguarding staff) who would also manage falls and diabetic referrals etc. VJ noted that the report was very comprehensive and thorough. JW advised that ST had completed a formal risk assessment of Safeguarding’s internal processes which would be presented at the next Quality Committee in July 2016. MW noted that the Trust looked very understaffed but not compared to Wales – she queried whether the Welsh Ambulance Service was doing something very clever which the Trust could replicate, for example, a direct link to Social Services. ST confirmed that she would look into this. ST confirmed that the campaign to generate more referrals had generated many more referrals, with another increase expected after December 2016. DP added that the new EPCR also made it easier for staff to make Safeguarding referrals and that the go live for EPCR in the North could cause another increase. KW confirmed that SWASFT was not contracted to provide a referral service and that they had established a service in which the team did not just receive the referral and forward them on but also gathered data and analysed the referrals in order to forward on those that were appropriate. ST advised that as soon as the team stopped doing the information gathering and analysing, they received a lot of activity in terms of having to resend referrals but of a higher quality. JW reiterated that the risk assessment would be presented at the Quality Committee in July 2016 but that how the service should be taken forward would be discussed at the Director Group. The Quality Committee took assurance from the Safeguarding Service Report.


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14.0 Staying Well Service Report

14.1 14.2 14.3 14.4 14.5 14.6 14.7

ST presented the Staying Well Service Report to the Quality Committee. ST advised that 111 and HART were hot spots for staff welfare with the North Hub emerging as a new hotspot. Drop in sessions had been increased to fortnightly for HART rather than monthly. She confirmed that she was working with EW and her team on TRiM. They were working on a three year TRiM training strategy and explained that a lot of people had been trained but were not using their training. They were going to work on aligning the amount of trained TRiM practitioners to the amount of trauma risk that actually occurred which was going to be a big piece of work. ST advised that the Service Standard Operating Procedure (SOP) had been completed which explained what the process was when someone made a referral into Safeguarding. ST advised that the first welfare newsletter had been distributed which they had received really good feedback from staff on. ST explained that there had been no surprises in the outcome of the Theme Analysis. 246 referrals had been received between December 2015 and 30 March 2016 –60% had come from the A&E service line with a reasonable spread between the divisions. She confirmed that she was distributing data to the heads of services to give them information about what was occurring in their areas. ST noted an increase in the support services accessing the Staying Well Service that month – KW noted that the Committee required an indication of the percentage of workforce numbers. MW queried whether station level data could be obtained in order to monitor the percentage of staff accessing the service on each station – ST confirmed that she would be able to complete this. HS noted that she had had a good experience at the last Association of Ambulance Chief Executives (AACE) meeting as SWASFT was quite a few steps ahead of other Trusts in the work that they had completed in relation to staff welfare and that she was very pleased to see staff being put at a high priority. KW added that staff welfare continued to be an uphill battle as people would still reference incidents which had occurred many years ago when SWASFT was a different service in terms of staying well. The Quality Committee took assurance from the Staying Well Service Report.


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15.0 Bruising Protocol

15.1 15.2 15.3 15.4

ST presented the Bruising Protocol to the Committee. ST advised that bruising was most common presenting feature in serious case reviews for physical abuse in children and that moderate bruising was not always being adequately picked up in children who were not independently mobile. The Bruising Protocol had therefore been written in order to inform and support staff to identify, manage and refer these cases on appropriately. ST added that the designated Safeguarding Doctor for Somerset had visited her the day before the Quality Committee (13 April 2016) and that she had been able to show this protocol in action. The Quality Committee moved to approve the Bruising Protocol.

16.0 Retention of Clinicians

16.1 16.2 16.3

EW presented the Retention of Clinicians paper to the Quality Committee and advised that it had been written due to a request by MW in a previous Committee. EW explained that the report included information on retention among clinical staff (i.e. nurses, paramedics and GPs) clinicians and had dissected the data further. She confirmed that overall Trust turnover for last year (2015/16) was 14.20% which was a rise of just under 1% from the year before (2014/15 at 13.58%). Overall the Trust had seen a reduction in clinician turnover which had reduced to 9.94% - of these 9.94%, 30% had either retired of been dismissed due to capability or ill health. 52% of these leavers had reported that they were joining other healthcare providers. Clinician retention was good within the Trust and rates were well within the NHS benchmark. EW explained that a lot of work had been undertaken around reducing clinician turnover, including developing career options and opportunities, launching the Staying Well Service and introducing contractual retention clauses which tied staff into remaining with the Trust for three to five years if they took advantage of Trust funded training. There were currently approximately 200 clinical staff with this type of clause written into their contract which would continue to give improvements to retention rates. She noted that results of the Staff Survey which had shown that staff were reporting an improvement in engagement and job satisfaction, improvement in recommending SWASFT as a place to work and an improvement in staff being happy with the standard of care


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provided by the organisation. She added that her team produced a lot of reports on A&E establishment which was reported to the Executive Director Group on a monthly basis as well as occasionally to the Quality Committee and Board of Directors. EW advised that they were also launching a new improved exit process to understand why people were leaving. The new process involved the leaver having a face to face discussion with their line manager which would be followed by a questionnaire which could be completed either online or over the telephone. They would also be offered a meeting with their local HR Business Partner in confidence. A new staff resignation form was also to be introduced which would be submitted directly to HR to give opportunities for proactive conversations and to start to capturing information more quickly and preferably before leaving. EW advised that a 111 Clinician Retention Group had been set up which she led. This was a working group to review why people left and how they could potentially be recalled back, how to motivate and support staff to stay as well as clinical development and career paths. EW explained that as well as a Trauma Risk Management (TRiM) revision and the introduction of the Staying Well Service, funding had also been obtained from NHS England for a ‘How Are You’ survey which had recently taken place and which they were awaiting the results of. The information gained from the survey would be used to understand wellbeing within 111, to explore the differences between 111 and 999 Hubs and would inform future practices within 111. VJ noted the comprehensiveness of the report and thanked EW and her team for it. IR noted that a huge blip would be seen in the leavers data once the Devon 111 contract ceased and queried why these staff members would be included as turnover when they were leaving due to a loss of contract. EW explained that turnover recorded all leavers regardless of the reason for leaving. IR advised that he felt this would obscure the data relating to what the Trust wanted to utilise. EW confirmed that it could but that the required data could be extrapolated. HS commented that it would be helpful to introduce pie charts and graphics to the report to clearly show proportions and total numbers. She advised that she found the table under 3.2 very informative but that it would be beneficial to understand the figures in terms of real terms and percentages of staff – for example, a higher percentage of turnover


