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Board March 2017

Palliative and End of Life Strategy

Author David Oxenham, Palliative Care Consultant

Reason for Submission Tick all that apply If none of the above, please provide rationale for submission

Standing item

Development / approval or update on strategy Decision reserved for Board

Statutory / regulatory requirement

Oversight of significant risks Update on action log item

Requires Board approval e.g. policies or business cases

Core performance information

Other rationale, please state below:

Purpose of Report Provide information to the board about strategy and developments in Palliative Care

Summary of Key Issues

[One or two sentences to summarise the key issues of the report]

Regulatory compliance implications

Tick for any implications for compliance with

NHS Constitution

Provider Licence (especially Condition 6)

CQC Fundamental Standards of Care

Health and Social Care Act

Other [State ]

Significant risks identified (if any)

Introduction of Regional End of Life Documentation without proper facilitation

Risk to clinical services associated with 7% cost reduction target.

Recommendation to the Board

The Board is asked to approve the attached strategy.

AGENDA ITEM [ ]

Private & Confidential Trust Board Meeting – [DATE] 2011

CDDFT End of Life and Palliative Care Strategy 1. Purpose of Report

To inform the board of the Palliative and End of Life Strategy 2. Background

Palliative Care is an important aspect of the work of the trust. The 2015 CQC report identified several areas requiring improvement. Many of these have been implemented. Some key issues remain unresolved requiring collaboration with commissioners and other service providers. The trust and service are well positioned to make substantial further improvements in the coming year.

3. Key Issues

1. Personalised Care Planning

a. Further education is needed for specific clinical areas.

b. Improved use of incident reporting to identify areas in need of support and

improvement.

c. The Trust is encouraging the CCGs to adopt and fund the ‘six steps’

programme for palliative care in care homes.

2. Evidence and Information

a. Substantial Improvement in Palliative Care Coding has been associated with a

reduction in Standardised Mortality.

b. There is continuing work to clarify other information sources relevant to

palliative care

3. Shared records

a. The trust is engaging positively with the regional process to develop an

electronic mechanism for sharing palliative care information

4. 24/7 access

a. The CCGs have agreed a one year pilot scheme to provide out of hours

specialist advice from an existing specialist palliative care provider (Marie

Curie Hospice, Newcastle). There is now agreement that this is the most

effective and sustainable model.

2

5. Education and training

a. Palliative and end of life education in the trust is present coordinated by a

fixed term Macmillan Facilitator. A business case has been made for a

substantive post to continue this important work and deliver the trust ambition

to make palliative care education mandatory for all clinical staff.

b. The CCGs have requested that the trust implement the regional Care of the

Dying Documentation. There are substantial risks associated with its

introduction without adequate education and facilitation, and no additional

resource available. The view of the steering group is that the documentation

should not be introduced without the right facilitation.

6. Co design

a. The trust steering group continues to work closely with the CCG palliative care

groups and local hospices to improve services for patients and families.

7. Leadership

a. The End of Life & Palliative Care Steering Group provides the leadership and

the structure to facilitate the on-going development, implementation,

maintenance and evaluation of a comprehensive, integrated and coordinated

system of end-of-life care throughout the Trust. It meets on a bi-monthly basis.

It is a sub-committee of the Quality and Healthcare Governance Committee to

which it reports annually.

b. The Group is chaired by the Executive Director of Nursing and has

representation from all care groups together with clear links to the Clinical

Commissioning Palliative Care Group and the Regional Strategic network

Group.

4. Consideration of Options / Detailed commentary* See attached appendix 5. Financial/Other Implications

Decisions about resource for education are being considered through the business planning process.

6. Recommendations

The Board is asked to approve the attached strategy. Name: David Oxenham Position: Consultant in Palliative Care Date: 13th March 2017

3

County Durham & Darlington NHS Foundation Trust

End of life and Palliative Care Strategy 2016 2019

Update January 2017

Prepared by: CDDFT End of Life & Palliative Care Steering Group

4

Executive Summary CDDFT is the largest provider of palliative care services in County Durham and provides care to most of the people who die in our area and specific palliative care to at least a third of those. The specialist service continues to improve and deliver more care. It also plays a key role in supporting other specialties and services with training and service improvement. We now have an effective strategy for palliative care with strong clinical leadership and commitment from executive and board. . There are substantial improvements in information streams, both quantitative measures and feedback from incidents and surveys. Many of the CQC recommendations and improvements identified by national audit have been implemented. There remains much to do with key issues remain unresolved requiring collaboration with commissioners and other service providers. The trust and service are well positioned to make substantial further improvements in the coming year. David Oxenham January 2017

Table of Contents Ambitions and Foundations .............................................................................................. 5

1. Personalised Care Planning....................................................................................... 6

2. Evidence and Information .......................................................................................... 7

3. Shared records .......................................................................................................... 8

4. 24/7 access ................................................................................................................ 8

5. Education and training ............................................................................................... 9

6. Involving Supporting and Caring for those important to the dying person ................ 10

7. Co design ................................................................................................................. 10

8. Leadership ............................................................................................................... 11

Appendix 1 .................................................................................................................. 12

5

Ambitions and Foundations There has been significant focus over the last year in the Trust to support the delivery of high quality, timely, effective, individualised services for patients with end of life care needs, support for their families and support for staff to provide these services. End of life care is a key theme in our trust strategy; Quality Matters and this document builds on Quality Matters and includes the recommendations from audit work, patient feedback, CQC inspections, national guidance (NICE, regional needs assessment) and collaboration with our local partner organisations. The National Palliative and End of Life Partnership sets out a national framework for local action encouraging organisations to make a collective decision to act together to do all we can to achieve for everyone what we would want for our own families www.endoflifecareambitions.org.uk. The ambitions emerge from a clear vision and can be delivered collaboratively by building from 8 key foundations. Our strategy and work plan has been defined around these foundations in line with the National Ambitions for Palliative and End of Life Care.

http://www.endoflifecareambitions.org.uk/

6

1. Personalised Care Planning Everybody approaching the end of their life should be offered the chance to create a personalised care plan. Opportunities for informed discussion and planning should be universal. Such conversations must be on-going with options regularly reviewed. The North East is at the forefront of comprehensive personalised care planning through the Deciding Right initiative. http://www.nescn.nhs.uk/common-themes/deciding-right/ . Key Achievements

• Deciding Right has been formally adopted by the trust and is incorporated into key educational initiatives. Deciding Right Documentation is used in all clinical areas.

• Our Safeguarding Adults Team has taken part in a multidisciplinary audit of the Mental capacity Act, identifying areas for improvement and development

• Individual departments have recognised the importance of care planning and have taken specific action:

o The new Acute Intervention Team have been trained to assess existing care planning and recognise where patients need specialist palliative care support for more individualised planning.

o The Critical Care Department is developing innovative systems for ensuring delivery of palliative care planning

o The Heart Failure Service has developed and adopted palliative care assessment and planning for appropriate patients

o Dietetics has updated policy on clinically assisted feeding to clarify individualised care planning and assessment of palliative care need.

o Community matrons and the Community Specialist Palliative Care Service continue to improve palliative planning and extend this to more patients in the community.

Areas to be progressed this year

• Further education is needed for specific clinical areas. • Improved use of incident reporting to identify areas in need of support and

improvement. • An audit of palliative care assessment and planning for patients from care homes

will be conducted in UHND A&E Department. • The Specialist Palliative Care Service is undertaking further work to improve their

systems for recording and counting personalised care planning. • The Trust is encouraging the CCGs to adopt and fund the ‘six steps’ programme

for palliative care in care homes.

http://www.nescn.nhs.uk/common-themes/deciding-right/

7

2. Evidence and Information Comprehensive and robust data are necessary to measure the extent to which the outcomes that matter to the person are being achieved. This, alongside strengthening the evidence-base, will help to drive service improvements.

Figure 1 Achievements Death In Usual Place of Residence Public Health England uses ‘death in usual place of residence’ (DIUPR) as a high level proxy marker of effective palliative care provision. County Durham and Darlington CCGs are improving on this measure and are above the national average (Figure 1). The corollary of this figure is that each year fewer patients are dying in our acute hospitals. Mortality Data Mortality Data is adjusted for palliative care involvement. In previous years our Trust mortality data was worsened by low recorded palliative care activity. Improvement in palliative care coding has more accurate HSMR figures and greater palliative care involvement in hospitals has further reduced mortality figures. Incident Reporting Substantial increase in quality of incident reporting with establishment of mechanism to collate all incidents relating to end of life care and mechanism for review/identification of themes for improvement Areas to be progressed this year

• Review and improvements in data quality are now underway to ensure accuracy of reporting. Agreement about system requirements for short and medium term data collection

• Production of accurate National Minimum Data Set information for acute and community palliative care service

• Discussion and agreement about whether to commit to data requirements for new palliative care currency information

• Further development of triangulation of data with patient led measures (incidents, surveys, complaints etc)

8

3. Shared records To ensure the plan can guide a person centred approach it has to be available to the person and, with their consent, be shared with all those who may be involved in their care. Electronic Palliative Care Co-ordination Systems (EPaCCS) enable the recording and sharing of people’s care preferences and key details about their care at the end of life (http://www.endoflifecare-intelligence.org.uk/resources/publications/epaccs_in_england ). The North East has adopted a regional approach to the development of EPaCCS; the trust is committed to this partnership approach as the most effective mechanism to sharing key information. Key achievements

• Agreement with Macmillan to fund project manager for 18 months.

• Inclusion of EPaCCS in Trust IT strategy

• The Trust Head of Systems and Delivery and the Clinical Lead for Palliative Care are members of the regional steering group.

Areas to be progressed this year

• Develop Project Implementation plan for delivering EPaCCS

• Engagement of all key stakeholders

4. 24/7 access When we talk about end of life care we have to talk about access to 24/7 services as needed, as a matter of course. The distress of uncontrolled pain and symptoms cannot wait for ‘opening hours’ The trust provides the largest element of specialist palliative care support to County Durham and Darlington. At present there is good provision of clinical nurse specialists but only access to this service 9-5, Monday to Friday. In addition there is insufficient support from palliative care doctors due to several unfilled consultant posts. Key achievements

• The trust delivers a range of services that support patient and families at end of life 24 hours a day including the Macmillan Carers Service (providing hands on specialised care to patients and support for families at home).

• The Unscheduled Care Service has developed more robust mechanisms for learning and improvement as a result of incidents and complaints

http://www.endoflifecare-intelligence.org.uk/resources/publications/epaccs_in_england

9

• The trust senior palliative care managers have worked with the CCGs to explore options around the provision of palliative care advice for all clinicians available at all times. There is now agreement that the most effective and sustainable model is provision of this service from an existing specialist palliative care provider (Marie Curie Hospice, Newcastle). The CCGs have agreed a one year pilot scheme;

• The trust continues to find consultant recruitment a challenge as a result of a

national specialist shortage combined with complex local issues. As a result the CCGs and trust have agreed and funded an innovative ‘training fellowship’ post.

Areas to be progressed

• Monitoring of pilot 24/7 advice service from Marie Curie.

• Continued improvements in unscheduled care service through incident monitoring, education and direct support for clinicians.

5. Education and training It is vital that every locality and every profession has a framework for their education, training and continuing professional development to achieve and maintain competence and allow expertise and professionalism to flourish. Key Achievements The CDDFT Education Strategy has been approved by the End of Life & Palliative Care Committee in September 2015 identified a range of staff groupings to enable differentiation of education requirements (Figure 3). It includes

1. Inclusion in Mandatory Training for all staff

2. Provision of role essential training for all

staff in groups B-C

3. Support for specialist training for staff in

group A

4. The development of an End of Life Education Forum

The successful recruitment to Macmillan Educator Post has enabled the development and the planned delivery of the trust wide Education Strategy. Along with the Macmillan Lead Nurse, this post facilitated and helped deliver A pilot programme of education to specific wards and departments for trained nurses and health care assistants.. Mandatory education has also been provided for all consultants in conjunction with the Cardiac Arrest Prevention Team. .

Areas to be progressed this year • Identification and mapping of available resources available to each staff group (a to D)

• Review of pilot education programme ( analysis of data)

10

• Preparation of business case for continuing funding of Macmillan Education Post

• Establish agreed palliative care mandatory training for all trust staff

6. Involving Supporting and Caring for those important to the dying person

Families, friends, carers and those important to the dying person must be offered care and support. They may be an important part of the person’s caring team, if they and the dying person wish them to be regarded in that way. They are also individuals who are facing loss and grief themselves.

Key Achievements • Completion of New Bereavement Suites in Each Acute Hospital

• Appointment of Bereavement Officers

• The 2012 national VOICES survey of bereaved relatives (appendix 1) showed high satisfaction. It is now time to repeat this valuable exercise.


• Develop plans and deliver repeat of VOICES survey to identify any gaps in support and care for carers.

• Develop actions from new incident reporting system

7. Co design End of life care is best designed in collaboration with people who have personal and professional experience of care needs as people die. Achievements

The clinical Lead and service manager assisted the CCG with the review and development of a refreshed strategy document that mirrors the “Ambitions Framework” layout of the trust strategy.

The Palliative Care Senior Team also collaborated with all other local palliative care organisations in a 24/7 Palliative Care task and finish group.


• Development and delivery of specific actions emerging from task and finish group

in collaboration with other organisations

11

• Explore benefits of regular integrated governance review of cross organisational

incidents

• Engagement with CCG review of inpatient palliative care provision in County

Durham

8. Leadership The leadership of Health and Wellbeing Boards, CCGs and Local Authorities are needed to create the circumstances necessary for action. Clinical leadership must be at the heart of individual service providers. Key Achievements • Strengthening of the End of Life & Palliative Care Steering Group

The End of Life & Palliative Care Steering Group provides the leadership and the structure to facilitate the on-going development, implementation, maintenance and evaluation of a comprehensive, integrated and coordinated system of end-of-life care throughout the Trust. It meets on a bi-monthly basis. It is a sub-committee of the Quality and Healthcare Governance Committee to which it reports annually. The Group is chaired by the Executive Director of Nursing and has representation from all care groups together with clear links to the Clinical Commissioning Palliative Care Group and the Regional Strategic network Group.

• Appointment of Specialist Palliative Care Service Manager/ Macmillan Lead Nurse

The Trust is developing a triumvirate with the Specialist Palliative Care Clinical Lead, Macmillan lead Nurse and Specialist Palliative Care Service Manager to provide strategic and managerial leadership to the specialist palliative care team and support service improvement in end of life care for the Trust.


• Ensure new management arrangements deliver palliative care priorities

• Successful navigation of anticipated CQC review

12

Appendix 1

A meeting of County Durham and Darlington NHS Foundation Trust Board of Directors held in the Executive Boardroom, Executive Corridor at Darlington Memorial Hospital

on Wednesday 29 March 2017 at 08.30hrs - 11:00hrs Part One (Open)

AGENDA

Item No Title of Item Presented By / Status

Item 1 Welcome & Apologies for Absence

Item 2 Declarations of Interest – Any Board member who is aware of a private or personal conflict of interest relating to any item on the agenda will be required to disclose it at this stage or when the conflict arises during consideration of the item.

Item 3

Minutes, Matters Arising and Action Log – From the Trust Board meeting(s) held on: Open Trust Board Meeting – 25 January 2017

Item 4 Chief Executive’s Report CQC Update Report Quarterly Review Meeting (QRM) Letter

SJ

Verbal

For info

Patient Safety & Quality

Item 5 Director of Nursing Report NS

To

follow

For info

Item 6 Medical Director’s Report JC To follow For info

Compliance and Performance Management

Item 7 Operational Performance & Efficiency Integrated Performance Report SP Attached For info

Item 8 Finance Report PD Attached For info

Agenda - Trust Board Part One (Open) 29.03.2017 Page 2 of 2

Item No Title of Item Presented By / Status

Other Business

Item 9 End of Life Care Strategy Plan D Oxenham Attached To agree

Item 10 Staff Matter – People Strategy MS Attached For approval

Item 11 Communications and Engagement Report GC Attached For info

Item 12 Any Other Business ALL

Item 13

Announcement of Next Public Meeting(s) Trust Board Date: Wednesday 26 April 2017 Time: from 09:00hrs Venue: Executive Boardroom, Executive Corridor at Darlington Memorial Hospital

Item 14

Motion to Exclude Press/Public Notice is hereby given that the Chairman at this point in proceedings will move the following motion: “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”. If carried, representatives of the press and public shall be required to leave the meeting.

Trust Board Action Log – updated 25/01/17 Page 1 of 2

TRUST BOARD ACTIONS at 25 JANUARY 2017 (OPEN MEETING)

Protocol: Actions confirmed as closed at the last Board Meeting are marked as ‘complete’ pending approval of the minutes of that meeting. Once the minutes are approved they are removed from the log. A small number of actions where implementation is self-evident to the Board are also marked as complete and will be removed following the Board meeting. Items on the agenda are marked. Future dates are shown in green, overdue dates in red.

No. Meeting Item Action Point Timescale Status Lead

1) 21/10/15 (Open) 127/16 Invite an R&D representative to a future Board meeting to provide an update on R&D

projects. March 2017 To action CG

2) 23/03/16 27/07/16 (Open)

223/16 99/17(c)

Draft palliative end of life care strategy to be presented to Board. To go to Quality Review Group.

February 2017 To action NS

3)

27/04/16 (Open) 21/01/17 (Open)

27/17 226/17

Post-implementation reviews to be brought to the Board covering the following investments: AMEC, RAMAC, RAS, CREST, the Acute Medical Units, nursing staff, Advanced Nurse Practitioners, Obstetrics and Gynaecology consultants and Paediatric consultants. Produce a schedule of PIRs in preparation for the February 2017 Board meeting, to link with the Audit Committee action to review investments with a value greater than £500k

February 2017 January 2017

To action To action

To be agreed WE/CL

4)

25/05/16 (Open) 21/12/17 (Open)

47/17 198/17

Provide a full paper to the Board in relation to the Maternity Thematic Review recommendations and subsequent monitoring

February 2017 Ongoing CG

5) 21/12/16 (Open) 198/17 Report on the activity case-mix to be undertaken in the Orthopaedic Centre of

Excellence February 2017 To action CL

6) 21/12/16 (Open) 200/17

In relation to the patient Safety and Experience Report, consider the level of complaints which would give cause for concern and require the Trust to do something different.


7) 21/12/16 (Open) 200/17

Include in the Duty of Candour Report, the trend over time, a legend to the chart and narrative where compliance levels were low. Provide an update monthly, as part of the Patient Experience Report


8) 21/12/16 (Open) 200/17

Arrange for a fuller debate to take place on the work around Duty of Candour compliance, potentially at IQAC Include the analysis in the Care Group Integrated Governance Reports

February 2017 To action WE

9) 25/01/17 (Open) 227/17 Include Nutrition as a main topic on the agenda of a future IQAC meeting March 2017 To action WE

Trust Board Action Log – updated 25/01/17 Page 2 of 2

No. Meeting Item Action Point Timescale Status Lead

10) 25/01/17 (Open) 228/17 Arrange for an audit to be carried out in relation to Duty of Candour requirements on

the Safeguard system March 2017 To action WE

11) 25/01/17 (Open) 228/17 Review the issue of completion confirmation in the Safeguard system in relation to

Duty of Candour, with Care Groups March 2017 To action NS

12) 25/01/17 (Open) 228/17 Provide feedback to the Board on the analysis of the reduced Friends and Family test

responses in relation to A&E March 2017 To action NS

13) 25/01/17 (Open) 228/17

Review the compliance reporting requirements in respect of the Nurse Staffing Report, with a view to updating the format of the report to include an executive summary at the beginning

March 2017 To action NS

14) 25/01/17 (Open) 230/17 Present a report to the Board seminar outlining the streams of work ongoing in

relation to A&E activity and the potential impact February 2017 Complete CL

15) 25/01/17 (Open) 230/17 Analyse the increase in community activity to determine the impact of mobile working March 2017 To action CL

16) 25/01/17 (Open) 230/17 Agree targets for discharges before midday March 2017 To action CL

17) 25/01/17 (Open) 233/17 Provide a detailed report to the Board on Medical Education risks and actions February 2017 Complete MS

18) 25/01/17 (Open) 233/17 Consider strategies for ensuring the embedding of learning from training April 2017 To action MS

Board 29 March 2017

Staff Matter 2017-2010

Author Andrew Thacker, Associate Director of Workforce

Lesley Roe, Associate Director of Organisation Development

Reason for

Submission

Tick all that apply

If none of the above,

please provide

rationale for

submission

Standing item

Development / approval or update on strategy

Decision reserved for Board


Oversight of significant risks

Update on action log item




Strategic Aim:

See overleaf for more

information

To transform care pathways and develop services which deliver the

best patient outcomes

To enable delivery of care by staff and in patient environments that

provide the best patient experience

To maximise our resources and relationships to sustain services and

deliver best efficiency

To attract, support, engage and develop our staff to provide care they

are proud of – best employer

Purpose of Report To present to the Board the revised Staff Matter Strategy for 2017-2020 and to

seek Board approval of the strategy.

Summary of Key Issues The strategy has been widely circulated for comments from staff, management

and staff-side colleagues and was approved at the IQAC meeting held on 21

March 2017.

Regulatory compliance

implications


NHS Constitution




Other [State]

Significant risks identified

(if any)

Action / decision required

from the Board

The Board is asked to accept and approve the 3 year Staff Matter (People)

strategy.

Page 1 of 13

Staff Matter County Durham and Darlington NHS Foundation Trust’s People Strategy

2017 - 2020

Page 2 of 13

1. Introduction and purpose

This document sets out the strategic workforce priorities the County Durham and Darlington

NHS Foundation Trust (CDDFT) has agreed for the next three years (reviewed annually)

and the work that is required to realise our workforce ambitions.

Our strategy for our workforce will be bold, ambitious and visionary and builds upon the

excellent foundations we have put down during the past two years. Our strategy will

support a workforce to operate effectively in a culture where “can do” becomes the norm.

This is a Trust wide strategic document which will provide a framework for the development

of workforce strategies and plans which will be owned and delivered by all Corporate and

Care Group services to ensure a consistent and high quality employment experience for all

of our staff.

In our vision to become a Best Employer we will create a workforce that as well as being

engaged, resilient and competent is also agile and prepared to adapt to a health service

that continues to experience unprecedented change. A whole systems approach is

required to make the most of our workforce, with ownership of plans at a local (service)

level being key to its success. We will empower both managers and staff to enable them to

do their best and provide high standards of service and care for our patients.

Robust workforce planning which drives out inefficiencies and encourages innovation and

best use of new roles across services will be a vital component of our work in the next 3

years. This work will be crucial to ensure that we create a workforce that is fit for the future

as we work with partner organisations to implement the vision of our own clinical strategies

and business objectives as well as contributing to the wider healthcare reform.

We acknowledge that the supply of some key staff groups remains an on-going issue at a

national and regional level. If we are to remain attractive to our prospective and existing

workforce, we need to be innovative in our offer to enable us to fulfil our ambition of being

the Best Employer in our local health economy; a key enabler in the attraction and retention

of our most valued asset.

We aim to develop the talents of all our employees and we will ensure robust succession

planning processes to enable a constant supply of emerging leaders, ready to take on the

challenges of the future heath economy. Our workforce, as well as our patients, are ageing

and we need to make sure that we support and nurture our staff so they can contribute fully

to the workplace, and find ways to enable them to continue working as they age, as well as

nurturing new and up and coming talent who will be the future of our Trust.

This document builds on the foundations that were developed through our outgoing ‘Staff

Matter’ strategy which identified a number of strategic priorities, including; the development

and communication of our clinical strategies to staff and stakeholders, the restructuring of

our care groups to enable the delivery of those strategies, the development of skills and

competencies of our managers and senior clinicians, the identification of talent pathways for

Page 3 of 13

key roles, staff engagement and developing a culture of engagement underpinned by the

cultural audit, values and behaviours framework and outlines the approach we will take to

deliver the revised strategy.

Page 4 of 13

2. Our Trust Mission and Vision

The following diagram outlines the Trust’s high level strategy and supporting strategies. Staff Matter is a key strategy in delivering

our ambition to be the Best Employer.

Page 5 of 13

3. Workforce & OD Vision

The characteristics of a Best Employer can be summarised under the following four

headings which will form the basis of our workforce framework.

These are underpinned by six key enablers which will focus our work over the next three

years and contribute to the creation of an engaged, resilient, competent and adaptable

workforce which is prepared for a changing healthcare economy.

TO DEVELOP THE TRUST AS A BEST EMPLOYER ENSURING THAT OUR PATIENTS ARE TREATED IN THE RIGHT PLACE BY THE RIGHT PERSON FIRST

TIME EVERY TIME

Engaged Organisational

Culture

Recruit and Attract

Develop Talent

Support and embed a high performance

culture

Maintain workforce health and wellbeing

Develop our supporting

infrastructure

Create a workforce for

the future

Page 6 of 13

4. Work-streams and Priorities

Our greatest asset is our staff and in order to meet the organisation’s strategic aims and

fulfil our objective of being a Best Employer, we need a highly skilled, committed and

engaged workforce. Throughout this strategy we will describe the opportunities we will offer

and the support we will provide to enable managers and staff to meet both the Trust’s and

their personal ambitions.

The development of this strategy has taken place during a time of unprecedented change

and financial challenge for the national and local health economies. Therefore, our strategy

needs not only to be challenging, but also realistic in terms of the scale of change required.

Details of our strategic workforce and organisation development priorities that will take us

through to the year 2020 are as follows:

How will we recruit and attract our workforce?

We will do this through:

Develop a strong employer brand which will emphasise our vision, mission and values

Develop a compelling offer which supports our bold ambitions for the workforce as outlined in this strategy.

Developing and delivering robust recruitment strategies maximising the use of social media and on-line systems to achieve streamlined processes which deliver an efficient, timely and quality recruitment experience for all stakeholders.

Developing proactive search and select approaches, establishing pipelining systems to attract scarce skills and talent acquisition and running bespoke campaigns to target hard to recruit posts

Build an effective and efficient bank to provide temporary staff across the Trust

Implement and maximise opportunities through appropriate arrangements for the supply of agency Clinical Staff within agreed cost and quality frameworks

The following action plans support delivery of these priorities:

Consultant Recruitment Plan

Nurse & HCA Recruitment Plan

Apprentice Development Plan

ESR Implementation Project Plan

Staff Bank & Agency Plan

Staff Health & Wellbeing Plan

Care Group & Corporate Workforce Plan

Communication Action Plan

Page 7 of 13

How will we develop Talent and maintain our future workforce?