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in one area could be misleading as the actual numbers of staff could be very small. She therefore felt as though the Committee could not take full assurance from the report. EW confirmed that she would take this forward for future reports. DP added that the Clinical Team had recently undertaken some work regarding medicines management after a suggestion that it was potentially newer staff making the errors. Dave Boyle (Clinical Development Officer, East Division) had matched the data against length of service and had found that (along with length of service having nothing to do with medicines errors) there was a significant drop off after fifteen years of staff leaving. Approximately 33% of staff currently serving in 999 had been in the trust less than three years and approximately 83% less than 15years. He noted that it would be interesting to ascertain whether this rise in leavers after fifteen years of service was a long standing historical issue or whether it was a more recent occurrence and whether it could allow the Trust to plot leavers moving forward, so that an analysis of length of service could be undertaken each year to evaluate the likely number of leavers based on the percentages provided remaining stable. This would allow us to predict leavers and therefore staff requirement. The Quality Committee took assurance from the Retention of Clinicians Report.

17.0 Serious and Moderate Harm Incident Policy

17.1 17.2

NC presented the Serious Incident Policy to the Committee for approval subject to any comments from the Committee members. HS queried whether the non-clinical Quality Committee was an appropriate forum for this policy, JW confirmed that it was. HS explained that the Committee members needed information of the route they the policy had taken through so that they had assurance of the approving policy the document had been through – for example, for this policy, to have it recorded that any clinical content had already been discussed at the Clinical Effectiveness Group would be greatly beneficial to the Committee members. NC confirmed that the policy had not been radically altered. KW commented that frontline staff could not be expected to read 49 pages of policy and stated that a set of guidance for staff should sit alongside the policy. NC confirmed that guidance would be written once the policy was approved and added that a Serious Incident Policy was a requirement. KW queried whether there was any guidance or easily


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accessible information on the Intranet as frontline staff needed to have access to a simple interpretation of the Serious Incident and Moderate Harm Policy. VW added that there was also a leaflet which would be updated in line with the new policy and disseminated to staff and that a new Patient Safety intranet page was currently being developed. ACTION – VW to ensure that guidance suitable for frontline staff on the Serious Incident Policy is written and that the leaflets are updated and both disseminated to staff, JNCC members and Board members. HS requested that a summary version of the policy, guidance and leaflet be circulated at the Joint Negotiating and Consultative Committee (JNCC) and to all Board members, asking them to submit any comments before being taken to the next Board Seminar on Thursday 28 April 2016. VW advised that there was a three week window for further comments. MW queried whether there was a mechanism for tracking changes on the cover sheet when comments were made on the policy. She suggested that the Board members bring their comments to the next Board Seminar with a view to approving the policy within the confidential section of the meeting. In tandem with this, the work on the communications (guidance and leaflet) would be further developed to a slightly longer timescale. The Committee agreed with this. ACTION – VW to circulate a summary version, staff guidance and leaflet to the Joint Negotiating and Consultative Committee (JNCC) and to all Board members to allow members to submit their comments on the policy to the next Board Seminar on Thursday 28 April 2016.

VW VW

18.0 Managing Allegations Policy

18.1 18.2 18.3

ST presented the updated Managing Allegations Policy to the Committee. ST gave a brief explanation of the amendments and updates to the policy and confirmed that the policy had previously been reviewed and approved at the Safeguarding Operation Group. The Quality Committee moved to approve the Managing Allegations Policy.


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19.0 PREVENT Policy

19.1 19.2 19.3 19.4 19.5

ST presented the PREVENT Policy to the Quality Committee. HS noted that an amendment was required under section five – references to the governing body and commissioning staff needed to be amended to the Board. MW expressed concerns that she did not understand who the policy was meant for and what would happen to it post approval. JW confirmed that responsibility for and ownership of the policy sat with her and that it had previously been reviewed at the Safeguarding Operational Group. ST confirmed that having a PREVENT Policy was a legal requirement and that all A&E staff had received PREVENT training. VJ noted that the table under section five made it clear what the responsibilities of all staff were in relation to the Policy. The Quality Committee took assurance that all staff have received PREVENT training. The Quality Committee moved to approve the PREVENT Policy subject to the amendments required in section five.

20.0 Restraint Policy

20.1 20.2 20.3

DP presented the Restraint Policy to the Quality Committee and confirmed that it was a new policy. DP advised that the policy set out the legislation regarding when restraint could be used by an Ambulance Service. There was currently little consensus on restraint amongst the services, with some reporting that they do not restrain when it could be argued that they are restraining on a daily basis... There is concern nationally about the requirement to effectively train such a large workforce and in managing continued competency. HS noted that the issue of restraint had been raised and discussed at length before SWASFT had merged with GWAS particularly in relation to patients who may attempt to leave a moving ambulance. DP advised that a former Health, Safety and Security Manager for SWASFT had previously taken the position that SWASFT did not restrain which has also created a degree of confusion. Some other services prefer to use the term Safe Handling rather than restraint. HS noted that they needed to be aware that although the policy was new, the work within it was not. DP explained that the policy was not fundamentally about how to carry