We will do this through:

Developing and implementing a comprehensive Leadership Development Programme covering all management roles across the Trust, focussed on embedding the values and behaviours framework and staff engagement.

Developing talent pathways for all key roles across the Trust linked to apprenticeship frameworks and professional standards.

Developing effective talent management processes to support succession planning for key roles across the Trust and improving retention of key workers

Continue to equip staff with the skills and capacity to do their job to ensure high rates of retention

Continuing to recognise the achievements of staff through our annual Staff Awards celebrations

Creating a culture of freedom to act and accountability for actions for all managers.


Leadership Development Framework and action plan

Organisation Development Plan

Apprenticeship Plan

Annual TNA Plan

Care Group & Corporate succession plans

16 Point Nursing Recruitment Plan

Consultant Recruitment Plan

Education Quality Plan

Page 8 of 13

How will we support a high performance culture?

We will do this through

Replacing the current appraisal system with a radically new approach focused on team-based objectives, to engender shared ownership, and individual talent conversations to maximise the potential of our staff

Improving how managers deal with conflict within teams by implementing mediation as a first step for resolution within our discipline and grievance processes.

Redesigning performance management systems to focus on values, behaviours and engagement underpinning collective leadership and individual accountabilities.

Monitor the implementation of any new system to ensure all deliverables are achieved

Driving out inefficiency through effective monitoring of policies

Encouraging real time data capture giving transparency of information to managers

Developing ‘readiness for change’ plans to support identified organisational change processes, focused on maintaining staff engagement and resilience.

Coaching leaders and managers to ensure the learning from development activities is effectively embedded and supports cultural change within their teams.

Measuring our effectiveness through the annual staff survey and Staff Friends and Family Test for the Trust

Ensure all staff have an annual appraisal and complete all essential training requirements

Empower managers and staff through organisational systems and processes

Introduce Frameworks which provide guidance without hindering dynamic decision making



Sickness Absence Plan

Appraisal Plan


Service level plans for appraisal & essential training

Page 9 of 13

How will we maintain workforce health and wellbeing?


Providing health and wellbeing initiatives and advice which support staff to look after their own physical, mental and emotional health

Prevent ill health caused by or exacerbated by work

Support staff who have difficulty in attending work through ill-health or those who are unable to return to work

Enable access to timely and high quality services which provide easy and early interventions for the main causes of sickness absence such as mental health & wellbeing, stress & anxiety and musculoskeletal complaints

Develop the skills of staff to enable them to build resilience and adapt to change

Enable managers to manage attendance at work

Seek to achieve the Better Health at Work Excellence Award which demonstrates our commitment to health and wellbeing



Sickness Absence Plan


Better Health at Work Action Plan

Page 10 of 13

How will we develop our supporting infrastructure?


Implementation of ESR Manager Self Service across the Trust to provide managers with information on their staff to enable them to manage effectively

Implementation of the Regional Streamlining Programme which will improve the portability of staff records in relation to recruitment of staff, occupational health and learning & development

Further development of blended learning facilities and courses to improve access to training for staff

Streamline all processes and systems to ensure they are paper-light and maximise the use of available technology to ensure we ‘Do things once and right first time’

Developing the use of Business Intelligence reporting across all areas of the Trust to support in KPI monitoring and decision making

Review and revise existing policies to remove bureaucracy and support managers in effectively leading and managing their teams

Effective partnership working with Trade Union representatives and other stakeholders to ensure staff are engaged in developing and implementing policies and processes which affect them

Providing easy access to policy and framework documents through redesigned intranet and internet sites


ESR Implementation Project Plan

Streamlining Workstream Action Plans

Information Strategy (IS) Action Plans

Technology-based Learning Action Plan

Trade Union Partnership Agreement

Regional Policy and Framework Review Plan

Communications Review

Page 11 of 13

How we create a workforce for the future?


Ensure full engagement from all staff groups in the development of workforce plans for their services

Continually improve Care Group and Corporate Directorates approach to workforce planning and the development of new roles to ensure we have the correct skill mix of staffing to support the delivery of services

Actively seek new ways of working

Continue to identify and develop opportunities to deliver efficient, cost-effective services and, working in partnership with other stakeholders, to develop policies that are comparable and remain fit for the future

Ensuring staff have positive employment experience that encourages retention


Care Group specific Workforce Strategies and Operational Plans

SCL Business Plan

Clinical Strategies

Financial Plans

Business Plans

Capacity & Demand Plans

STP Plans

Page 12 of 13

5. Roles and Responsibilities

This strategy and supporting action plans need to be owned and managed at a number of

levels within the organisation.

The Board is responsible for providing the strategic direction of the Trust to inform

Workforce & OD priorities.

Directors are responsible for ensuring priorities are integrated within Care Groups

and Corporates.

Managers are responsible for managing and delivering priorities at team level.

Care Group and Corporate leads are responsible for cascading information and

supporting their management team to meet priorities.

The Workforce & OD Team are responsible for leading the agreed Workforce & OD

priorities, developing the appropriate support for the Trust and advising on best

practice.

Trade Unions are responsible for supporting the implementation of this strategy

6. Monitoring and Reporting of the Strategy and Associated Action Plans

The Director of Workforce & Organisation Development will have overall responsibility for

the People Strategy. Implementation and progress monitoring of the People Strategy will

take place through the Strategic Change Board which will inform a quarterly report for the

Integrated Quality Assurance Committee and the Board of Directors. Each Care Group and

Corporate Directorate will be required to produce evidence of actions taken to implement

the strategy. A template for monitoring progress against actions is included at Appendix A.

7. Risks to the delivery of the strategy

Individual risk registers developed with the individual Action Plans will be monitored through

the corporate risk management process. Corporate risks will be monitored through the

Integrated Quality Assurance Committee and Board of Directors, in line with the risk

management processes.

Page 13 of 13

Appendices

Appendix Description Attachment

A Progress Monitoring Plan

Staff Matter Action Plan 2017-2020.docx

Board Cover Sheet – Care Quality Commission Update 1

Trust Board – 29th March 2017

Care Quality Commission Update (Item 4)

Open Session Private & Confidential Session

Author Warren Edge, Senior Associate Director of Assurance and Compliance

Reason for

Submission

Tick all that apply

If none of the above,

please provide

rationale for

submission

Standing item









Strategic Aim:

See overleaf for more

information

To transform care pathways and develop services which deliver the

best patient outcomes

To enable delivery of care by staff and in patient environments that

provide the best patient experience

To maximise our resources and relationships to sustain services and

deliver best efficiency

To attract, support, engage and develop our staff to provide care they

are proud of – best employer

Purpose of Report To update the Board with respect to the actions from the last mock inspection and

preparations for the CQC inspection, now expected in Quarter 1 of 2017/18.

Summary of Key

Issues

All actions have been completed, with two exceptions (Paediatric Nursing in the

Trust’s Emergency Departments and out of hours cover for end of life care). Both

are close to completion, however, the delay in implementation is a risk. Some

further actions are subject to on-going monitoring.

A communications plan is underway to ensure that all teams and wards are well

prepared for the visit, which is summarised in the attached.

Care Groups have been asked to provide an update on their services to the

seminar, which will inform focused, independent assurance checks through back

to practice Fridays over the next few weeks. Work has commenced on a risk

assessment to inform these checks, with the intention of providing a definitive

view early in April. It is recommended that an additional meeting of the Integrated

Assurance Committee is held to review, support and as necessary, challenge the

results of this work.


Regulatory

compliance

implications


NHS Constitution




Other [State]

Significant risks

identified (if any)

The delay with respect to implementing some actions (noted above), with the

effect that they are not yet embedded.

As noted above, a service by service risk assessment is in development to inform

assuance checks over the coming weeks and Care Groups will provide their

assessments for there services in the Board Seminar later on 29th March 2017.

Action / decision

required from the

Board

The Board is asked to note the current position, and the communication plans

outlined in the attached report.

The Board is asked to approve the recommendation for an additional meeting of

IQAC in the first half of April to review the risk assessment and confirm the

assurance available for each service.

STRATEGIC OBJECTIVES

Best Outcomes Best Experience Best Efficiency Best Employer

• Moving care closer to home, preventing admission and supporting discharge.

• Enabling consultant delivered care

• Working with partners to provide acute and planned care, where needed in line with best practice clinical standards.

• Establishing specialty teams across acute sites and beyond.

• Embed our culture of learning and transparency and processes to minimise harm

• Improving how we listen, learn and respond to our patients, carers and the public

• Developing our estate and facilities in line with the highest standards of safety and patient-friendliness

• Developing services to meet the needs of the elderly patient.

• Acquiring, retaining and effectively deploying resources to implement our strategy and sustain clinical services

• Enhancing the capability of IS systems to fully enable patient care

• Leading and governing our business well

• Attracting and retaining high calibre staff to lead and deliver services

• Engaging and equipping our staff to fulfil their potential and to continuously improve our services


REPORT ON PROGRESS - TRUST CARE QUALITY COMMISSION (CQC)

ACTION PLAN: MARCH 2017

INTRODUCTION

This paper has been prepared to update the Committee on progress against the action plan agreed with CQC, plans to seek assurance that actions have been embedded and preparations for the forthcoming follow-up inspection. CQC Inspection Process From 1st April 2017, the CQC inspection process will change. They will no longer carry out comprehensive inspections and the Trust will not be given 100 day notice of their intent to inspect its hospitals. Instead inspections will be unannounced to specific core services based on the CQC intelligence gathering and risk monitoring using ‘CQC Insights model’. Safeguarding Children Inspection CQC carried out a review of health services for Looked After Children and Safeguarding in County Durham from 14 November 2016. The CQC looked at the role of healthcare providers and commissioners over a five day period. The draft report has been received by the Trust for factual accuracy and comments have been submitted to the Commissioners accordingly.

ACTION PLAN PROGRESS

Action Details MUST DO SHOULD

DO

Completed Actions 38 30

Partially complete

(initial action date has been completed but further

action being followed through)

2 1

On-going (including those behind schedule) 2 2

Total Number of Actions (75) 42 33

Must Do Actions

Partially complete action: record-keeping and care planning (two actions)

Monthly data has been collected via Quality Matters ward audits which generally demonstrates compliance with Trust record-keeping and care standards. Themes where compliance requires improvement concern falls discharge and nutrition which have been the focus of Back to Practice check during February and March 2017

In addition to the above, the Senior Nurses, Midwifery and AHP Leadership Group are reviewing futher options to improve standards and will focus efforts on delivering education on care planning to wards. Matrons are also considering, with a view to implementing, care plans with ‘considerations’ which will prompt patient individualisation of care plans.


On-going ‘must do’ actions are set out as follows:

Area Action / progress No of

actions

End of life care – out of hours support

North Durham and DDES have approved a pilot for OoH support. Commissioners are finalising the details of a one year pilot with Marie Curie this week (13 March 2017). The details are to be confirmed but it is understood there will be two levels of support; level 1 from Marie Curie Specialist nurses and Level 2 from Consultants based in Newcastle.

Darlington had decided not to take part in the regional arrangements for OoH and will commission this separately from St Theresa’s Hospice. Details of this to be confirmed.

1

Paediatric nurse cover in A&E

Paediatric Nursing Cover in the Emergency Department at Darlington Memorial Hospital (DMH) is in place for 12 hours per day, as approved by ECL. However, there is a need for more robust, transparent management of the rotas around this.

At University Hospital North Durham (UHND), there have been some staffing issues; a member of staff is on maternity leave (this post is not being backfilled as the member of staff returns in May 2017). A Band 5 vacancy has been filled and the post holder commences employment this week (13 March 2017). Emergency Department has an existing band 6 paediatric nurse to cover some shifts. It is, however, expected to take until May (when the nurse on maternity leave returns) for the Trust to be able to sustain 12 hour cover within the Emergency Department.

1

Should Do Actions

On-going ‘should do’ actions are as follows:

Area Action No

Supervisory time for ward sisters

Reports are being produced; the amount of management time on wards varies according to nursing vacancies and patient activity and this is being reviewed on a ward to ward basis. There are plans to review E-rostering shift options, to clearly record management team for reporting purposes, but this is a longer term action.

Dedicated management time is in place in most areas but is dependent on patient demand.

1

College of Emergency Medicine audits

Follow –up audits of specific areas are planned but have been delayed because of patient demand and medical staff capacity within the Emergency Departments. The Clinical Audit team will work with the Care Group to plan in these audits for early in 2017/18.

1


ASSURANCE

The following assurance processes are in place. However, as noted in the covering paper, work has commenced on a risk assessment which will inform focused, independent assurance checks using peer review and review by senior nurses on Back to Practice Fridays over the next few weeks and it is recommended that the results of this work are reviewed by IQAC in an additional meeting convened for this purpose.

Quality Matters

A monthly audit, covering 16 quality domains is completed for every ward. In the main the teams involved are from the ward itself, although the system is designed to ensure that one team member is independent. Monthly reports are being taken to the Senior Nurses, Midwifery and AHP Leadership Group and work is being done to highlight month on month trends by ward and theme.

Back to Practice

Back to Practice Fridays have been refreshed and reinvigorated with teams focusing on going home and transfer procedures for two weeks from end of November. The Director of Nursing leads these days, with between 6 and 12 senior nurses, plus Associate Directors of Nursing typically involved in carrying out live checks on wards and providing real-time advice and coaching where improvements are needed.

Back to Practice days have will continue to focus on fridge temperature checks, resuscitation trolley checks and preoxygen flow meters as specifics as well as record keeping and care planning.

Mock Inspections

Mock inspections of the DMH and UHND sites were undertaken in December 2016 and January 2017. The findings from the mock inspection have been shared with the clinical areas. Each area has produced action plans and Back to Practice sessions in March will check on implementation of the actions. The action plans have been sense checked and challenged by ARC where relevant.

Matrons have been closely involved in the production of the action plans, and key themes have been the subject of detailed discussion at the Senior Nurses, Midwives and AHPs Group. As a result of these discussions, senior nurses will be holding a dedicated session to look at simplying and improving care planning and will use ‘Perfect March’ as an opportunity to improve discharge management and documentation.

COMMUNICATION AND PREPARATION

The Director of Nursing has developed presentations to prepare nursing staff for inspections under the new inspection process from the first quarter of 2017/18, with key communication events planned for February as follows:

24th March: Part of the Quality Accounts event will be given over to sharing of good practice between wards and by theme;

28th March: The Senior Nurses Away Day will receive presentations on the CQC Care Standards and the inspection process and there will be a series of events where all wards and teams will be encouraged to share good practice with each other. Intentionally, there will be an emphasis on encouraging staff to celebrate what we do well and where we are improving, both as part this wider group and with CQC inspectors as and when they come on site, in addition to sharing learning.

The Director of Nusing and the Communications Manager have agreed a programme of communications as follows:

Key messages to be advised through ECL (23rd March 2017)


Podcast to all staff from the Director of Nursing with key messages (week commencing 27th March), supported by the staff bulletin and screen savers.

‘Countdown’ presentation covering essential preparations to be delivered to senior nurses and ward sisters as part of the event on 28th March 2017.

Communications staff will attend the event on 28th March and will produce posters for wards and teams covering both what they are proud of and their quality improvement priorities.

Prompt cards / briefing materials to be issued to ward sisters to aid briefing to their teams with key messages in line with the Appendix to this paper.

Welcome packs to be prepared for the wards to provide to CQC, with key information. These will be issued according to a prioritised risk assessment, given that unannounced inspections could take place from April onwards.

The Trust’s vision, values and strategic objectives are being communicated through presentations and on TV screens and directly to wards.

Conclusion

The Board is asked to note the current position, and the communication plans outlined in the attached

report.

The Board is asked to approve the recommendation for an additional meeting of IQAC in the first half of

April to review the risk assessment and confirm the assurance available for each service.


APPENDIX – KEY MESSAGES FOR BRIEFING AND / OR PROMPT CARDS

Materials will cover:

The inspection process, domains and areas covered

Don’t be afraid of the inspectors, be open, share what we do well and don’t be afraid to correct any

misunderstandings

Sing your own and your team’s praises (linked to the achievements prompt cards)

Key actions to get ready

Being at our best (messages about keeping the ward tidy, having basic checks up to date, escalating

dirt to cleaners etc

One or two prompt cards around the Board / Trust’s quality agenda and improvements in recent year

The key content of some of the above will include:

Inspection coverage

Safe:

Clinical area’s track record on safety, and lessons learned (examples from recent incidents on the ward or elsewhere)

Systems to keep people safe (equipment, including resus, medicines, health and safety, medical gases, waste, mandatory training in safe systems, care plans written to keep people safe

Risk assessment to keep people safe – including staffing, temporary staffing and handover

Emergency preparedness, awareness of risks in the area

Safeguarding processes and training

Effective:

Policies, procedures, guidelines and compliance with NICE and evidence-based standards

Use of IT to support delivery of care and evidence-based practice

Support for patients under the Mental Health Act

Nutrition

Pain management

Needs assessment and care planning

Outcomes for patients and how information on these is collected and communicated in the clinical area, and used to improve

How outcomes benchmark with others

Local and national audits and how we learn from them (accreditation and peer review also)

Qualifications, competencies, skills of staff and learning and development of staff

Teamwork, co-ordination, planning of care

Availability of all relevant information for care to staff

Consent

Caring

Dignity and privacy, respect and compassion

Involvement of patients and families in their care

Emotional support to patients and families


Responsiveness

Service planning to meet the needs of various people

Responsiveness of services to those with dementia and / or learning disabilities

Responsiveness to urgent needs

Access to services at times which are convenient, as far as possible,

Cancellations and delays

Timeliness

Responsiveness to concerns and complaints and learning from them

Well-led

Vision, strategy, values, performance management framework, governance, visibility of senior leaders

Resolution of quality related risks

Assurance arrangements

Leadership and culture (visibility, supportive approach)

Service improvement

The inspection process

Unannounced in the main

Inspectors and clinicians like you

Interviews with staff and patients, observations, review of records

Staff should be open and not be afraid of inspectors,

If inspectors misunderstand anything, please politely challenge and correct their understanding

Let them know what we do well

If you don’t have information to hand, say you will get it to them and ask for help (ward sister, who can escalate up the line)

Singing your praises (and your teams)

We all do some things very well and should be proud of them

On this ward, we have…. (what we are proud of)

Key actions in readiness

Brief all staff

Encourage open discussion on questions and concerns

Share the good practice

Share the clinical area’s challenges (and actions being taken) and priorities for improvement

Share good stories re improvement

See next slide

Know that the key issues were last time and what has been done to address them

Being at our best

Keep the area tidy and clean (escalate issues to cleaners) and notices etc. up to date

Ensure equipment checks are up to date and issues have been actioned and evidenced

Keep medicines and equipment secure and locked away when appropriate

Observe hand hygiene technique and bare below the elbows

Meet them with a smile and with confidence

Information Department

CDDFT Integrated Performance Report

February 2017


Contents and Format

Experience Summary 4 Outcome Summary 23Referral To Treatment (18wks) Detail Carole Langrick 5 HCAI Detail Noel Scanlon 24

A&E Indicators Detail Carole Langrick 6 VTE Detail Noel Scanlon 25

Diagnostics (6wks) Detail Carole Langrick 7 Patient Safety Detail Noel Scanlon 26

Cancer 2WW Detail Carole Langrick 8 Readmissions within 30 Days Detail Carole Langrick 27

Cancer 31 Days Detail Carole Langrick 9 Mortality Detail Chris Gray 28

Cancer 62 Days Detail Carole Langrick 10

Cancelled Operations Detail Carole Langrick 11

Maternity Detail Carole Langrick 12

Stroke Detail Carole Langrick 13

Non Elective Admissions Detail Carole Langrick 14

Elective Inpatient Admissions Detail Carole Langrick 15

Elective Daycase Admissions Detail Carole Langrick 16

Patient Experience - Complaints Detail Noel Scanlon 17

Patient Experience - Compliments & Patient Experience Questions Detail Noel Scanlon 18

Patient Experience - Friends & Family Detail Noel Scanlon 19

Community - Contract Activity Detail Carole Langrick 20

Community - ALOS, Bed Occupancy, Detail Carole Langrick 21

Choose & Book Detail Carole Langrick 22

Efficiency Summary 29 Workforce Summary 37

Electronic Discharge Letters Detail Carole Langrick 30 Shortfall and Turnover Detail Morven Smith 38

Discharges Detail Carole Langrick 31 Essential Training and Appraisal Detail Morven Smith 39

Discharge Length Of Stay Detail Carole Langrick 32 Agency Spend and Sickness Detail Morven Smith 40

Outpatient DNA, New to Review Detail Carole Langrick 33 Finance Income and Expenditure Detail Peter Dawson 41

Audit Compliance, Late Start & Cancelled Clinics Detail Carole Langrick 34 Finance Care Group performance Detail Peter Dawson 42

Outpatient Activity Detail Carole Langrick 35 Finance Agency Cap Detail Peter Dawson 43

Digital Dictation Detail Carole Langrick 36 Finance Cost Reduction Detail Peter Dawson 44

Quality Account Summary 45

CQUIN 2016/17 Summary 46

C - Caring

E - Effective

R - Responsive

S - Safe

W - Well Led

CQC Domain Key

NOS - National Operating Standards

NQR - National Quality Requirement

LQR - Local Quality Requirement

Contents Type Director Lead PageContents Type Director Lead Page

Type Director Lead PageContents Type Director Lead Page Contents

The Integrated performance report is designed and structured to give current positions on the Organisations key performance areas as well as historical trend analysis and relevant related narrative to support assurance. • The indicators are split accordingly across the 4 Trust Touchstones as shown in the quartered contents table below • Each section is preceeded by a summary table and then includes individual detail pages • Indicators are flagged against the five CQC domains • Indicators categorised against National Operating Standards, National Quality Indicators, Local Quality Requirements or Inter nal Monitoring

Page 2

Experience

Data Kite Marking Met (Green) Not met (Red)

(All of the following) (Any or all of the following)

Signed off formally prior to publication on Board report. Not signed off formally prior to publication on Board report

Validation

Subject to agreed and documented validation procedures Supporting accuracy checks Not supported by agreed and documented validation procedures

Minimum level of records validated (KPI owner to confirm levels) Minimum level of records validated below accepted levels (KPI owner to confirm levels)

Compliance to national guidance for derivation of the indicator Derivation of indicator is not compliant to national guidance

(Any of the following reporting cycles) (Any of the following reporting cycles)

Timeliness

Whether daily, weekly, monthly quarterly or annual information is required to support

indicator – it is up to date, reviewed and reported within agreed national or local reporting

period.

Whether daily, weekly, monthly quarterly or annual information is required to support

indicator – it is not up to date, and has not been reviewed and reported within agreed

national or local reporting period.

(Parts 1 or 2 and 3 ) (Any of the following)

Predominantly supported by computerised/IT solution subject to controls to ensure data

integrity.System issues have been identified.

Reliable Manual process –supported by documented procedures (data flows mapped) Manual process – not supported by documented procedures (data flows mapped)

Recording and Reporting methodologies have remained consistent over last 12months

(unless required to support a known statutory or operational requirements.

Recording and Reporting methodologies have been subject to unexpected change since

last reporting period (not as a result of a known statutory or operational requirements). This

can result in inconsistencies in a reporting period and for comparative purposes.

(Relevant to at least one of the following) (Not relevant to any of the following)

Relevance

National Operating standard /Trust performance goal/ Strategic objective National Operating standard /Trust performance goal/ Strategic objective

(All met) (Any or all of the following)

Source data being used has no more than 5% incomplete due to blank, unknown or , invalid

data in relevant fields being used to derive the indicator (unless subject to documented and

agreed alternative tolerance levels)

More than 5% incomplete and not subject to agreed and documented alternative tolerance

levels)

Completeness

100% of source data is being used unless subject to documented and agreed exclusion

criteria. (This may include snapshot data used for reporting.)

Less than 100% of source data being used and not subject to documented and agreed

exclusion criteria)

(All) (Any or all of the following)

Data is available at appropriate level of granularity to support performance management of

the KPI (site/service/Patient level to support ) – may be provided direct to service leads or

other forums supporting the Board assurance process

Data is not provided at appropriate level of granularity to any forum

Granularity

Level of granularity provided is subject to validation processes Level of granularity provided is not subject to validation processes (record checks)

(Any of the following) (Any or all of the following)

Independent audit undertaken in last three years (internal or external)- Review of process and

procedures supporting data collection and reporting has resulted in :

Independent audit in last three years (internal or external)- Review of process and

procedures supporting data collection and reporting has resulted in :

Independent AssuranceSignificant assurance or recommendations have been completed

(supported by follow up audit)

Limited assurance or recommendations remain outstanding (supported

by follow up audit)

Where independent audit has taken place - a spot checking process in place (if not in annual

audit cycle).

Where independent audit has not taken place and is not included in

either annual audit plan or a spot-checking process.

Part of annual audit programme

Example of data kite marking graphic used in the report

The purpose of the Data Kite mark symbol is to provide continuous assurance in relation to the quality of the data being used to support the monitoring of the national operatng standards being reported to the Board. This is seen as good practice

and is recommended as part of Monitor Governance framework. This provides Board members with an ‘at a glance’ process through which to quickly understand the level of assurance being achieved and any actions being taken, where

appropriate, at indicator level. Kite Marking at this stage has been rolled out against the National Operating Standards only, as these are regularly subjected to external audit and scrutiny.