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out restraint but instead provided guidance regarding the legal framework for staff including that of the Mental Health Act (1983) and Mental Capacity Act (2005). DP added that there were also discussions within NASMED and AACE taking place relating to restraint and how this can be addressed nationally. The Crisis Care Concordat meant that police were less likely to be available to support ambulances services with regards Mental Health and therefore ambulance staff needed to aware of the legal framework around restraint. The police would still continue supporting with violent people, but they consider that health resources are better placed to manage those in crisis. MW stated she felt having a policy in place might encourage the use of restraint. She confirmed that she saw the importance of the policy, particularly where it referred to the Mental Capacity Act and queried whether a legal position could be ascertained before the policy was approved. DP advised that the policy had been written based on relevant mental health legislation but that it had not been passed formally to a solicitor for review. MW recommended that the policy be kept as a draft until a legal opinion had been sought and queried whether it needed to be so detailed. She expressed concern that SWASFT would be an outlier in terms of detail compared to other organisations and advised that the Trust needed to protect itself and its staff. DP explained that other national ambulance services had also sought the advice of solicitors and none of the legal opinions agreed. JW advised that there were concerns that the Trust would be more at risk if there was not a policy. DP confirmed that the Clinical Effectiveness Group and Director Group had previously approved it. MW suggested that the policy be approved as a pilot for six months with legal advice being sought in the meantime. At the end of the six months, it could be reviewed in conjunction with other policies and that because of its nature, it should be reviewed periodically. VJ queried what the timing requirements were with regard to approval of the policy. JW advised that it needed to be approved in the right way and that they needed to do what they believed to be the right thing without unnecessarily prolonging approval. She agreed with the six month pilot with a review to be presented to the Quality Committee in quarter three. The Quality Committee approved the Restraint Policy as a six month pilot policy to be brought back to the quarter three Quality Committee for review in conjunction with the legal advice gained during the trial.


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20.9 ACTION – DP to roll out the policy as a six month trial and to seek legal advice on its content during the pilot.

DP

21.0 Minimal Lifting in Care Homes Policy

21.1 21.2 21.3 21.4 21.5

DP presented the Minimal Lifting in Care Homes Policy to the Quality Committee. DP advised that this was a new policy. He explained that there were issues regarding domiciliary care as well as care homes calling 999 because patients had fallen and as they did not have a lifting policy in place, they were refusing to lift the patients. DP had met with the CQC who supported the policy. IR commented that he was very supportive of the policy and queried whether SWASFT could charge care homes and domiciliary care providers when they called 999 inappropriately for non-injury fallers as this would be the easiest and quickest way to change behaviour. DP advised that there was no legal framework for this to take place and agreed to look into it in more detail. He added that the Trust could also liaise with the CCGs to query this. ACTION – DP to investigate whether the Trust could charge care home and domiciliary care providers when inappropriate 999 calls are made for non-injury fallers and report his findings back to the Quality Committee. The Quality Committee moved to approve the Minimal Lifting in Care Home Policy.

22.0 IM&T Security Policy

22.1 22.2

The Quality Committee noted that the recommendations made within the IM&T Security Policy were very clear and explicit. The Quality Committee moved to approve the IM&T Security Policy.

23.0 Clinical Effectiveness Report

23.1 23.2

DP presented the Clinical Effectiveness Report to the Quality Committee. DP referred to paper 19b explained that new JRCALC guidelines had very recently been produced. The last set published contained a number of statements and processes which SWASFT fundamentally disagreed with including poor clinical practice in some areas. The Medical


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Directorate had therefore created a suite of thirty-four clinical practices to sit alongside the JRCALC guidelines. The same team was currently in the process of reviewing the updates to the guidelines to determine whether there were any issues the Trust disagreed with. The clinical team had been invited to write some of the sections of the new guidelines including those about sepsis and mental health. Once the guidelines had been properly reviewed, an agreement would be reached regarding whether the Trust would follow the new JRCALC guidelines in isolation or whether they would use a blend of JRCALC and SWASFT clinical guidelines as they had previously. He reiterated that SWASFT was very proud of being the best clinical ambulance service in the country. TF queried what would happen if the Trust decided not to follow the new JRCALC guidelines at all. DP explained that discussions would need to take place and that it would be a very difficult decision and unprecedented to go completely against these guidelines but that they did need to ensure that SWASFT continued to have the best guidelines possible. DP referred to paper 19a and advised that a high amount of work was taking place within the Medical Directorate. HS referred to the risks identified in Appendix A and requested that the Quality Committee monitored progress and look in more detail at the Ambulance Quality Indicators (AQIs). The Quality Committee took assurance from the Clinical Effectiveness Report.

25.0 Medicines Management Update

25.1 25.2 25.3

DP explained that there had been issues regarding controlled drugs including ongoing issues with drug licensing which Sue Oakley (Pharmaceutical Advisor) was taking up with the Home Office. DP advised that the Clinical Development station audits had included an audit of medicines management and processes. They had found that medicines were generally managed very well but that there was more work that needed to done with lower Schedule control drugs. Additional safes for the lower Schedule control drugs were being procured. DP advised that the Trust had taken delivery of brand new drug bags which were waiting to be sent out to the East and West Divisions and which the North Division already had. These new bags would bring the


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25.4

East and West Divisions in line with the North and would also enable staff to manage medicines in a much more productive way. The Quality Committee took assurance from the Medicines Management Update.

26.0 Clinical Performance Measurement: ACQI/Clinical Audit

26.1 26.2 26.3 26.4

DP presented the Clinical Performance Measurement paper. DP explained that it was very difficult to benchmark clinical performance against other services and confirmed that the Clinical Performance Measurement paper covered clinical practice for example in relation to strokes and heart attacks and the overall quality of care provided for these conditions. Performance for these patients was affected by the rural nature of the Trust patch and the operational difficulties faced by crews travelling long distances to attend patients and then convey them to hospital in a timely fashion. He explained that the Clinical Development and Research, Audit and Quality Improvement teams were reviewing the use of EPCR to ascertain whether it had the potential to assist with improving Ambulance Quality Indicators (AQIs). He explained that Sarah Black (Research and Audit Manager) had concerns that use of the EPCR to prompt clinicians might artificially inflate performance rather than changing clinician behaviour which would be the desired outcome. Further discussions were required to ascertain whether utilising EPCR would change behaviour as the Trust wanted to provide the highest quality clinical care and not create data which may provide artificial assurance. HS commented that she felt there should be more detail in the report in order to instigate more conversation. JW confirmed that she would liaise with Adrian South (Deputy Clinical Director) regarding this. DP confirmed that a lot of work was being undertaken by the Medical Directorate which had not been captured or reported and was therefore not generating discussion. The Quality Committee took assurance from the Clinical Performance Measurement: ACQI/Clinical Audit report.

27.0 Quality and Innovation Report

27.1 27.2

DP presented the Quality and Innovation Report. DP advised that the Right Care initiative continued to be a huge success


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and that SWASFT was by far the highest non-conveying ambulance service in the county. A very good network of Right Care champions was now in place across the Trust patch and some very successful events had taken place which other organisations and professionals had been invited to attend – this had allowed open and honest conversations. DP explained that the level of non-conveyance was plateauing and that this was expected. Particular growths had been seen in the North Division. Cornwall and Dorset had been high and were now plateauing and that it was becoming difficult to see what more could be done by the Trust without alternative care pathways being opened up. This was in part difficult due to the way in which hospitals were funded i.e. by footfall through Emergency Departments and Acute Trusts were therefore reluctant to open alternative pathways into their care. MW noted that Right Care continued to be an excellent piece of work and that the CQUIN money was a real benefit for SWASFT and better for patients. The Quality Committee took assurance from the Quality and Innovation Report.

28.0 Enhanced Skills Policy

28.1 28.2 28.3 28.4

DP confirmed that the Enhanced Skills Policy which he was presenting was a revised policy which provided a framework to encourage staff to add skills to their paramedic training. Paramedics wanted to undertake learning new skills and the policy ensured that the processes were in place to support staff and to ensure that any enhanced or additional skills were assessed and staff were deemed competent with assurance processes in place. DP confirmed that the policy had previously been reviewed and approved the Clinical Effectiveness Group meeting. The Quality Committee moved to approve the Enhanced Skills Policy.

28.0 Clinical Photography Policy

28.1 28.2

DP presented the Clinical Photography Policy to the Quality Committee. DP confirmed that this was a new policy with guidance previously existing in the form of an Operational Instruction which had sat within the Delivery Directorate and had been largely aimed at Air Ambulances’ use


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28.3 28.4 28.5 28.6 28.7

of cameras. DP explained that the new Electronic Patient Care Records (EPCRs) had given the Trust a great opportunity to take secure photographs. In order to take a photograph using the EPCR device, a clinical record had to be open which ensured a legitimate clinical relationship. The photograph would attach itself to the open clinical record and would then embed itself within it. Nothing else could be done with the photograph and it could only be accessed through a clinical workstation. It could not be downloaded via a USB stick or cable etc. and it was also encrypted. He explained that this functionality was particularly useful for safeguarding cases and road traffic collisions. It was also useful for other interagency working, for example District Nurses. DP confirmed that this policy had previously been reviewed and approved at the Clinical Effectiveness Group. IR referred to paragraph 4.5 and patient lack of capacity to consent and queried whether the paragraph could be reworded in order to be clearer regarding best interest. DP confirmed that he would look at the wording and confirmed that best interest guidance was very specific under the Safeguarding Policy. HS queried what guidance should be followed in the areas where EPCRs were not yet in place. DP confirmed that where EPCR was not live, staff were not permitted to take photographs. He also referred to section eight of the policy which referred to the Hazardous Area Response Team (HART) and Critical Care Operations which operated under separate guidelines and protocols. The Quality Committee moved to approve the Clinical Photogrpahy Policy subject to the amendments to be made to paragraph 4.5.

29.0 Dementia Strategy

29.1 29.2

DP presented the Dementia Strategy to the Quality Committee. DP confirmed that the Dementia Strategy was a new document and that dementia was becoming a priority nationally. The strategy documented how the Trust could work better at managing patients with dementia, the Trust’s aims and objectives etc. He noted that there was also other work being undertaken which had not been added to the strategy, for example work on analgesia for dementia patients and therefore the strategy was not limiting what they were doing but did set out clear objectives.


Page 27 of 29

29.3 29.4 29.5 29.6

VJ commented that she welcomed the strategy and its aims and noted that there was quite a reliance on raising staff awareness through a programme of training and promotional mechanisms. She noted that it also relied on ensuring that environments were dementia friendly but that she did not see a focus on the resourcing of the strategy. DP confirmed that he would add resourcing to the strategy. HS noted that during a number of station visits she had taken part in recently, staff had commented that they were really appreciative of dementia training. She queried whether they was any scope for working with care homes and particularly EMI care homes in order to share learning. DP confirmed that he was linked in with the Dorset and Somerset Care Provider Association already and could begin to share learning with them. MW noted that it could be beneficial to cross the Dementia Strategy with the Learning Disability Strategy. The Quality Committee moved to approve the Dementia Strategy subject to the addition of resourcing of the strategy.

30.0 Clinical Supervision Policy

30.1

The Quality Committee agreed to postpone the Clinical Supervision Policy to the next Quality Committee on Thursday 14 June 2016.

31.0 Patient Engagement

31.1 31.2 31.3

NC presented the Patient Engagement report to the Quality Committee. NC explained that Patient Engagement had moved to a combined team and that Sara Coburn (Patient Engagement Manager) was continuing to experience success with the South West Ambulance Group (SWAG) and were working very closely with the Trust. KW had been invited to one of their meetings with HS also having been invited and planning to attend. NC advised that Healthwatch Engagement Day had been really successful and very positive. NC advised that it was difficult to record communication difficulties easily with regard to the Accessible Information Standard and explained that an education campaign would be developed in order to inform patients of their need to inform SWASFT of any communication difficulties before


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31.4

a crew attended. The Quality Committee took assurance from the Patient Engagement report.

33.0 Compliments, PALS and Complaints

33.1 33.2 33.3 33.4 33.5

VW presented the Compliments, PALS and Complaints report to the Quality Committee. VW advised that the Trust had seen a 13% increase in compliments, an 18% increase in complaints and a 19% increase in PALS enquiries which was consistent with the rest of year. Complaints were mainly about communication, demand and response times and these trends were reflected in Serious Incidents also. She noted that the methods by which people could make complaints had also expanded. Despite the number of complaints increasing, only 0.07% of all patients had made complaints or raised concerns. VW advised that the capacity of the team was stretched due to the amount of complaints increasing. This also affected the Investigating Officers which had a knock on effect throughout the Trust and investigations were therefore not always completed in the time scales the team would like. She added that 99% of all comments were acknowledged within the Trust’s timeframe. VJ queried the remedial actions generated from the PHSO independent review and VW confirmed that there had been a lot of individual actions and that a process was being developed with Adrian South’s team to disseminate learning from complaints and Serious Incidents to all staff through the weekly Chief Executive’s bulletin and the intranet. The first article was planned for the next week’s bulletin (20 April 2016). The Quality Committee took assurance from the Compliments, PALS and Complaints report.