Page 3

Experience

Director Month Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTD

RTT - % Incompletes waiting <18wks R - NOS CL 92% 92.40% 93.88% 93.37% 92.56% 92.33% 93.11% 5

RTT waits over 52 weeks R - NQR CL 0 0 0 0 0 0 0 5

A&E % seen in 4hrs - Trust Total R - NOS CL 95% 91.6% 93.4% 95.4% 91.9% 89.3% 92.9% 6

A&E % seen in 4hrs - All UCC 'Walk-ins' Type 3 R - NQR CL 95% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 6

Ambulance handovers >15-30mins R - NQR CL 0 489 1547 1185 1799 1194 5725 6

Ambulance handovers >30-60mins R - NQR CL 0 182 379 239 595 549 1762 6

Ambulance handovers >60mins R - NQR CL 0 21 217 70 264 254 805 6

12 Hour Trolley Waits R - NQR CL 0 0 1 0 3 1 5 6

% Diagnostic Tests >=6wks R - NOS CL 99% 99.88% 99.76% 99.85% 99.94% 99.92% 99.86% 7

Cancer 2WW* R - NOS CL 93% 93.4% 93.3% 92.0% 94.5% 93.4% 93.2% 8

Cancer 2WW Breast Symptoms* R - NOS CL 93% 93.7% 91.0% 88.5% 96.1% 93.7% 92.1% 8

Cancer 31 Days Diagnosis to Treatment* R - NOS CL 96% 99.3% 99.4% 99.8% 99.8% 99.3% 99.6% 9

Cancer 31 Days Subsequent Treatment - Surgery* R - NOS CL 94% 97.8% 96.6% 100.0% 100.0% 97.8% 98.8% 9

Cancer 31 Days Subsequent Treatment - Anti Cancer Drug* R - NOS CL 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 9

Cancer 62 Days to First Treatment* R - NOS CL 85% 86.4% 85.5% 86.9% 83.9% 86.4% 85.5% 10

Cancer 62 Days Screening* R - NOS CL 90% 76.9% 77.3% 70.3% 80.0% 76.9% 75.0% 10

Cancer 62 Days Consultant Upgrade* R - NOS CL 85% N/A N/A 100.0% N/A N/A 100.0% 10

Patient Satisfaction (National Survey) C - NQR NS N/A

A&E % Seen in 4hrs - DMH R - LQR CL 95% 86.2% 85.4% 89.9% 87.8% 81.3% 86.6% 6

A&E % Seen in 4hrs - UHND R - LQR CL 95% 80.4% 85.7% 90.3% 78.7% 75.4% 83.3% 6

A&E CI - Unplanned Re-attendance rate R - LQR CL <=5% 0.8% 0.8% 0.9% 1.0% 0.9% 0.9% 6

A&E CI - Time to treatment (median) R - LQR CL <=01:00 00:37 00:37 00:35 00:37 00:38 00:36 6

Ambulance Handovers - no. >120 minutes R - LQR CL 0 1 30 1 36 37 104 6

Maternity 12 week bookings R - LQR CL 90% 90.7% 90.1% 90.9% 89.98% 89.87% 90.2% 12

Stroke - 90% of time on a stroke unit* E - LQR CL 90% 93.0% 91.4% 87.2% 88.3% 93.0% 89.6% 13

Stroke - CT scan within 24 hours* E - LQR CL 90% 95.7% 97.8% 94.8% 94.8% 95.7% 95.9% 13

Sleeping accommodation - failure to agree EMSA (mixed sex accommodation) plan C - LQR NS 0 0 0 0 0 0 0 N/A

Sleeping accommodation - breach of an EMSA (mixed sex accommodation) milestone C - LQR NS 0 0 0 0 0 0 0 N/A

Sleeping Accomodation Breach C - NQR NS 0 0 0 2 0 0 2 N/A

Choose and Book ASI % of DBS Bookings ** R - LQR CL 4% 19.6% 16.5% 23.4% 21.6% 19.8% 22

Cancelled Operations - Breaches of 28 Days R - NQR CL 0 2 1 3 0 2 6 11

Urgent Operations cancelled for 2nd time R - NQR CL 0 0 0 0 0 0 0 N/A

Community nursing - urgent and OOH referral waiting times* (72 hr target) R - LQR CL 93% 92.2% 91.5% 92.2% 91.3% 92.2% 91.8% N/A

Community nursing - non-urgent referral waiting times* (72 hr target) R - LQR CL 62% 59.0% 62.8% 60.3% 58.0% 59.0% 60.1% N/A

Experience

Month: February 2017 * One month in arrears ** Two months in arrears

Indicator

CQC Domain/

Touchstone Target

2016/17

Page

Page 4

Experience

Specialty / TargetGeneral Surgery 3429 381 88.9% Jul-15 6451 11933

Urology 346 34 90.2% Aug-15 6059 12409

Trauma & Orthopaedics 3093 379 87.7% Sep-15 6373 12119

Ear, Nose & Throat (ENT) 1153 22 98.1% Oct-15 6652 11818

Ophthalmology 1728 200 88.4% Nov-15 6766 11271

Oral Surgery 292 8 97.3% Dec-15 6760 10768

NHSI Trajectory May Jun Jul Aug Sep Oct Nov Dec Jan Feb Neurosurgery 0 0 0% Jan-16 7064 11212

52 Week Wait Trajectory 1 0 0 1 0 0 1 1 0 0 Plastic Surgery 628 41 93.5% Feb-16 6826 11159

Performance 0 0 0 0 0 0 0 0 0 0 Cardiothoracic Surgery 6 0 100.0% Mar-16 6864 11435

18 weeks RTT May Jun Jul Aug Sep Oct Nov Dec Dec Dec General Medicine 485 33 93.2% Apr-16 6916 11744

Total Patients Waiting 21361 21361 21361 21361 21361 21361 21361 21361 21361 21361 Gastroenterology 931 58 93.8% May-16 6708 12413

Waiting Over 18 wks 1400 1400 1400 1400 1400 1500 1500 1500 1500 1500 Cardiology 1095 34 96.9% Jun-16 6706 12034

NHSI Trajectory 93.4% 93.4% 93.4% 93.4% 93.4% 93.0% 93.0% 93.0% 93.0% 93.0% Dermatology 1890 33 98.3% Jul-16 6569 12146

Performance 94.10% 94.01% 93.94% 93.31% 92.87% 92.78% 92.56% 92.32% 92.27% 92.40% Thoracic Medicine 783 12 98.5% Aug-16 6557 12773

Neurology 72 11 84.7% Sep-16 6753 12089

Rheumatology 608 24 96.1% Oct-16 6668 12177

Geriatric Medicine 328 2 99.4% Nov-16 6432 11049

Gynaecology 1223 51 95.8% Dec-16 6346 11127

Other 2580 248 90.4% Jan-17 6419 10721

Trust Total 20670 1571 92.4% Feb-17 6394 10713

Referral to Treatment within 18 weeks for Incomplete

Pathways. Financial consequence at Specialty and CCG

level.

IP OP

Key: Green = achieved both NHSI trajectory and the national standard; Amber = failed either NHSI or national

standard; Red = failed both NHSI and the national standard

Month End Waiters

(Stage of Treatment)

Month

Referral To Treatment (18 weeks)National Operating Standards / NHSI

RequirementsCQC Domain: Responsive

Incomplete Pathways

Target 92%Feb-17

> 18

WksTotal

% < 18

Wks

80%

85%

90%

95%

100%

Feb

-16

Mar

-16

Ap

r-16

May

-16

Jun

-16

Jul-

16

Au

g-16

Sep

-16

Oct

-16

No

v-16

De

c-1

6

Jan

-17

Feb

-17

Incomplete % Within 18 weeks - Surgical Specs

Trust Total Target General SurgeryUrology Trauma & Orthopaedics Ear, Nose & Throat (ENT)Ophthalmology Oral Surgery Plastic Surgery

90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

100%

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Incomplete % Within 18 weeks - Medical Specs

Trust Total Target General Medicine Gastroenterology

Cardiology Dermatology Thoracic Medicine Geriatric Medicine

Comment: Since August, performance has fallen short of the NHSI STF trajectory but has remained above the 92% national standard. The Trust expects this trend to continue for the remainder of the financial year. During April 2016 – February 2017, referrals fell by 2.2% (GP by 2.1%, non-GP by 2.4%). Since the introduction of the North Durham CCG referral triage system in October (focussing on six Specialties), GP referrals from that CCG have fallen 5.7%. Of the Specialties focussed on only ENT has avoided a significant fall in referrals. However, over the same period, DDES GP referrals fell 8%, and Darlington GP referrals fell by 7%, including falls in the same Specialties focussed on by North Durham. These trends have been partly balanced by growth in referrals from other CCGs. The number of patients on the in-patient waiting list has remained stable over the last 19 months although the out -patient waiting list is lower than at any time since December 2015. Actions: - Action Plans are monitored through the weekly RTT Assurance meeting. Only Integrated Adult Care is ahead of its year-end backlog target but all Care Groups apart from Surgery are ahead of the 92% national target as at 28th Feb. Surgery stands at 89.7% and continues to be in formal escalation for RTT performance. All Surgery Service Managers provided assurance to Executives at a recent Performance Review that they would achieve their backlog targets and the national standard by the end of March.

Page 5

Experience

Feb-17

A&E Clinical Indicator/MeasureA&E % seen in 4hrs - Trust Total >=95% 91.6% 89.3% 92.9%

A&E % seen in 4hrs - DMH Type 1 >=95% 86.2% 81.3% 86.6%

A&E % seen in 4hrs - UHND Type 1 >=95% 80.4% 75.4% 83.3%

A&E % seen in 4hrs - All UCC 'Walk-ins' Type 3 >=95% 100.0% 100.0% 100.0%

A&E Attendances - Trust Total 19,121 41,147 254,688

A&E Attendances - DMH Type 1 4,307 9,266 55,370

A&E Attendances - UHND Type 1 5,161 10,856 63,636

A&E 4hr Wait Target Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Ambulance Handovers - Trust Use of Screens % >=95% 91.2% 89.1% 89.3%

NHSI Trajectory 91.62% 93.19% 95.46% 96.78% 96.62% 96.55% 95.73% 93.75% 90.91% 88.00% 87.00% Ambulance Handovers - DMH Use of Screens % >=95% 91.2% 89.4% 87.4%

Performance 91.62% 93.19% 95.48% 95.16% 95.70% 95.37% 94.32% 91.82% 89.53% 87.30% 91.60% Ambulance Handovers - UHND Use of Screens % >=95% 91.2% 89.0% 90.6%

Ambulance Handovers - no. 30-60 minutes 0 182 549 1,762

Ambulance Handovers - no. 60-120 minutes 0 20 217 701

Ambulance Handovers - no. >120 minutes 0 1 37 104

Ambulance Handovers - % <30 minutes 100% 83.2% 76.5% 81.7%

A&E CI - Unplanned Re-attendance rate <=5% 0.8% 0.9% 0.9%

A&E CI - Total Time (95th percentile) <=04:00 05:34 06:30 05:15

A&E CI - Left without being seen rate <=5% 1.7% 2.1% 1.9%

A&E CI - Time to initial assessment (95th percentile) <=00:15 00:54 01:15 01:01

A&E CI - Time to treatment (median) <=01:00 00:37 00:38 00:36

12 Hour Trolley Waits 0 0 1 5

Key: Green = achieved both NHSI trajectory and 95% standard; Amber = failed either NHSI or 95% national

standard; Red = failed both NHSI and the 95% national standard

A&E 4hr Target, Activity, Ambulance Handover,

Clinical Indicators and 12 Trolley Waits

YtD

National Operating Standards / NHSI


Accident & Emergency Target Month Qtr

65%

70%

75%

80%

85%

90%

95%

100%

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

A&E 4hr Performance (Against STF Target)

DMH 4hr % UHND 4hr %Trust 4hr % (including UCC) STF Trajectory

4,000

4,500

5,000

5,500

6,000

6,500

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

A&E Activity - Type I Attendances

DMH Current Year UHND Current Year

DMH Previous Year UHND Previous Year

0

100

200

300

400

500

600

700

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Ambulance Handover- Trust over 30 mins split

Handovers >30-60mins Handovers >60-120mins

Handovers >=120mins Zero Tolerance - Over 30mins

Comment In Apr 16 -Feb 17, A&E attendances grew by 0.6% compared to the same period in 2015 (-0.7% at DMH and 1.7% at UHND). In February, attendances fell by 10.8% including falls at both sites, whilst NEAS ambulance arrivals fell by 2.4%, including 1.2% at DMH and 3.3% at UHND. 85.8% of handovers at DMH took place within 30 mins; at UHND the figure was 81.5%. The comparable figures in Feb 2016 were 46.4% (DMH) and 72.2% (UHND). Actions: The Trust submitted an appeal to NHSI as to why it should not be penalised for failing to achieve the 4-hr wait trajectory in Q3. If the Appeal is unsuccessful the Trust still has an opportunity to earn back any monies lost in Q3. A&E 4-hour performance has improved considerably in February and this trend has accelerated in March. As at 13th, the Trust averaged 23 breaches per day in March. If this performance continues it may be sufficient to earn back any monies lost in Q3. The improvement in Q4 is due to the fall in activity and to the Perfect Month in March. Since 2nd March, the Trust has achieved the 95% target every day. On 4th March DMH ED achieved 100%. UHND ED did the same on 8th March. Since the start of the month the Trust has been consistently in the top 10 out of 134 Trusts nationally. For the period 6th- 12th March it was at number six nationally. As at 13th March, performance for March is 96.89%. Weekly metrics in March show significant improvements not only in 4-hour waits but in a range of associated indicators including shorter: time taken to be seen by a clinician, trolley waits, time taken to decision to admit; and fewer GP admissions diverted to A&E.

Page 6

Experience

Feb-17 Activity Waiters <6 Wks %

Modality / Target 99%Magnetic Resonance Imaging 1,197 902 0 100.00%

Computed Tomography 3,151 1,356 0 100.00%

Non-obstetric ultrasound 4,817 2,940 0 100.00%

Barium Enema 1 3 0 100.00%

DEXA Scan 211 328 0 100.00%

Audiology - Audiology Assessments 1,137 162 0 100.00%

Cardiology - echocardiography 1,346 435 0 100.00%

Cardiology - electrophysiology 0 0 0 N/A

Neurophysiology - peripheral neurophysiology 57 100 0 100.00%

Respiratory physiology - sleep studies 101 47 0 100.00%

Urodynamics - pressures & flows 18 19 0 100.00%

Colonoscopy 449 360 6 98.33%

Flexi sigmoidoscopy 346 183 3 98.36%

Cystoscopy 114 45 0 100.00%

Gastroscopy 537 417 0 100.00%

Trust Total 13,482 7,297 9 99.88%

NHSI Trajectory May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Total Patients Waiting 7641 7641 7641 7641 7641 7641 7641 7641 7641 7641

Patients Waiting < 6 Weeks 40 40 40 40 40 70 70 70 70 70

NHSI Trajectory 0.5% 0.5% 0.5% 0.5% 0.5% 0.9% 0.9% 0.9% 0.9% 0.9%

Performance 0.1% 0.4% 0.2% 0.2% 0.1% 0.1% 0.0% 0.0% 0.0% 0.1%Key: Green = achieved both NHSI trajectory and national standard; Amber = failed either NHSI or

national standard; Red = failed both NHSI and the national standard

National Operating Standards / MONITOR

Requirements

Waiters

>6 Wks

% of Diagnostic Patients waiting over 6 weeks for

their test. Financial consequence at Trust and CCG

level.

CQC Domain: Responsive

Diagnostic Waiters

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Activity

Trust Total

6500

7000

7500

8000

8500

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Waiters

Trust Total

Comment: Diagnostics waits remain stable and within target. Endoscopy booking is due to be centralised in the Central Booking Team in April. This will strengthen operational grip on waiting times for the diagnostic element of the 18 week RTT pathway. A recent change in national guidance regarding the use and payment of locums has given rise to a potential threat to the Trust's breast service in April. This service relies on radiology scanning capacity, about 50% of which is provided by locum staff. General radiology reporting capacity will also be badly affected. Urgent discussions, including HR and legal advice, are taking place to try to reach a rapid resolution.

Page 7

Experience

Referrals for Suspected Cancer

Jan-17

Target 93.0% 93.0%No Site Recorded 0 0 N/A N/A N/A

Acute Leukaemia 0 0 N/A N/A N/A

Bone Cancer 0 0 N/A N/A N/A

Brain/CNS Cancer 0 0 N/A N/A N/A

Breast Cancer 278 4 98.6% 98.6% 96.5%

Children's cancer 1 0 100.0% 100.0% 86.7%

Gynaecological Cancer 112 2 98.2% 98.2% 96.5%Haematological Cancer 17 0 100.0% 100.0% 98.3%Head & Neck Cancer 96 3 96.9% 96.9% 96.8%Lower GI Cancer 258 60 76.7% 76.7% 83.1%Lung Cancer 56 0 100.0% 100.0% 97.6%Other Cancer 0 0 N/A N/A 100.0%Sarcoma 0 0 N/A N/A N/ASkin Cancer 327 12 96.3% 96.3% 94.4%Unknown Primary Cancer 0 0 N/A N/A N/AUpper GI Cancer 171 10 94.2% 94.2% 93.7%Urological Cancer 56 0 100.0% 100.0% 94.4%Urological Cancer - Testicular 0 0 N/A N/A N/ATrust Total 1,372 91 93.4% 93.4% 93.2%

Referrals for Breast SymptomsBreast Symptomatic 175 11 93.7% 93.7% 92.1%

% patients seen within two weeks of an urgent

GP referral for suspected cancer. % patients seen

within two weeks of an urgent referral for breast

symptoms where cancer is not initially suspected

YTD

PerformanceNational Operating Standards / MONITOR


Cancer 2 Week Waits (2ww) VolumeTotal

BreachedPerformance

Qtr 4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nov-16Dec-16 Jan-17 Nov-16Dec-16 Jan-17 Nov-16Dec-16 Jan-17 Nov-16Dec-16 Jan-17

Breast Cancer Lower GI Cancer Skin Cancer Upper GI Cancer

Cancer 2 Week Waits for Selected Tumour Groups

60%

65%

70%

75%

80%

85%

90%

95%

100%

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Trust Cancer 2 Week Wait Trend

2 Week Wait Breast Symptomatic Target

Comment - Cancer 2ww: The Trust achieved the Quarter 3 (Q3) target with a performance of 94.51% and is currently well placed to meet the Q4 target. In addition to the January figures shown in the Table, February performance is close to being fully validated and stands at 95.5%. Themes for breaches of this target in January and February were: - patient choice (all patients have been offered at least one appointment in target). - some capacity issues were experienced in lower GI, especially with straight to test referrals Comment - Breast Symptomatic: The Trust achieved the Q3 target and is well placed to meet the Q4 target. The reasons for breaches of this target in Q3 and January were a combination of capacity and patient choice. Although a small service has now re-started in Sunderland it has done little to stem the flow of referrals to CDDFT clinics. Regional discussions have not resulted in any significant agreement regarding joint working between Trusts using a hub and spoke model based on the screening centres. The Trust continues to make extensive use of the independent sector to achieve waiting time targets.

Page 8

Experience

First Definitive Treatment

Jan-17

Target 96.0% 96.0%No Site Recorded 0 0 N/A N/A N/A

Acute Leukaemia 0 0 N/A N/A N/A

Bone Cancer 0 0 N/A N/A N/A

Brain/CNS Cancer 0 0 N/A N/A N/A

Breast Cancer 20 0 100.0% 100.0% 100.0%

Children's cancer 0 0 N/A N/A N/A

Gynaecological Cancer 4 0 100.0% 100.0% 100.0%Haematological Cancer 13 0 100.0% 100.0% 100.0%Head & Neck Cancer 3 0 100.0% 100.0% 95.2%Lower GI Cancer 21 0 100.0% 100.0% 98.6%Lung Cancer 19 0 100.0% 100.0% 100.0%Other Cancer 2 0 100.0% 100.0% 100.0%Sarcoma 0 0 N/A N/A 100.0%Skin Cancer 38 1 97.4% 97.4% 99.8%Unknown Primary Cancer 0 0 N/A N/A N/AUpper GI Cancer 12 0 100.0% 100.0% 99.0%Urological Cancer 14 0 100.0% 100.0% 100.0%Urological Cancer - Testicular 0 0 N/A N/A N/ATrust Total 146 1 99.3% 99.3% 99.6%

Subsequent TreatmentsSurgery (Target: 94%) 45 1 97.8% 97.8% 98.8%Drug (Target: 98%) 32 0 100.0% 100.0% 100.0%

% patients receiving first definitive treatment

within one month of decision to treat following a

cancer diagnosis. % patients receiving subsequent

surgery or drug treatments for cancer within 31

days

YTD

PerformanceNational Operating Standards / MONITOR


Cancer 31 Day Waits Volume Total Breached PerformanceQtr 4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nov-16 Dec-16 Jan-17 Nov-16 Dec-16 Jan-17 Nov-16 Dec-16 Jan-17 Nov-16 Dec-16 Jan-17


Cancer 31 Day Waits for Selected Tumour Groups

93%

94%

95%

96%

97%

98%

99%

100%

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

Trust Cancer 31 Day Wait Trend

31 Day Wait Sub Treat Surgery Sub Treat Drug Target

Comment This standard continues to be unproblematic due to the fact that it involves pathways which are wholly within the control of the Trust.

Page 9

Experience

Referrals for Suspected Cancer

Jan-17

Target 85.0% 85.0%No Site Recorded 0.0 0.0 N/A N/A N/A 0

Acute Leukaemia 0.0 0.0 N/A N/A N/A 0

Bone Cancer 0.0 0.0 N/A N/A N/A 0

From an urgent GP referral for suspected cancer Brain/CNS Cancer 0.0 0.0 N/A N/A N/A 0

From an NHS Screening Service referral Breast Cancer 17.0 0.0 100.0% 100.0% 97.6% 0

From a consultant upgrade Children's cancer 0.0 0.0 N/A N/A N/A 0

Gynaecological Cancer 4.5 0.5 88.9% 88.9% 81.3% 0Haematological Cancer 6.0 1.0 83.3% 83.3% 76.5% 0Head & Neck Cancer 4.0 3.0 25.0% 25.0% 40.7% 1Lower GI Cancer 10.0 1.0 90.0% 90.0% 82.4% 6Lung Cancer 14.5 5.0 65.5% 65.5% 67.9% 1Other Cancer 1.5 0.0 100.0% 100.0% 81.8% 0Sarcoma 0.0 0.0 N/A N/A 50.0% 0Skin Cancer 23.5 0.5 97.9% 97.9% 98.5% 2Unknown Primary Cancer 0.0 0.0 N/A N/A N/A 0Upper GI Cancer 10.0 1.0 90.0% 90.0% 77.5% 2Urological Cancer 8.5 1.5 82.4% 82.4% 75.7% 3Urological Cancer - Testicular 0.0 0.0 N/A N/A N/A 0Trust Total 99.5 13.5 86.4% 86.4% 85.5% 15

Non GP ReferralsScreening (Target: 90%) 6.5 1.5 76.9% 76.9% 75.0%Consultant Upgrade (Target: 85%) 0.0 0.0 N/A N/A 100.0%

NHSI Trajectory Apr May Jun Jul Aug Sep Oct Nov Dec

Total Patients Seen 105.5 96.5 91.5 115.5 99 112.5 114.5 94.5 89

> 62 Days Wait 88 81 78 99 83 96 98 81 76

NHSI Trajectory 83.4% 83.9% 85.2% 85.7% 83.8% 85.3% 85.6% 85.7% 85.4%

Performance 85.63% 84.51% 86.21% 86.21% 88.46% 86.18% 83.64% 80.50% 87.91%

NHSI Trajectory Jan Feb Mar

Total Patients Seen 86.5 92.5

> 62 Days Wait 74 79

NHSI Trajectory 85.5% 85.4% February Provisional

Performance 86.43% 83.78%

Key: Green = achieved both NHSI trajectory and national standard; Amber = failed either NHSI or national standard; Red = failed both

NHSI and the national standard

% patients receiving first definitive treatment for cancer

within 62 days:

Pts Waiting

104 Days Or

More

YTD

Performance

National Operating Standards / NHSI Requirements CQC Domain: Responsive

Cancer 62 Day Waits VolumeTotal

BreachedPerformance

Qtr 4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nov-16 Dec-16 Jan-17 Nov-16 Dec-16 Jan-17 Nov-16 Dec-16 Jan-17 Nov-16 Dec-16 Jan-17


Cancer 62 Day Waits for Selected Tumour Groups

Comment - 62 day urgent GP referral: As predicted, the Trust fell short of the NHSI trajectory for Q3 with a performance of 83.28% as a result of which it had to make an appeal to NHSI to avoid the penalty. The outcome of the appeal is not yet known . The Trust anticipates that losses will be restricted to those incurred in October and November. Performance recovered in December and January and although February shows as below target validation is not complete. Actions: As part of the Appeal to NHSI the Trust had to submit an Action Plan to demonstrate how it would recover. This is now being implemented and monitored through the weekly RTT meeting. Care group managers receive daily reports of patients with 21 days or less to go in their pathway to proactively manage these potential breaches. Other key actions in train include: redesigned referral forms with the target date included; increased capacity for CT guided biopsies; start of a local EBUS service to avoid the need to made referrals to North Tees; planned pilot in Darlington for patients with suspicious chest X -Ray to be sent directly to CT; redesigned prostate pathway. Comment - 62 day screening: As shown in the Table opposite, performance has fallen short in the month, quarter and year to date. The Trust is likely to f all short of the target at year end. The very small numbers using this pathway make the percentage target very high risk every month.

Page 10

Experience

Feb-17 Feb-17

Specialty Reason100 100 - General Surgery 21 1 1 - ITU/HDU Bed Unavailable 2101 101 - Urology 2 2 2 - Ward Bed Unavailable 11

110 110 - Trauma & Orthopaedics 12 3 3 - Staff Unavailable 2

120 120 - Ear Nose And Throat 3 4 4 - List Over run 22130 130 - Ophthalmology 2 5 5 - Equipment Failure/Unavailable 1

140 140 - Oral Surgery 0 6 6 - Emergencies/Trauma Priority 9

160 160 - Plastic Surgery 1 7 7 - Other hospital non-clinical 1

191 191 - Pain Management 0 Trust Total 48

301 300 - General Medicine 0

502 301 - Gastroenterology 0

502 - Gynaecology 7

Trust Total 48 Feb-17Performance

Feb-17 Cancelled Ops 48

Site 28 Day Breaches 2

Bishop 0 FFCE's 5,591

Darlington 22 % Cancelled 0.9%

Shotley Bridge 0

Durham 26

Cancelled

Ops

Cancelled

Ops

Cancelled Operations



The number of last minute cancellations by the hospital for non clinical reasons. Last minute

means on the day the patient was due to arrive, after the patient has arrived in hospital or

on the day of the operation or surgery.

Cancelled

Ops

Cancelled

Ops

Comment: Cancelled operations in February fell back from their two-year January high. This has been influenced by falls in elective and non-elective admissions reducing pressure on beds. Elective in-patient FFCEs were 9.1% lower than in February 2016, whilst day cases were 10.7% down and non-elective admissions down 1%. In addition, more elective Orthopaedics work is going through the BAH Centre of Excellence where it is sheltered from non-elective pressures.

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

0

10

20

30

40

50

60

70

80

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Cancelled Operations by Month with % of FFCE's

Cancelled Ops % Cancelled

Page 11

Experience

Booked Performance Births Performance Births Performance

Month / Target 90% 60% 22.4%

Mar-16 422 91.5% 443 56.7% 443 18.5%

Apr-16 424 88.7% 446 62.8% 446 15.2%

May-16 433 90.8% 424 57.3% 424 17.2%

Jun-16 420 90.7% 403 57.3% 403 16.4%

Jul-16 440 91.6% 487 57.9% 487 19.5%

Aug-16 399 91.5% 439 57.6% 439 16.4%

Sep-16 464 89.9% 443 59.1% 443 14.9%

Oct-16 427 90.4% 436 56.2% 436 15.8%

Nov-16 428 89.5% 405 56.8% 405 17.0%

Dec-16 362 90.1% 435 59.1% 435 18.9%

Jan-17 513 89.1% 374 61.8% 374 14.4%

Feb-17 484 90.7% 364 58.0% 364 17.0%

Maternity <12 week bookings & Smoking and Breast Feeding at delivery

Maternity <12 Weeks at Booking Breast Feeding at Delivery Smoking at Delivery

Local Quality Requirement CQC Domain: Responsive

87%

88%

89%

90%

91%

92%

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

<12 Weeks & Booking

<12Weeks Target

50%

52%

54%

56%

58%

60%

62%

64%


Breast Feeding at Delivery

Breastfeeding Target

0%

5%

10%

15%

20%

25%

30%


Smoking at Delivery

Smoking Target

Comment - Bookings >12 weeks: Every booking outside of target is reviewed whilst community midwifery teams help promote early booking. Posters encouraging this are also displayed within GP surgeries. Comment - Breastfeeding Initiation: The Service constantly reviews what can be done to improve breastfeeding initiation rates. All staff training has also been reviewed and refreshed.

Page 12

Experience

Eligible Performance Eligible Performance Eligible Performance

Month / Target 90% 90% 50%

Feb-16 76 93.4% 72 90.3% 3 33.3%

Mar-16 79 81.0% 69 97.1% 29 37.9%

Apr-16 72 94.4% 75 97.3% 22 95.5%

May-16 70 91.4% 67 98.5% 17 82.4%

Jun-16 55 87.3% 36 97.2% 17 88.2%

Jul-16 41 97.6% 40 97.5% 8 87.5%

Aug-16 48 83.3% 39 89.7% 22 40.9%

Sep-16 52 82.7% 55 96.4% 17 82.4%

Oct-16 55 92.7% 62 96.8% 18 77.8%

Nov-16 78 82.1% 57 93.0% 14 64.3%

Dec-16 46 93.5% 55 94.5% 20 65.0%

Jan-17 71 93.0% 70 95.7% 10 60.0%

12 Month Total 743 89.1% 697 95.4% 197 68.02%

% of eligible Stroke patients to have spent 90% of their stay on a Stroke unit and received

scans within 24hrs and 1hr where clinically appropriate.

Stroke Care 90% Stay On Stroke Unit Scan Within 24 Hours Scan Within 1 Hour

Local Quality Requirement CQC Domain: Responsive / Caring

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

90% Stay on Stroke Unit

Perf Target

84%

86%

88%

90%

92%

94%

96%

98%

100%

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Scan within 24 Hours

Perf Target

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Scan within 1 Hour

Perf Target

Comment: Stroke remains a high risk area for medical staffing with the service heavily reliant on locums.

Page 13

Experience

Variation

Apr 15 -

Feb 16

Apr 16 -

Feb 17 %

Apr 15 -

Feb 16

Apr 16 -

Feb 17Paediatrics/Neonates 9,354 10,122 8.2% 1.5 1.3

Obstetrics/Midwife Led 7,384 6,636 -10.1% 1.6 1.9

Gynaecology 2,656 2,604 -2.0% 0.6 0.6

Surgery (Exc T&O) 8,147 8,779 7.8% 3.0 2.8

Trauma & Orthopaeds (Exc Paeds) 2,338 2,346 0.3% 6.7 7.3

RAMAC Direct Discharges 4,025 4,349 8.0% 0.0 0.0

Medicine (Exc RAMAC discharges) 27,935 27,389 -2.0% 5.7 5.6

All Medicine 31,960 31,738 -0.7% 5.7 5.6

All Non Electives 61,839 62,225 0.6% 4.0 3.9

*LOS figures includes discharges from all Trust locations

Admissions Average LOS

Non Elective Admissions across all specialties (excluding GP admissions direct into Community

Hospitals)

Specialty AreaNon Elective Admissions

Internal Monitoring CQC Domain: Responsive

0

500

1000

1500

2000

2500

3000

3500

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Non Elective Medicine Admissions

Medicine (Inpatient) Medicine (All) Medicine (Ambulatory Care)

0

100

200

300

400

500

600

700

800

900

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Non Elective Surgery Admissions

Surgery (Exc T&O) Trauma & Orthopaeds (Exc Paeds)

0

200

400

600

800

1000

1200

1400

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Non Elective Paeds/Obs/MW/Gynae Admissions

Paediatrics/Neonates Obstetrics/Midwife Led Gynaecology

Comment: All Specialty non-elective admissions fell in February by 2.9% but there were pockets of

pressure: Medical admissions rose 5.6% in total (8.8% at DMH; 3.5% at UHND); Trauma grew by 16.9% at DMH but fell by 12.5% at UHND; Surgery fell at both sites (DMH by 9.6%; UHND by 0.3%). Average length of stay for medical patients has fallen slightly on both acute sites compared to January 2016. Actions: - The Trust's Transforming Emergency Care Programme, led by the Acute and Emergency Care Group, remains the vehicle through which non-elective flow improvements are being made, monitored fortnightly. Two key current work-streams are the stranded patient reviews and the embedding of SAFER care bundles. - The Perfect Month initiative appears to have been having a significant effect on patient flow and A&E performance (see also the A&E page)

Page 14

Experience

Variation

Apr 15 - Feb

16

Apr 16 - Feb

17 %

Apr 15 - Feb

16

Apr 16 - Feb

17

Surgery (Inc Breast) 2,063 2,058 -0.2% 3.0 3.1

Urology 334 369 10.5% 1.4 1.3

Trauma & Orthopaedics 1,842 2,063 12.0% 3.4 3.3

ENT 755 678 -10.2% 1.0 1.0

Ophthalmology 242 215 -11.2% 2.1 1.4

Oral 93 115 23.7% 0.4 0.5

Plastics 737 598 -18.9% 2.0 2.1

Medicine 494 523 5.9% 8.4 5.6

Paediatrics 115 83 -27.8% 1.4 1.3

Gynaecology 1,036 1,076 3.9% 1.8 1.4

Others 20 17 -15.0% 1.2 0.2

All Elective in-patients 7,731 7,795 0.8% 2.9 2.6

*LOS figures includes discharges from all Trust locations

Admissions Average LOS

Elective In-patient Admissions across all specialties

Specialty Area

Elective In-patient Admissions


0

50

100

150

200

250

300

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Elective Surgery/T&O/Plastics

Surgery (Inc Breast) T & O Plastics

0

10

20

30

40

50

60

70

80

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Elective Urology/ENT/Ophthal/Oral

Urology ENT Ophthalmology Oral

0

20

40

60

80

100

120

140

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Elective Medicine/Paediatrics/Gynae/Others

Medicine Paediatrics Gynaecology Others

Comment: although elective in-patient admissions have risen marginally over the year as a whole there has been a sharp decline in Q4. Admissions in January and February are 6.4% down on the same months in 2016 , including 9.1% in February alone. This may be linked to a number of factors including a continuing trend towards day case activity, falling referrals and continuing non -elective medical pressures (although the latter eased in February). For waiting time issues, see RTT page.

Page 15

Experience

Variation

Apr 15 - Feb

16

Apr 16 - Feb

17 %

Apr 15 - Feb

16

Apr 16 - Feb

17Surgery (Inc Breast) 8,200 8,120 -1.0% 79.9% 79.7%

Urology 4,075 3,951 -3.0% 92.4% 91.5%

T&O 2,735 2,643 -3.4% 59.6% 56.2%

ENT 915 830 -9.3% 54.8% 55.1%

Ophthalmology 8,291 7,097 -14.4% 97.2% 97.1%

Oral 1,809 1,756 -2.9% 95.0% 93.8%

Plastics 3,695 3,574 -3.3% 83.3% 85.7%

Pain Mgt 1,115 1,219 9.3% 98.4% 98.6%

Gastroenterology 11,569 11,197 -3.2% 99.1% 98.9%

Cardiology 1,329 1,322 -0.5% 90.2% 93.4%

Dermatology 2,182 1,968 -9.8% 99.2% 97.6%

Rheumatology 2,501 2,643 5.7% 99.3% 99.6%

Haematology 5,533 6,089 10.0% 99.0% 99.0%

Oncology 6,514 7,056 8.3% 99.0% 99.2%

Other Medicine 1,646 1,715 4.2% 94.7% 93.2%

Paeds 131 211 61.1% 53.3% 71.8%

Gynaecology 1,817 1,828 0.6% 63.7% 62.9%

All Daycases 64,057 63,219 -1.3% 89.2% 89.0%

Admissions% Daycase Activity of all

Elective AdmissionsElective Daycase Admissions


Elective Daycase Admissions across all specialties (Includes Regular Daycases)

Specialty Area

0

100

200

300

400

500

600

700

800

900

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Elective DC Surgery/T&O/Plastics

Surgery (Inc Breast) T&O Plastics

0

100

200

300

400

500

600

700

800

900

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Elective DC Urology/ENT/Ophthalmology/Oral

Urology ENT Ophthalmology Oral

0

100

200

300

400

500

600

700

800

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Elective DC Haematology/Oncology/Gynae/Other Medicine

Haematology Oncology Other Medicine Gynaecology

Comment: Day case activity in Q4 has declined by 5.8% over January/February, including 10.7% in February alone. The reasons are likely to be the same as those behind the decline in elective in-patient activity. If this trend continues it will ease pressure on RTT performance but Care Groups will have to review capacity to achieve efficiencies and align capacity with a lower level of demand.

Page 16

Experience

Q3 2016-17

Complaints received and acknowledged by Patient Experience Officer within 3

working days 100.0%

Complaints response provided within negociated timescale 100.0%

New requests for information from PHSO 4

Number of cases closed by the PHSO 9

Number of complaints currently with Ombudsman 11

Monitoring of the timeliness of complaint responses, complaints with the ombudsman and PALs

contacts

Patient Experience - Complaints

Internal Monitoring CQC Domain: CaringComplaints and PHSO Performance Monitoring

0

100

200

300

400

500

600

700

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Complaints - Cumulative Total

2011-12

2012-13

2013-14

2014-15

2015-16

2016-17

0

5

10

15

20

25

30

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Care Group Complaints - Moving Annualised Total

IAC

Surgery

Family Health

AEC

CSS

0

200

400

600

800

1000

1200

1400

1600

1800

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

PALS Cumulative Total

2011-12

2012-13

2013-14

2014-15

2015-16

2016-17

Comment: See Patient Experience report for more detail. The top three categories for complaints during February are: clinical treatment – delay in diagnosis and treatment, misdiagnosis, nursing care; customer care; attitude of staff. The top four areas generating complaints in January and February were the same as in Q3, namely: Emergency Departments, Orthopaedics, Unscheduled Care and General Surgery Of 19 cases with the Ombudsman, two were closed (1 partly upheld & 1 not investigated); three new requests for information were received (Surgery 2, Family Health 1) and 14 are on-going.

Page 17

Experience

2012-13 3662 8360 14090 18583

2013-14 5297 11079 15602 20465

2014-15 5288 10761 16884 231122015-16 6058 13464 19542 23444

2016/17 4761 9714 15069

Q3 Q4

Monitoring of responses to patient experience questions.

Patient Experience - PALS and Compliments

Internal Monitoring/ Quality Account CQC Domain: Caring Compliments Q1 Q2

76% 88% 83% 77% 85% 81% 77% 80% 82% 81% 76%

67% 78% 71% 67% 64% 70% 63% 62% 72% 67%

83% 87% 78% 71% 81% 82% 78% 83% 85% 84% 77%

83% 87% 87% 86% 88% 89% 86% 88% 90% 86% 85%

83% 84% 80% 74% 76% 81% 79% 81% 80% 80% 79%

0%

20%

40%

60%

80%

100%

Q1

14

/15

Q2

14

/15

Q3

14

/15

Q4

14

/15

Q1

15

/16

Q2

15

/16

Q3

15

/16

Q4

15

/16

Q1

16

/17

Q2

16

/17

Q3

16

/17

Did you feel involved enough in decisions about your care and treatment?

Were you given enough privacy whendiscussing your condition or treatment?

Did you find a member of staff to discuss any worries or fears that you had?

Did a member of staff tell you about any medication side effects that you should watch out for after yougot home in a way that you could understand?

Did hospital staff tell you who you should contact if you were worried about your condition or treatmentafter you left hospital?

0

5000

10000

15000

20000

25000

Q1 Q2 Q3 Q4

Cumulative Compliments Total

2012-13

2013-14

2014-15

2015-16

2016/17

Comment: See Patient Experience report for more details. The top three categories for PALS during February 2017 are: customer care, appointments , clinical treatment. General Medicine and Respiratory Medicine were the top two areas generating PALS queries.

Page 18

Experience

Sep-16 Oct-16 Dec-16 Jan-17% Recommended 92.0% 92.0% 92.0% 92.0% 92.0% 91.0%

% Not recommended 2.0% 2.0% 2.0% 2.0% 2.0% 2.0%

Response rates - In patient & Daycase 16.3% 16.7% 18.0% 17.4% 15.8% 29.0%

Response rates - ED & UCC 17.9% 14.2% 13.5% 12.2% 13.1% 13.9%

Response rates - Maternity 30.5% 35.8% 40.5% 40.5% 31.3% 30.3%

Feb-17Nov-16

Monitoring of Family and Friends response rates and % recommended

Patient Recorded Outcome Measures: Percentage of patients who are satisfied with the outcome of

surgery

Patient Experience - Friends & Family /PROMS

Internal Monitoring/ Quality Account CQC Domain: Caring

0%

10%

20%

30%

40%

50%

60%

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

FTT Response Rates from April 2015

Inpatient ward response rate

Emergency Departments response rate

Maternity response rate

Overall monthly response rate (Emergency Departments and Inpatients)

0

20

40

60

80

100

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Inpatient Recommended/Not Recommended (%)

% Recommended % Not Recommended

0

10

20

30

40

50

60

70

80

90

100

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

Dec

-15

Feb

-16

Ap

r-1

6

Jun

-16

Au

g-1

6

Oct

-16

Dec

-16

Feb

-17

A&E Recommended/Not Recommended (%)


0

10

20

30

40

50

60

70

80

90

100

Ap

r-1

5

Jun

-15

Au

g-1

5

Oct

-15

Dec

-15

Feb

-16

Ap

r-1

6

Jun

-16

Au

g-1

6

Oct

-16

Dec

-16

Feb

-17

Maternity Recommended/Not Recommended (%)


Comment: F&F response rates remain disappointing. The corporate patient experience team are working with Wards where response rates are at their lowest. However,of patients and carers who do respond, since April 2015 between 91-95% of in-patients have always said they would recommend CDDFT as a place to receive care. The comparable figures for A&E are 83-92% (91% in February 2017); and for Maternity 82-99% (87% in February 2017). Particularly positive responses were received in relation to: - Inpatients: involvement; information; family Involvement. - A&E: cleanliness Information, family involvement

Page 19

Experience


Community Contract Activity

No ServiceJan-16 Jan-17

Contract

BaselineMonth

Contract

BaselineActual Baseline

1 District Nursing 52,309 57,409 45,330 5,100 12,080 565,556 453,2952 Community Hospitals 1,852 1,493 1,891 -359 -398 15,728 18,908

3 Intermediate Care + 1,230 1,304 457 74 847 11,853 4,5734 Podiatry 7,646 8,749 7,076 1,103 1,673 84,347 70,7585 Community Rehabilitation 1,760 1,753 1,850 -7 -97 17,222 18,503

6 Palliative Care 2,979 2,386 2,544 -593 -158 27,916 25,4387 Coronary Heart Disease 2,994 3,101 2,303 107 798 30,203 23,032

8 Adult Physiotherapy 4,167 4,122 2,769 -45 1,353 38,038 27,6909 Continence 385 498 674 113 -176 4,115 6,740

10 Adult SALT 518 658 464 140 194 5,317 4,64311 Paediatric Occupational Therapy 807 1,167 None 360 12,10512 Musculo Skeletal 699 691 605 -8 86 6,485 6,05313 Dermatology 551 1,157 939 606 218 10,703 9,39314 Nutrition & Dietetics 788 1,313 210 525 1,103 9,339 2,10315 Paediatric Physiotherapy 966 1,344 638 378 706 12,051 6,38316 Falls & Osteoporosis 788 780 400 -8 380 6,718 4,00317 Stroke 318 378 280 60 98 3,533 2,798

* Variance from Contract: Green (0-500 variance), Amber (501-999 variance), Red (1000+ variance)

YTD

Community Services Activity taken directly from the Community Block Contract

Monthly Variances *Community Services


74,00076,00078,00080,00082,00084,00086,00088,00090,00092,00094,000

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Community Contacts by Month

Comment: The future of the community services block contract continues to be the subject of negotiation with commissioners. Services will be delivered from Community Hubs but the precise configuration of services, including what services can be provided within the funding envelope available, is still to be agreed. Commissioners wish to protect District Nursing more than originally anticipated. This will have an impact on the provision of other services.

Page 20

Experience


Ward Episodes

Hospital/Ward Jan-16 Jan-17 VarianceBishop Auckland Ward 6 33 24 -9 24Chester-le-street Ward 1 19 27 8 29

Sedgefield Franziska Willer Ward 45 53 8 47Richardson Starling Ward 44 70 26 57Shotley Bridge Ward 2 17 0 23

Weardale Ward 1 25 17 -8 25Totals 183 191 8 199

Average LOS

Hospital/Ward Jan-16 Jan-17 VarianceBishop Auckland Ward 6 23.54 27.75 4.2 28.00Chester-le-street Ward 1 37.21 18.41 -18.8 23.45Sedgefield Franziska Willer Ward 13.42 10.25 -3.2 11.47Richardson Starling Ward 12.59 9.17 -3.4 9.16Shotley Bridge Ward 2 26.94 0.00 19.27Weardale Ward 1 17.87 23.65 5.8 18.33Totals 19.38 14.40 -5.0 16.06

Bed Occupancy

Hospital/Ward Jan-16 Jan-17Variance from

Target

Bishop Auckland Ward 6 90.9% 96.8% 10.9% 94.4%Chester-le-street Ward 1 99.0% 74.5% 19.0% 95.4%Sedgefield Franziska Willer Ward 74.6% 97.1% -5.4% 81.3%Richardson Starling Ward 89.6% 88.4% 9.6% 71.5%Shotley Bridge Ward 2 99.6% 0.0% 64.0%Weardale Ward 1 82.7% 76.5% 2.7% 74.9%Totals 88.9% 76.1% 8.9% 81.3%

Rolling 12

Months

Average

MonthlyRolling 12

Months

Average

Monthly (Target 80%) Rolling 12

Months

Average

Community Hospitals


Community Hospitals Analysis. Ward Episodes, Average length of Stay and Bed Occupancy

Monthly

Comment: The future use of Community hospitals is still to be determined and continues to be discussed in the context of the Community Hubs.

10

12

14

16

18

20

22

24

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Average Length of Stay in Days

70%

75%

80%

85%

90%

95%

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Bed Occupancy

Page 21

Experience

Dec-16

Month / Specialty ASIs % of Total ASIs % of Total

2WW 209 16.7% 2,729 18.6%

Cardiology 76 6.1% 597 4.1%

Children's & Adolescent Services 94 7.5% 862 5.9%

Dermatology 26 2.1% 1,047 7.1%

Diabetic Medicine 1 0.1% 42 0.3%

Diagnostic Physiological Measurement 0 0.0% 5 0.0%

Ear, Nose & Throat 83 6.6% 615 4.2%

Endocrinology and Metabolic Medicine 12 1.0% 234 1.6%

General Medicine 3 0.2% 55 0.4%

Geriatric Medicine 0 0.0% 36 0.2%

GI and Liver (Medicine and Surgery) 145 11.6% 1,199 8.2%

Gynaecology 61 4.9% 581 4.0%

Haematology 27 2.2% 204 1.4%

Neurology 11 0.9% 225 1.5%

Ophthalmology 148 11.8% 1,430 9.8%

Oral and Maxillofacial Surgery 8 0.6% 74 0.5%

Orthopaedics 126 10.0% 1,394 9.5%

Pain Management 51 4.1% 487 3.3%

Physiotherapy 8 0.6% 139 0.9%

Podiatry 1 0.1% 469 3.2%

Respiratory Medicine 0 0.0% 322 2.2%

Rheumatology 36 2.9% 578 3.9%

Sleep Medicine 59 4.7% 435 3.0%

Surgery - Breast 28 2.2% 359 2.5%

Surgery - Not Otherwise Specified 3 0.2% 65 0.4%

Surgery - Plastic 3 0.2% 53 0.4%

Surgery - Vascular 8 0.6% 122 0.8%

Urology 28 2.2% 286 2.0%

Total ASIs 1,255 14,644

% Of DBS Bookings that have resulted in an ASI (Appointment Slot Issue). Target of less than 4%,

with a staged penalty consequence applied to performance between 4 and 15%.

Choose and Book Month Year To Date

Local Quality Requirement CQC Domain: Responsive

Comment: The Trust is a national leader for the proportion of its services available on Choose and Book, and has been invited to participate in an exemplar project to demonstrate good practice and to make 100% of services available electronically. A Project Group has been established, led by the Director of Performance. This is a timely initiative as one of the 2017-18 CQUINs requires all Trusts to put 100% of services on Choose and Book by April 2018. CQUIN income will be lost if this target is not achieved.

0%

5%

10%

15%

20%

25%

30%

35%

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

% Appointment Slot Issues of DBS Bookings By Month

ASI % Target

Page 22

Outcome

Director Month Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTDClostridium difficile cases S - NQR NS 19 1 4 4 6 2 16 24

MRSA Bacteraemia S - NQR NS 0 0 0 1 2 2 5 24

MSSA S - NQR NS 1 6 7 6 3 22 24

Ecoli S - NQR NS 32 78 123 83 68 352 24

VTE* S - NQR NS 95% 96.8% 96.4% 96.9% 97.0% 96.8% 96.8% 25

Failure to publish formulary S - NQR NS Compliance N/A

Duty of candour S - NQR NS Compliance N/A

Never events S - NQR NS 0 1 3 3 1 1 8 26Certification against compliance with requirements regarding access to health

care for people with a learning disability (Q) R - NQR NS Compliance N/A

Serious Incidents reported within 2 working days of identification* S - NQR NS 100% 100% 100% 100% 100% N/A

Total number of incidents reported (Monitoring trends)* S - NQR NS 1712 4972 4931 4884 1712 16499 26

Serious Incidents Interim reports within 72 hours * S - NQR NS 100% 100% 100% 94% 100% 99% N/ASUIs reported via STEIS as a proportion of all incidents involving severe injury or

death within a Trust* S - NQR NS 6 32 23 20 11 86 N/A

Serious Incident RCAs submitted within 60 working days*** + S - NQR NS N/A

Ambulance Handovers - Trust Use of Screens % R - LQR CL >=95% 91.21% 89.53% 90.60% 87.92% 89.15% 89.28% 6

Delayed transfers of care* R CL 3.5% 0.07% 0.16% 0.11% 0.09% 0.07% 0.12% N/A

6 hour wait in Urgent Care Centres R CL 95% 99.8% 99.9% 99.8% 99.8% 99.8% 99.8% N/A


2016/17

OutcomePageCQC DomainIndicator Target

+ New national framework reporting of serious incidents from 1st April 2015: all

should be reported within 60 working days. Report updated to reflect this.

Page 23

Outcome

Feb-17

Specialty / TargetAcute & Emergency Care Group 1 12

Clinical Specialist Service Care Group 0 0

Surgery Care Group 0 1

Integrated Adult Care 0 3

Family Health Care Group 0 0

Cdiff Trust 1 16 18 -2 19 -3

Acute & Emergency Care Group 0 2 0 2 0 2

Clinical Specialist Service Care Group 0 0 0 0 0 0

Surgery Care Group 0 1 0 1 0 1

Integrated Adult Care 0 2 0 2 0 2

Family Health Care Group 0 0 0 0 0 0

MRSA Trust 0 5 0 5 0 5

Acute & Emergency Care Group 0 12





MSSA Trust 1 22

Acute & Emergency Care Group 25 288





Ecoli Trust 32 352

Health Care Associated Infections


RequirementsCQC Domain: Safe

February

Cases

Health Care Associated Infections 1. Clostridium

Difficile cases 2. MRSA bacteraemia cases 3.

MSSA bacteraemia cases 4. E. Coli infections

YTD

Cases

YTD

Target

Performance

against YTD

target

Year End

Target

Performance

against Year

End target

0

5

10

15

20

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

Cdiff Actuals and Cumulative

Cdiff Trust Cumulative Cdiff Trust

0

10

20

30

40

50

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

MSSA and Ecoli Actuals

MSSA Total Ecoli Trust

Comment: See Patient Safety Report for details.

Page 24

Outcome

Jan-17 VTE Total Performance

Specialty / Target 95%General Surgery (Breast Surgery) 1353 1418 95.4%

Urology 281 282 99.6%

Trauma & Orthopaedics 518 540 95.9%

Ear, Nose & Throat (ENT) 122 134 91.0%

Ophthalmology 502 506 99.2%

Oral Surgery 73 73 100.0%

Plastic Surgery 453 471 96.2%

General Medicine 1557 1660 93.8%

Gastroenterology 1022 1026 99.6%

Cardiology 306 329 93.0%

Dermatology 274 274 100.0%

Thoracic Medicine 257 269 95.5%

Rheumatology 204 206 99.0%

Geriatric Medicine 346 377 91.8%

Gynaecology 468 472 99.2%

Accident & Emergency 239 241 99.2%

Clinical Haematology 525 525 100.0%

Diabetic Medicine 180 190 94.7%

General Practice 76 76 100.0%

Medical & Clinical Oncology 653 655 99.7%

Obstetrics & Midwife Episode 520 530 98.1%

Pain Management 126 126 100.0%

Other 5 8 62.5%

Trust Total 10060 10388 96.8%

VTENational Operating Standards / MONITOR

RequirementsCQC Domain: Safe

% Adult inpatients with a VTE Risk Assessment on admission to Hospital (Trust) using the clinical

criteria of the national tool

93%

94%

95%

96%

97%

98%

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

VTE Risk Assessment on admission to hospital

VTE Target

Comment: There is now a more robust process in place to accurately record VTE performance, and figures over the last year suggest Care Groups have a good grip of this issue.