33.0 Managing Complaints from Volunteers

33.1 33.2

JW presented the Managing Complaints from Volunteers paper to the Quality Committee for approval. JW explained that the policy had been amended in order to clarify the process when a Community Responder made a complaint and to rectify an issue regarding confusion and overlapping between the Incidents


Page 29 of 29

33.3

team, Complaints team and Community Responders team when a complaint was made. The Quality Committee moved to approve the Managing Complaints from Volunteers policy.

34.0 Agree Quality Report to Board

34.1

VJ confirmed that a number of items had been raised during the Quality Committee to be taken to the next Board Seminar.

35.0 Any Other Business

35.1 35.2 35.3 35.4

MW requested that DP add a paragraph to the Restraint Policy regarding the safety and protection of SWASFT staff. DP confirmed that he would consider this and draft a paragraph during the six month pilot phase in addition to seeking legal advice. No new risks were identified. ST advised that the PREVENT Policy was new legislation. VJ thanked all for attending and confirmed that it had been an extraordinary Committee in preparation of the June CQC visit.

Date of Next Meeting: Thursday 14 July 2016, 14:00 to 16:00

Signed:

(Chair)

Dated:


Trust Public Board of Directors’ Meeting, 26 May 2016

Page 1 of 6


Title: Board Assurance Paper for the Audit and Assurance Committee on 24 March 2016 and approved Minutes from meeting on 14 January 2016.

Prepared by: Kelly Richardson, EA to Deputy Chief Executive/Executive Director of Finance

Presented by: Paul Love, Non-Executive Director and Chair of Audit Committee

Main aim: The paper is to share with the Trust Board of Directors the business of the Audit and Assurance Committee on 24 March 2016 and the approved minutes of the last meeting on 14 January 2016.

Recommendations: Members of the Trust Board of Directors are requested to take assurance regarding the business conducted at the committee meeting.

Previous Forum: This paper has not been presented to any other forum


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Board Assurance Report – Audit and Assurance Committee 1. Overview of the Meeting

1.1 In order to provide assurance to the Board of Directors on the work of the Audit and Assurance Committee a report has been prepared below containing a summary of the business conducted at its meeting on 24 March 2016.

1.2 A copy of the Minutes from the previous meeting dated 14 January 2016 are also

included at the end of the report for assurance.

2. Assurance Report Document

Key Items of assurance obtained

Decision/Actions to be taken

Accounting Matters The Committee received a briefing on the key areas Audit Committee members could expect to consider within the 2015/16 Annual Accounts in May 2016. No areas of material concern were brought to the Committee’s attention. Reference was made to the 90 days debtors and creditors information which the Committee agreed would be discussed in detail at the Finance and Investment Committee later that day.

Report noted for assurance.

Monitor and TDA Requirement to use approved frameworks for all agency procurement

The Committee received a briefing note on the introduction of the agency rules being introduced by NHS Improvement from 1 April 2016 and its impact on the Trust. The Committee having considered the report requested further detail to be shared with

Paper noted for information. Action: Board of Directors to receive the report for their consideration at the March meeting.


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the Board of Directors for its consideration at its March 2016 meeting.

An overview of the activities undertaken by Internal Audit covering the period 1 January to 10 March 2016 was shared. Assurances were provided that the audit plan remained on track for delivery by the end of the financial year. The Committee considered those audits where there were outstanding recommendations. The Committee agreed a revised date for the completion of work relating to the Fleet Management Audit.


Internal Audit Report: SME Training

An overview of the report was shared. It was noted that the report had been rated Amber/Red. Assurances of the work being undertaken to address recommendations within the report were shared by the Executive Director of HR and OD. Discussions were held concerning the ongoing review of progress against the actions and in which forum this would be monitored. The Deputy Chief Executive/Executive Director of Finance and Trust Secretary agreed to consider the matter.

Report noted for assurance. Action: The Deputy Chief Executive/Executive Director of Finance and Trust Secretary to consider and agree most appropriate reporting route for reviewing the delivery of the SME Training actions.

Internal Audit Report: Validation of Qualification and Registration

An overview of the report was shared. The report had been rated Green/Amber. The Committee was briefed on



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the areas requiring improvement and assurance was given on the actions being taken.

Internal Audit Report: IG Toolkit Part 2

An overview of the findings of the review was shared. It was noted that the exercise was a compliance review against the IG Toolkit and not a detailed assurance review of Trust processes. Therefore, a rating had not been applied. No further assurance was requested.


Internal Audit Report: Board Assurance Framework

An overview of the report was shared. The audit had been rated Green and Low. No further assurance was requested.


Draft Head of Internal Audit Opinion

An overview of the draft Head of Internal Audit Opinion was shared. The Committee was informed that Internal Audit proposes to present the Trust with Significant Assurance subject to the Care Quality Commission/Station visits and Risk Management audits being finalised. However, it is not anticipated that the outcome of the audits will impact on the overall Opinion rating. The final Head of Internal Audit Opinion will be presented to the Committee in May 2016. No further assurance was requested.



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Draft Internal Audit Plan 2016/17

The Draft Audit Plan for 2016/17 was presented to the Committee for approval. The Committee approved the plan subject to noting that changes may apply in year depending upon the Trust’s requirements.

Report approved.

Local Counter Fraud Progress Report

An overview of the Local Counter Fraud’s activities was shared. No further assurance was required.


Local Counter Fraud Audit Plan 2016/17

The 2016/17 Local Counter Fraud Plan was presented to the Committee and was approved. No further assurance was requested.

Report approved.

External Audit Interim Report

An update on the progress of the Audit was shared. No material issues were brought to the Committee’s attention. No further assurance was requested.


Risk Register A briefing on the latest updates to the Trust Risk Registers were shared and noted. No further assurance was requested.