Page 25

Outcome

Trust

Acute &

Emergency

care

Clinical

Specialist

services Surgery

Integrated

Adult

Family

Health

Never Events 1 0 0 1 0 0

Total Incidents Reported* 1,712 485 124 291 523 177Grade 3&4 newly acquired avoidable pressure ulcers (Acute)* 0 0 0 0 0 0

Grade 2 newly acquired avoidable pressure ulcers (Acute)**** 0 0 0 0 0 0

Month February 2017 *Month in arrears

Jan-17 Falls

per 1000

Bed Days TargetTrust 196

Acute 157 6.1 5.6

Community 19 5.8 8.0

UHND 90 6.8 5.6

DMH 58 5.5 5.6

BAGH (excl w6) 9 4.8 5.6

BAGH (W6) 2 4.0 8.0

SBCH 0 6.2 8.0

CLSCH 5 6.3 8.0

WCH 1 3.8 8.0

RCH 7 8.6 8.0

SCH 4 6.3 8.0

Patient Safety

National Operating Standards & Quality

AccountCQC Domain: Responsive

0

0.5

1

1.5

2

2.5

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Never Events

Acute & Emergency Surgery

Clinical Specialist Service Integrated Adults

0

100

200

300

400

500

600

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Total Incidents Reported

Acute & Emergency Clinical Specialist ServiceSurgery Integrated AdultsFamily Health

0

20

40

60

80

100

120

140

160

180

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Falls

Falls

pe

r 1

00

0 b

ed

day

s

Falls

Acute Falls Community Falls

Acute Falls per 1000 beddays Community Falls per 1000 beddays

Comment: A Never Event was reported in February, relating to a retained item post surgery (a piece of drain in breast tissue.) The incident occurred in December 2014 but was only reported in February 2017. In addition, in March it was identified that 2 patients had an ovary removed when they were consented for conservation of ovaries. These incidents occurred in September 2010 and February 2011. Reviews have identified that this should not have happened. As a result two historic Never Events have been reported and these will show in March 2017 data. Surgical activity has been cancelled for a day in March for clinicians to attend a Never Events workshop to review how further events can be avoided. Duty of Candour compliance has been escalated to the Board as this had slipped. The latest report shows that this is back on track. Compliance will continue to be monitored via fortnightly patient safety forum and IQAC See Patient Safety Report for further comments.

Page 26

Outcome

100 - General Surgery 268 687 313 733

101 - Urology 5 3 5 5

103 - Breast Surgery 1 1 0 2

110 - Trauma & Ortho 50 149 48 126

120 - Ear Nose And Throat 48 52 33 37

130 - Ophthalmology 6 3 4 2

160 - Plastic Surgery 29 48 23 87

171 - Paediatric Surgery 2 0

180 - Accident & Emergency 79 539 70 492

214 - Paed Trauma Ortho 0 1 2 4

215 - Paediatric Ent 1 0 0 1

219 - Paed Plastic Surg 1 5 0 6

300 - General Medicine 560 2,777 566 2,699

301 - Gastroenterology 2 8 7 12

303 - Haem Clinical 5 3 1 2

307 - Diabetic Medicine 32 131 25 144

320 - Cardiology 12 50 6 48

330 - Dermatology 4 0 0 1

340 - Thoracic Medicine 4 29 3 47

420 - Paediatrics 10 172 16 182

430 - Geriatric Medicine 22 89 16 144

502 - Gynaecology 68 164 59 127

All Readmissions Within 30 Days 1,207 4,911 1,199 4,901

Following

Emergency

Following

Elective

Apr 15-Jan 16 Apr 16-Jan 17

Following

Emergency

Readmissions Within 30 Days


Emergency readmissions with 30 days of previous discharge using PBR guidance and methodology

for calculation and exclusion criteria.

Following

Elective

Specialty

-

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Spells

All Spells Emergency Spells

0%

2%

4%

6%

8%

10%

12%

14%

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Readmission Rates

Readmission Rate All Spells Readmission Rate Emergencies

-

100

200

300

400

500

600

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Readmissions Following Elective/Emergency

EM Admit Following EL Admit EM Admit Following EM Admit

Comment: Re-admissions between Apr 2016 - Feb 2017 fell by 0.3% as a result of marginal falls in re-admissions following both non-elective and elective spells. Short stay areas in surgery and medicine, and endoscopy remain the main contributors. Reclassification of Endoscopy recording from “day cases” to “Outpatients” will take place in April 2017. This should reduce the number of re-admissions considerably. The proposed Re-admissions Audit is planned for July 2017. It will be conducted by a multi-agency group of clinicians and managers . The outcome will inform decisions about where investments in community services will be most effective and will also affect Trust income from re-admissions.

Page 27

Outcome

Dec-15 4.72% 105.49 77.13 109.95

Jan-16 5.72% 122.34 123.23 130.57Feb-16 4.71% 104.87 93.65 107.63

Mar-16 4.15% 97.32 104.18 105.96

Apr-16 4.47% 111.93 92.41 112.21

May-16 3.57% 93.56 108.77 90.69

Jun-16 3.89% 106.18 96.67 106.28

Jul-16 4.06% 114.30 109.96 103.38

Aug-16 3.61% 104.52 97.89 101.46

Sep-16 3.36% 94.59 113.58 93.68

Oct-16 3.49% 90.51 102.92 107.20

Nov-16 3.79% 101.35 123.72 108.49

Rolling YTD 4.13% 104.19 103.55 106.73

Internal Monitoring CQC Domain: Effective

Mortality

MonthCrude HSMR SHMI

Weekend

HSMR

0%

1%

2%

3%

4%

5%

6%

7%

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Crude mortality

0

20

40

60

80

100

120

140

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

SHMI

HSMR Funnel Plot SHMI Timeline Funnel Plot

Comment: See Mortality Report

0

20

40

60

80

100

120

140

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

HSMR

Weekend HSMR

Page 28

Efficiency

Director Month Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTDData completeness community services - RTT* W - NQR CL 50% 99.9% 100.0% 100.0% 99.9% 99.9% 99.9% N/A

Data completeness community services - Referrals* W - NQR CL 50% 99.6% 99.6% 99.7% 99.8% 99.6% 99.7% N/A

Data completeness community services - Treatment activity* W - NQR CL 50% 99.7% 99.7% 99.7% 99.8% 99.7% 99.7% N/A

% of SUS data altered* W - LQR CL 10% 54.3% 27.6% 34.3% 48.6% 47.1% 38.4% N/A

Discharge summaries within 24 hours R - LQR CL 95% 95.2% 93.1% 94.2% 92.6% 94.3% 93.5% 30

Valid NHS number field submitted via SUS - Acute* W - LQR CL 99% 99.6% 99.7% 99.7% 99.6% 99.7% 99.7% N/A

Valid NHS number field submitted via SUS - A&E* W - LQR CL 95% 98.5% 98.7% 98.7% 98.6% 98.8% 98.7% N/A

Efficiency

Page

CQC Domain/

Touchstone


2016/17

Indicator Target

Page 29

Efficiency

Feb-17 Within 24 Hrs Within 96 Hrs Not Signed off

Specialty / Target 95%General Surgery (Breast Surgery) 95.81% 96.76% 2.50%Urology 99.01% 99.50% 0.00%

Trauma & Orthopaedics 95.38% 96.67% 1.48%

Ear, Nose & Throat (ENT) 96.50% 97.50% 1.50%Ophthalmology 96.58% 98.74% 1.08%

Oral Surgery 93.94% 95.96% 4.04%

Plastic Surgery 92.75% 93.39% 5.76%

Accident & Emergency 98.68% 98.68% 0.66%

General Medicine 91.38% 94.23% 3.58%

Gastroenterology 98.89% 99.19% 0.60%

Clinical Haematology 99.11% 99.11% 0.89%

Diabetic Medicine 92.15% 93.72% 3.14%

Cardiology 90.63% 92.75% 3.32%

Dermatology 98.65% 98.65% 1.35%

Thoracic Medicine 91.27% 93.45% 5.24%

Medical & Clinical Oncology 99.78% 99.78% 0.22%

Rheumatology 98.37% 98.37% 1.22%

Geriatric Medicine 91.40% 92.47% 5.02%

Pain Management 100.00% 100.00% 0.00%

Paediatrics 93.78% 95.18% 3.05%

Obstetrics & Midwife Episode 95.45% 96.24% 3.56%

Gynaecology 92.89% 96.03% 2.51%

Other 92.03% 92.75% 5.07%

Trust Total 95.16% 96.43% 2.44%

Electronic Discharge Letters

Local Quality Requirement CQC Domain: Effective

Electronic Discharge summaries arriving within 24 hours

75%

80%

85%

90%

95%

100%

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Within 24 Hrs

Within 24 Hrs Target

75%

80%

85%

90%

95%

100%

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Within 96 Hrs

Within 96 Hrs

0%

1%

1%

2%

2%

3%

3%

4%

4%

5%

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Not Signed Off

Not Signed Off

Comment: For the first time, performance in February exceeded the 95% target for the month. Three of the four Care Groups to whom this target is relevant exceeded 95%. Only Family Health fell short at 94.4%. This follows a year in which the Trust consistently exceeded 90%; the last month in which the Trust fell short of 90% was January 2016. This standard remains a high priority for commissioners and a key topic for scrutiny in Executive-led and monthly Care Group Performance Reviews.

Page 30

Efficiency

Feb-16 15.49% 54.70% 14.56% 59.61%

Mar-16 13.03% 62.90% 15.73% 57.41%

Apr-16 13.51% 56.17% 15.61% 68.09%

May-16 12.87% 55.96% 15.97% 66.47%

Jun-16 12.22% 49.22% 17.08% 56.41%

Jul-16 12.83% 58.13% 18.31% 60.76%

Aug-16 12.03% 58.64% 15.44% 58.95%

Sep-16 13.00% 51.88% 16.35% 60.53%

Oct-16 14.10% 52.82% 16.46% 66.06%

Nov-16 14.62% 56.57% 16.27% 60.93%

Dec-16 13.10% 60.82% 15.20% 66.97%

Jan-17 13.63% 53.04% 14.83% 57.57%

Feb-17 14.57% 50.76% 15.53% 62.42%

DMH UHND

Discharges Before midday - The number of discharges before midday as a % of all discharges

Weekend Discharges as a percentage of Weekday Discharges - The average number of

weekend discharges as a % of average weekday discharges

Discharge Profile

Internal Monitoring CQC Domain: Responsive Month Discharges

Before Midday

Weekend Dis as

a % of

WeekDay

Discharges

Before Midday

Weekend Dis as

a % of

WeekDay

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Discharge Before Midday

DMH UHND

Comment: A multi-agency Programme has been established under the auspices of the A&E Delivery Board (LADB) to implement recommendations arising from the recent ECIP review of non-elective and A&E performance; one of the key themes of which is timely discharge. The working hours of the discharge lounge have been extended using winter resilience monies. In addition, a programme manager has been appointed and work is underway in key areas, including: * Increase in empty beds before 12.00 noon by identifying Golden patients who can be worked up for discharge the day before and moved early in the morning to the discharge lounge. * AMU emptied before 17.00 to create capacity for overnight. * The Director of Nursing is sponsoring work in 3 Exemplar Wards, with support from ECIP, to identify and resolve process problems and embed SAFER principles, such as senior review early in the day. This project will be reviewed in June with a view to further roll-out. * Reviewing and promoting effective use of the discharge policy and the discharge lounges * Develop two care co-ordination centres (single point of access) for County Durham and for Darlington. * Establish an effective Multi-agency discharge team trusted assessor model and discharge to assess pathway. The impact of the March Perfect Month is being seen in significant increases in the percentage of patients being discharged via the Discharge Lounge, before mid-day and before 4pm.

0%

10%

20%

30%

40%

50%

60%

70%

80%

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Weekend as % of Weekday Discharges

DMH UHND

Page 31

Efficiency

Specialty Group Site Dec Jan Feb Dec Jan Feb Dec Jan Feb

DMH 2.3 2.9 2.5 2.6 2.4 2.0 13.0% -17.2% -20.0%

UHND 3.1 2.6 2.8 3.0 2.6 2.7 -3.2% 0.0% -3.6%

DMH 3.8 4.2 4.8 5.4 4.0 4.4 42.1% -4.8% -8.3%

UHND 6.3 5.1 5.4 4.8 5.0 5.8 -23.8% -2.0% 7.4%

DMH 4.9 5.2 5.4 4.8 5.0 5.8 -2.0% -3.8% 7.4%

UHND 4.5 4.1 4.4 4.1 4.5 5.1 -8.9% 9.8% 15.9%

DMH 1.2 1.6 1.5 2.1 1.2 1.4 75.0% -25.0% -6.7%

UHND 1.2 1.0 1.3 1.1 1.1 1.3 -8.3% 10.0% 0.0%

DMH 1.6 1.7 1.6 1.6 1.5 1.7 0.0% -11.8% 6.2%

UHND 2.0 1.9 1.8 1.8 2.2 2.1 -10.0% 15.8% 16.7%

DMH 1.1 0.8 1.5 0.9 1.0 1.1 -18.2% 25.0% -26.7%

UHND 0.8 0.7 0.6 0.7 0.5 0.8 -12.5% -28.6% 33.3%Gynaecology

Previous Year This Year Var %

Discharge Average Length Of Stay - Average Length of stay in days for any Inpatient

discharged within the report period.

Surgery (exc T&O)

Trauma & Orthopaedics

Medicine

Paediatric/Neonates

Obstetric/Midwife Led

Discharge Average Length Of Stay


0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Surgery (exc T&O) length of stay

DMH UHD

Comment: See Discharges page

0

1

2

3

4

5

6

7

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Trauma & Orthopaedics length of stay

DMH UHD

0

1

2

3

4

5

6

7

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Medicine - length of stay

DMH UHD

Page 32

Efficiency

Aug-15 7.27% 8.16% 8.53% 8.53% 1:1.67 1:4.40

Sep-15 7.31% 8.60% 8.52% 8.41% 1:1.76 1:3.88

Oct-15 7.24% 8.14% 8.19% 8.01% 1:1.74 1:4.08

Nov-15 7.37% 8.65% 8.07% 8.33% 1:1.76 1:4.06

Dec-15 7.94% 8.98% 8.83% 8.47% 1:1.70 1:4.35

Jan-16 7.69% 8.68% 7.57% 8.19% 1:1.87 1:4.00

Feb-16 6.83% 8.35% 7.07% 7.41% 1:1.77 1:4.25

Mar-16 6.71% 8.66% 8.37% 8.13% 1:1.82 1:4.45

Apr-16 6.57% 8.03% 8.49% 7.70% 1:1.84 1:4.32

May-16 6.85% 8.64% 9.26% 7.93% 1:1.73 1:4.45

Jun-16 7.15% 9.57% 8.45% 7.65% 1:1.74 1:4.32

Jul-16 7.69% 8.78% 10.43% 8.20% 1:1.74 1:4.44

Aug-16 7.13% 8.60% 8.56% 8.30% 1:1.74 1:4.14

Sep-16 7.35% 8.66% 8.10% 7.97% 1:1.70 1:4.08

Oct-16 7.08% 8.61% 8.74% 8.59% 1:1.73 1:4.15

Nov-16 7.37% 8.63% 8.74% 8.62% 1:1.78 1:3.88

Dec-16 7.84% 8.64% 8.32% 9.12% 1:1.73 1:3.98

Jan-17 7.65% 9.48% 8.59% 8.10% 1:1.89 1:4.18

Feb-17 6.90% 9.14% 7.76% 7.66% 1:1.75 1:4.41

* Please note, reclassification of OP New's to follow-up for consultant responsible from 1st Apr 15

Outpatient DNA & New/Review Ratio

CQC Domain: ResponsiveInternal Monitoring

DNA Rates - The number of Did Not Attends (DNAs) as a % of the total attends

New/Review Ratio - The number of New OP attends as a ratio to Fup attends

New/Review Ratio

Cons LedNurse Led Cons

RespCons Led New

DNA Rates

Month Cons Led

Review

Nurse Led Cons

Resp

Nurse Led Cons

Resp Review

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

New DNA Rates

Cons Led New Nurse Led Cons Resp New

Comment: The Out-patient Review Group has now been re-constituted under the leadership of the ADO for Family Health and CSS. The initial meeting scoped out the work programme which includes: reducing the number of ad hoc clinics; extending the use of text messaging to reduce DNA rates; extending the SOS scheme currently used by Plastics in which, rather than offering a follow-up out-patient appointment, patients are offered the opportunity to request a follow-up or to seek advice if they are worried about anything.

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Review DNA Rates

Con Led Review Nurse Led Cons Resp Review

1:0.00

1:0.50

1:1.00

1:1.50

1:2.00

1:2.50

1:3.00

1:3.50

1:4.00

1:4.50

1:5.00

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

New/Review Ratio

Cons Led new/Review Ratio Nurse Led Cons resp New/Review Ratio

Page 33

Efficiency

Aug-15 80.15% 6.48% 11.53% 754 2890

Sep-15 75.47% 13.40% 15.11% 611 2164

Oct-15 79.65% 8.98% 19.12% 857 2005

Nov-15 80.74% 9.19% 23.06% 615 1777

Dec-15 76.43% 14.91% 22.59% 1049 2311

Jan-16 75.18% 16.24% 35.75% 983 1898

Feb-16 73.20% 13.94% 29.90% 1193 2443

Mar-16 73.80% 7.93% 28.71% 1140 2370

Apr-16 75.69% 12.44% 35.61% 1750 2874

May-16 75.69% 14.13% 26.68% 986 2257

Jun-16 72.41% 7.08% 26.74% 1036 2300

Jul-16 66.71% 7.96% 26.80% 1410 2849

Aug-16 69.23% 9.82% 19.98% 1471 3122

Sep-16 69.20% 8.95% 31.94% 1645 2958

Oct-16 72.02% 9.37% 32.71% 1572 2751

Nov-16 66.90% 9.92% 20.73% 770 1894

Dec-16 69.27% 9.81% 25.86% 1257 2406

Jan-17 73.62% 9.97% 33.17% 1136 2230

Feb-17 74.60% 10.38% 25.52% 821 2416

Audit Compliance - Monitoring the collection of clinic start and end time against all clinics held in

the recording month.

% Late Starts - The recording of consultant arrival time against the actual clinic start time but only

for clinics that have a time recorded

Number of

Patients Canc <8

Weeks

Audit Compliance & %Late

StartsCancelled Clinics

Month Audit

Compliance% Late Starts

% Cancelled

Clinics < 8 Weeks

Total Number of

Patients

CancelledCQC Domain: ResponsiveInternal Monitoring

Audit Compliance, % Late Starts & Cancelled Clinics

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Au

g-15

Sep-1

5

Oct-1

5

No

v-15

Dec-1

5

Jan-16

Feb-1

6

Mar-16

Ap

r-16

May-16

Jun

-16

Jul-1

6

Au

g-16

Sep-1

6

Oct-1

6

No

v-16

Dec-1

6

Jan-17

Feb-1

7

Audit Compliance & %Late Stats

Audit Compliance % Late Starts

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0%

5%

10%

15%

20%

25%

30%

35%

40%

Au

g-15

Sep-1

5

Oct-1

5

No

v-15

Dec-1

5

Jan-16

Feb-1

6

Mar-16

Ap

r-16

May-16

Jun

-16

Jul-1

6

Au

g-16

Sep-1

6

Oct-1

6

No

v-16

Dec-1

6

Jan-17

Feb-1

7

Clinics Cancelled <8 Weeks with Patients Cancelled

Number of Patients Cancelled <8 Weeks % Cancelled Clinics < 8 Weeks

0

500

1000

1500

2000

2500

3000

3500

Au

g-15

Sep-1

5

Oct-1

5

No

v-15

Dec-1

5

Jan-16

Feb-1

6

Mar-16

Ap

r-16

May-16

Jun

-16

Jul-1

6

Au

g-16

Sep-1

6

Oct-1

6

No

v-16

Dec-1

6

Jan-17

Feb-1

7

Total Patients Cancelled

Total Number of Patients Cancelled

Comment See Outpatient 1 page

Page 34

Efficiency

Apr-Feb 16 Apr-Feb 17 % Apr-Feb 16 Apr-Feb 17 %

100 - General Surgery 11569 11201 -3.2% 23469 26230 11.8%

101 - Urology 1830 1778 -2.8% 3738 3636 -2.7%

103 - Breast Surgery 5493 5348 -2.6% 4013 3560 -11.3%

110 - Trauma & Ortho 20582 19956 -3.0% 40335 38619 -4.3%

11J - JAT 1561 1641 5.1% 1840 1973 7.2%

120 - Ear Nose And Throat 10920 10885 -0.3% 11263 11183 -0.7%

130 - Ophthalmology 14089 13630 -3.3% 41529 41934 1.0%

140 - Oral Surgery 1496 1473 -1.5% 1282 1129 -11.9%

160 - Plastic Surgery 8240 7923 -3.8% 20331 18534 -8.8%

170 - Cardiothoracic Surg 41 24 -41.5% 59 62 5.1%

180 - Accident & Emergency 2047 1966 -4.0% 342 312 -8.8%

190 - Anaesthetics 275 307 11.6% 1 1 0.0%

191 - Pain Management 2087 1979 -5.2% 14752 15970 8.3%

200 - Paediatric Sub Specialties 4439 4853 9.3% 6600 6892 4.4%

300 - General Medicine 107 201 87.9% 3551 3594 1.2%

301 - Gastroenterology 4578 3846 -16.0% 7807 7274 -6.8%

303 - Haem Clinical 1171 1191 1.7% 9215 9178 -0.4%

306 - Hepatology 534 354 -33.7% 1072 777 -27.5%

307 - Diabetic Medicine 2960 2846 -3.9% 9596 10330 7.6%

320 - Cardiology 7083 6935 -2.1% 11706 12079 3.2%

329 - Transient Ischaemic Attack 1293 963 -25.5% 0%

32A - Palpatations & Arrhythmia 244 225 -7.8% 0%

32E - Direct Access Echo 3407 3250 -4.6% 1 0%

330 - Dermatology 13275 14497 9.2% 33803 33953 0.4%

340 - Thoracic Medicine 5251 5456 3.9% 11761 12051 2.5%

370 - Medical Oncology 215 184 -14.4% 995 1142 14.8%

400 - Neurology 611 550 -10.0% 397 461 16.1%

410 - Rheumatology 3483 3742 7.4% 13291 13082 -1.6%

420 - Paediatrics 5620 5396 -4.0% 8626 9198 6.6%

430 - Geriatric Medicine 2173 2647 21.8% 5300 4923 -7.1%

501 - Obstetrics 7775 7609 -2.1% 30891 31973 3.5%

502 - Gynaecology 12025 12181 1.3% 11396 12246 7.5%

560 - Midwife Led Care 2017 1865 -7.5% 6570 6000 -8.7%

650 - Physiotherapy 8480 8862 4.5% 26285 24797 -5.7%

800 - Clinical Oncology 253 227 -10.3% 1640 1395 -14.9%

Total 167224 165991 -0.7% 363456 364489 0.3%

Outpatient Activity

NewSpecialty Follow Up

Outpatient New/Review Activty

CQC Domain: ResponsiveInternal Monitoring

Comment See Outpatient 1 page. The main areas of work continue to be the two CQUIN schemes for Paediatric and Diabetes, both of which are on course to improve the ability of Primary Care to deliver more care for patients closer to home. Other pathways are also subject to review via the Joint Working CQUIN, one of the high priority ones being ophthalmology pathways where CDDFT is said to be an outlier for the number of follow-up appointments which take place. Given the number of Consultant vacancies in Ophthalmology it is in the Trust's as well as the patients' interests to transfer follow-up activity into the community where possible.

0

5000

10000

15000

20000

25000

30000

35000

40000

04

/20

15

05

/20

15

06

/20

15

07

/20

15

08

/20

15

09

/20

15

10

/20

15

11

/20

15

12

/20

15

01

/20

16

02

/20

16

03

/20

16

04

/20

16

05

/20

16

06

/20

16

07

/20

16

08

/20

16

09

/20

16

10

/20

16

11

/20

16

12

/20

16

01

/20

17

02

/20

17

New/FUp Outpatient Attendances

New OP Attends Follow Up Attends

Page 35

Efficiency

Jan-17

Care GroupAcute & Emergency Care 3.4 2.9 6.3Clinical Support Services 1.0 1.0 2.0

Family Health 5.6 3.4 9.0

Integrated Adults 8.1 4.4 12.4Surgery 6.7 4.5 11.2

Totals 6.1 3.9 10.0

Time from Upload to

Transcribed In Days

Time from

Transcribed to

Approved In Days

Time from Uploaded

to Approved In DaysDigital Dictation

Local Quality Requirement CQC Domain: Effective

0123456789

10

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Time from Upload to Transcribed In Days

Time from Upload to Transcribed In Days

0123456789

10

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Time from Transcribed to Approved In Days

Time from Transcribed to Approved In Days

0

2

4

6

8

10

12

14

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Time from Uploaded to Approved In Days

Time from Uploaded to Approved In Days

Comment: Like electronic discharge letters , the timely receipt in the Practice of letters following an out-patient or diagnostics appointment is viewed by GPs as essential to them being able to offer their patients an appropriate level of care. All Care Groups have been challenged to dispatch letters within five working days, but have been warned that a more challenging target will apply in 2017-18.

Page 36

Workforce

Month Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTDTrust Effective Shortfall W - NQR MS <5% 6.4% 7.4% 7.3% 7.3% 6.4% 7.1% 38

Consultant Shortfall W - NQR MS <5% 8.6% 6.7% 8.1% 9.9% 8.6% 9.9% N/A

Voluntary Turnover W - NQR MS <7.5% 9.2% 9.3% 9.4% 9.4% 9.2% 9.4% 38

Essential Training W - NQR MS 95.0% 92.7% 22.9% 53.6% 86.1% 92.7% 88.6% 39

Overall Appraisal Rate W - NQR MS 95.0% 81.2% 3.2% 20.4% 51.3% 81.2% 63.9% 39

Total Agency Spend W - NQR MS Reduce £1,240,439.0 £4,989,297.0 £4,410,463.0 £3,924,472.0 £2,523,416.0 £15,847,648.0 40

Sickness W - NQR MS <3.5% 4.8% 4.3% 4.3% 4.9% 4.8% 5.1% 40

Bank Spend W - NQR MS Increase £811,339.0 £2,125,252.0 £2,490,090.0 £2,447,977.0 £1,778,779.0 £8,842,098.0 N/A

Bank Spend as % of Total Pay W - NQR MS Increase 3.2% 3.1% 3.4% 3.1% 3.2% 3.9% N/A


Page

WorkforceIndicator CQC Domain Target

2016/17Director

Page 37

Workforce

Shortfall and Turnover

Internal Monitoring CQC Domain: Well-Led

0%

2%

4%

6%

8%

10%

12%

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

Effective Shortfall

Trust Cons Target

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%


Voluntary Turnover

Actual Target

Comment: The clinical workforce remains one of the key challenges facing the Trust. Care Groups are working with HR to target adverts carefully, and to consider all options for recruitment including advertising internationally and ensuring that once a candidate has been offered a post, there are no delays in the appointment process. HR conduct exit interviews with all staff who leave the organisation voluntarily. Most medical, nursing and other health professional shortfall occurs in Specialties where there is a national or local shortage of qualified staff. In other areas, there are special causes. For example: - pharmacists are currently attracted by better terms and conditions in community pharmacy, linked with uncertainties about the Trust's future. - radiographers are currently influenced by the fact that the Trust is now the only one in the NE not to use digital equipment. Where special causes are identified, the Care Groups and HR are attempting to put in place bespoke solutions.

Page 38

Workforce

Essential Training and Appraisal


0%

20%

40%

60%

80%

100%


Essential Training Compliance

Actual Target

0%

20%

40%

60%

80%

100%


Staff Appraisal

Actual Target

Comment: All Care Groups are making good progress in ensuring their staff receive essential training but several Care Groups remain well behind trajectory for the number of appraisals completed each month in spite of significant progress in the last couple of months. HR have identified all non-compliant staff and send out weekly lists to Care Group Managers who have been tasked with prioritising the achievement of this target. This continues to be monitored via the Performance Review process.

Page 39

Workforce

Agency Spend and Sickness


£0

£200,000

£400,000

£600,000

£800,000

£1,000,000

£1,200,000

£1,400,000

£1,600,000

£1,800,000

£2,000,000

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Agency Spend

Actual Target

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Sickness

Actual Target

Comment: the Table opposite show the progress that has been made on reducing agency spend. In relation to sickness, HR produce monthly reports detailing long and short term sickness in each Care Group and assist Managers to implement Trust sickness and absence policies effectively.

Page 40

Finance

Income 480,575 438,701 436,396 -2,305

Expenditure; Pay Costs -306,112 -280,235 -276,784 3,451Non Pay Costs -140,290 -129,563 -129,218 344CRT 9,736 4,947 0 -4,947Reserves -10,121 -3,086 0 3,086Total Expenditure -446,785 -407,937 -406,003 1,934

EBITDA 33,789 30,765 30,394 -371

Depreciation and Amortisation -11,397 -10,447 -10,103 344

Surplus / (Deficit) from Operations 22,393 20,318 20,291 -27

Profit / (Loss) on Asset Disposals 0 0 -32 -32Interest Recievable 272 256 148 -108Interest Payable -14,462 -13,257 -13,314 -57PDC Dividend -1,645 -1,508 -1,263 245Donated Asset Income 0 0 48 48

Surplus / (Deficit) 6,557 5,809 5,878 69

Variance

Financial Sustainability Risk Rating 3

Performance against NHSI Plan - The Trust is reporting an overall cumulative surplus to February

2017 of £5,878k compared to an original planned position of £5,968k surplus. The Trust is therefore

£90k behind the April NHSI plan at month 11. This however includes Sustainability & Transformation

Fund (STF) funding and any performance penalty consequences. Excluding ST&F the Trust are £690k

ahead of plan (Plan £8,332k Deficit / Actual £7,642k Deficit).

Performance against live budgets - The April plan submitted to NHSI is fixed for the purposes of their

monitoring of our financial performance. The revised plan, submitted in July, demonstrated that the

control total could still be achieved, but required a significant phasing adjustment in recognition that

the income loss would be suffered evenly across the year, but that the additional cost reduction and

mitigating actions would be phased progressively, biased more towards the end of the year. In

addition to this, we had to estimate the likely deployment of reserves, and timing of income and

expenditure adjustments. In order to prevent windfall gains and losses at cost centre level, and

maintain the integrity of the budgetary control system as a means for holding budget holders to

account, the budgets are adjusted appropriately in real time to reflect actual deployment of reserves,

and other changes such as contract variations and additional income and expenditure received during

the year. Comparing the February surplus position of £5,878kk against the live budgetary position

shows that the trust is £69k ahead of the planned month 11 surplus of £5,809k.

It should be noted that inherent in the reported position are £2m savings regarding theatre stock

which have been recognised following validation of the detailed stock take which took place in

September and also £1.2m of aged accruals released as previously detailed. Contributing to the

Income Deficit is £780k penalties associated with anticipated failures against ST&F trajectories for

A&E and Cancer.

Summary I&E Account (Live Budgets) Annual Plan

£000's

Plan to Date

£000's

Actual to Date

£000's

Variance Chart

Page 41

Finance

Income Pay Non Pay CRT Grand Total

Acute and Emergency Care -£41 -£133 £88 -£1,032 -£1,118

Surgery Care Group -£26 £1,345 -£1,151 £500 £669Clinical Support Services -£57 £758 £117 £344 £1,161Family Health £211 -£239 £203 -£672 -£496Integrated Adult Care -£12 £1,617 £109 £174 £1,888Corporate -£1,029 £102 £978 £17 £69Care Group Performance -£955 £3,451 £345 -£669 £2,172Income -£1,350 -£1,350Synchronicity CRT -£415 -£415Central CRT -£3,863 -£3,863Reserves £3,086 £3,086EBITDA -£2,305 £3,451 £3,431 -£4,947 -£371

Care Group Performance (Live Budgets) Variance Analysis (£000's)

Care Group / Corporate Variance £2,171,839

Care Group Performance is detailed on the table to the right and charts below.

-£1,500

-£1,000

-£500

£0

£500

£1,000

£1,500

£2,000

Acute and Emergency Care Surgery Care Group Clinical Support Services Family Health Integrated Adult Care Corporate

Care Group / Corporate Performance - Income, Pay and Non Pay

Income Pay Non Pay

Page 42

Finance

Area

Acute and Emergency Care £8,392 £7,118 -£1,274

Surgery Care Group £4,207 £4,253 £46Clinical Support Services £1,171 £1,184 £13Family Health £847 £1,280 £433Integrated Adult Care £3,861 £2,847 -£1,014CEO £26 £4 -£21Commercial £114 £0 -£114Finance £53 £70 £17HR £163 £42 -£122Nursing £4 £20 £16Ops £28 £0 -£28E&F £108 £126 £18Medical £0 £0 £0Total £18,972 £16,944 -£2,027

Headlines

NHSI wrote to the Trust on 17 March 2016 confirming that a total agency cap of £20.696m would

apply for 2016/17. The ceilings were calculated based on the trust’s reported 2015/16 spend

extrapolated. This all-staff ceiling replaces the nurse agency ceiling issued during 2015/16.

The ceiling has been allocated at a care group and corporate level, the table to the right shows the

year to date performance, with the chart below detailing the month on month positions.

Agency CapCumulative

Control Total

Month 11

£000's

Cumulative Actual

Total

Month 11

£000's

Cumulative

Variance

Month 11

£000'sYTD Position -£2,027,338

Page 43

Finance

Central SchemesCare Group /

CorporateTotal Central Schemes

Care Group /

CorporateTotal

Planned Delivery (Target) £14,303 £16,398 £30,701 £16,435 £21,035 £37,470Delivery to Date £10,398 £15,356 £25,755 £10,994 £16,737 £27,731

Performance to Date -£3,905 -£1,042 -£4,947 -£5,441 -£4,299 -£9,739The Trust’s cost reduction target (CRT) was originally set at £28.018m in the budget setting papers

in order to achieve the requisite level of clinical efficiency and financial surplus expected by the

board. Following the Board approved financial re-plan which was required to ensure we can still

meet the control total surplus following the loss of arbitration the CRT target increased to £34m and

subsequently to £37.47m following inclusion of 3 further schemes.

In month 11, actual CRT delivery for the year amounts to £27.731m, of which £16.737m has been

delivered from care groups and corporate departments and the remaining £10.994m has been

delivered from the central schemes.

Comparing the £25.755m delivered to date, against the profiled target of £30.701m leaves the CRT

behind of plan as at month 11 by £4.947m.

Cost Reduction Year to Date - £000's Annual Position (Based on actual delivery to

date) - £000's

Variance -£4,947,171

-£5,000

£0

£5,000

£10,000

£15,000

£20,000

Central Schemes Care Group / Corporate

Year to Date Cost Reduction Performance

Planned Delivery (Target) Delivery to Date Performance to Date

Page 44

Quality Account

Page

CQC Domain Month Qtr 1 Qtr 2 Qtr 3 Qtr 4 YTD

Falls - Acute (Incident Report) ** S 157 449 405 428 157 1439 26

Falls - Community (Incident Report) ** S 19 53 48 66 19 186 26

Reduction in Falls - Acute (per 1000 beddays) (Cumulative)** S 5.6 6.1 6.3 6.1 6.1 6.1 6.1 N/A

Reduction in Falls - Community (per 1000 beddays) (Cumulative)** S 8 5.8 5.3 5.1 5.8 5.8 5.8 N/A

Continuation of Sensory Training into staff education programmes 180 per Q N/A

Falls & Fragility fractures - patients screened** S 382 1182 1191 1169 3160 N/AFalls & Fragility fractures - % eligible patient receiving follow up assessment for

osteoporosis** S 50% 42.5% 80.6% 61.2% 50.9% 66.6% N/AFalls & Fragility fractures - % patients with appropriate regerral for axial scan (as a

proportion of eligible patients)*** S 91.4% 94.8% 91.0% 92.0% 92.8% N/AFalls & Fragility fractures - % patients commenced on bone sparing drugs (as a

proportion of eligible patients)***** S 35.3% 52.4% 39.2% 52.4% N/A

Grade 3 & 4 newly acquired avoidable pressure ulcers - Acute * S 0 0 0 0 1 0 1 26

Grade 3 & 4 newly acquired avoidable pressure ulcers - Community*** S 0 0 1 1 1 0 3 N/A

Grade 2 newly acquired avoidable pressure ulcers - Acute* S Monitor 0 1 2 1 0 4 26

Grade 2 newly acquired avoidable pressure ulcers - Community*** S Monitor 1 1 0 1 0 2 N/A

% adult patients that are correctly screened for undernutrition within 6 hours R 98% 89.07% 90.3% 83.3% 84.0% 89.07% 89.07% N/A

% adult patients rescreeened weekly for undernutrition R 98% 83.40% 92.1% 78.9% 76.2% 83.40% 83.40% N/A% adult patient identified at moderate or high risk of undernutrition have evidence

that a nutrition care plan has been implemented, which fulfils recommendation on

the 'MUST' nutritional tool R 98% 75.00% 81.6% 63.7% 59.9% 75.00% 75.00% N/A% adult patients identified at moderate or high risk of undernutrition have evidence

of well completed food and fluid record charts R 90% 71.68% 78.0% 62.3% 55.4% 71.68% 71.68% N/A% adult patients identified at high risk of undernutrition have evidence of a referral to

the dietician R 75% 71.58% 81.4% 60.9% 53.5% 71.58% 71.58% N/A% adult patients receiving prescribed oral nutritional supplements have evidence of

involvement from the dietitian R 50% 72.83% 74.5% 59.2% 49.7% 72.83% 72.83% N/A% adult patients receiving prescribed oral nutritional supplements are at high risk of

undernutrition R 75% 77.88% 80.3% 59.6% 51.6% 77.88% 77.88% N/A

Rate of patient safety incidents resulting in severe injury or death E

Within

national

average N/A

Rate of patient safety incident reporting E 75th %ile N/A

Did you feel involved enough in decisions about your care and treatment? C 76% 79.0% 80.0% 80.0% 79.0% 79.0% 18

Were you given enough privacy when discussing your condition or treatment? C 80% 85.0% 90.0% 86.0% 85.0% 85.0% 18

Did you find a member of staff to discuss any worries or fears you had? C 85% 77.0% 85.0% 84.0% 77.0% 77.0% 18Did a member of staff tell you about any medication side effects that you should

watch out for after you got home in a way that you could understand? C 65% 60.0% 72.0% 67.0% 60.0% 60.0% 18Did hospital staff tell you who you should contact if you were worried about your

condition or treatment after you left hospital? C 75% 76.0% 82.0% 81.0% 76.0% 76.0% 18% of staff who would recommend the trust to family and friends needing care (Staff

Survey) Annual W N/A

Friends and Family Test - increased response rate in A&E* C 13.1% 8.2% 15.6% 14.2% 13.5% 13.2% N/A

Friends and Family Test - increased response rate in In patients* C 15.8% 16.9% 16.8% 16.7% 21.2% 17.5% N/A

Summary Hospital Mortality Indicator (SHMI) *** E 108.5 103.2 99.5 107.9 103.0 28

Hospital Standardised Mortality Ratio (HSMR) *** E 101.4 104.0 104.5 96.0 102.01 28

Crude Mortality*** E 3.79% 3.97% 3.68% 3.65% 3.78% 28

Deaths with a palliative care code (Z515)*** E 21.4% 22.8% 23.2% 24.0% 23.2% N/A

Readmissions within 28 days* E 7% 10.2% 13.1% 11.8% 12.0% 10.2% 12.2% N/A

Month: February 2017

Indicator Target

2016/17

Quality Account Indicators not elsewhere reported

*One month in arrears **Two months in arrears

Nutrition: The 98% targets are stretch targets as part of the Nutrition Strategy. Actions include: - Health care assistant training on under nutrition is being led by a Nutrition Specialist Nurse. - Nutrition Champions - 1 trained nurse and 1 HCA per ward (all sites, acute and community) -have been recruited and will be trained in October and November on the Nutrition Bundle. - Nutrition Bundle will be launched across the Trust in November bringing in full nutritional care planning and nutritional rounding, re-evaluated weekly, so triggering a re screen.This action should enable us to reach the strategy target. - National scoping work re pregnancy screening for malnutrition is taking place to see if this is an area where screening needs to commence. Currently pregnancy admissions are not screened.

Note: Please see narrative on detail tabs for further comments in relation to the measures above

Page 45

CQUIN

CQUIN 2016-17

Q1 Q2 Q3 High Medium Low

Sepsis screening and treatment in A&E and for

emergency patients £329,534 £82,383

Sepsis screening and treatment for in-patients £329,534 £82,383

Staff Health: health initiatives £659,068

Staff Health: 'flu vaccinations £659,068

Healthy food for patients, staff and visitors £659,068

Reducing antibiotic consumption £527,254 £131,813 £131,813 £131,813

Review of antibiotic usage £131,814 £32,953 £32,954

Local CCG CQUINs

Dementia Strategy £1,558,100

Paediatric transformation £1,558,100

Diabetes transformation £500,000

Financial Recovery CQUIN £1,058,100

AREA TEAM CQUIN

Diabetic Eye Screening £22,000

Aycliffe Young People's Centre Nursing £22,000

Dental Clinical Network £22,000

Quality Dashboard for Dental £22,000

SPECIALIST COMMISSIONERS

Chemotherapy Dose banding £28,000

Delayed transfers from Intensive Care Unit £82,000 £50,000

Total Risk £181,813 £164,766 £329,533

Indicator

Approximate

value CCG CQUIN

Q4 Financial RiskQuarterly Performance

Comment: The Trust achieved all CQUIN targets for Q1 and Q2 of 2016-17. Evidence for Q3 has been submitted and commissioners have agreed that all targets have been achieved with the possible exception of the Joint Working CQUIN, with respect to which further dialogue is taking place. The extent of the risk is £66,000. The other main risks for 2016-17 continue to be the CQUIN's relating to antibiotic usage and delayed transfers of Care from ICU in both of which Q4 losses appear inevitable, as projected from the outset. The other main risk has been Sepsis but it now looks unlikely that losses will be incurred on this CQUIN. In order to assure themselves of the Trust's ability to achieve 2017-18 CQUIN targets, Executives have commissioned a series of lead officer presentations to ECL through March/April of CQUIN Action Plans .

Page 46

NHSI is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams.

Cumbria and North East

Waterfront 4 Newburn Riverside

Newcastle upon Tyne NE15 8NY

Email: [email protected]

01 March 2017

Dear Sue,

Summary of the Quarterly Review Meeting (QRM) held on 6 February 2017

Following the QRM on 6 February 2017, I am writing to confirm the key points and

actions from our discussion. I am grateful to you and your team for making the time

to meet with us.

As you are aware the purpose of the QRM is to allow us to have a meaningful

conversation about the current situation of the trust, the key challenges you are

currently facing, how these might be addressed and a review of the progress the

trust has made against these.

SOF segmentation

The trust is currently categorised as being in Segment 2 of the Single Oversight

Framework (SOF).

We briefly discussed the steps that need to be taken to move the SOF rating into

Segment 1. In summary these are for the trust to:

achieve a CQC rating of good or outstanding;

consistently deliver the operational performance standards; and,

move to a position of sustainable financial surplus.

As I set out in the meeting it is my objective for all the trusts in Cumbria and North

East to be in Segment 1 of the SOF and to achieve a rating of Outstanding from the

CQC. It is my expectation that this is an ambition that you and your team share.

Quality of care

In preparation for a likely CQC inspection in quarter 1 of 2017/18 NHS Improvement

had supported the trust in a two day process of ward-level thematic reviews. The

trust confirmed that an action plan had been developed to respond to findings from

Sue Jacques Chief Executive County Durham and Darlington NHS Foundation Trust Darlington Memorial Hospital Darlington DL3 6HX

mailto:[email protected]


the reviews. This is being supplemented by a range of communications to staff

members to support inspection preparation and focus on embedding the SAFER

bundle.

The implementation of 7 day services (7DS) was also discussed and it was noted

that progress has been made in a number of areas. These include:

the roll out of 7DS in medicine has been extended;

weekend ward rounds;

maintenance of &DS within stroke services despite staffing pressures;

presence of acute intervention team 24/7 as first responders to emergencies

on both sites; and,

introduction of extended roles to support junior doctors.

NHS Improvement emphasised the importance of the trust continuing to make

progress against the four key standards.

The meeting then went on to discuss the never events (NE) and learning from these,

with a paper provided with detail on each case. The trust took us through the 7 never

events that have occurred in 2016/7 but also informed NHS Improvement of a further

NE which took place in the week prior to the QRM.

The trust has started to ensure teams meet after an incident to identify themes and

areas where changes need to be made immediately. All incidents are discussed at

weekly staff meetings with a number of channels of communication also

implemented to improve learning.

NHS Improvement requested that the trust inform them of the condition of all patients

affected by the NEs. The trust informed NHS Improvement that all patients were

confirmed as being well, with the exception of the ophthalmology patient. The trust

will review and update NHS Improvement.

At the meeting the trust informed NHS Improvement of a further possible never event

which had occurred within pathology and that the review was currently being

undertaken. The trust would provide NHSI with a 72 hour report. Following the

meeting the trust informed NHS Improvement of a further Never Event concerning a

retained object from surgery in December 2014, which was only reported following

receipt of a legal claim from the patient concerned.

NHS Improvement concluded by stating that the volume of NEs was extremely

concerning and that the trust’s approach appeared to be reactive in nature when

what was required was the pro-active introduction of robust preventative measures.

Upon considering the issue following the meeting, NHS Improvement is of the view

that additional regulatory oversight and support is necessary in order to for the trust

to achieve a sustainable improvement in this area and that of 12 hour breaches in

A&E (see separate discussion in the performance section of the document). NHS


Improvement will therefore establish regular Additional Support Meetings (ASMs)

with the trust on these issues. The details of these will be provided shortly but to

support the process NHS Improvement requests sight of:

the external review of NEs commissioned by the trust from Newcastle

University Hospitals NHS Foundation Trust;

the human factors training programme that it understands the trust is

considering undertaking; and,

for completeness and by 20th February all the RCAs associated with NEs that

have taken place year to date.

Finance and use of resources

It was noted that the financial position had been discussed in detail between the trust

and NHS Improvement prior to the formal QRM.

In summary the key points covered were as follows:

At Q3 the trust is £895k ahead of plan (excluding STF).

The forecast outturn is that the trust will over achieve its control total by £1million, though it was noted that the revaluation of assets which contributes to this was still to be completed.

The cost improvement programmes for this financial year are now being reported clearly and include recurrent and non-recurrent achievement, and the bridge to the underlying position for 2017/18 is well understood.

Contract meetings are being undertaken between the trust and CCGs seeking to address the risk associated with block contracts and community hub developments as well demand management, and a group led by the system Chief Executives has been established to monitor progress with clear reporting arrangements.

For 17/18 the trust still has £9 million to identify for CIP but is aiming for these schemes to be in place by the beginning of March

The trust is continuing to work with the NHS Improvement economics team to address the shortfall in the CIP

NHS Improvement confirmed that the formal investigation into financial governance

that had been initiated in December 2015 by Monitor would now be closed as the

trust has completed all the actions recommended by PWC’s external assurance

report.

Operational Performance

NHS Improvement noted that the trust was continuing to seek to drive improvements

in A&E performance through working with ECIP. With regard to the latter NHS

Improvement would like to see a copy of the trust’s action plan response to the ECIP

report as soon as it is available.


Against this generally positive context the volume of 12 hour breaches was a major

concern. The trust has had 5 such breaches since November 2016. NHS

Improvement made the point that this was an unacceptably high number and was

without parallel in Cumbria and the North East this winter. A discussion followed

regarding the drivers behind the breaches during which the trust explained that on

number of occasions a patient’s admission had been delayed due to a deterioration

in their condition. NHS Improvement accepts that breaches should be considered

individually and often have complex causes; however the situations presented by the

trust were not unique, and it needed to be understood why CDDFT finds this issue

so challenging. In view of this NHS Improvement will consider the Root Cause

Analysis associated with each breach. As discussed in relation to Never Events NHS

Improvement will establish regular ASMs to monitor the trust’s actions against this

issue.

Both RTT and Cancer performance for this year were discussed, whilst the trust has

achieved the standard for RTT this year it is likely to fail the cancer standard for Q3.

The trust was considering making some changes to pathways to achieve

improvement. The trust is also working with other providers to ensure that patients

who are treated across organisational boundaries are within the standards as well.

It was noted that the trust had appealed the A&E trajectory for Q3 and was intending

to submit an appeal in relation to Cancer.

Strategic Change

The trust occupies a position in two STPs. NHS Improvement emphasised the

pivotal role of the trust in relation to the success of the STPs concerned and the risk

of inertia should CDDFT not participate fully in both. In particular a personal request

was made of Sue Jacques to provide leadership to both STPs and to clearly

establish a direction of travel for the trust and its services within them.

Leadership and Improvement Capability

The trust is undertaking a well led review and the report from this will form part of the

Board development programme.

The trust is currently recruiting to the posts of Medical Director and Finance Director.

Next Steps

The following next steps and actions were agreed at the meeting:

Further discussions to take place once NHS Improvement had considered the

RCAs in relation to the 12 hour A&E breaches.

Trust to provide NHS Improvement with a copy of its action plan response to

the ECIP report once complete.

Sue Jacques to take a lead role in the development of both STPs.


In addition and upon reflection, NHS Improvement will contact the trust separately

with details of ASMs covering serious concerns regarding the volume of NEs and 12

hour breaches at the trust. To support these NHS I requests:

The trust provide it with a copy of the review into NEs that it has

commissioned from Newcastle University Hospitals NHS Foundation Trust.

A summary of the trust’s intentions with regard to human factors training

(undertaken as part of the response to NEs).

A copy of all the RCAs that have completed in relation to NEs that have

occurred year to date.

Our next QRM will be held in three months; though we will be in touch regarding the

above on a regular basis.

Can I ask that this letter is shared with your board at its public meeting.

In conclusion the trust is delivering strong performance in many areas but needs to

ensure that robust remedial action is taken to reduce NEs and 12 hour A&E

breaches. In addition it is essential that the trust’s clinical and managerial leadership

proactively engages with the STP process to ensure that a clear direction of travel is

established for the services it provides.

I will be asking my team to work closely with you on these issued over the coming

months.

If you have any questions in the meantime, please do not hesitate to get in touch.

Yours sincerely,

Tim Rideout Director of Delivery & Improvement – Cumbria & North East

www.cddft.nhs.uk Finance Report Page 1 of 17

Trust Board Meeting 29 March 2017

Agenda Number 8 – Finance Report

Open Board Item Private Board Item

Author Name and Title

Reason for

Submission

Tick all that apply

If none of the

above, please

provide rationale for

submission

Standing item









Purpose of Report To report the financial position of the trust as at 28th February 2017

To report performance against the Sustainability and Transformation Fund (S&TF) criteria

To update on NHSI submission re 2017/18 – 2018/19 financial plan

To review and record the Trust’s Going Concern Status

Summary of Key

Issues

2016/17 plan on track to be delivered, subject to audit

Significant risk of further cash erosion

Regulatory

compliance

implications


NHS Constitution




Other [State ]

Significant risks

identified (if any)

Further cash erosion


Action / decision

required from the

Board

The Board is asked to:

Note the Month 11 position

Confirm that a resubmission of CDDFT’s 2017/18 – 2018/19 is not required under the limited rules approach.

Endorse the trust’s going concern status.


FINANCIAL REPORT FOR THE PERIOD ENDING 28th February 2017

1. Purpose The purpose of the paper is to

Report the financial position of the trust as at 28th February 2017.

Report on the trust performance against the Sustainability and Transformation

Fund (S&TF) criteria.

To update on 2017-19 operational planning submission to NHSI

To review the trust’s going concern status

2. Background

In April 2016, the trust submitted a plan to NHS Improvement (NHSI) which set out how it would achieve its control total and so secure the £15.6m S&TF available to it, subject to achieving performance trajectories. In May 2016, the trust was advised of the outcome of the 2016/17 contract arbitration, which resulted in a loss of £5.8m of income compared to the April plan. In addition, as the CQUIN and penalty regime were also agreed in May 2016, the trust was able to quantify a £1.06m risk in respect of this which was not factored into the April plan. On 28 July, the trust submitted a revised 2016/17 plan to NHSI, taking into account the impact of arbitration and the CQUIN/penalty risk, and which aimed to deliver the control total. This plan was submitted to NHSI for the purposes of their on-going formal investigation of the trust, but does not replace the plan submitted in April which remains the basis upon which our financial performance is monitored for the purpose of the control total and S&TF. NHSI have yet to make any comment on this revised plan.