Draft Annual Governance

A summary of the Annual Governance Statement was



Page 6 of 6

Statement shared and noted. Comments on the content of the Statement are to be fed back to the Trust Secretary ahead of its formal presentation to the Committee in May 2016. The Committee agreed that a copy of the report would be circulated to the Board of Directors for information.

Action: The Draft Statement to be circulated to the Board of Directors for information.

IG Report An overview of the Trusts position regarding Information Governance was shared and noted. An update was sought on the Trusts training compliance % which was shared. No further assurance was requested.


2.1 Issues referred to the Board of Directors 2.1.1 The Board of Directors are to receive the following at the March 2016 meeting:

Agency Rules

3. Recommendations

3.1 Members of the Board of Directors are asked to take assurance regarding the

business conducted at the Committee meeting.

Paul Love Chair of Audit and Assurance Committee

Audit Committee Meeting – 14 January 2016

Page 1 of 13

Minutes Audit Committee Meeting

Thursday 14 January 2016 at 09.30 Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Sowton, Exeter EX27HY

Chair Mr Paul Love, Non Executive Director Administration Miss K Richardson, EA to Deputy Chief Executive /Executive

Director of Finance

Members in attendance: Mr Hugh Hood

HH

Non-Executive Director

Mrs Venessa James VJ Non-Executive Director Mr Paul Love PL Non-Executive Director Mr Ian Reynolds IR Non-Executive Director Non Members in attendance: Ms Jenny Winslade JW Executive Director of Nursing and Governance

Mr Marty McAuley MM Trust Secretary Mr Jonathan James JJ Deputy Director of Finance Mr Robert Loader RL Deputy Director of Audit, Audit SouthWest Mr Phil Rogers PR Internal Audit Manager, Audit SouthWest Mrs Heather Ancient HA Partner, PricewaterhoueCoopers Ms Anne Payne AP Health and Safety Manager Mr Mike Pearce MP Head of Procurement Mr Craig Holmes CH Governor



1.1 PL opened the meeting as new Chair of the Committee under the new Terms of Reference. Craig Holmes, Governor was introduced as an observer. Apologies were noted from Tony Fox and Mary Watkins.


2.1 There were no conflicts of interest declared.


3.1 No report was given.


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4.0 Minutes of Previous Meeting

4.1 The minutes of the previous meeting on 12 November 2015 were approved as a true and accurate record.


5.1

5.2

5.3

5.4

The Committee reviewed the Action Point Registers for both 2014/15 and 2015/16 and noted the updates against each of the actions. The following was noted:

2014/15

Market Testing – MM advised that market testing scoping of

Internal Audit and External Audit Services is expected to take place in Quarter 3. An update to the Committee will follow thereafter;

Audit Committee Training – MM advised that he would be meeting with the Deputy Chief Executive/Executive Director of Finance in the new financial year to discuss the scope. PL advised that he was keen for the Committee to be clear of its requirements for both training and reviewing the effectiveness of the Committee which MM and JK acknowledged.

2015-16

Risk Platform – MM advised of a meeting planned with the Head of

Procurement within the next week to determine a timeline for the Risk Platform tender. The Committee noted the update.

Financial

6.0 Current Questions for Audit Committee’s

6.1

6.2

6.3

JK advised that the “Current Questions for Audit Committee’s” paper prepared by PwC had been referred from the Board of Directors for further consideration.

The Committee sought advice from External Auditors on how other clients had taken the matter forward. HA advised that the questions had been used as a tool to link Board Assurance Frameworks, Risk Registers and Committee and Board agendas. The Committee agreed that this approach was consistent to the intention of the Trust.

JK advised that the questions had been shared with senior management for their input and proposed that the findings be referred to the Directors


Page 3 of 13

Group for consideration of system wide global risks which have the potential to have impact on Trust operations and how these are reported through the Risk process. Action JK: It was suggested that the findings be shared with the Committee thereafter. The Committee was supportive of the suggestion and welcomed an update at a future meeting. It was also agreed that the information would be shared with the Trust Chairman.

JK

7.0 Trust Expenditure

7.1

7.2

7.3

7.4

7.5

7.6

JK presented a paper to the Committee setting out details of expenditure incurred by the Trust for the period 1 April 2014 to 31 March 2014 and 1 April 2015 to 30 September 2015.

JK explained that significant investment had been made within the Procurement team since 2014 to strengthen governance processes and enable the Trust to secure value for money. The paper demonstrates the progression made by the Procurement team over this time.

MP provided an overview of compliance/non-compliance against contracts in 2014/15 which he reported continued to improve for 2015/16. It was noted that changes had been made to the catagorisation of the 2015/16 workplan to identify categories such as third party providers, banking, training, facility management and agency etc. The Procurement team continues to focus on improvement of compliance against rolling contracts.

The Committee discussed how it was keen to understand the ambition of the workplan and its projection for compliance against contracts moving forward. ACTION JJ: It was agreed that a further report will be prepared towards the end of the new financial year to include an ambition trajectory.

PL sought comment from the auditors on how the Trust compared to other health organisations to which it was noted that the level of detail had not previously been seen in other organisations but that the data was considered good practice in providing the Committee with assurances of the Trust’s procurement activities.

The report was noted for assurance.

JJ


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Internal Audit

8.0 Internal Audit Progress Report

8.1

8.2

8.3

8.4

8.5

8.6

8.7

8.8

RL reported that the Internal Audit Progress Paper provided detail of the activities undertaken by auditors during the period 30 October and 31 December 2015.

RL advised that the delays reported to the previous Committee on the audit plan had since been improved. However it was noted that the delivery of audits relating to IT continue to be impacted as a result of the CAD implementation project. Assurance was provided that the auditors are continuing to work closely with the management team to ensure that the audit plan is delivered.

RL reported that there were two pending audit reports concerning the Estates Validation Review and SME training. PL confirmed that the SME report which had been expected to be received at the meeting had been withdrawn. The final report will be received by the Committee in due course.

RL confirmed that there were no outstanding Internal Audit Recommendations for the Committee to note. The Committee commended auditors and colleagues in reaching the position.

A Cyber Security Briefing was presented to the Committee noting that it had been shared with all its organisations. RL advised of 10 key steps that organisations should take in improving its cyber security and advised that the steps were being considered as part of the IT/Cyber Security audit currently being undertaken.

HH asked if human factors were also covered as part of the audit to which PR confirmed they were. FG confirmed that IT security is regularly monitored and any issues of concern brought to the Executive Director’s Group attention.

PL questioned if the Trust as part of its reviews conducted penetration testing. FG advised that such testing had been undertaken as part of the CAD project.

The Committee noted the update for assurance.


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9.0 Internal Audit Report: Data Quality

9.1

9.2

9.3

9.4

PR reported that the Data Quality report had been rated green and low. A number of recommendations have been made and progress against actions will be monitored.

An audit on the Quality Report KPIs is expected to take place in March/April 2016 which will inform the External Auditors Opinion at the end of the financial year.

An update on the single CAD timeline was requested by PL. FG reported that the CAD had been rolled out in November 2015 in the East and West division. The second phase is expected to be implemented in February 2015.


10 Internal Audit Report: Urgent Care Services

10.1

10.2

10.3

10.4

10.5

10.6

PR reported that the Urgent Care Services audit had been commissioned upon the request of the Executive Director of Nursing and Governance.

PR advised that the issues arising from the review were already known to the Trust and actions are being taken to address the concerns.

An overview of the findings were shared and the following areas highlighted:

Performance – The audit had identified a number of performance issues in the Gloucester OOH. However, it has been recognised that the Trust took over the management of the service in April 2015 and that many of the issues have largely been attributed to resourcing which remains a significant challenge.

Clinical audit – An observation was made with regard to how regularly the Royal College of General Practitioners, (RCGP) toolkit is completed and whether the toolkit is utilised for other staff groups such as Nurses.

Medicine Management – A number of medicine management areas of improvement had been identified following visits to a number of treatment centres across the Trust. However, the Trust has since devised a plan of work which is being rolled out Trustwide and improvements have since been recognised by auditors.


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10.7

10.8

10.9

10.10

10.11

10.12

10.13

10.14

Recruitment – The audit identified that that the recruitment process managed by the HR department was fit for purpose. However, some changes to the operational delivery had been recommended particularly with regard to the recruitment of sessional GPs. The Trust has since identified a plan to strengthen the operational aspects of the process.

Agency Staff – The internal procurement arrangements for the use of agency staff are to be improved. The Trust has taken action in addressing this issue through its Procurement department;

GP payments – Improvements Should be made in triangulating sit-rep reports against operational rotas. However, it was noted that the overall finance process is appropriate. Assurances have been received that appropriate actions are being taken to address this matter.

JW explained that the recommendations have been incorporated into a programme of change for the Urgent Care Service which has commended implementation. It was noted that a large amount of the programme of work requires input and support from across the directorates. The Committee noted that some change were only possible through joined up working through the local healthcare system.

HH was mindful of the amount of change required and pressure within the system and asked if the Trust felt confident that it has sufficient resources to deliver the action plan. JW confirmed that the Trust is taking a systematic approach to prioritise the actions within the plan with support from other directorates and was confident that the plan would be achieved.

The GP payroll issue was referred to by JK who provided the Committee with details of the findings and assurances given that the errors were not material and should not be considered a concern for the Committee. The Committee confirmed that it was satisfied that the information helped put the matter into context and assurance was taken.

The Committee reviewed the timescales for completion of the recommendations noting that some actions were on plan to be achieved earlier than planned. It was agreed that the dates within the action plan would be re-reviewed in line with the Programme of Change.


JW


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11 Internal Audit Report: Financial Systems Review

11.1

11.2

PR advised that the Financial Systems Review had been rated green and low. A small number of house-keeping improvements have been recommended which are being taken forward by the Finance department. However, there were no significant issues to bring to the attention of the Committee.

The Committee noted the report for assurance.

12 Internal Audit Report: Information Governance Toolkit v13 Review Part 1

12.1

12.2

12.3

12.4

PR advised that Part 1 of the Information Governance Toolkit had been completed. A summary of the report was provided and the highlights shared.

PR advised that the audit had been positive overall. Governance training has been identified as an area for improvement. The Committee discussed the projected trajectory for its achievement and the actions being taken to meet the 95% target. It was noted that the target remains a local target.

PL asked for an overview of the risks facing the Trust. FG advised that the main risks related to clinical records which will be addressed through the implementation of ECS and ongoing communication with staff concerning the appropriate use of email.

PR reported that Part 2 of the toolkit review is expected to be undertaken in February/March 2016.

13 Internal Audit Report: SME Training

13.1 PL confirmed that the Draft SME Training report had been withdrawn. The final report is to be received at a future meeting.

14 Internal Audit Report: Mid-Year Review of Audit Plans

14.1 PR advised that the Audit Plan had been reviewed by Internal Audit and the Trust in August 2015 and January 2016. Two proposed changes were presented to the Committee:

the CAD post project evaluation be transferred to the 2016/17

Audit Plan and to release the audit days for a review of SIs;

to review the scope of the Dispatch on Disposition review against


Page 8 of 13

14.2

the work being undertaken by ORH which may provide the Trust with the relevant assurance it needs. If the audit is found unnecessary it is proposed that the 8 planned days be transferred to the 2016/17 Plan.

The Committee approved the changes to the plan.

Counter Fraud and Security

15 Report from LCFS

15.1

15.2

15.3

15.4

15.5

15.6

15.7

15.8

SB presented the Local Counter Fraud Progress Report to the Committee for assurance.

SB reported that new legislation had been released on “The False or Misleading Information Offence”. A summary of the legislation was shared.

HH advised of the importance of ensuring that the Trust is clear of its corporate responsibility and its impact on the Board of Director’s. SB advised that further information is still being received on the matter. ACTION MM: It was agreed that MM would follow up on the legislation and inform the Board of Directors as appropriate.

SB provided an overview of the activities undertaken since the last meeting. It was noted that she continued to attend staff inductions and had also attended the Controlled Drugs Local Intelligence Network.

An update on current investigations was shared and noted.

SB reported the release of a CEO mandate concerning fraudulent email activity and how it is to be reported. SB advised that she would be liaising with the Executive Director of IM&T on the mandate. The Committee noted the update and acknowledged that the Trust needed to remain vigilant.