3. Headlines Month 11 Position: The trust is £690k ahead of its original (April) plan (excluding STF) as at 28th February 2017. With S&TF included, this reduces to £90k behind of plan due to performance adjustments relating to A&E (£650k) and Cancer (£130k) taking the total possible ST&F income receivable to date from £14.3m to £13.52m. A&E STF income can be recovered in subsequent months if cumulative performance matches or exceeds the planned performance standards profile. In addition, an appeal has been submitted to NHSI for both A&E and Cancer trajectory failures – the outcome of which is not yet known.


The trust is ahead of the revised (July) plan submitted to NHSI by £3,105k (assuming S&TF is secured as described above).

4. Key Issues

4.1 Summary Financial Position

Planned level = 3

NHSI - Use of Resources Risk

1

2

3

4

As at 28th February 2017 the trust is reporting a

year to date surplus of £5,878k compared to the

NHSI plan for month 11 of £5,968k surplus, the

trust is therefore £90k behind plan at month 11.

The trust is ahead of the control total (excluding

S&TF) by £690k.

As at 28th February 2017 the trust is reporting a

use of resources risk rating of 3 in line with plan.

As at the 28th February 2017 the cash balance is

£19.354m which is £1.275m ahead of plan.

Capital expenditure is £5.565m behind schedule

Receivables is £5.438m higher than planned

due to the outstanding £5.7m STF funding.

Deferred income remains higher than forecast,

offset by the lower levels of Trade Payables

Cost reduction plans for the 2016/17 financial

year total £28.02m in the original NHSI plan.

As at 28th February 2017, £25.755m has been

delivered against a profiled target of £25.463m,

which is £0.292m ahead of the original (April

2016) NHSI plan.


4.2 Overall Surplus/Deficit for the Period to February 2017 Month 11 Performance vs. NHS Improvement Plan The trust is reporting an overall cumulative surplus to February 2017 of £5,878k compared to an original planned position of £5,968k surplus. The trust is therefore £90k behind the April NHSI plan at month 11. Excluding the ST&F from this position shows that the trust is £690k ahead of its control total value as at February 2017.

The position has factored in the loss of £5.8m of income as determined by the arbitration decision. Based on the published S&TF criteria, CDDFT are anticipating ST&F income of £13.52m from a possible £14.30m, with the £0.78m reduction being predicated by operational performance as detailed within section 8 below.

Whilst we are not being monitored against the NHSI re-plan submitted on the 28/07/2016, the current position against that re-plan is:

Performance against the NHSI re-plan is noted as £3,105k ahead of plan, with £5,978k surplus reported against a planned surplus of £2,773k.

Monitor Plan Actual Variance Variance

Plan To Date To Date

£000's £000's £000's £000's %

Total Income 485,883 444,814 436,396 -8,418 -1.9%

Pay Costs

Employee expenses, substantive, bank and overtime staff -282,750 -259,278 -259,839 -561 0.2%

Employee expenses, Locum and agency -18,757 -17,348 -16,945 403 -2.3%

Total Pay Costs -301,507 -276,626 -276,784 -158 0.1%

Non Pay Costs -149,546 -136,498 -129,218 7,280 -5.3%

Total Operating Expenditure -451,053 -413,125 -406,003 7,122 -1.7%

EBITDA 34,830 31,689 30,394 -1,295 -4.1%

Depreciation & Amortisation -11,799 -10,816 -10,103 713 -6.6%

Surplus / (Deficit) from Operations 23,031 20,873 20,291 -582 -2.8%

Net Non-Operating -16,473 -14,905 -14,413 492 -3.3%

Overall Surplus/(Deficit) Monitor Plan 6,557 5,968 5,878 -90 -1.5%

ST&F included in Position -15,600 -14,300 -13,520 780 -5.5%

2016/17 Control Total -9,043 -8,332 -7,642 690 -8.3%

Period to February 2017

Montor

Annual Plan Actual Variance

RePlan To Date To Date

£000's £000's £000's £000's

Month 11 Surplus / (Deficit) -8,925 -11,527 -7,642 3,885

Month 11 STF 15,600 14,300 13,520 -780

Month 11 Replan 6,675 2,773 5,878 3,105

As at 28th February 2017 the trust has spent

£20.884m of the £26.448m planned capital

programme which is £5.564m (21%) behind the

planned spend reported to NHS Improvement

(NHSI).


Month 11 Performance vs. Budget The April plan submitted to NHSI is fixed for the purposes of their monitoring of our financial performance and accessing S&TF. The revised plan, submitted in July, demonstrated that the control total could still be achieved, but required a significant phasing adjustment in recognition that the income loss would be suffered evenly across the year, but that the additional cost reduction and mitigating actions would be phased progressively, biased more towards the end of the year.

In addition to this, we had to estimate the likely deployment of reserves, and timing of income and expenditure adjustments. In order to prevent windfall gains and losses at cost centre level, and maintain the integrity of the budgetary control system as a means for holding budget holders to account, the budgets are adjusted appropriately in real time to reflect actual deployment of reserves, and other changes such as contract variations and additional income and expenditure received during the year. The table below summarises the month 11 performance against the NHSI plan and then bridges both factors detailed above to reflect the current live budget position at month 11.

Comparing the February surplus position of £5,878k against the live budgetary position shows that the trust is £69k ahead of its planned month 11 surplus of £5,809k.

Monitor Plan Actual Variance Variance


£000's £000's £000's £000's %

Overall Surplus/(Deficit) Monitor Plan 6,557 5,968 5,878 -90 -1.5%

Reconciliation From Monitor Plan to Month 11 Budgets

Rephasing re arbitration impact and mitigating actions 0 -1,878 0 1,878 -100.0%

Winter Plan Rephasing 0 -228 0 228 -100.0%

Rephasing adjustments actioned 0 1,947 0 -1,947 -100.0%

Total Adjustments 0 -160 0 160 -100.0%

Month 11 Ledger Position 6,557 5,809 5,878 69 1.2%



4.3 Income

Income is reported as (£2,305k) under-recovered against the live budget position;

ST&F expectant performance failures contribute (£780k) of the reported income deficit made up of (£650k) for A&E and (£130k) for Cancer – as detailed in section 7.

PBR performance contributes the (£661k) contract income deficit which was driven primarily due to Flex to Freeze position deterioration from the prior months’ reported position. It is therefore important to note once more that the level of fully coded activity is currently at only 47% for January’s actual activity, which in fiscal terms results in circa £10.0m of contractual income being based upon average tariffs applied to un-coded activity. Whilst these average tariffs had historically proven robust in prior periods, the negative movement noted above therefore does indicate that this represents a real risk to the reported income position.

Annual Plan Actual Variance Variance


£000's £000's £000's £000's %

Income

NHS Clinical Income 439,303 401,448 400,339 -1,109 -0.3%

Non NHS Clinical Income 12,578 11,577 11,457 -120 -1.0%

Non Clinical Income 28,693 25,676 24,600 -1,076 -4.2%

Total Income 480,575 438,701 436,396 -2,305 -0.5%

Expenditure

Pay Costs

Employee expenses, substantive, bank and overtime staff -290,983 -266,377 -259,839 6,538 -2.5%

Employee expenses, Locum and agency -15,128 -13,858 -16,945 -3,087 22.3%

Total Pay Costs -306,112 -280,235 -276,784 3,451 -1.2%

Non Pay Costs -140,290 -129,563 -129,218 344 -0.3%

CRT 9,736 4,947 0 -4,947 -100.0%

Reserves -10,121 -3,086 0 3,086 -100.0%

Total Expenditure -446,785 -407,937 -406,003 1,934 -0.5%

EBITDA 33,789 30,765 30,394 -371 -1.2%

Depreciation & Amortisation -11,397 -10,447 -10,103 344 -3.3%

Surplus / (Deficit) from Operations 22,393 20,318 20,291 -27 -0.1%

Profit / (Loss) on Asset Disposals 0 0 -32 -32 -

Interest Recievable 272 256 148 -108 -42.3%

Interest Payable -14,462 -13,257 -13,314 -57 0.4%

PDC Dividend -1,645 -1,508 -1,263 245 -16.3%

Donated Asset Income 0 0 48 48 -

Surplus / (Deficit) 6,557 5,809 5,878 69 1.2%

(Impairment)/Reversals of Fixed Assets 0 0 0 0 -

Overall Surplus/(Deficit) 6,557 5,809 5,878 69 1.2%

Use of Resources Risk Rating 3 3 3



Care Group / Corporate income performance contributes (£864k) of the reported deficit. This under performance relates primarily to the loss of the Non-Patient Care SLA within Estates and Facilities. This loss should however be partially offset by reduced costs from the new provider for which we are currently awaiting confirmation from NHSPS.

4.4 Pay Costs Pay costs are under budget by £3,451k. As shown in the table above this relates to underspends of £6,538k on substantive staff due to vacancies being offset by overspends on agency staffing of £3,087k. The table below shows the agency spend by staff group for Month 11 of 2016/17 compared to the same period in the previous financial year.

The graphs below show:

the trends on agency & locum spend over the last 2 years.

the trends on bank usage over the last 2 years.

01. NHS Clinical

Income

02. Non NHS

Clinical Income

03. Non Clinical

Income

Grand Total

Contract Under Performance -£586 £9 -£84 -£661

STF A&E Performance Penalties -£650 -£650

STF Cancer Penalties -£130 -£130

Total Income Division -£1,366 £9 -£84 -£1,441

Care Group / Corporate Income £257 -£129 -£992 -£864

Total Care Group / Corporate

Income£257 -£129 -£992 -£864

Grand Total -£1,109 -£120 -£1,076 -£2,305

2015/16

£000s

2016/17

£000s

Movement 2016/17

less 2015/16

£000s

Agency & Locum Medical Staff 16,599 12,942 -3,657

Agency Nursing & HCA 8,643 2,721 -5,921

Agency Admin & Clerical 1,130 383 -747

Agency PAMS 959 592 -367

Agency Prof and Technical 872 306 -565

Agency Other 0 1 1

Grand Total 28,202 16,945 -11,257


Nurse and HCA agency costs have shown a (£33k) reduction compared to January 2017, and nurse and HCA bank costs have shown a (£155k) reduction compared to the levels seen in January 2017. The cumulative month 11 year on year position is shown in the table below:

Medical agency & locum spend has shown a (£205k) reduction compared to the January 2017 position. 4.5 Agency Cap

NHSI wrote to the Trust on 17 March 2016 confirming that a total agency cap of £20.696m would apply for 2016/17. The ceilings were calculated based on the

Nurse and HCA2015/16

£000s

2016/17

£000s

Movement 2016/17

less 2015/16

£000s

Agency 8,642 2,721 -5,921

Bank 2,572 8,205 5,634

Total 11,214 10,927 -287


trust’s reported 2015/16 spend extrapolated. This all-staff ceiling replaces the nurse agency ceiling issued during 2015/16. The ceiling has been allocated at a care group and corporate level, the table below shows the year to date and forecast performance.

4.6 Non Pay Costs Non pay expenditure is under budget by (£344k). It is important to note that inherent in the year to date position, is that non-pay budgets have had a corresponding reduction to match the stock take benefit of £2m, as this has been taken towards delivering the trusts cost reduction target on a non-recurrent basis. Whilst YTD performance is currently under budget, within this there is one area of particular adverse performance to highlight which is Purchase of Healthcare Services. Cumulatively, this is £2,658k overspent which predominately relates to work referred to the Independent Sector within T&O and General Surgery / Endoscopy, above the run rate expectation.

This is partly offset by underspends throughout other expenditure headings with dressings & medical and surgical equipment, appliances & implants, bedding, linen & laundry generating a cumulative underspend of £1,442k.

The remaining offsets relate to training costs, travel & transport, establishment, furniture and office/computer equipment, where tight cost control continues to be exercised.

4.7 Cost Reduction The trust’s cost reduction target (CRT) was originally set at £28.018m in the budget setting papers in order to achieve the requisite level of clinical efficiency and financial surplus expected by the board. The paper agreed by the board as the basis for the submission of a 2016/17 replan in July 2016 increased the CRT to £37.47m taking into account all of the measures required to deliver the control total following the loss in arbitration.

Control Total

to Month 11

2016/17

Expenditure as

at Month 11

2016/17

Variance 2016/17

Control Total

2016/17

Forecast

Outturn

Variance

£000's £000's £000's £000's £000's £000's

AEC 8,392 7,118 -1,274 9,155 7,570 -1,584

Surgery 4,207 4,253 46 4,589 4,615 26

CSS 1,171 1,184 13 1,277 1,346 69

Family Health 847 1,280 433 924 1,370 446

Integrated Adult Care 3,861 2,847 -1,014 4,212 3,236 -976

CEO 26 4 -21 28 4 -24

Commercial 114 0 -114 124 0 -124

Finance 53 70 17 58 77 19

HR 163 42 -122 178 48 -130

Nursing 4 20 16 4 23 19

Ops 28 0 -28 30 0 -30

E&F 108 126 18 118 137 19

Medical 0 0 0 0 0 0

18,972 16,944 -2,027 20,697 18,426 -2,270


Of the total £37m CRT target £21m relates to care groups and corporate department schemes and £16m is linked to centralised trust wide schemes and flexibilities. In month 11, actual CRT delivery for the year amounts to £27.731m, of which £16.737m has been delivered from care groups and corporate departments and the remaining £10.994m has been delivered from the central schemes. Comparing the £25.755m delivered to date, against the profiled target of £30.701m leaves the CRT behind plan as at month 11 by £4.947m, with slippage across a number of areas. 4.9 Cash Management The trust’s cash position stands at £19.354m as at 28th February 2017, which is £1.275m ahead of the planned cash position. There are however several offsetting areas of spend which continue to show material differences from plan; Capital expenditure has returned to be £5.6m lower than plan, which has had a positive impact on cash levels in the short term. Inventory levels remain higher than plan due to the stocktake carried out during 2016/17, with these forecast to increase further at March 2017, effectively reducing cash further. Trade and other receivables are £5.4m higher than plan, almost entirely due to the £5.7m STF cash payments (relating to Q3 and Q4) that remain in accrued income. The actual levels of receivables as at the 31st March was forecast to reduce further as is normal in March, however a small number of high value invoices have remained outstanding, resulting in cash income forecasts having been reduced. This has had an impact on the cash availability between 15th March and 15th April and daily cash controls have been implemented until the receipt of the SLA payments on the 15th April. The trust was already forecasting that cash balances would be tight, however these late payments have exacerbated the situation. Without any intervention a cash deficit of £1m would have occurred during the start of April. The following mitigating actions have been enacted to manage the position:

Cash balances managed on a daily basis.

High value debts followed up on a daily basis.

Creditor payments held and released subject to additional cash being received.

CCG’s requested to make April contract payment at the start of the month not the 15th.

Discussions are on-going with those organisations to try to ensure that payment is received by the 24th March, the final date for making inter NHS payments. Non NHS Payables and Capital payables continue to be lower than planned which provides the trust with some flexibility to extend payment periods to manage the


cash pressures, so it is likely that Trade and other Payables balances will be higher than forecast as at 31st March 2017. The thirteen weekly rolling cash forecast continues to be monitored closely.

5 Care Group and Corporate Department Budget Performance As shown in the table below Care Groups and Corporate Directorates have underspent by £1,761k against their budgets as at the Month 11 position;

Whilst the Corporate departments are operating within a cumulative overall surplus of £73k – it is worth noting that within this surplus, Estates & Facilities are currently showing a deficit of £791k.

The Care Groups and Corporate Directorates are forecasting to be £715k overspent at the year-end after factoring in the deployment of remaining reserves (primarily £2.498m relating to excluded drugs and devices which are funded monthly via the matched income received from commissioners).

Note that this forecast overspend will incorporate the Care Group and Corporates’ view on their CRT delivery (referencing the CRT risk identified at 4.7 above). This risk is currently being managed via FSP currently, although there is no assurance on full delivery. This position has improved by £0.511m from the January position reported as a consequence of the on-going escalation process, which is manifested in the monthly results. This process, led by the Chief Executive, continues to operate with those care groups and corporate departments forecasting an overspend, with the objective of returning them to balance.

Division Annual

Budget

£000's

Budget to

Date

£000's

Actual To

Date

£000's

Variance to

Date

£000's

ACUTE & EMERGENCY CARE £85,438 £79,684 £80,802 £1,118

SURGERY £93,200 £86,122 £85,453 -£669

CLINICAL SPECIALIST SERVICES £67,451 £63,230 £62,069 -£1,161

CORPORATE DIVISION £64,052 £57,870 £57,797 -£73

FAMILY HEALTH £46,561 £43,272 £43,768 £496

INTEGRATED ADULT CARE £58,523 £53,925 £52,037 -£1,888

COMMERCIAL CRT -£500 -£415 £0 £415

Grand Total £414,725 £383,687 £381,926 -£1,761

Division

Forecast

Budget

£'000s

Forecast

Actuals

£'000s

Forecast

Risk to

Monitor

Plan

£'000s

ACUTE & EMERGENCY CARE 87,176 88,519 1,342

CLINICAL SPECIALIST SERVICES 69,067 68,761 -306

FAMILY HEALTH 46,934 48,276 1,342

INTEGRATED ADULT CARE 58,545 56,850 -1,694

SURGERY 94,735 94,730 -5

CORPORATE DIVISION 66,975 67,009 34

Total 423,432 424,145 714


6 Capital

The Trusts 2016/17 capital programme was forecast at £27.33m within the annual plan submitted to Monitor. As at the 28th February 2017 the trust has spent a total of £20.884m of the capital programme. This is £5.564m (21%) below the planned spend of £26.448m, and this reflects the trust’s deliberate control over capital spending, as previously reported.

7 Performance against STF

Following the original guidance published in January 2016 and March 2016, NHSI wrote to Foundation Trusts on 7 July 2016 confirming the conditions and criteria to access the STF during 2016/17. Compliance, against these criteria as at Month 11 reporting are detailed as follows;

The criteria were reported to Finance Committee and Trust Board in July. The STF has been secured for Q1 and Q2, resulting in income of £7.8m, which has now been paid to CDDFT in full. As the cumulative financial position for month 11 is ahead of the planned level, then the STF funding of £5,720k for months 7 to 11 has been accrued within the overall financial position. The A&E and cancer performance measures up to Month 11 performance are shown in the table above. The consequence of the A&E and cancer failures are 12.5% & 5% respectively of the monthly £1.3m and this is excluded from the financial position. The A&E STF income can be recovered in subsequent months if cumulative performance matches or exceeds the planned performance standards profile.

8 NHSI 2017/18 and 2018/19 Plan

Following providers submissions of the NHSI 2017/18 and 2018/19 Plan in December 2016, NHSI have wrote to all providers on the 15th March 2017 to offer a limited rules-based opportunity to refresh plans to;

Correct errors

Ensure plans have the appropriate monthly profile for in year monitoring

To align with plans sign off by your board.

Measure

M7 M8 M9 M10 M11 Total

Is the Provider Delivering the Control Total (net of STF)? Yes Yes Yes Yes Yes Yes Yes £0k £0k £0k £0k £0k £0k

Is the Provider delivering above the standard or above the

agreed trajectory where this is below the standard for;

>A&E Yes Yes No No No No Yes 162.5k 162.5k 162.5k 162.5k £0k £650K

>Cancer Yes Yes No No Yes Yes Yes 65k 65k £0k £0k £0k £130k

>RTT Yes Yes Yes Yes Yes Yes Yes £0k £0k £0k £0k £0k £0k

>Diagnostics Yes Yes Yes Yes Yes Yes Yes £0k £0k £0k £0k £0k £0k

£780K

Q1 Q2 M10

STF Funding not yet achieved

M7 M8 M9 M11


The rules based opportunity is based upon the following;

1. Where previous CT (Control Total) agreement has been reached in 2017/18 this must stand

2. There must be no deterioration in bottom line financial position

And in-line with normal submission process;

3. The correct total value of STF is included in plan, and that it is consistent with acceptance or rejection of the CT

4. Any validation errors must be cleared

On the basis of the above, we are proposing that we do not wish to deviate from our original

submission in December. Our original submission remains valid and is reflective of plans signed

off by Board and for which operational planning is based upon. Given we cannot deviate from

the original financial position declared and our acceptance of the control total per the rules based

approach above, we feel that there is little benefit in re-evaluating and resubmitting.

Subsequent to the correspondence received on the 15th March 2017 – we received an additional

email on the 17th March 2017 from NHSI indicating that following review of our submission in

December they advise that for our trust a refresh of the finance planning forms is not mandatory.

This additional feedback received confirmed there were no capital / cash queries to be answered

and no feedback required from the trust. This, in conjunction with the aforementioned

paragraphs, help confirm our recommendation not to pursue a re-plan submission.

9 Going Concern

Appendix A provides an update on the Trusts going concern status. This paper requests

that the Board formally confirm their opinion on the going concern status of the Trust as

part of the requirements for completing the Trust’s Annual Report and Accounts as at

31st March 2017.

Whilst we do not have any evidence to suggest that a going concern is not appropriate,

the Trust Board should review the information provided and confirm that there is a

reasonable expectation that the trust will continue in operational existence for the

foreseeable future.


10 Recommendations

The board is asked to:-

Note the financial position of the trust as at 28th February 2017.

Note the criteria for eligibility to the STF and performance against it.

Confirm that no resubmission of our NHSI 2017/18 to 2018/19 is required.

Endorse the going concern status of the trust prior to the Trust Board’s consideration

Peter Dawson Executive Director of Finance March 2017


Appendix A

GOING CONCERN STATUS

1. Purpose of the Report

This paper requests that the Board formally confirm their opinion on the Going Concern status of the Trust as part of the requirements for completing the Trust’s Annual Report and Accounts as at 31st March 2017.

2. Background

The Trust needs to consider whether it is appropriate to prepare its Annual Accounts and Annual report for 2016/17 on a ‘Going Concern’ basis. IAS 1 and the FT Annual reporting manual provide the guidance under which management should consider whether the trust is a going concern. The guidance states that financial statements should be prepared on a going concern basis unless management either intends to apply to the Secretary of State for the dissolution of the Trust without the transfer of the services to another entity, or has no realistic alternative to do so. The anticipated continuation of the provision of a service in the future, as evidenced by inclusion of financial provision for that service in published documents, is normally sufficient evidence that the Trust should be considered a going concern. It should be noted that this is a slightly different basis to that which is usually considered during this annual ‘Going Concern’ review. Background to 2017/18

The Board approved and submitted to its regulator an operational plan covering the period 2017 to 2019 which aims to meet the requisite control totals. The basis of this plan is being considered by the board to form the basis of 2017/18 operational budgets.

The Trust will hold minimum cash balances of £1.3m, which are dependent on a challenging cost reduction target.

Capital expenditure is forecast to be £21.8m in 2017/18, reducing to £10.3m in 2018/19


Appendix A

3. Recommendations

The trust does not have any evidence to suggest that a going concern is not appropriate, based on:

NHSI having given no indication that they intend to intervene in this trust at any time during the next twelve months.

Contracts have been signed for both 2017/18 and 2018/19 and the trust’s commissioners have given no indication that they do not expect to contract with this trust in 2019/20.

The Trust Board should review the information provided and confirm that there is a reasonable expectation that the trust will continue in operational existence for the foreseeable future. For this reason, it is recommended that the Trust Board confirms the appropriateness of adopting the going concern basis in preparing the accounts.

Trust Board Minutes (Part 1: Open): 25 January 2017 Page 1 of 16

BOARD OF DIRECTORS

Minutes of the Meeting of the Board of Directors of County Durham and Darlington NHS Foundation Trust held on Wednesday 25 January 2017 from 08:45hrs in the Board Room, Executive Corridor, Darlington Memorial Hospital

Part One (Open) Present: Prof Paul Keane OBE Chairman Mr Michael Bretherick Non-Executive Director Ms Jenny Flynn MBE Non-Executive Director Mr Paul Forster-Jones Non-Executive Director Dr Ian Robson Non-Executive Director Mr Andrew Young Non-Executive Director Ms Sue Jacques Chief Executive Mr Peter Dawson Executive Director of Finance Prof Chris Gray Executive Medical Director Ms Carole Langrick Executive Director of Operations In Attendance: Ms Alison McCree Director of Estates & Facilities Ms Morven Smith Director of Workforce & OD Ms Joanne Todd Associate Director of Nursing (Patient Safety) Mr Warren Edge Senior Associate Director of Assurance & Compliance Ms Hayley Robertson Minute Taker Ms Debra Chamberlain KPMG There were 15 members of the public in attendance. Action 224/17 Apologies for Absence

The Trust Chairman welcomed those members of the public who were in attendance. A further welcome was extended to Ms Chamberlain, who was in attendance as an observer, as part of the Well-Led Review currently being undertaken within the Trust. Apologies for absence were received from Mr Noel Scanlon, Executive Director of Nursing. Ms Todd was in attendance on his behalf. The Chairman highlighted the opening of the Trust’s Faith Centre, at Darlington Memorial Hospital, which was taking place that day.

225/17 Declarations of Interest Any Board Member who was aware of a conflict of interest relating to any item on the agenda was required to disclose it at this stage or when the conflict arose during consideration of a particular item. Ms McCree and Dr Robson declared their interests as Directors of


Synchronicity Care Ltd.

226/17 (a) (b) (c)

Minutes and Matters Arising from the Previous Open Meeting held on Wednesday 21 December 2016 Accuracy The minutes of this meeting were approved as an accurate record, subject to the following amendments: Minute 201/17 Medical Director’s Report (page 8, fifth paragraph) (NENE) to be updated to read (HENE). Minute 201/17 Medical Director’s Report (page 8, sixth paragraph, third sentence) To be updated to read “Locally, Durham University had withdrawn their participation against the two year Phase One programme.” Minute 202/17 Operational Performance & Efficiency (page 9, fifth paragraph) Replace the first full stop (following the word “control”) with a comma. Matters Arising from the Minutes: Not Featured on the Action Log Minute 201/17 Medical Director’s Report In relation to Health Education North East training programmes for Obstetrics and Gynaecology, Mr Young advised that he had recently attended a meeting where the NHS Improvement Chief Executive, Jim Mackey, had commented on the supply of Obstetricians in that it was expected that demand would be easily met. In Ms Jacques view, this did not sit comfortably with the current training numbers and would require translation into future plans. Minute 202/17 Operational Performance & Efficiency (b) Winter Plan Ms Jacques advised that, in respect of the region wide agreed approach to the OPEL escalation system, a review meeting was planned for February 2017, with all Local Area Delivery Boards (LADB) contributing. Mr Young enquired as to the outcome of the review of the Home Equipment Loans Service and the provider’s ability to meet demand. Ms Langrick advised that from an operational perspective, there had been very few instances of delay. A weekly stranded patient review report was in place which included reasons for patients not being fully discharged and there had been no recent instances of delays relating to equipment loans. Minute 204/17 Communications and Engagement Blueprint In relation to the £30k use of Charitable Funds to create the Trust’s new website, Ms Flynn advised that discussion had taken place at the Charitable Funds Committee, however a paper had not yet been formally submitted. The Communications Manager, Ms Curry had been tasked with providing an explanation of the anticipated patient benefit. Action Log Minute 27/17 (27 April 2016: Open) Post-implementation reviews (PIR) to be brought to the Board covering the following investments: AMEC, RAMAC, RAS, CREST, the Acute Medical Units, Nursing


Staff, Advanced Nurse Practitioners, Obstetric and Gynaecology Consultants and Paediatric Consultants. Ms Jacques requested that a schedule of PIRs be produced before the February 2017 Board meeting. Mr Young highlighted that an action from the recently held Audit Committee meeting was for Mr Edge to produce a list of investments with a value greater than £500k for the Board to review and determine whether a PIR was required. He suggested the two actions be linked. Ms Jacques agreed with the suggestion. Minute 200/17 (21 December 2016: Open) Arrange a fuller debate to take place on the work around Duty of Candour compliance, potentially at IQAC Mr Edge advised that the detailed discussion would take place at the February 2017 IQAC meeting.

CL (Jan

2017)

WE/CL (Jan

2017)

227/17 (a)

Chief Executive’s Report Care Quality Commission Action Plan Update Ms Jacques introduced the item, explaining that the paper was not only concerned with the actions in relation to the Care Quality Commission (CQC) inspection, but also concerned the work to assure the Trust that actions were embedded appropriately. Ms Jacques went on to advise that the second mock CQC inspection had now been completed and the Trust had benefited from involvement of independent individuals outside of the organisation. In relation to the section of the report on Quality Matters, Ms Jacques drew the attention of Board members to the results for measures concerning nutrition. For various reasons, there were some concerns around this area, which would also be highlighted in the performance report later in the agenda. As a result, it had been agreed that a future meeting of the Integrated Quality and Assurance Committee (IQAC) would include this as a main topic on the agenda. As a more general comment, issues such as nutrition being identified in separate Board papers, but without necessarily a consistent commentary and action plan, suggested that it would be a good time for the Executive Directors to review how they reported to the Board, to better service the Board as a whole. There was a need for reporting to be more joined up and thematic and further details would follow. Ms Jacques handed over to Mr Edge to talk through the detail of the report. Mr Edge advised that six of the 75 actions remained open at the present time, with five more partially complete pending on-going monitoring. The open actions were all progressing. Assurance was being collated from various sources including; Quality Matters monthly ward audits, ‘Back to Practice Fridays’ and mock inspections on both sites.

WE (Mar 2017)


In relation to the open actions around Palliative Care, Prof Gray provided an update on the recruitment of a Palliative Care Consultant. Interviews were being held in the following week and it was hopeful an appointment would be made. Mr Young noted from ECL minutes provided, that in relation to the CQC peer review, the result would be ‘requires improvement’. Ms Jacques reminded Board members that the Trust’s aim was for ‘outstanding’ by September 2017. In the case of the actual inspection, the Trust would be given 100 days’ notice and a great deal of preparation would take place. Most importantly, the Trust needed to ensure good patient experience on a day to day basis and the mock inspection had enabled the Trust to ensure focus was on the right areas to enable this. Mr Forster-Jones asked for some further clarity on how the shared learning between wards worked in practice. Ms Jacques advised that the Executive Director of Nursing had asked those wards with areas of best practice to share their experience with clinical teams, explaining the work that had been carried out. This was proving useful within clinical teams and provided practical examples from colleagues. Mr Edge added that this practice was now running through monthly meetings of the Senior Nurses, Midwives and AHPs forum, both in terms of progress and preparation, and using best practice examples. Ms Todd reiterated the point and added that the Quality Matters audits had become more mature and were focussing in on specific areas that appeared to be an issue across the board. Ms Flynn appreciated that nursing staff were heavily involved in the work, on a day to day basis, however she wished to understand how medical staff were involved. Mr Edge advised that there was some representation from medical staff on peer review panels, which were required to be supported by medical staff. In addition, medical staff were leading or supporting some specific actions; for example Dr David Oxenham was supporting on DNAR training. Medical staff involvement was therefore on a more specific, rather than general basis. Mr Bretherick wished to give further assurance around the maturing of Quality Matters. In his experience, the focus on commencement of IQAC had been on processing of data. More recently, the system appeared to be starting to work well and was enabling a focus on emerging themes. The Chairman highlighted the reference to E-rostering in the report, which was an issue that was regularly cited. Ms Jacques advised that the issue was included in more detail in the Director of Nursing Reports, which would be discussed in a later part of the meeting. Noting the reference to improvements identified in relation to care of patients requiring non-invasive ventilation, as a result of the mock


(b) (c)

CQC inspection, the Chairman highlighted an issue he was aware of from attendance at the Clinical Quality and Safety Panel. Discussion had taken place at the meeting regarding an exceptional spike in respiratory illness, causing an unprecedented influx of 11 patients requiring non-invasive ventilation. Ms Jacques explained that the contingency plan had been deployed on that day; however the level of activity experienced was not envisaged. The team on the ground had utilised the best of their abilities to manage well in extremis, with similar conditions seen elsewhere in the region. The contingency plan was currently being rewritten to include a much higher level of activity. The Trust Board NOTED the Report on Progress against the Care Quality Commission Action Plan and requested further updates to provide assurance that actions from mock inspections were resulting in improvements where required. Better Health Programme / Sustainability and Transformation Plan Update Ms Jacques advised that the Trust was continuing to actively work with both the South and North Sustainability and Transformation Plans (STPs) on both a clinical and non-clinical level. The timetable for the South was for consultation to run in summer 2017 and was as yet undecided in the North. The Board had reviewed the pre-consultation business case draft for the South STP, and a letter responding with the Board’s views which was sent to the STP Programme Board earlier in the month. There was no further update to report. The Trust Board NOTED the update on the position with regard to the Better Health Programme and the Sustainability and Transformation Plan. Board Assurance Framework Ms Jacques introduced the item by highlighting the example of minimising avoidable harm. There was significant evidence that improvements had been made in the area and results were relatively good; however, new risk factors had emerged and the risk had not reduced in line with trajectory. It was important for the Board to be cited on how judgements were made around the risk profiles for areas and Ms Jacques proposed that the example of minimising avoidable harm could be used to review this in more detail. Part of the Trust Board seminar in February 2017 would therefore be used to review the Board Assurance Framework in more detail and look specifically at the minimising avoidable harm objective. Mr Young welcomed the proposal, noting that most of the objectives had risk management trajectories which ran only to July 2017 and were therefore due for review anyway. Ms Jacques handed over to Mr Edge, who summarised the key points in the document circulated. In terms of the proposal for the


Board to review the risk management trajectories, he highlighted that the initial recommendation was for Sub-Committees to do this, however following discussion with Ms Jacques it had been agreed that it was more appropriate for the Board as a whole to review them. Mr Edge advised that the framework included 15 principal business objectives, of which 11 remained on trajectory and four had slipped. In terms of those that had slipped behind trajectory, the position had not worsened; rather, the anticipated further progress had not been made. The detail on actions completed was included in the report for the assurance of the Board. Objectives that were the responsibility of Finance Committee and IQAC had been reviewed at those Committees since the publication of the report and whilst suggestions had been made, there were no comments that would significantly change the content of the report. Mr Young noted the reference in the report to a skills gap and cultural issues in relation to a ward at Chester-le-Street Hospital. Whilst he appreciated that it may not be appropriate to share the detail in the public part of the Board meeting, he sought assurance that the cultural issues could and would be addressed. Ms Jacques advised that an immediate action plan had been put in place and subsequent work had begun which would be shared with Board members. The Executive Director of Nursing was directly leading on this. The issue was in relation to a specific incident and would be discussed later in the meeting as part of the Director Nursing Report. The Chairman thanked Mr Edge for a very comprehensive document. As there were a significant number of actions and project work to monitor, the Chairman asked how Board members could be assured that appropriate monitoring was in place. Ms Jacques advised that there was a process in place for actions to be scrutinised by Sub-Committees and it was aimed that meetings would be scheduled further in advance of the Board meeting in future to enable a smoother process. Additionally the Board Assurance Framework itself was well developed and useful. Ms Jacques advised Board members that Mr Stuart Dabner, Guardian of Safe Care working for the Trust, planned to bring a full report to the February 2017 Board meeting. The Trust Board RECEIVED the Board Assurance Framework.

Patient Safety & Quality

228/17 (a)

Director of Nursing: Reports Patient Safety & Experience On behalf of Mr Scanlon, Ms Todd spoke to the report, which was contained within the agenda pack. The purpose of the report was to


update the Board on; • key patient safety incidents and progress against actions; • the position with regard to Healthcare Acquired Infections

(HCAI); and • patient experience indicators.

Ms Todd advised that since the period reported on, a case of C-Difficile had been reported in January, which was not included in the report. Additionally, a case of MRSA Bacteraemia had very recently been reported, taking the total to 15 against a threshold of 19. Ms Jacques noted the position with regard to compliance with WHO Five Moments for Hand Hygiene, which showed reduced compliance for some areas in Quarter Three. Ms Todd advised that this included visiting staff, which analysis of results had suggested was an area for further focus. It was noted that there had been no further cases of Pertussis since December 2016. In terms of reporting on serious incidents, Ms Todd advised that the format had changed. The report now included only those incidents which had not previously been reported to the Board. The latest position in relation to the Duty of Candour was noted. Ms Jacques asked for clarification on the figures provided for each quarter. Ms Todd advised that the figures were per quarter, rather than cumulative and reflected the numbers of incidents occurring in each quarter for which one or more Duty of Candour requirement was not yet evidenced as complete. Ms Jacques requested a plan for how those outstanding would be remedied, noting that some of those from 2014/15 remained open. Ms Todd advised that the detail of each case had been requested from Care Group leads, which would support such an action plan. Ms Flynn recalled that discussion had taken place at IQAC in relation to recording in this area. It was thought that the tick box on the Safeguard IT system to confirm completion was potentially not being done in all cases. As this was a relatively new requirement, Ms Jacques suggested that an audit could be carried out to ensure the practice was embedded. Mr Bretherick supported this approach and noted that there appeared to be other areas where simple IT actions were not being completed. Ms Jacques asked Ms Todd and Mr Scanlon to review the issue with Care Groups to gain an understanding of the issue. The Chairman summarised the position. There was some further work required to ensure the system was correctly implemented. This would be monitored by the Board as a monthly report had been agreed to be provided until such point that the Board was satisfied with the position.

WE (Mar 2017)

NS (Mar 2017)


(b)

Moving on to Never Events, Ms Todd advised that regional comparative data was now included, at the request of the Board. Noting the national position, as provided in appendix one, Mr Young was disappointed that the Trust’s relative performance appeared poor. In relation to patient experience, and specifically complaints, Mr Young commented that the position with regards to complaints regarding staff attitude appeared to have worsened month by month and year by year. He was pleased to read that action was being taken to address this issue. Mr Bretherick advised that he had been made aware that funding in relation to Friends and Family Tests would cease at the end of the financial year. He asked whether this was likely to be an issue for the Trust. Ms Jacques responded that she was not aware of an issue in this area but it would be reviewed and feedback given to the Board. In terms of response rate, she added that the low response rate was an issue experienced across the region. Mr Young noted the reduced performance in A&E in this area and asked if this was being analysed further. Ms Todd agreed to feedback on the issue. Mr Forster-Jones highlighted that the supporting documents appeared to show a positive trend in relation to the Maternity Services position. Prof Gray cautioned that there was still work to be done in the area and issues were not yet fully resolved. Nursing Staffing Compliance Report Ms Todd presented the report, the purpose of which was to inform the Board of monthly key themes around safe staffing and temporary staff expenditure. Question and comments were invited. It was noted that fill rates were at the best level seen since reporting in that format commenced, shown on page five of the report. Ms Jacques advised that work had taken place to review nursing establishments against budgets. This was not quite complete and therefore was not factored in to the establishment figures. In relation to nurse recruitment, the Chairman enquired on the number recruited in the most recent cohort of overseas numbers. Whilst Ms Todd did not have the exact figures to hand, she advised that the number was less than 10. Mr Forster-Jones pondered whether the scheme had reached the point where it was no longer effective to continue. Ms Todd advised that it was too early to make that assumption, however the latest scheme would give further data to make that determination. Mr Bretherick highlighted the summary at the end of the document which he felt was useful, along with the assurance statement in the

NS

(Mar 2017)


middle of the document. He suggested that the two elements could be combined into the executive summary at the beginning of the document. Mr Young was in agreement with that point and made a further suggestion that, an exception report to highlight anything new or to focus on specific trends, might add more value. Ms Todd advised that there were some specific requirements in terms of reporting the data that the Trust needed to be compliant with. She agreed to review these with Mr Scanlon and report back to the Board. Trust Board Members RECEIVED and NOTED the reports from the Executive Director of Nursing on patient Safety and Experience Staffing.

NS (Mar 2017)

229/17

Medical Director’s Report Prof Gray presented the report, contained within the agenda pack. He advised that the report was very brief and served to provide an overview of the progress made by the Trust during his tenure. It would be his final report as Executive Medical Director of the Trust, as he would be leaving the Trust to take up a new appointment with NHS England. Prof Gray thanked members of the Board who had supported him during his time working within the Trust. No questions or comments were raised. The Trust Board RECEIVED the report from the Executive Medical Director.

Compliance & Performance Management

230/17 (a)

Operational Performance & Efficiency Integrated Performance Report for the period ending 31 December 2016 Ms Langrick introduced the Integrated Performance report, contained within the agenda pack. She focussed on the following performance challenges, as those of particular importance:

• A&E Indicators • Referral to Treatment (18 weeks) • Cancer 62 Days • CQUIN 2017/18

In relation to A&E, Ms Langrick advised that, whilst the Trust had previously been performing in the top quarter of Trusts on daily reporting, the report from the previous day (24th January 2017) showed significantly lower performance. This needed to be investigated further before any conclusions could be drawn.


In Quarter Three, the Trust had fallen short against the National A&E Four Hour Wait Target and the agreed NHSI trajectory. The Trust was committed to achieving the trajectory by the end of the year and a number of actions had been agreed to assist this. The undertaking of a ‘Perfect Month’ in March 2017 was one such action. Ms Jacques felt it important to emphasise that it was unlikely the target could be achieved in isolation and stakeholders of the Trust would be involved in the agreed actions, particularly the ‘Perfect Month’. Noting the increased demand experienced, Mr Forster-Jones asked whether there had been any analysis carried out around the volume of patients seen that could potentially have been seen elsewhere. Ms Langrick advised that, as part of the Emergency Care Improvement Project (ECIP), a focussed piece of work on that particular issue had been carried out. Using that analysis, and other work carried out nationally, it was suggested that potentially 20-40% of the patients admitted could have been seen elsewhere; however this was dependent on the alternative provision being in place. Dr Robson commented that national data in respect of ambulance journeys appeared to suggest that around 50% may not have required an A&E attendance. Mr Forster-Jones asked what might be different if the same volume of A&E activity was experienced in the following year. Ms Jacques advised that due to numerous streams of work, significant differences would be expected. Ms Langrick agreed to present a report to the February 2017 Trust Board Seminar on this work and the impacts being aimed for. Mr Bretherick highlighted a discussion that had taken place at IQAC around the potential for an additional ambulance handover bay at UHND. It appeared that the project had stalled. Ms Langrick explained that other Trusts had been able to establish handover bays, where patients where supervised by healthcare professionals, which enabled quicker turnaround for ambulance crews. This had been explored as an avenue for the Trust; however, due to physical constraints at both UHND and DMH, a more innovative approach was required and this continued to be worked on. Ms Flynn was pleased to note the plans for the ‘Perfect Month’ in March 2017 and she asked for clarification on whether the whole Trust would be involved. Ms Langrick confirmed it would be a Trust-wide exercise. Given the demands on staff and the increasing pressures faced, Mr Forster-Jones asked how staff morale was being affected. In Ms Langrick’s opinion, staff appeared to have noticeably pulled together,

CL (Feb 2017)


more than had previously been seen. Executive Directors were ensuring their visibility to staff and were recognising and thanking staff for their efforts. Another factor was the tone of the support from the Local Area Delivery Board (LADB), which was markedly different to the approach by the predecessor organisation and was greatly welcomed. Moving on to Referral to Treatment (RTT) requirements, Ms Langrick advised that the Trust was meeting the national standard but not the NHSI trajectory. A steady fall in performance had been seen since July 2016 and this was therefore a particular focus. A number of actions were in place to address the issue, including weekly monitoring of action plans. In terms of the Cancer 62 Day Waits Target, it was highlighted that the Trust would almost certainly fall short of the national target and the NHSI trajectory for Quarter Three; however, Ms Langrick was confident that the position could be recovered during Quarter Four. A large step change in performance had been seen between November and December, which if sustained, would enable the recovery. Finally, Ms Langrick highlighted the information provided on the last page of the report on CQUIN for 2017/18, this was provided in more detail than had previously been reported. The next stage would be to ensure established leads were in place for each scheme with action plans with key deliverables. Further questions and comments were invited. Dr Robson noted the relatively low occupancy in some community hospitals and queried whether the Trust was making the best use of that capacity, given that there was evidence of issues around releasing patients to the community where an acute bed was not necessary. Ms Langrick advised that part of the issue in transferring patients to particular community hospitals was in relation to location. A balance was required in making such decisions. Ms Langrick provided assurance that there were a number of projects being pursued to ensure appropriate step down arrangements were in place in the Trust. Mr Forster-Jones asked a point of clarity on the performance figures in relation to A&E, which appeared contradictory in different areas of the report. Ms Langrick explained that there were a number of different measures in place. Urgent Care Centres, classed as ‘type 3’ activity were included in the headline figures, which resulted in higher levels of performance for the Trust, compared to figures for Type 1 attendances which related solely to A&E patients. Mr Young noted with interest that a formal link had been created with the Ophthalmology service at Newcastle NHS FT and he asked if


posts would be appointed to in a joint manner, which would aid recruitment. Ms Langrick confirmed that would be the case. Mr Young was pleased to note the community activity in the report, which appeared to have sustained an increase from July 2016 to November 2016; he asked what was behind it. Ms Langrick advised that this was potentially due to the impact of mobile working, releasing time to care but this would need to be analysed further to make that point with certainty. Mr Young’s final point was in relation to the number of discharges before midday which remained low. He asked whether some targets to improve this should be established. Ms Langrick agreed to action this. The Chairman enquired whether any further progress had been made in relation to the regional network review of Vascular Surgery Services, which had been discussed at previous Board meetings. Ms Jacques advised that the recent response to the Trust’s letter from February 2016 had been shared with Board members and a final draft of the Trust’s latest response was in preparation. It was understood informally that the Vascular Network was intending to run a consultation; however, this had not been formally communicated.

CL (Mar 2017)

CL (Mar 2017)

231/17

Finance Report for the period ending 31 December 2016 Mr Dawson presented the Finance Report, the purpose of which was to:

• Update the Board on the financial position and forecast; • Advise the content of the Month 9 financial monitoring

submission to NHSI; • Report on the Trust’s Performance against the Sustainability

and Transformation Fund (STF); and • Report the results of 2015/16 Reference Costs exercise.

Mr Dawson advised that the report had been presented to the Finance Committee and had been scrutinised in detail. In terms of the financial position, the Trust was ahead of its original plan (excluding STF), as at 31st December. Due to the quarter’s performance in relation to A&E and Cancer, 12.5% of the quarterly STF income (£487.5k) for A&E and 5% of the quarterly STF income (£195k) for Cancer, could not be accrued into the position. Underlying performance issues had been discussed in the Operational Performance update earlier in the meeting. The Trust was ahead of the original Cost Reduction Target and the cash position was ahead of plan, due mainly to slippage in the capital programme, which was expected to reduce towards the year end due to forecast planned expenditure on the STEM project. Noting that the level of fully coded activity was currently at only 46%


for November’s actual activity, Ms Jacques asked if the level of performance within the Coding team was optimum. Ms Langrick explained that there had been some issues experienced in relation to high turnover of staff, and a lower staff base than other organisations, which had been addressed. A plan was in place and there was no perceived risk to income. In relation to income under-recovery, Mr Dawson highlighted the table on page eight of the report, summarising the analysis carried out by the Director of Performance, on activity projections. The initial assessment confirmed that income for the remaining period was broadly consistent with the plan. This would however be kept closely under review. In terms of the Reference Costs position, Mr Dawson advised that the Trust’s relative performance had worsened in 2015/16 compared with the previous year. An opportunity of around £12m was suggested, which was largely consistent with the deficit reported in that financial year. On behalf of the Finance Committee, Mr Forster-Jones commented that the financial position was better than expected; however, there were a number of risks that required careful management in the approach to the financial year end. These included; variability on income, sickness levels and a drift towards non-recurring CRT savings. The Trust Board NOTED the updates provided in the Finance Report.

232/17 Register of Sealings Mr Edge confirmed that the Trust seal was not used within the quarter.

Workforce & OD

233/17

Workforce & OD Assurance Report Ms Smith presented the report, the purpose of which was to provide assurance to the Board around the Workforce and OD agenda and escalate any areas which were challenged in performance against target. It was noted that the sickness rate had decreased from 4.95% in November to 4.86% in December, against an annual target of 3.5%. Ms Smith advised that the controls in place around reporting had been strengthened significantly. It was intended that rates of pay of pay for bank staff would be reduced from February 2017, however the reduced rates would


remain favourable compared with agency rates and with bank rates paid by other NHS Trusts. A significant improvement in the rate of staff having had an appraisal was highlighted and it was anticipated that the improvement would continue over the coming months. In addition, the intelligence around the quality of appraisals had improved. In relation to Medical Education, Ms Smith highlighted the risks outlined in the report and the actions to be taken. She proposed that a more detailed update be brought to the next Board meeting. Finally, Ms Smith highlighted good news around the recently introduced Trust graduate training programme which had proved very successful. Questions and comments were invited. Mr Bretherick congratulated Ms Smith and her team on the significant improvement of appraisal rates. In terms of mandatory training, Mr Bretherick understood that this was a challenging area and he asked for further information on an issue relating specifically to training on the Information Governance Toolkit. Ms Jacques advised that a risk had been highlighted in this area, however a plan was in place which was believed to be achievable. . In relation to sickness levels and the ability of the Trust to recruit and retain staff, Dr Robson enquired as to how the Trust compared with others. Ms Smith advised that the Trust was not an outlier in either area. The issues around retaining staff were very similar to other Trusts regionally, due to the close proximity of organisations, which enabled staff to move easily between locations and Trusts. In terms of sickness levels, there was now a greater degree of control and consistency around recording in this area, which could potentially be masking a further improvement on sickness levels, as it was likely that some absences were previously not recorded. Mr Forster-Jones noted the 9% of voluntary leavers mentioned in the report, which from his experience in the private sector, appeared high. He asked what might be driving this. Ms Smith advised that some staff returned to the Trust, however this was not captured in the recording. As already explained, the Trust was not an outlier in terms of retention of staff and the ease of moving between Trusts was cited as one of the main issues. Mr Forster-Jones asked whether exit interviews were undertaken with staff. Ms Smith advised that there was more work to be carried out in that area and HR Business Managers were in the process of picking it up with line managers. Mr Young welcomed the Workforce and OD Reports, which were

MS (Feb 2017)


now regularly received. He highlighted the performance in relation to flu vaccination, which was well below the national target of 75%. Ms Jacques advised that regionally, the performance of the Trust was similar to others. The Local Area Delivery Board (LADB) was reviewing the learning from those Trusts who had performed particularly well. Noting that the Trust would be required to pay an apprenticeship levy to the Government from April 2017, Mr Young asked for clarification on how this would be funded. Mr Dawson clarified that the funding was included in the tariff uplift. There was therefore an opportunity for the Trust to use the levy to fund apprenticeships for some staffing requirements whilst being fully funded for it. The Chairman referred to a discussion that had taken place at a recent Clinical Quality and Safety Panel, around Safeguarding training and the embedding of learning. He asked how it could be ensured that training was effective. Ms Smith agreed that this was an issue relevant to any kind of training. Ms Jacques suggested that training with an assessment incorporated usually appeared successful. The Chairman agreed and highlighted this as an issue for further consideration. The Trust Board RECEIVED the Workforce and OD Assurance Report.

MS (April 2017)

Other Business

234/17 (a) (b) (c)

Other Business Trust Performance The Chairman felt it was important to highlight the positive feedback the Trust had received at a recent event for NHS providers. The Trust had been commended for its performance and development over the last 12 months and also comparatively against other organisations. Ms Jacques added that the region overall was highlighted as performing well against the rest of the country. Medical Director As had been mentioned earlier in the meeting, it was the last formal Board meeting that Prof Gray would be in attendance for. The Chairman expressed his sincere thanks, on behalf of the Board, for Prof Gray’s hard work over the last four years and wished him the best for the future. MRI Scanner Appeal Ms Flynn advised that the MRI Scanner Appeal was to be formally launched on 7th February 2017 with a press launch. Volunteers were being requested to help with a photo session. The Chairman wished to recognise the positive impact the Trust


Charity had made since Ms Flynn became Chairperson. Ms Flynn wished for it to be noted that the willingness was already in place and her focus was on encouragement.

235/17 Questions from the Public No questions were raised by members of the public.

236/17 Announcement of Next Public Meeting(s) Trust Board Date: Wednesday 29 March 2017 Time: From 09:00hrs Venue: Executive Board Room, Executive Corridor at Darlington Memorial Hospital

237/17 Motion to Exclude Press/Public The Chairman moved the following motion. “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.” There were no objections to the motion.

238/17 Close There being no further business, the Chairman thanked all for their attendance. He emphasised the importance of the public observing the transparency of Trust Board business. The Chairman then declared the open session of the meeting closed at 11.30hrs

Chair – Prof Paul Keane OBE ……………………………. Date: …………………………………………………..

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