SB advised of the release of a document from the Association of the British Pharmaceutical Industry concerning the release of a database containing details of the benefits in cash or in kind provided to healthcare oganisations.

The Committee note the report for assurance.

MM


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16 NHS Protect Self-assessment Tool (SRT) Submission

16.1

16.2

16.3

16.4

16.5

AP reported that the NHS Protect Self-assessment Tool submission is an annual requirement for the Trust and had been submitted in December 2015. The Trust has submitted green to each of the sections with the exception to “Strategic Governance” which had been rated red and Inform and Involve which had been rated amber.

AP advised that the Trust had submitted a red rating for Strategic Governance as it does not have a Security Management Strategy in place. However, it is considered in the view of the SMD and Health, Safety and Security Manager that the Trust does have sufficient policies in place to address the requirements. This was reported to the NHS Protect in May 2015 and to date no response has been received.

AP advised that the Trust had submitted amber for Inform and Involve. It was noted that the Trust has a rolling programme of security inspections but is felt that further work is required by the Trust to review and evaluate the effectiveness of the inspections.

AP provided the Committee with an update on the 2015/16 work plan for the Committee’s information.

The Committee noted the submission for information.

External Audit

17 Audit Plan 2015/16

17.1

17.2

17.3

17.4

17.5

HA presented the Audit Plan to the Committee. It was noted that the approached to the audit remained the same as the previous year.

An overview of the Plan was shared for information.

The Committee was reminded that the audit was risk based and takes into account areas that are considered significant and areas of interest within the Health Sector.

HA advised of challenges within the current economic climate. It was noted that the Trust’s financial position remains strong compared to other organisations which the Committee recognised.

It was noted that the audit will take into account, journal testing, risk of fraud to revenue and that the liabilities of expenditure are reported within the correct periods. In addition the Trust will be assessed on its liabilities


Page 10 of 13

17.6

17.7

17.8

17.9

17.10

17.11

17.12

17.13

based on District Valuations.

HA advised that the audit will review and report issues of materiality in excess of £229k.

HA advised of the increasing focus on the disclosure and sign off of the Annual Report and Financial Statements which the auditors will also be reviewing. It was noted that one of the requirements for the 2015/16 year will be to reduce the length of the Trust’s Annual Report and auditors will work with the Trust to achieve this.

HA advised of the auditors responsibility to review any areas of fraud. To date there have been no concerns to bring to the Committee’s attention.

HA advised of an additional requirement to the accounting standards for the Charitable Funds which will affect the format of the accounts. Auditors are working with the finance team on how this will look.

There is no significant change to the timeline for the audit and submission of accounts for the Committee to note.

The Committee noted the proposed fees for the 2015/16 audit.

PL noted the requirement for members of the Board to disclose any statutory independence and asked how this would be managed. MM confirmed that members of the Board of Directors would be receiving a form to disclose any interests which will be formally presented to the Board of Directors.

The Committee noted the update for information.

Governance Effectiveness

18 Ensuring Compliance with Monitors Regulatory Regime

18.1

18.2

18.3

MM explained that the Ensuring Compliance with Monitors Regulatory Regime paper had been updated to address the discussion raised at the previous meeting concerning the reporting process and regime requirements of how the Trust complies with Monitor requirements.

The Committee welcomed the report and confirmed that it was satisfied that the paper addressed the assurances it required.



Page 11 of 13

19 Risk Register

19.1

19.2

19.3

19.4

19.5

JW advised that she had been working with the Trust Secretary and Risk Manager on the development of a Risk Register platform which she advised remained work in progress.

JW advised that there had been a number of changes to the Corporate Risk Register since being received by the Board of Directors. It was noted that:

a new risk had been identified concerning safeguarding referrals.

A paper is due to be presented to the Directors Group in the next week for consideration;

the Mandatory Training risk had been reduced as a result of evidence received by the HR & OD Directorate and moved across to the Directors Group Risk Register;

changes had been made to the format of the Risk Register and additional controls added.

The Committee discussed the Dispatch on Disposition project and how the Trust intended to manage any reputational risk. Assurance was given that risk registers are in place for all projects. The risks are regularly reviewed and escalated up through the risk system as appropriate.

JW advised that the Governance team had undertaken a deep dive into HR prior to Christmas. The exercise had been found useful for both the directorates. A boarder set of risks have been formed as a result of the review.

The Committee noted the Risk Register for assurance.

20 Standing Financial Instructions

20.1

20.2

20.3

MM presented a paper setting out proposed amendments to the Trusts in- house financial activity limits. It was noted that the limits had been reviewed as a result of changes to the Public Contracts Regulations which included an uplift of the OJEU threshold.

An overview of the proposed limits was shared and the Committee was asked to consider recommending the approval of the thresholds to the Board of Directors.

The Committee recommended the approval of the proposed limits. It


Page 12 of 13

was noted that the recommendation will be presented to the January Board of Directors meeting.

MM

21 Disclosure Statements: Annual Report Development Plan

21.1

21.2

MM presented the Committee with a paper setting out key changes to Monitor’s Annual Reporting Manual, (ARM) and a timetable for the completion of the Annual Report and Accounts for the Committee’s information. The following was noted:

the Trust is required to submit its Annual Report on 24 June 2016; an Audit and Assurance Committee and Trust Confidential Board

of Directors will be held on 19 May 2016 to review and approve the post audited Annual Accounts and Annual Report.

The Committee noted the report for information.

Information Governance

22 IG Report

22.1

22.2

The Committee noted the report for assurance and agreed that it was satisfied that Information Governance had been discussed in detail under Item 12, (Internal Audit Report: Information Governance Toolkit v13 Review Part 1).


23 Business Continuity and Information Governance Assurance

23.1

23.2

FG provided confirmation that all actions arising from the Business Continuity Internal Audit had been completed. ACTION: FG agreed to circulate a report evidencing the completion of the actions for the Committee’s assurance.

The Committee noted the update.

FG

Closing Business

24 Any Other Business

24.1 No further business was discussed.

25 Identification of New Risks

25.1 Safeguarding as referred to under the Risk Register report pending the Directors Group meeting.


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26 Identification of New Legislation

26.1 The False or Misleading Information Offence.

Signed:

(Chair)

Dated:
